Metastatic Lung Tumor Resection and Lung Nodule Resection

Metastatic (met-uh-STAT-ick) tumor resection and lung nodule (NOD-yool) resection are surgeries performed to remove abnormal lung tissue. These procedures can be used to treat children with cancerous tumors that form in the lungs or benign (noncancerous) masses that develop from infections or illnesses.

“Resection” means to cut. In a lung resection surgery, the surgeon may cut and remove small pieces of lung tissue, full lung lobes, or an entire lung.

If your child’s doctor is talking to you about lung tumor removal surgery, it may be an appropriate course of action to improve your child’s quality of life.

What are the types of resection surgeries?

Doctors use different types of lung resection procedures depending on the type of tumor or mass your child has.

Pulmonary metastatic tumor resection

Pulmonary (pool-mo-NARE-ee) metastatic (met-uh-STAT-ick) tumor resection involves the removal of metastatic tumors in the lung tissue. Metastatic lung tumors are cancerous tumors that have spread to the lungs from cancer that started somewhere else in the body.

For children, most lung tumors form from cancer that has spread from:

• Bone cancer (osteosarcoma).
• Kidney cancer (Wilms tumor).
• Muscle cancer (rhabdomyosarcoma).
• Soft tissue cancer (Ewing sarcoma).

When tumors from the original cancer have spread to the lungs, they may need to be removed to relieve symptoms and prolong life.

Pulmonary nodule resection

Like lung tumor removal surgery, pulmonary nodule (NOD-yool) resection surgery does not always come with a cancer diagnosis. Nodules are small, round masses that can develop in the lungs. This procedure is done to help diagnose or understand a lung nodule.

Lung nodules could be from:

• Benign (be-NINE) tumors, which means they are noncancerous.
• Infection.
• Lung cancer that started in the lungs.
• Metastatic (met-uh-STAT-ick) cancer that has not yet been diagnosed.

What are the methods used for lung resections?

Doctors will decide on and use the best method for your child’s symptoms, diagnosis, and overall health.

One of these methods of procedure may be the best option:

• Wedge resection — The surgeon makes wedge-shaped cuts to remove a section of lung tissue. This surgical option is common when other, more invasive or extensive treatments aren’t necessary, or the cancer is in its earliest stages. It removes as small an amount of lung tissue as possible to retain the most lung function.
• Lobectomy (low-BECK-toe-mee) — Removal of an entire lung lobe. This procedure is often chosen for lung cancer that is only affecting one lobe.
• Pneumonectomy (new-moe-NECK-toe-mee) — Removal of an entire lung. Depending on the size, number, and location of the tumor(s), this option may be best. Some children may receive a lung transplant, while others can live with just one lung.
• Sleeve resection — A sleeve is cut from the lung and sewn back together. If tumors are in the main airway of a lung, this technique can be used to remove a section of the lung and sew the two ends back together.

Each of our right lungs has three lobes, and each of our left lungs has two. Either lung can exist without some of its lobes if the remaining lung tissue is healthy.

Children can lead full, healthy lives having only one lung or missing part of a lung. In the very rare case that both of a child’s lungs are severely damaged, lung transplant surgery may be an option.

All lung resection procedures aim to remove part or all of a lung tumor with the least amount of disturbance to nearby tissues and the best chance of removing all the disease.

Depending on your child’s specific condition, the surgeon may use:

• Minimally invasive surgery or video-assisted thoracic (thor-ACK-sick) surgery (VATS) — Also called thoracoscopy (thor-uh-KOSS-co-pee), this minimally invasive technique involves a thoracoscope (thor-ACK-uh-scope), a lighted tube with a camera at the end, that is inserted into the chest. Other small incisions (in-SIZH-yunz) are made for small, narrow instruments to work with the thoracoscope to remove all diseased lung tissue through the tiny incisions. This method reduces surgery complications, which also shortens hospital recovery time.
• Open surgery, also called thoracotomy (thor-uh-COT-uh-mee) — A more traditional surgical approach in which the surgeon makes a large incision in the chest and opens the body to remove the infected lung tissue. Open surgery is known for longer recovery times and more pain and discomfort from larger incisions and the movement of organs and tissues during surgery. However, it may provide better surgical access to tumors and vital chest structures, so your child’s doctor may choose this approach.

What happens during lung resection surgery?

Before surgery

You can expect your child’s doctor to run some preoperative tests to determine the size, number, location, stage, and characteristics of the tumor or nodule.

These tests could include:

• Blood tests.
• Biopsy of lung tissue.
• CT scan.
• PET scans.
• Pulmonary function tests.

Your child’s care team will discuss the best course of treatment based on the imaging results. These options may include different procedure methods and surgery types.

You can expect your child’s doctor to explain the procedure steps, risks, and expectations after surgery so that you and your child feel prepared and confident for surgery.

During surgery

Your child will be given general anesthesia and remain asleep for the duration of the procedure. The surgeon will then begin the process of removing the infected lung tissue by the decided method and procedure type.

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.

One business day before your child’s surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age.

The following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.

For infants under 12 months

• Up to six hours before the scheduled arrival time, formula-fed babies may be given formula.
• Up to four hours before the scheduled arrival time, breastfed babies may nurse.

For all children

• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before the scheduled arrival time, give them nothing to eat or drink.

Once your child has been registered for the surgery, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery. They will ask questions about your child’s health and about when your child last ate.

Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

• As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
• If your child is very scared or upset, the doctor may give a special medication to help them relax. This medication is flavored and takes effect in about 10 to 15 minutes.
• If you wish, you may be allowed to go with your child to the room where the surgery will be done and stay while the sleep medication is given.
• Younger children will get their sleep medication through a “space mask” that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.
• Older children may choose between getting their medication through a mask or directly into a vein through an intravenous (IV) line.
• When your child has fallen asleep, you will be taken to the waiting room. If it has not already been done, an IV will be started so that medication can be given to keep your child sleeping throughout the surgery.

While your child is asleep, their heart rate, blood pressure, temperature, and blood oxygen level will be checked continuously. Your child will have a breathing tube placed while they are asleep. Your child might have a sore throat after the surgery.

To keep your child asleep during the surgery, they might be given anesthetic medication by mask, through the IV tube, or both. When the surgery is over, the medications will be stopped, and your child will begin to wake up.

After surgery, your child will be moved to the recovery room to allow the anesthetic to wear off. You will be called so that you can be there as they wake up.

• Children coming out of anesthesia react in different ways. Your child might cry, be fussy or confused, feel sick to their stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off.
• While your child is in recovery, your surgeon will talk to you about the surgery. This is a good time to ask questions about pain medications, diet, and activity.
• When your child is awake enough, they might be given a Popsicle® or “slushy” to drink in the recovery room.
• Once the anesthesiologist sees that your child is recovering and their pain is controlled, they will be moved to their hospital room. This usually takes about an hour, but every child is different, so times may vary.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

• You are encouraged to talk to your child or hold their hand before the surgery, while sleep medication is given, and while in recovery.
• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold before and after the surgery.

During the surgery, your child will be given numbing medication directly into the incision to relieve discomfort after the surgery. Your child will continue to receive pain medication while they are in the hospital.

Before you go home, your doctor will prescribe pain medication for your child.

After your child is discharged and goes home, they should avoid strenuous activity for the next two to four weeks. Your child may feel tired, uncomfortable, or in pain when recovering from surgery. The overall recovery process may take up to a few months.

Your child will have a follow-up visit with the surgeon between four and six weeks after the surgery.

Activity

Following the surgery, your child's activity needs to be somewhat restricted.

• Your child's surgeon will determine when they can resume normal activities.
• Your child may return to school when they feel up to it.
• Participation in contact sports and gym class is not permitted until cleared by the surgical team (typically four to six weeks after surgery).
• Swimming is permitted one to two weeks after surgery.
• Walking and stair climbing are encouraged.

Bathing

Your child may take a shower one to three days after the surgery. Baths are allowed five to seven days after surgery.

Monitoring

Your child’s care team will talk with you about follow-up appointments and monitoring. This may include imaging every few months to actively keep tabs on the lungs to ensure the surgery was successful. These monitoring imaging tests can also catch any recurrence at an earlier stage.

If your child has a fever higher than 101.5 F, bleeding, or foul-smelling drainage from the area around the incisions, call your surgeon right away.

Also, call the doctor if your child has:

• Increased or unexplained pain.
• Increased swelling or redness at the incision site.
• Increased tenderness near the incision.
• Nausea, vomiting, diarrhea, or constipation that is not improving.

Children’s takes every precaution to make sure your child is safe during surgery. There can be complications with any surgery, and lung resections are no different.

Complications from lung tumor removal surgery include:

• Arrhythmia — Irregular heartbeat.
• Blood clots in the lungs or legs.
• Bronchopleural fistula — An abnormal passageway formed in the lung.
• Infection.
• Prolonged air leak.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before the surgery. After the surgery, you may call the Division of Pediatric General and Thoracic Surgery at UPMC Children’s and ask to speak with your child’s surgeon or speak with them during the follow-up visit, if needed.

If your child has any special needs or health issues you feel the doctor needs to know about, please call the Division of Pediatric General and Thoracic Surgery at UPMC Children's Hospital of Pittsburgh before the follow-up visit and ask to speak with a nurse. It is important to notify us in advance about any special needs your child might have.

At UPMC Children’s Hospital of Pittsburgh, every child who needs lung resection surgery receives an individualized treatment plan and family-centered care.

• Surgeons at UPMC Children’s have trained at the nation’s leading pediatric surgery treatment centers and are among the country’s most experienced in lung resection surgeries.
• In addition, surgeons at UPMC Children’s are pioneering the use of Intraoperative Molecular Imaging to help guide the most complete and safest resection of the tumor as possible.