Lobectomy, pulmonary

Definition

A lobectomy is the removal of a lobe, or section, of the lung.

Purpose

Lobectomies are performed to prevent the spread of cancer to other parts of the lung or other parts of the body, as well as to treat patients with such noncancerous diseases as chronic obstructive pulmonary disease (COPD). COPD includes emphysema and chronic bronchitis, which cause airway obstruction.

Demographics

Lung cancer

Lung cancer is the leading cause of cancer-related deaths in the United States. It is expected to claim nearly 157,200 lives in 2003. Lung cancer kills more people than cancers of the breast, prostate, colon, and pancreas combined. Cigarette smoking accounts for nearly 90% of cases of lung cancer in the United States.

Lung cancer is the second most common cancer among both men and women and is the leading cause of death from cancer in both sexes. In addition to the use of tobacco as a major cause of lung cancer among smokers, second-hand smoke contributes to the development of lung cancer among nonsmokers. Exposure to asbestos and other hazardous substances is also known to cause lung cancer. Air pollution is also a probable cause, but makes a relatively small contribution to incidence and mortality rates. Indoor exposure to radon may also make a small contribution to the total incidence of lung cancer in certain geographic areas of the United States.

In each of the major racial/ethnic groups in the United States, the rates of lung cancer among men are about two to three times greater than the rates among women. Among men, age-adjusted lung cancer incidence rates (per 100,000) range from a low of about 14 among Native Americans to a high of 117 among African Americans, an eight-fold difference. For women, the rates range from approximately 15 per 100,000 among Japanese Americans to nearly 51 among Native Alaskans, only a three-fold difference.

Chronic obstructive pulmonary disease

The following are risk factors for COPD:

• current smoking or a long-term history of heavy smoking
• employment that requires working around dust and irritating fumes
• long-term exposure to second-hand smoke at home or in the workplace
• a productive cough (with phlegm or sputum) most of the time
• shortness of breath during vigorous activity
• shortness of breath that grows worse even at lower levels of activity
• a family history of early COPD (before age 45)

Description

Lobectomies of the lung are also called pulmonary lobectomies. The lungs are a pair of cone-shaped breathing organs within the chest. The function of the lungs is to draw oxygen into the body and release carbon dioxide, which is a waste product of the body's cells. The right lung has three lobes: a superior lobe, a middle lobe, and an inferior lobe. The left lung has only two, a superior and an inferior lobe. Some lobes exchange more oxygen than others. The lungs are covered by a thin membrane called the pleura. The bronchi are two tubes which lead from the trachea (windpipe) to the right and left lungs. Inside the lungs are tiny air sacs called alveoli and small tubes called bronchioles. Lung cancer sometimes involves the bronchi.

To perform a lobectomy, the surgeon makes an incision ( thoracotomy ) between the ribs to expose the lung while the patient is under general anesthesia. The chest cavity is examined and the diseased lung tissue is removed. A drainage tube (chest tube) is then inserted to drain air, fluid, and blood out of the chest cavity. The ribs and chest incision are then closed.

Lung surgery may be recommended for the following reasons:

• presence of tumors
• small areas of long-term infection (such as highly localized pulmonary tuberculosis or mycobacterial infection)
• lung cancer
• abscesses
• permanently enlarged (dilated) airways (bronchiectasis)
• permanently dilated section of lung (lobar emphysema)
• injuries associated with lung collapse (atelectasis, pneumothorax, or hemothorax)
• a permanently collapsed lung (atelectasis)

Diagnosis/Preparation

Diagnosis

In some cases, the diagnosis of a lung disorder is made when the patient consults a physician about chest pains or other symptoms. The symptoms of lung cancer vary somewhat according to the location of the tumor; they may include persistent coughing, coughing up blood, wheezing, fever, and weight loss. Patients with a lung abscess often have symptoms resembling those of pneumonia, including a high fever, loss of appetite, general weakness, and putrid sputum. The doctor will first take a careful history and listen to the patient's breathing with a stethoscope . Imaging studies include x ray studies of the chest and CT scans . If lung cancer is suspected, the doctor will obtain a tissue sample for a biopsy. If a lung abscess is suspected, the doctor will send a sample of the sputum to a laboratory for culture and analysis.

For patients with lungs that have been damaged by emphysema or chronic bronchitis, pulmonary function tests are conducted prior to surgery to determine whether the patient will have enough healthy lung tissue remaining after surgery. A test may be used before surgery to help determine how much of the lung can safely be removed. This test is called a quantitative ventilation/perfusion scan, or a quantitative V/Q scan.

Preparation

Patients should not take aspirin or ibuprofen for seven to 10 days before surgery. Patients should also consult their physician about discontinuing any blood-thinning medications such as Coumadin (warfarin). The night before surgery, patients should not eat or drink anything after midnight.

Aftercare

If no complications arise, the patient is transferred from the surgical intensive care unit (ICU) to a regular hospital room within one to two days. Patients may need to be hospitalized for seven to 10 days after a lobectomy. A tube in the chest to drain fluid will probably be required, as well as a mechanical ventilator to help the patient breathe. The chest tube normally remains in place until the lung has fully re-expanded. Oxygen may also be required, either on a temporary or permanent basis. A respiratory therapist will visit the patient to teach him or her deep breathing exercises. It is important for the patient to perform these exercises in order to re-expand the lung and lower the risk of pneumonia or other infections. The patient will be given medications to control postoperative pain. The typical recovery period for a lobectomy is one to three months following surgery.

Risks

The specific risks of a lobectomy vary depending on the specific reason for the procedure and the general state of the patient's health; they should be discussed with the surgeon. In general, the risks for any surgery requiring a general anesthetic include reactions to medications and breathing problems. As previously mentioned, patients having part of a lung removed may have difficulty breathing and may require the use of oxygen. Excessive bleeding, wound infections, and pneumonia are possible complications of a lobectomy. The chest will hurt for some time after surgery, as the surgeon must cut through the patient's ribs to expose the lung. Patients with COPD may experience shortness of breath after surgery.

Normal results

The outcome of lobectomies depends on the general condition of the patient's lung. This variability is related to the fact that lung tissue does not regenerate after it is removed. Therefore, removal of a large portion of the lung may require a person to need oxygen or ventilator support for the rest of his or her life. On the other hand, removal of only a small portion of the lung may result in very little change to the patient's quality of life.

Morbidity and mortality rates

A small percentage of patients undergoing lung lobectomy die during or soon after the surgery. This percentage varies from about 3–6% depending on the amount of lung tissue removed. Of cancer patients with completely removable stage-1 non-small cell cancer of the lung (a disease in which malignant cancer cells form in the tissues of the lung), 50% survive five years after the procedure.

Alternatives

Lung cancer

The treatment options for lung cancer are surgery, radiation therapy, and chemotherapy, either alone or in combination, depending on the stage of the cancer.

After the cancer is found and staged, the cancer care team discusses the treatment options with the patient. In choosing a treatment plan, the most significant factors to consider are the type of lung cancer (small cell or non-small cell) and the stage of the cancer. It is very important that the doctor order all the tests needed to determine the stage of the cancer. Other factors to consider include the patient's overall physical health; the likely side effects of the treatment; and the probability of curing the disease, extending the patient's life, or relieving his or her symptoms.

Chronic obstructive pulmonary disease

Although surgery is rarely used to treat COPD, it may be considered for people who have severe symptoms that have not improved with medication therapy. A significant number of patients with advanced COPD face a miserable existence and are at high risk of death, despite advances in medical technology. This group includes patients who remain symptomatic despite the following:

• smoking cessation
• use of inhaled bronchodilators
• treatment with antibiotics for acute bacterial infections, and inhaled or oral corticosteroids
• use of supplemental oxygen with rest or exertion
• pulmonary rehabilitation

After the severity of the patient's airflow obstruction has been evaluated, and the foregoing interventions implemented, a pulmonary disease specialist should examine him or her, with consideration given to surgical treatment.

Surgical options for treating COPD include laser therapy or the following procedures:

• Bullectomy. This procedure removes the part of the lung that has been damaged by the formation of large air-filled sacs called bullae.
• Lung volume reduction surgery. In this procedure, the surgeon removes a portion of one or both lungs, making room for the remaining lung tissue to work more efficiently. Its use is considered experimental, although it has been used in selected patients with severe emphysema.
• Lung transplant. In this procedure a healthy lung from a donor who has recently died is given to a person with COPD.

Resources

books

Braunwald, Eugene, M. D., Anthony S. Fauci, M. D., Dennis L. Kasper, M. D., et al., eds. Harrison's Principles of Internal Medicine , 15th ed. New York: McGraw-Hill Professional, 2001.

Henschke, Claudia I., Peggy McCarthy, and Sarah Wernick. Lung Cancer: Myths, Facts, Choices—And Hope , 1st ed. New York, NY: W. W. Norton & Company, Inc., 2002.

Johnston, Lorraine. Lung Cancer: Making Sense of Diagnosis, Treatment, and Options . Sebastopol, CA: O'Reilly & Associates, 2001.

Pass, H., M. D., D. Johnson, M. D., James B. Mitchell, PhD., et al., eds. Lung Cancer: Principles and Practice , 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2000.

Tierney, Lawrence M., Stephen J. McPhee, and Maxine A. Papadakis, eds. Current Medical Diagnosis & Treatment 2003 , 42nd ed. New York, NY: McGraw-Hill/Appleton & Lange, 2002.

periodicals

Crystal, Ronald G. "Research Opportunities and Advances in Lung Disease." Journal of the American Medical Association 285 (2001): 612-618.

Grann, Victor R., and Alfred I. Neugut. "Lung Cancer Screening at Any Price?" Journal of the American Medical Association 289 (2003): 357-358.

Mahadevia, Parthiv J., Lee A. Fleisher, Kevin D. Frick, et al. "Lung Cancer Screening with Helical Computed Tomography in Older Adult Smokers: A Decision and Cost-Effectiveness Analysis." Journal of the American Medical Association 289 (2003): 313-322.

Pope III, C. Arden, Richard T. Burnett, Michael J. Thun, et al. "Lung Cancer, Cardiopulmonary Mortality, and Long-Term Exposure to Fine Particulate Air pollution." Journal of the American Medical Association 287 (2002): 1132-1141.

organizations

American Cancer Society. 1599 Clifton Road, N.E., Atlanta, GA 30329-4251. (800) 227-2345. http://www.cancer.org .

American Lung Association, National Office. 1740 Broadway, New York, NY 10019. (800) LUNG-USA. http://www.lungusa.org .

National Cancer Institute (NCI), Building 31, Room 10A03, 31 Center Drive, Bethesda, MD 20892-2580. Phone: (800) 4-CANCER. (301) 435-3848. http://www.nci.nih.gov .

National Comprehensive Cancer Network. 50 Huntingdon Pike, Suite 200, Rockledge, PA 19046. (215) 728-4788. Fax: (215) 728-3877. http://www.nccn.org/ .

National Heart, Lung and Blood Institute (NHLBI). 6701 Rockledge Drive, P.O. Box 30105, Bethesda, MD 20824-0105. (301) 592-8573. http://www.nhlhi.nih.gov/ .

other

Aetna InteliHealth Inc. Lung Cancer . [cited May 17, 2003]. http://www.intelihealth.com. .

American Cancer Society (ACS). Cancer Reference Information [cited May 17, 2003]. http://www3.cancer.org/cancerinfo .

Michael Zuck, Ph.D.
Crystal H. Kaczkowski, M.Sc.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Lobectomies are performed in a hospital by a thoracic surgeon, who is a physician who specializes in chest, heart, and lung surgery. Thoracic surgeons may further specialize in one area, such as heart surgery or lung surgery. They are board-certified through the Board of Thoracic Surgery, which is recognized by the American Board of Medical Specialties. A doctor becomes board certified by completing training in a specialty area and passing a rigorous examination.

QUESTIONS TO ASK THE DOCTOR

• What benefits can I expect from a lobectomy?
• What are the risks of this operation?
• What are the normal results?
• How long will my recovery take?
• Are there any alternatives to this surgery?