Surgeons often take a fifth of the lungs to remove a small tumor. There may be a better way

CHICAGO — Claudia Donohue was on the operating table first thing in the morning. It wasn’t where she wanted to end up when she first learned she had lung cancer. When she saw the constellation of white dots on her chest scan, she figured the last 59 years of smoking cigarettes had finally caught up to her. Plus, she’d already had cancer once before, in her bladder. It seemed to her that the odds at her age, 76, weren’t good.

“I just felt if I had lung cancer, it was probably terminal, and I wasn’t very positive about surgery and recovering for it,” Donohue said. But Ankit Bharat, her doctor and the chief of thoracic surgery at Northwestern Medicine in Chicago, breezily told her not to worry. His department, he said, had a new surgical program for early-stage lung cancers that could remove less of her lung, improve her chances, and get her back on her feet quickly. That caught Donohue’s attention.

It’s called A-PLUS or Ambulatory Precision Lung Sparing surgery. With it, Bharat hopes to push forward the emerging idea that in early-stage lung cancers, surgeons should take less of the lung out. But what exactly is the best way to do that, for which patients, and how much of the lung ought to be excised is a subject of fierce debate among thoracic surgeons.

“It’s somewhat controversial,” said Jeff Velotta, a thoracic surgeon at Kaiser Permanente Northern California and an adjunct assistant professor at the University of California, San Francisco. “The trials on this are only just coming out.”

Among cancers, lung is the deadliest, responsible for nearly 25% of all cancer deaths, and second in incidence only to prostate cancer in men and breast cancer in women. If a patient is lucky enough to discover a tumor early on, the first option is almost always surgery. And for decades, Bharat explained, the standard of care has been to remove one of the five lobes of the lung — a lobectomy — to take out early-stage tumors.

“That’s what everybody does,” Bharat said before one of the A-PLUS surgeries in early September. He crossed his arms and shook his head. The upper lobes represent 15 to 20 percent of a person’s lung capacity, while the lower lobes constitute up to 25 percent. One lost lobe could translate into lost exercise or activities, and — for patients who already have compromised lungs from heavy smoking or other disease — the need for supplemental oxygen. “You lose your lung capacity by that much, it’s a huge lifestyle change,” he said.

Not only that, Bharat added, many lung cancer patients experience a recurrence over the next couple of decades after surgery. Then, he said, you’d have to take yet more of the lung out. “So we really have to start thinking about preserving the lung while still being able to treat the cancer,” he said.

Lobes are further divided into segments, which share a single airway and blood vessel branch within the lobe. In patients with cancer, Bharat and the surgeons in his department seek to remove just one of these segments. In a study published this year in The Lancet, surgeons showed that patients who received segmentectomies had a 95% overall survival rate after 5 years compared to 91% for lobectomies, an improvement Bharat attributes to the lung-sparing approach.

Plus, when using less invasive techniques like robotic surgery or VATS — keyhole operations where surgeons guide finger-sized instruments into the chest through small incisions — patients recover faster and can often go home the same day as the surgery.

Still, after Donohue had her biopsy done and surgery scheduled, she remained apprehensive. In a pre-operative meeting with Bharat, she showed him a Do Not Resuscitate form in case anything went wrong. The tumor was close to her heart. That scared her. “I don’t want to wake up with a bunch of tubes in me,” she told him. She’d rather be dead than live her life as a vegetable.

Bharat looked back at her, shocked. Then he laughed. “You never give a thoracic surgeon a DNR,” he said. Don’t worry, he told her. It’s going to be fine.

OK, Donohue said after a moment. She put the form down.

Things can go wrong when surgeons attempt a segmentectomy. Lung cancers aren’t always easy to see with the naked eye. In this kind of procedure, surgeons must know exactly where the tumor begins and ends.

Depending on the tumor, that can be difficult. Some are soft, barely palpable, with diffuse borders. Some may be deeper in the lung or may cross the boundaries of different, anatomically defined sections of the lung.

“It’s like a little needle in a haystack. And you never want to get into a scenario where you took out the wrong segment or the pathologist has not even found the tumor or that the margins are involved in the tumor,” Bharat said. “So, normally people take the whole lobe because, that way, you don’t need to know where the tumor is located.”

Donohue had a trickier tumor. It was located in the lower lobe of her left lung, a spot that’s much harder to reach. But surgeons have their own tricks. Bharat started the surgery with a robotic bronchoscopy: a pulmonologist piloted a robot that snaked a catheter down the patient’s throat and into the lungs. Using a 3D map of the organ’s branching airways that the clinical team created based on CT scans, the pulmonologist navigated to the nodule and positioned the robot in front of it. Then, the doctor inserted a tiny needle into the tumor and pumped a deep indigo dye into the cancer site.

With the tumor painted, Bharat would be able to easily identify the tumor once he’d cut into Donohue. After the surgical team stowed away the bronchoscopy robot, they rearranged themselves around Donohue, cut into her chest, and slipped a small camera into the lung cavity. Bharat and the other doctors gazed at the feed on monitors hovering over the head of the table. A splotch of dark blue on pale pink marked the cancer.

The surgeons guided long, instrumented wands through the small incisions and, gently, began isolating the diseased segment of lung, dissecting blood vessels and airways and the connective tissue that bound it to the rest of the organ. Smoke and the acrid smell of cauterization hung in the air.

About three hours later, the team had pulled the separated segment out, sent it in a specimen jar to pathology, and stitched Donohue’s chest shut.

“The next thing I remember is waking up in recovery,” she recalled later. Someone was slowly pulling a drainage tube out of her. She went home that evening.

The push toward taking less lung tissue out in stage one cancer surgeries is a good one, said Kaiser Permanente’s Velotta, if controversial. In the context of sub-lobar surgeries like segmentectomies, Velotta said A-PLUS’ use of additional technology could improve the accuracy and outcomes of more complicated operations.

“It’s a great idea,” he said, adding that other academic centers have also been performing similar procedures. “Combining the CT guidance, robotic bronchoscopy, and surgery is a benefit — hopefully it can delineate the tumor better.” But whether it’s always better for the patient to have less than a lobe taken out isn’t settled, and it wasn’t until this year that clinical trials began showing that sub-lobar surgeries might be just as good as or even better than lobectomies. “We previously were so dogmatic about lobe, lobe, lobe,” Velotta said, because of the fear cancer cells would otherwise be left behind. “I do think the trend will be towards more sub-lobar or lung-sparing resections, but whether I would say the gold standard should be lung-sparing is still a discussion.”

In the past, studies had always shown that lobectomies had far less recurrence than lung-sparing surgeries, but two new trials contradicted that this year. In a Lancet paper, Japanese surgeons compared segmentectomies to lobectomies and found after five years, 11% of both groups experienced a relapse. Nasser Altorki, director of thoracic surgery at Weill Cornell Medical Center/NewYork-Presbyterian, presented data at the World Conference of Lung Cancer in August, again showing that sub-lobar resections were equivalent to lobectomies.

In Altorki’s trial, those sub-lobar resections included both segmentectomies — the operation that Bharat performs — and another sub-lobar surgery known as a wedge resection. Where segmentectomies remove an anatomical division of the lobe, wedge resections ignore the geometry of the lung and cut a non-discriminate pie slice to remove the tumor. It’s a far easier and faster surgery, Altorki said.

Roughly 60% of the 340 sub-lobar surgeries included in Altorki’s trial were wedge resections. The rest were segmentectomies. Together, the patients who received either wedge or segment resections had a survival curve that was identical to the patients who received a lobectomy. That suggested to Altorki that either wedge or segment resections are likely both good options for patients who have small, stage 1 lung cancers located near the edge of the lung.

“You can do it by wedges or segments, as long as you do it well,” Altorki said. “If the tumor meets the criteria, you can do either with the expectation the outcome will be good.”

When asked about that idea, Bharat responded, absolutely not. “Biologically, it makes no sense to me,” he said. Wedges, Bharat said, mutilate the lung’s organization, while taking out segments doesn’t. Wedges, he said, are like cutting a rectangle out of a pizza and destroying the ordered triangular slices. They also often fail to take enough lymph nodes, Bharat added, which could hold undetected cancer cells.

“Maybe if someone is 95 and old, frail, you want to do a quick wedge resection because the likelihood the patient dies of natural causes is higher than cancer-specific outcomes,” Bharat said. “But in a 40-year-old, these patients will probably come back with recurrences.”

But Altorki remained firm. “I had the same trepidation as other surgeons,” he said, “like, ‘oh my god. We’re doing wedges and wedges are bad and they’re going to be a bad outcome.’ But now I feel it’s OK.”

All of this, Altorki added, is case dependent and only relevant for early stage 1 cancers. There are some cases where a segmentectomy would work, but a wedge wouldn’t, he said. It matters who the patient is, what the tumor is like, and where it’s located.

For Velotta, the jury’s still out. It’s possible, he said, that taking out segments is better than taking wedges in general, but it’ll be years before the data will truly answer that question. For now, the decision boils down to practicality for him. Wedges, he said, are just easier — but most surgeons still think they’re worse than taking out segments or lobes.

“Then if you do a segment, it’s just as technically difficult as a lobe. You’re hoping to save a little bit more lung, but just a little bit,” he said. “So if you’re going to do a segment, then at that point why not just do the lobe?”

But saving as much of her lungs as possible mattered to Donohue. Her recovery was easy, she said. After the surgery, her chest ached for about a week or two when she laughed or coughed or laid on her left side. Then, she was normal. She was able to return to the summer home she shares with her husband in Harbor Springs, Mich., and spend time gardening or sailing with her grandkids. With Bharat’s encouragement, she reluctantly quit smoking, too.

“I’m really grateful that I ended up with the doctor that I did and the procedure that I did,” she said. “I feel like major surgery — it’s really not easy on someone in their mid-70s. Bharat made it very easy, and I came through very well. He’s a good doctor.”

If the cancer ever comes back, she said, she’d do the same thing again.

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