Goldilocks…the principle, not the character.

The thoracic surgeon must get the operation “just right.” Take out too much lung and the patient is forever short of breath; not enough and the cancer is not cured.

As I discussed in a previous blog, Evarts Graham, a surgeon in St. Louis, performed the first successful operation for lung cancer when in 1933 he performed a pneumonectomy (removal of an entire lung) in a patient with lung cancer. Interesting to note that the patient, a physician, had to have been nervous as he bought a grave site for himself just before his procedure. Nonetheless he proceeded and eventually outlived his surgeon.

Since this seminal operation experience has shown that lobectomy (removal of part of a lung called a lobe) is usually the preferred operation for a lung cancer. If staging (see my previous blog) confirms the cancer is entirely within a single lobe, removing the lobe provides as good a chance of cure as a pneumonectomy while leaving the patient with more functioning lung which means less likelihood of shortness of breath and a higher quality of life after surgery. Occasionally a pneumonectomy is necessary to get all the cancer because of its location within the lung. Conversely, removal of even smaller amounts of lung is the only possible operation if the patient’s lungs are so weakened by years of smoking that they cannot tolerate the loss of lung that a lobectomy constitutes, much less a pneumonectomy.

Things are more complicated if staging identifies cancer in lymph nodes in the mediastinum, the area in the middle of the chest, between the two lungs and behind the heart. Surgery alone is rarely curative so these patients usually receive radiation and/or chemotherapy first. Subsequently the appropriate operation is performed if the cancer has responded to these agents and the patient is fit enough.