Surgery for Locally Advanced Lung Cancer: What You Should Know

Traditionally as soon as doctors notice involvement of the lymph nodes in the central chest, they often exclude surgery as an option. Today, thanks to a combination of improved systemic treatment, evaluation and thought leadership for which my work has made important contributions, many people are offered surgery as part of multi-modality treatment.

What Is Locally Advanced Lung Cancer?

I currently define as a single tumour that is more than 4cm with involvement of the lymph nodes on the same side of the chest without any disease outside the chest. Traditionally, this is defined as involved lymph nodes in the central chest, but with new treatment pathways, (in my opinion) it is more useful and practical to consider any lymph node involvement in the same side of the chest in this categorization (I expect it will take a thoracic cancer community a little while longer to made this adaptation).

Is Surgery Still an Option?

In patients with N2 disease (lymph nodes involved in the center of their chest) it is often asked if surgery in this setting is beneficial. Whilst there have been no direct trials to compare, my research of all published clinical trials indicate the outcomes of radiotherapy and chemotherapy is the same as surgery and chemotherapy[1] supporting lung resection as a valid treatment option.

Multimodality Approach: Combining Treatments

Today treatment regimens have improved so much that surgery is now considered standard after initial chemotherapy and immunotherapy to improve survival and reduce the risk of cancer coming back. The treatment combination is so good that in 18 to 24% of people there no cancer left when an operation is done (unfortunately there is no reliable means to determine if all the cancer has been eradicated before surgery).[2,3] In light of these critical improvements to outcome I offer systemic treatments to all patients before and not after surgery to maximize very best outcomes for you as identified in my research.[4]

Surgical Techniques Used

An interesting and not well researched (yet) consideration is that amount of lung to be removed in the setting where lymph nodes are involved. If the tumour is large or lymph nodes within the lobe are involved in the lobe, then its perfectly logical to remove the entire lobe to achieve complete cancer clearance.

However, if the cancer is small (less than 2cm) and the lymph nodes in the central chest but not lung are involved, there is the option to remove the lymph nodes and a section of lung (wedge or segments) to preserve your lung function. However, if a reduction in recurrent cancer is a predominant consideration for you, then removal of the lobe would be more suitable. We will discuss these options when I meet you.

What to expect before and after surgery

Once you have agreed to surgery, we will conduct a series of blood tests, heart trace, a chest-x-ray and review of your medications. This is often undertaken by the preassessment team to screen for any disorders that may need attention before the operation.

On the day of surgery, you will be admitted in the morning, change into hospital gown, and I will meet you to let you know of the likely timing of your operation. In general, we ask that you do not eat anything after midnight the day before your operation, and you will be allowed to drink a glass of water every hour until we send for you.

Many patients will be suitable for day case surgery and allowed home (with or without a drain) as long as your pain is controlled and you feel well and confident. The aches and pains may take 3 to 6 months to recover (depending on keyhole or open surgery), and we will issue you with painkillers and advise you how to slowly come off with time. Please note that some painkillers can make you very constipated, so you need to ensure you are well hydrated and mobile, and if necessary we can also give you medication to help your bowels (laxatives).

We will see you in clinic usually a week later to review your progress and inform you of the results of the operation, and if all is well, we will discharge you from clinic back to your referring doctor.

Success Rates and Outcomes

In the vast majority of cases, the cancer will be completely removed. It is important to be seen and evaluated in centers of expertise as often patients with locally advanced lung cancer are not offered surgery due to existing, poorly formulated or outdated views. We must not overlook surgeon expertise as well, as the quality of the lymph node dissection is key to the success of any operation especially in a minimal access surgery setting.

Survival rates overall depend on lung cancer stage and the number of lymph nodes involved, and it is not usually as high as earlier stage lung cancer and also carries a higher recurrence risk. My patients will also be offered the option of continuing immunotherapy for a year, and will undergo detailed CT assessment every 6 months to screen for cancer returning.

Why choose Professor Eric Lim for locally advanced lung cancer surgery?

Surgery for locally advanced lung cancer has been my strong area of research with contributions to the medical literature and guidelines across the world. Many specialists remain confused on this topic regarding the appropriateness, timing and selection for surgery in locally advanced lung cancer, and I have successfully treated many people who have not been given options and turned down for surgery.

If you would like to discuss your individual management or obtain a second opinion, please contact me.

References

[1] McElnay P,…Lim E. Outcome of surgery versus radiotherapy after induction treatment in patients with N2 disease: systematic review and meta-analysis of randomised trials. Thorax 2015 Aug;70(8):764-8. doi: 10.1136/thoraxjnl-2014-206292. Epub 2015 May 12.

[2] Wakelee H, et al. Perioperative Pembrolizumab for Early-Stage Non-Small-Cell Lung Cancer. N Engl J Med 2023 Aug 10;389(6):491-503. doi: 10.1056/NEJMoa2302983.

[3] Forde P, et al. Neoadjuvant Nivolumab plus Chemotherapy in Resectable Lung Cancer.N Engl J Med 2022 May 26;386(21):1973-1985. doi: 10.1056/NEJMoa2202170.

[4] Patel A,…Lim E. Impact of the timing of immunotherapy administration on overall survival for resectable non-small cell lung cancer (iACORN study): A systematic review and meta-analysis of randomised trials. Eur J Cancer 2025 Jan:214:115118.