Stage 4 lung cancer with a single site of spread:
can the lung tumour still be removed?

For most patients with stage 4 lung cancer it is right, because the cancer is in several places and an operation on one of them would leave the rest. For a small group, the answer depends on whether the spread is in one place. Where the cancer has spread to a single site, and that site has been treated or can be treated, the lung tumour may be removed or irradiated as part of radical treatment, which means treatment given to every known site with the intention of cure. This is offered to selected patients at Guy’s and St Thomas’ and privately at London Bridge Hospital, and every case is decided at the multidisciplinary meeting.

The group is defined by the number of sites, by what the sites are, and by whether the lung tumour itself can be removed completely. A single deposit in the brain, the adrenal gland or a bone, with a lung tumour that has not spread to the lymph nodes in the middle of the chest, is the situation in which surgery is most often considered. Several deposits, or involved nodes in the middle of the chest, weigh against it, and in those cases drug treatment with or without radiotherapy is the plan.

If the only reason you were given for not considering an operation was the stage, the question to ask is whether the case has been considered as oligometastatic disease. If you were told surgery is not an option for a different reason, the told surgery is not an option page sets out the other reasons and which of them can change.

Patients are sometimes given stage 4 on a single area of activity on a PET scan, in the adrenal gland, the liver or a bone, that has not been biopsied and has had no dedicated MRI. Some of these areas are benign. The adrenal gland in particular is a common site for a growth that has nothing to do with the cancer, and a healing injury in a bone or an area of inflammation can take up the tracer in the same way as a deposit. A single possible site of spread is the difference between a cancer treated with the intention of cure and one treated to control it, which is why the multidisciplinary team at Guy’s and St Thomas’ asks for a single site to be biopsied wherever possible.

Where a biopsy is not practical, a dedicated scan often settles it. An MRI of the adrenal gland or the liver characterises the tissue in a way a PET scan cannot. An MRI of the brain is more sensitive than a CT and is done as part of staging in any patient being considered for treatment with the intention of cure. Where the scan leaves doubt, the area is sampled by a needle under image guidance.

The same question applies to the lymph nodes in the middle of the chest. Nodes that look involved on a PET scan are sometimes not, and in oligometastatic disease the state of those nodes is one of the main things that decides whether the lung tumour is operated on. They are sampled by EBUS, or by cervical mediastinoscopy where EBUS is not possible or not tolerated.

If you were given stage 4 on one scan finding and no sample was taken, that is a question for a second opinion. The sequence of staging tests and what each one answers is on the tests and staging page.

Oligometastatic means a small number of sites of spread, often one. The staging system records where the cancer has been found, so a cancer with one deposit outside the chest is stage 4 and stays stage 4 after the deposit has been treated. What changes is the intention of the treatment. Stage 4 in several places is treated to control the disease for as long as possible. Oligometastatic disease in a fit patient can be treated with the intention of cure, by treating the deposit and the lung tumour and giving drug treatment alongside.

Patients describe this as “still classed as stage 4, but technically no spread any more” once the deposit has been removed. That is an accurate description. The remaining disease is the lung tumour, and the question becomes the same one asked in stage 1 to 3: can it be removed completely, and is the patient fit for the operation.

The word is used for lung cancer that has spread to one or a few sites. The reverse situation, a cancer from the bowel, the kidney or the breast that has spread to the lung, is also treated surgically in selected patients and is covered on the pulmonary metastasectomy page.

A single brain deposit is the most frequent way this situation arises. The deposit is removed by a neurosurgeon or treated with stereotactic radiosurgery, and the lung tumour is then the remaining known disease. In a fit patient whose lymph nodes in the middle of the chest are clear, the lung tumour is removed by lobectomy with removal of the lymph nodes, or treated with radiotherapy, with chemotherapy and immunotherapy given alongside. The sequence, and whether the lung is treated before or after the drug treatment, is decided at the multidisciplinary meeting.

A single adrenal deposit is managed in the same way, with the adrenal deposit removed or treated with radiotherapy, and the lung tumour treated separately. A single bone deposit is usually treated with radiotherapy rather than surgery. In each case the lung operation is the standard operation for the tumour, most often a robotic lobectomy, and the recovery is the same as for any patient having that operation.

The operation is described on the lung cancer surgery page.

Both are used, and the choice is made on the tumour, the fitness assessment and the patient’s own view. Stereotactic radiotherapy suits a small tumour at the edge of the lung and a patient who is not fit for an operation. Surgery suits a larger or more central tumour, a tumour close to structures that limit the radiotherapy dose, and a patient who is fit for the operation. Surgery also removes the lymph nodes, which gives the final stage, and provides the specimen on which the full set of biomarkers is tested.

Patients ask whether radiotherapy can be just as effective as surgery. For the lung tumour in oligometastatic disease, both are accepted local treatments, and neither is offered as better in every case. The multidisciplinary meeting includes a clinical oncologist who delivers the radiotherapy and a surgeon who performs the operation, and the recommendation comes from both.

Where the tumour is removed, the operation is a robotic or keyhole lobectomy in most patients, with the same hospital stay and recovery as for an early-stage cancer. Fitness for it is assessed in the same way, against the operation planned, and is set out on the fitness for lung surgery page.

The operation does not replace the drug treatment. In oligometastatic disease, local treatment to the lung is added to drug treatment that is working, and the drug treatment continues afterwards. The reason for adding it is that the lung tumour is the site most likely to grow again when the drugs stop working, and removing or irradiating it while the disease is controlled is intended to prevent that. A period of drug treatment first also shows whether new sites appear, which is the best available evidence that the disease is confined to the places already known.

Patients ask whether the cancer is still in the bloodstream even when the scans are clear. No scan can show single cells, and that is true at every stage. The drug treatment is given for the cells the scans cannot see; the operation or the radiotherapy is given for the sites they can.

The timing of the operation, after how many cycles and on which restaging scan, is agreed between the oncologist and the surgeon at the multidisciplinary meeting. The pathway from the first scan to recovery is set out on surgery after chemotherapy and immunotherapy.

A PET-CT of the whole body, an MRI of the brain, a biopsy or a dedicated scan of the single site of spread, sampling of the lymph nodes in the middle of the chest where there is any concern about them, and the biomarker tests on the tumour tissue. Fitness for the operation is assessed with lung function tests, a cardiopulmonary exercise test where needed, and a scan that measures how much work each part of the lung is doing. Each test answers a different question, and the decision is made only when all of them have been answered.

What each test shows, and what it cannot show, is on the tests and staging page.

The multidisciplinary meeting. It brings together the thoracic surgeon, the medical oncologist who gives the drug treatment, the clinical oncologist who gives the radiotherapy, the thoracic radiologist, the pathologist, a respiratory physician and a specialist nurse. The scans, the biopsy results, the biomarker results and the fitness assessment are reviewed together, and the recommendation is the team’s. No decision about surgery in stage 4 disease is made by one doctor.

The surgeon’s contribution is two questions: can the lung tumour be removed completely, and is the patient fit for the operation that would do it. The oncologists’ contribution is whether the disease is controlled on drug treatment and whether local treatment is likely to add to it. The radiologist’s is whether the single site is confirmed.

Private patients are discussed at the London Bridge Hospital chest multidisciplinary meeting, which Dr Okiror attends. NHS patients are discussed at Guy’s and St Thomas’. A patient seen for a second opinion whose case has not been considered in this way is presented to the meeting before any surgical decision is made.

Yes. Most patients in this situation have started chemotherapy and immunotherapy under an NHS oncologist, or had the brain or adrenal deposit treated at another hospital, before the question of surgery to the lung is raised. The records, scans and biopsy slides are requested from the hospitals that hold them. The drug treatment stays with the oncologist who is giving it, and the operation is planned around it.

The operation can be done privately at London Bridge Hospital or The Lister Hospital Chelsea, with the patient returning to the NHS team for the treatment that follows, or the recommendation can be taken back to the NHS team to carry out. Surgery is usually within a week of completing investigations. Patients already under an NHS team can be transferred; the HCA Medical Concierge team arranges the bed and the insurer authorisation.

Contact Jo Mitchelson on 020 7952 2882 or pa@lungsurgeon.co.uk. Self-referrals welcome. Tell us which hospital performed the scans, and send the staging letter, the scan reports, the letter with the multidisciplinary team’s decision and the biopsy result. Dr Okiror requests the images and reviews them himself before the consultation. Video within 24 hours, in person within 2–3 days at London Bridge Hospital, The Lister Hospital Chelsea, Canary Wharf or the City of London. A written report follows within 48–72 hours.

Out-of-area patients are seen by video first. Several people can join the same consultation from different places, so a parent in one city and an adult child in another, or in another country, can be in the consultation together. Patients travelling from outside the UK can read how the international pathway works.

The consultation fee is £250–£350. Most insurers, including AXA Health, Bupa, Aviva, Vitality, WPA and Cigna, fund a second opinion consultation and usually settle it in full, less any excess written into the policy. If an operation follows, guide prices are on the fees page; hospital charges are the largest part of every total, the hospital issues a written fixed quote before treatment, and insurers usually settle the hospital, surgeon and anaesthetist fees in full, less any policy excess. A second opinion does not commit you to private treatment. How the review works in detail is on the lung cancer second opinion page.