Surgery for Small Cell Lung Cancer

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Surgery is not done as commonly for people with small cell lung cancer as with non-small cell lung cancer, but there are times when it may be an option. For those with extensive-stage small cell lung cancer, chemotherapy, radiation therapy, and possibly immunotherapy is a better option. With limited stage disease, however, there may be a small subset of people who could not only benefit but live a long time due to surgery (though results are mixed). Most commonly, this includes tumors that are in the outer regions of only one lung, and have not spread to lymph nodes. Learn more about who may be a candidate for this surgery, the types of surgery that may be done and why, treatments that may be required along with surgery, and the prognosis.

When Surgery May be an Option

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, radiation therapy, and immunotherapy are better treatment options, as surgery would not extend life, but would decrease the quality of life.

There is, however, a small subset of people with small cell lung cancer 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 and 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 that 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 but only in a subset of people. This includes those with:

  • Cancer that is is present in only one lung
  • Cancer that does not involve lymph nodes or is present only in nearby lymph nodes, such as hilar 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 known as the mediastinum (mediastinal lymph nodes).

With limited-stage small cell lung cancer, surgery is more likely to be an option if the cancer is in the outer parts of the lungs.

Types of Surgery

There are different types of surgery that may be done, with the choice often depending on the location and size of the tumor. These include:

  • Pneumonectomy: A pneumonectomy is a surgery that 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. 
  • Segmentectomy: The lobes of the lung are divided into segments. A segmentectomy involves the removal of one or more of these segments, including the tumor plus some surrounding tissue.
  • Wedge resection: 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: A sleeve resection is sometimes done as an alternative to pneumonectomy, for tumors that surround the airways.

Of these procedures, lobectomy appears to have the best results overall for people with small cell lung cancer, but again, the choice depends on the characteristics of a person's unique tumor.

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 that the cancer has not spread to lymph nodes in this region (N2 lymph nodes). PET/CT scans are now an alternative to mediastinoscopy for some people and is much less invasive.

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 that 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. In some cases, people can get a remote second opinion without the need to travel to these centers, to see if it is worth traveling for the surgery.

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.

Pulmonary rehabilitation after lung cancer surgery is a relatively new field but has been beneficial for many people who experience breathing problems following surgery.

Effectiveness and 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. Other studies, however, have found no increase in survival, or lower survival with surgery as compared with radiation therapy.

Of note is that the treatment of brain metastases due to lung cancer is changing, and in 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.

A Word From Verywell

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.

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