Cardiothoracic Surgery · Supplementary · from Cardiothoracic Surgery

Case 3: Lung Cancer Lobectomy

Patient Presentation

Demographics: 64-year-old female retired schoolteacher

Chief Complaint: "They found a spot on my lung during a screening CT — my doctor says it might be cancer."

History of Present Illness: Mrs. P.G. underwent a low-dose CT chest as part of lung cancer screening (she meets USPSTF criteria: age 50-80, 30+ pack-year smoking history, quit within past 15 years). The scan identified a 2.8 cm spiculated nodule in the right upper lobe with associated ground-glass component. A PET-CT was performed showing intense FDG uptake in the nodule (SUVmax 8.4) with no mediastinal lymph node uptake and no distant metastatic disease.

A CT-guided percutaneous core needle biopsy confirmed lung adenocarcinoma. Molecular testing revealed KRAS G12C mutation, PD-L1 TPS 30%, no EGFR/ALK/ROS1 alterations. Clinical staging: cT1cN0M0, Stage IA3.

She is referred to thoracic surgery for evaluation of surgical resection. She is asymptomatic from the lung nodule — no cough, hemoptysis, dyspnea, chest pain, or weight loss. She reports good exercise tolerance, walking 2-3 miles daily with her dog without limitation.

Past Medical History:

• COPD (moderate; FEV1 68% predicted on most recent PFTs 8 months ago)
• Hypertension (well-controlled)
• Osteoporosis (vertebral compression fracture T12, 3 years ago)
• Gastroesophageal reflux disease
• Depression (well-managed)
• Former smoker: 40 pack-years (1 pack/day x 40 years, quit 4 years ago)

Medications:

• Tiotropium 18 mcg inhaled daily
• Albuterol 90 mcg PRN (uses 2-3x/week)
• Amlodipine 10 mg daily
• Alendronate 70 mg weekly
• Omeprazole 20 mg daily
• Escitalopram 10 mg daily
• Calcium 600 mg + Vitamin D 800 IU daily

Social History:

• Former smoker: 40 pack-years (quit 4 years ago); no secondhand smoke exposure currently
• No alcohol
• Widowed 6 years ago; lives alone with dog
• Active in church community and book club
• Retired elementary school teacher; volunteers at library
• Two adult daughters, supportive

Family History:

• Father: lung cancer (diagnosed age 62, died age 64 — smoker)
• Mother: COPD (died age 78)
• Sister: breast cancer (survivor, age 70)

Physical Examination

• Vital Signs: BP 132/76 mmHg, HR 72 bpm, RR 16, SpO2 95% on room air, Temp 36.7°C, BMI 23.4 kg/m², Height 162 cm, Weight 61.5 kg
• General: Well-appearing, well-nourished woman in no acute distress; appears younger than stated age
• Pulmonary: Mild bilateral end-expiratory wheeze; slightly prolonged expiratory phase; breath sounds otherwise clear; no crackles; chest wall symmetric, no palpable masses
• Cardiovascular: Regular rate and rhythm, no murmurs, no JVD
• Lymph nodes: No palpable cervical, supraclavicular, or axillary lymphadenopathy
• Extremities: No clubbing (significant — suggests absence of advanced disease); no edema
• Musculoskeletal: Mild thoracic kyphosis; no bony tenderness
• Neurological: Alert, oriented; no focal deficits; normal gait; no signs of paraneoplastic syndrome

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• Low-dose CT chest (screening): 2.8 cm spiculated solid nodule with partial ground-glass component (part-solid) in right upper lobe, posterior segment; no mediastinal or hilar lymphadenopathy; no pleural effusion; emphysematous changes bilateral upper lobes (centrilobular)
• PET-CT: Hypermetabolic right upper lobe nodule (SUVmax 8.4); no FDG-avid mediastinal or hilar lymph nodes; no distant metastatic disease; liver, adrenals, bone — no abnormal uptake
• MRI brain (with contrast): No intracranial metastases
• CT-guided biopsy pathology: Lung adenocarcinoma, acinar predominant; molecular: KRAS G12C mutation; PD-L1 TPS 30%; EGFR wild-type; ALK negative; ROS1 negative
• Pulmonary function tests (pre-operative):
• FEV1: 1.76 L (68% predicted)
• FVC: 2.82 L (85% predicted)
• FEV1/FVC: 0.62 (obstructive pattern)
• DLCO: 72% predicted
• Predicted postoperative (ppo) FEV1 after RUL lobectomy: 1.41 L (54% predicted) — using segment counting method (RUL = 3/20 segments removed from right lung contribution)
• ppo DLCO: 58% predicted
• Quantitative perfusion lung scan: Right lung perfusion 55%, left lung 45%; right upper lobe contributes 18% of total perfusion; ppo FEV1 (perfusion-based): 1.44 L (56% predicted) — adequate for lobectomy (threshold >40% predicted or >0.8 L)
• Cardiopulmonary exercise testing (CPET): VO2max 18.2 mL/kg/min (>15 mL/kg/min = acceptable for lobectomy; >20 = low risk)
• Stair climb test: 5 flights without stopping (good surgical candidacy)
• EBUS (endobronchial ultrasound) mediastinal staging: Stations 4R, 7, 10R sampled — all negative for malignancy (confirmed N0 status)

Clinical Image

Illustration showing the right upper lobe lung adenocarcinoma with staging workup summary, planned video-assisted thoracoscopic surgery (VATS) lobectomy port placement, and mediastinal lymph node station map for systematic dissection. Source: Educational illustration.

Diagnosis

Right Upper Lobe Lung Adenocarcinoma, cT1cN0M0, Stage IA3 (AJCC 8th Edition) — KRAS G12C Mutant, Surgical Candidate

Key Diagnostic Criteria:

• Tissue-confirmed lung adenocarcinoma on CT-guided biopsy
• Tumor size 2.8 cm (T1c: >2 cm to ≤3 cm)
• No lymph node involvement on PET-CT and confirmed by EBUS (N0)
• No distant metastases on PET-CT and brain MRI (M0)
• Stage IA3 per AJCC 8th edition
• Physiologically fit for lobectomy: ppo FEV1 56% predicted (>40% threshold), VO2max 18.2 mL/kg/min (>15 threshold), adequate functional capacity

Treatment Plan

1. Pre-operative optimization (1-2 weeks):

• Smoking cessation confirmation and counseling reinforcement (already quit 4 years)
• Pulmonary prehabilitation: incentive spirometry (10 repetitions/hour while awake), walking program intensification, inspiratory muscle training
• Optimize bronchodilator therapy: ensure tiotropium and albuterol PRN are continued through day of surgery
• Hold alendronate 1 week pre-op (esophageal irritation risk with positioning)
• Nutritional optimization: high-protein diet; albumin adequate at 4.2
• Anesthesia pre-operative assessment with focus on airway and lung isolation strategy

1. Surgical procedure:

• Video-Assisted Thoracoscopic Surgery (VATS) Right Upper Lobectomy with systematic mediastinal lymph node dissection
• Preferred approach: 3-port VATS or uniportal VATS (surgeon preference/experience)
• Lung isolation: double-lumen endotracheal tube for one-lung ventilation
• Complete anatomic lobectomy: individual ligation/stapling of RUL pulmonary artery branches (truncus anterior, ascending artery), RUL pulmonary vein, and RUL bronchus
• Fissure completion with endoscopic stapler
• Systematic lymph node dissection: stations 2R, 4R, 7, 8, 9, 10R (minimum 3 N2 stations sampled per guidelines)
• Single chest tube placement to apex
• Specimen extraction via utility incision; send for permanent pathology with margins

1. Intra-operative considerations:

• Protective one-lung ventilation (tidal volume 4-5 mL/kg IBW, PEEP 5 cmH2O)
• Avoid excessive fluid administration (pulmonary edema risk in remaining lung)
• Multimodal analgesia: paravertebral or intercostal nerve blocks with liposomal bupivacaine; avoid excessive opioids
• Extubation in the operating room (ERAS protocol)

1. Post-operative management:

• Enhanced Recovery After Thoracic Surgery (ERATS) protocol
• Ambulation day 0 (evening of surgery)
• Incentive spirometry every 1-2 hours while awake
• Pain management: multimodal (acetaminophen scheduled, NSAIDs, gabapentin, PCA or low-dose IV opioid for breakthrough only)
• Chest tube management: water seal (not suction) protocol; remove when output <200 mL/24 hr, no air leak, lung expanded on CXR
• VTE prophylaxis: enoxaparin 40 mg SC daily starting 6-12 hours post-op
• Anticipated discharge: post-operative day 2-4

1. Pathology and adjuvant therapy decisions:

• If final pathology confirms pT1cN0M0 (Stage IA3): observation with surveillance CT per NCCN guidelines (CT chest Q6 months x 2 years, then annually)
• If unexpected nodal upstaging (pN1 or pN2): adjuvant chemotherapy (cisplatin-based doublet x 4 cycles) ± radiation for N2 disease; consider adjuvant osimertinib trial eligibility (though EGFR wild-type, KRAS G12C targeted agents like sotorasib may have future adjuvant roles)
• If Stage IB-IIIA on final pathology: ctDNA-guided adjuvant therapy decision (IMpower010 for PD-L1+ tumors: atezolizumab adjuvant immunotherapy)
• Ongoing lung cancer screening for remaining lung tissue

1. Surveillance schedule:

• CT chest with contrast: every 6 months for years 1-2, then annually for years 3-5, then as clinically indicated
• CEA at baseline and serially if elevated (limited utility)
• Annual PFTs to monitor remaining lung function
• Continued smoking abstinence support

Key Learning Points

• Low-dose CT lung cancer screening reduces lung cancer mortality by 20% (NLST trial) and up to 24% (NELSON trial); anatomic lobectomy with systematic lymph node dissection is the standard of care for stage I-II NSCLC in physiologically fit patients
• Pre-operative physiological assessment for lobectomy requires three pillars: (1) spirometry with predicted postoperative FEV1 and DLCO (>40% predicted = adequate), (2) cardiopulmonary exercise testing with VO2max (>15 mL/kg/min = acceptable, >20 = low risk), and (3) functional assessment (stair climb test — 3+ flights correlates with acceptable risk)
• VATS lobectomy is associated with less pain, shorter hospital stay, fewer complications, better preserved pulmonary function, and equivalent oncological outcomes compared to open thoracotomy; it is the preferred approach when technically feasible
• Systematic mediastinal lymph node dissection (not just sampling) is essential for accurate staging and may provide therapeutic benefit; upstaging from cN0 to pN1/N2 occurs in 10-15% of cases, fundamentally changing adjuvant therapy decisions
• KRAS G12C mutation is the most common actionable mutation in lung adenocarcinoma (~13%); sotorasib and adagrasib are FDA-approved for advanced/metastatic disease, with adjuvant trials ongoing — molecular profiling at diagnosis informs both immediate and future treatment decisions

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