Surgery for Small Cell Lung Cancer

Guidelines and Prognosis

Surgeon with doctors operating patient at hospital
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Surgery is not done as commonly for small cell lung cancer as with non-small cell lung cancer, and many people wonder why. Let's talk about when it may be possible, and the reasons why chemotherapy and radiation therapy are often better options for treatment.

Can it Be Done?

In the past, surgery for small cell lung cancer was not really considered an option.

Most often, when small cell lung cancer is found, it has already spread to areas beyond the lungs (metastasized) or is present in both lungs. In those settings, chemotherapy and radiation therapy are better treatment options.

But physicians are again looking at a small subset of people who may benefit, and live for a long time, following successful surgery for small cell lung cancer.

When Surgery Isn't Recommended

Small cell lung cancer accounts for around 15 percent of lung cancers. It is broken down into two stages: limited stage and extensive stage. If someone has extensive stage small cell lung cancer (present in around 70 percent of people at the time of diagnosis), surgery does not improve life expectancy. With extensive stage small cell lung cancer, a combination of chemotherapy and radiation therapy may work quite well, at least initially. If surgery were to be done it would not only be ineffective but could interfere with treatments which do help.

When Surgery May Be Effective

Surgery may offer the chance for long-term survival in some people with limited-stage small cell lung cancer in which:

  • The cancer is present in only one lung.
  • The cancer does not involve lymph nodes or is present only in nearby lymph nodes. (In other words, surgery is not a good option for people with N2 disease on TNM lung cancer staging, which refers to lymph nodes which contain cancer in the area between the lungs (mediastinal lymph nodes).
  • Surgery is more likely to be an option if the cancer is in the outer parts of the lungs.

Types of Surgery

There are 4 main types of surgery which are done for lung cancer:

  • Pneumonectomy. A pneumonectomy is a surgery which involves the removal of an entire lung. Some people are surprised that this surgery is possible, but in people with otherwise good function, many people have tolerated the procedure quite well.
  • Lobectomy. A lobectomy is a procedure in which a lobe of a lung is removed.  The right lung has 3 lobes and the left lung has 2. 
  • Wedge resection or segmentectomy. A wedge resection is a surgery in which a tumor plus a wedge-shaped area of surrounding tissue is removed. This results in less tissue being lost than in a lobectomy, but may also carry a higher risk of recurrence.
  • Sleeve resection.

Of these, lobectomy appears to have the best results overall for people with small cell lung cancer.

Prior to Surgery

If surgery is considered, a very careful evaluation will need to be done, including a mediastinoscopy (a procedure that looks for cancer in the area between the lungs), to make sure the cancer has not spread to lymph nodes in this region (N2 lymph nodes). PET/CT may be an alternative to mediastinoscopy for some people.

Pulmonary function tests will also be done to make sure that a person will tolerate the surgery and have adequate lung function after the surgery.

Since survival from surgery for small cell lung cancer appears to be better in cancer centers which perform greater volumes of these surgeries, it is important to research your cancer prior to your surgery and consider getting a second opinion at a larger cancer center.

After Surgery

If surgery is done, it is important that chemotherapy and most often radiation therapy be used after surgery, since this improves survival.

Prophylactic cranial irradiation (PCI), a type of radiation designed to help prevent the spread of cancer to the brain, may also be used to lower the risk of cancer spreading to the brain after surgery.

The risk of brain metastases occurring three years after surgery increases with the stage of the tumor, and one study found this risk to be 9.7 percent for stage 1, 18.5 percent for stage 2, and 35.4 percent for stage 3 disease.

Prognosis

Studies suggest that for people with early-stage (limited stage) small cell lung cancers (T1 or T2), surgery improves the survival rate. In a large review, it was found that survival for people with both local and regional disease was improved with surgery.

For those with localized disease who had a lobectomy, the median survival rate was 65 months and the overall 5-year survival rate was over 52 percent. These numbers may sound frightening until you compare them to the survival rates of people who do not have surgery which included a median survival rate of 25 months and an overall 5-year survival rate of 31.8 percent.

Of note is that the treatment of brain metastases due to lung cancer is changing, and some cases people who only have a few metastases ("oligometastases") may be treated with a curative intent with either stereotactic body radiotherapy (SBRT) or proton beam therapy.

Bottom Line

In the past, surgery was rarely considered as an option for treating small cell lung cancer. This appears to be changing as newer studies have found a survival advantage for some people with the disease. Particularly, people with limited stage lung cancer have significantly better 5-year survival rates with surgery than with chemotherapy and radiation therapy alone. Of the different procedures available, lobectomy had the best overall results.

It's important to keep in mind that everyone is different. Some early-stage (limited stage) small cell lung cancers may be difficult or impossible to treat with surgery due to the location of the tumor. The presence of other medical conditions may also lead to the risk of surgery outweighing the potential benefits.

If you are living with lung cancer it is important to be your own advocate in your care. The treatment options for small cell lung cancer are improving and new treatments are being evaluated in clinical trials. Some of these treatments, such as those using the newer immunotherapy drugs offer the promise of significantly improved outcomes in the future. While many people have a fear of clinical trials, it's important to remember that every treatment we now have available was once part of a clinical trial.

Sources:

Finely, C. The effect of surgeon volume on procedure selection in non-small cell lung cancer surgeries. Journal of Thoracic and Cardiovascular Surgery. 2016. 151(4):1219.

Koletsis, E., Prokakis, C., Karanikolas, M., Apostolakis, E., and D. Dougenis. Current role of surgery is small cell lung carcinoma. Journal of Cardiothoracic Surgery. 2009. 4:30.

National Cancer Institute. Small Cell Lung Cancer Treatment (PDQ) – Patient Version. Updated 11/09/17.

Schreiber, D., Rineer, J., Weedon, J. et al. Survival outcomes with the use of surgery in limited-stage small cell lung cancer: should its role be re-evaluated? Cancer. 116(5):1350-7.

Zhu, J., Bi. Y., Han A. et al. Risk factors for brain metastases in completely resected small cell lung cancer: a retrospective study to identify patients most likely to benefit from prophylactic cranial irradiation. Radiation Oncology. 2014. 9:216.