Radiotherapy or chemoradiotherapy given with the intention of cure sometimes leaves disease behind, or the cancer returns in the same place. Surgery is then sometimes possible. It is called salvage surgery. It is a difficult operation, offered to a narrow group of patients, and for some of them it is the remaining route to cure. Dr Lawrence Okiror performs robotic navigational bronchoscopy to establish what the new area actually is, and carries out the surgery that follows. Second opinions at London Bridge Hospital and The Lister Chelsea within 2–3 working days. Self-referrals welcome.
Last reviewed: October 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
Whether an operation is possible depends on this particular chest: how much radiotherapy it received, where, how long ago, and what the tissue has become since. Two people with the same cancer in the same place can get opposite answers.
For that reason it cannot be settled from a clinic letter or a scan report, and the answer given at the time of the original treatment may not hold now. Request a second opinion within 2–3 days →
Chemoradiotherapy given with the intention of cure works for many people. When it does not fully work, the disease very often reappears where it started rather than elsewhere. In that situation an operation may still achieve something, because there is one place to deal with.
Historically this was rarely attempted. Operating through an irradiated chest was regarded as too hazardous, and the assumption after failed radical treatment was that the disease must be beyond local control. Both views have changed: surgical technique and perioperative care have improved, and modern imaging can establish with reasonable confidence whether disease really is confined to one place.
It remains an uncommon operation performed on carefully chosen patients. It is not straightforward, and it suits a small number of people.
Patients choosing between radiotherapy and surgery at diagnosis are often told that choosing radiotherapy closes the door on an operation. The operation afterwards is more difficult, because radiotherapy leaves scarring, and it suits a narrower group of people. It is still possible where the disease is confined to the chest, all of it looks removable, and you are fit enough for the operation.
Each of these is assessed afresh at the time, with restaging scans, a sample where one can be taken, and a current fitness assessment. If you have been told surgery is not possible for this or another reason, the reasons given and which of them can change are set out on the page told surgery is not an option →
The two are easily confused, and the difference in difficulty is substantial. Where chemotherapy and immunotherapy are given before a planned operation, the tissue is largely normal to work through and the timing is chosen for surgical convenience. More on planned surgery after chemoimmunotherapy →
Salvage surgery has none of those advantages. The chest has received a radical dose of radiotherapy, the timing is dictated by when the problem was discovered, and the tumour may now involve structures it did not originally touch.
One planned operation does follow radiotherapy by design. For a Pancoast tumour at the top of the lung, chemotherapy with radiotherapy is given first and the operation follows three to five weeks later as part of the original plan. That is planned trimodality treatment, with the radiotherapy dose and the timing chosen for the operation, and it is not salvage surgery.
The assessment decides whether an operation is offered. Three things are established: that this is one problem and not many, that all of it could realistically be removed, and that you could withstand the operation and recover from it. A weakness in any one of the three usually settles the matter.
Time since radiotherapy has more influence than people expect. Cancer that reappears very soon after treatment tends to behave more aggressively; a longer interval before anything reappears is a favourable sign, and published series consistently find it among the features associated with better outcomes.
A lung operation normally proceeds by separating structures along planes that exist naturally between them. Radiotherapy removes those planes. Tissue that should come apart has to be divided, and the structures a surgeon is trying to protect are less clearly defined and more easily injured.
Healing is the second problem, and the more serious one. Irradiated tissue heals less reliably, and where an airway has been closed, a closure that fails is a major complication. Surgeons operating in these circumstances often reinforce the closure with healthy tissue brought in from outside the irradiated field.
The practical consequence is that these operations are more often done through an open incision than by keyhole. This is a judgement about safety: where the anatomy is unpredictable and control of a major blood vessel may be needed quickly, direct access is safer.
The imaging answers whether this is one problem. The fitness testing answers whether you could withstand the operation. The radiotherapy records answer a question specific to this situation: how much treatment the tissue has already absorbed, and therefore what the surgeon will be working through.
That last item is often left behind when a patient moves between hospitals; ask for it to be sent with your scans. More on fitness for lung surgery →
Robotic navigational bronchoscopy is the most accurate method currently available for sampling small and deeply placed areas within the lung. It is not yet widely available: the equipment is expensive, the training specific, and most UK units do not offer it. A three-dimensional map is built from your CT scan and a fine steerable instrument is guided along the airways to the target. You are asleep, there is no cut in the chest wall, and most people go home the same day.
In this setting it can establish that an area is not cancer, and spare someone a major operation they did not need. Dr Okiror performs it himself and performs any operation that follows, which means the person who took the sample is the person who discusses it in the multidisciplinary meeting and carries out the treatment. More on robotic navigational bronchoscopy →
That comparison shapes the whole assessment. The question is whether an operation can realistically achieve complete removal. An operation that leaves cancer behind carries all of the risk and, on those figures, little of the benefit.
It also explains why the answer is often no. Where complete removal looks unlikely, the operation is not recommended.
A proportion of people assessed for salvage surgery are advised against it, and that advice is one of the purposes of the assessment.
Equally, some people are told locally that nothing surgical can be done, when the question has not been asked with full restaging and a tissue diagnosis. The two situations are different, and a second opinion tells them apart.
These figures are given because the decision cannot be made properly without them. This is not a routine operation.
Individual risk is not the published average. It depends on what is being removed, how much radiotherapy was given and where, how well you breathe, and your general condition. Part of the consultation is converting these general figures into an estimate for you specifically,, and discussing it with you before the consent form.
One risk deserves separate mention because it is specific to this operation. The nerve that drives the diaphragm runs close to the areas often involved, and in a scarred field it can be difficult to preserve. Where it is injured, the diaphragm on that side stops working and rises, which worsens breathlessness. That can be addressed by tightening the diaphragm during the same operation, and where the risk is anticipated it is discussed in advance. More on diaphragm surgery →
Radiotherapy to the lung reduces its function in the treated area, sometimes considerably, and a breathing test done before treatment does not describe the person sitting in the clinic now. The assessment has to be repeated.
Fitness can change in both directions. It declines with treatment, and it also recovers: someone judged unfit for surgery during a difficult course of chemotherapy may be a different person a year or two later, particularly where the reason for that judgement was a side effect that has since resolved. A decision about operability taken at a hard moment does not automatically hold indefinitely, and it is reasonable to ask whether it has been revisited. More on borderline lung function →
There is a particular difficulty in this group. You have already been through a long and demanding course of treatment, probably with the expectation that it would be the end of it, and you are now being asked to do something harder. People arrive at this operation tired in a way that first-time surgical patients are not.
This is discussed openly before surgery. It affects how the recovery is supported, what help is arranged at home, and how the timing is set. More on recovery after lung surgery →
Patients are rarely warned about this, and it is one of the hardest parts of the whole experience. After a difficult operation, you enter a period of surveillance in which the scans are often ambiguous. A follow-up scan describes increased soft tissue at the operated site. A PET scan is arranged and shows uptake that could be inflammation, infection, or cancer. A camera test is then done to settle it, and shows scarring from the radiotherapy. Months pass in that loop.
Your scans will be difficult to read for a long time. Scar is usually told apart from cancer by taking a sample rather than by further imaging, and an uncertain scan in this setting is far more often nothing than something.
Repeated scans in a treated chest will frequently show something. Most of it is not cancer.
The useful pattern is change over time across several scans. Where a finding cannot be resolved by watching it, it is sampled, often through the airways rather than by another operation.
Thymoma is the clearest example. It can come back locally, sometimes long after the original treatment, and it tends to return in the chest rather than elsewhere. That pattern is the one in which removing it can help. Where the area has already received a radical dose of radiotherapy, further radiotherapy at that dose is generally not possible, and surgery becomes the remaining option.
These operations are assessed in the same way: is the disease confined, could all of it be removed, and could this person withstand the operation. More on thymoma surgery → and mediastinal surgery →
| Situation | Suggested action |
|---|---|
| Persistent or recurrent tumour in the irradiated field, PET and brain imaging clear | Surgical opinion before palliative intent is settled; complete resection is the deciding variable |
| Indeterminate PET uptake at a previously treated site | Tissue rather than serial imaging where the area is safely reachable |
| Further radiotherapy precluded by prior radical dose | Surgery may be the remaining radical option, including for chest wall and mediastinal disease |
| Patient judged unfit during chemoradiotherapy | Reassess; fitness recovers, and the earlier judgement may not hold now |
| Recurrent thymoma or anterior mediastinal tumour in a treated field | Same assessment framework; not confined to lung cancer |
| Radiotherapy records unavailable | Obtain dose, volume and dates before assessment; they determine what the surgeon will encounter |
Referrals and self-referrals are seen at London Bridge Hospital and The Lister Chelsea, usually within 2–3 working days. Imaging, radiotherapy records and oncology correspondence can be reviewed in advance. Clinic letters go to GPs electronically within two working days, and within three working hours where urgent.
If radiotherapy or chemoradiotherapy has not fully worked and surgery has been ruled out without full restaging or a tissue diagnosis, an independent review is reasonable. Most patients are seen within 2–3 working days.
Book a Consultation →Or call Jo Mitchelson:
020 7952 2882
Salvage surgery is demanding and suits a narrow group. Establishing whether you are in that group takes full restaging, a tissue diagnosis where one can be obtained, and a current fitness assessment. Second opinions at London Bridge Hospital and The Lister Chelsea within 2–3 working days. Self-referrals welcome.
Jo Mitchelson, PA · 020 7952 2882 · pa@lungsurgeon.co.uk
St Thomas’ Hospital #1 UK · Guy’s Hospital #2 UK · London Bridge Hospital #10 UK · Newsweek World’s Best Hospitals 2026
Planned surgery after chemoradiotherapy for a tumour at the top of the lung, which is the standard sequence for that tumour and is not salvage surgery
Mediastinoscopy & Lymph Node BiopsyWhole lymph nodes removed as a day case when EBUS has not answered the question: lymphoma, molecular testing, staging
Sleeve ResectionLung-sparing reconstruction of the airway for central tumours, the alternative to removing a whole lung
PneumonectomyWhen removing the whole lung is the correct operation: indications, fitness assessment, and life with one lung
Cancer Invading the Chest WallChest wall involvement by lung cancer: what decides operability, and how the defect is reconstructed.
Lung Cancer Returning After SurgeryRecurrence after a previous operation, and when a further operation is possible.
Planned Surgery After ChemoimmunotherapyA different situation, where drug treatment and surgery are planned together from the start.
Robotic Navigational BronchoscopyTelling scar from cancer in a treated chest, through the airways.
Locally Advanced Lung CancerStage 3 (stage III) disease and the treatments given before salvage is ever considered.
Thymoma SurgeryWhere the same salvage reasoning applies outside lung cancer.
Diaphragm SurgeryTightening the diaphragm where the nerve is injured or not working.
Fitness for Lung SurgeryBreathlessness, operative risk and cardiac risk, reassessed after treatment.
Told Surgery Is Not an Option?The reasons people are given that surgery is not possible, and which of them can change.
Lung Cancer SurgeryPrivate robotic and keyhole lung cancer surgery at every stage, and how quickly it can happen.
Lung Cancer Second OpinionIndependent review of imaging, staging and treatment plan within 2–3 working days.
Tumour in the Airway: Can It Be Removed?Clearing an airway blocked by tumour after radiotherapy, and when airway resection is still possible