The Evolution of Lung Cancer Surgery
Nov 17, 2021 Nicole Levine
Dr. Harmik Soukiasian came to the United States at age 7, and though he was still learning to speak English fluently, he quickly decided he wanted to be a doctor.
His grandparents both needed surgeries when he was a child, and that’s when he first knew he wanted to be a surgeon. During his studies, the collaboration among teams treating conditions affecting the lungs and heart fascinated him. He did his training in cardiothoracic surgery at UCLA followed by an advanced fellowship at Cedars-Sinai, where today he’s the division chief.
Since he completed his fellowship here in 2008, Dr. Soukiasian has witnessed firsthand the massive shifts in how lung cancer is treated—and has been a pioneer in innovative surgical treatments for lung cancer.
Dr. Soukiasian shared the biggest changes in treating what remains the No. 1 cause of cancer deaths in the United States, myths about the disease and what drew him to the field.
"Seeing these changes that have helped to cure so many people, helping to prolong their lives with their loved ones, is why I’m so glad to be a cardiothoracic surgeon."
Lung cancer doesn’t only affect smokers
If he could use his scalpel to surgically remove just one lung cancer myth, Dr. Soukiasian would cut out the idea that lung cancer only affects smokers.
“It’s a staggering number of non-smokers who get this disease,” he says. “We don’t know the exact genetic reasons behind non-smokers developing lung cancer. It could be environmental factors or genetic factors. But the point is, it can affect many different people.”
The Centers for Disease Control and Prevention estimates up to 20% of lung cancers occur in people who never smoked or smoked fewer than 100 cigarettes in their lifetime.
Cancer can be addressed by removing only part of the lung in many cases
The first lung cancer surgeries 50 years ago required large incisions, and sometimes removing a rib, to get to the affected lung—and generally the entire lung was removed.
In the 2000s, video-assisted thoracic surgery revolutionized lung cancer surgery. Using three- or four-inch incisions and a tiny camera, surgeons could operate on the lungs. Cedars-Sinai physicians helped redefine lung cancer surgery, publishing multiple papers showing that removing a lobe of the lung affected by a tumor was as safe and effective for addressing cancer as removing the entire lung. Dr. Soukiasian worked on some of those trials.
Now, new techniques allow for even smaller incisions, less lung tissue removed and faster healing times for patients. Lobes of the lung can be divided into “branches,” and in some cases, these smaller segments of the lung can be removed. This can safely remove the cancer and help protect the patient’s lung function and improve healing time.
Robots assist in better surgical options for lung cancer patients
The introduction of a new version of the Da Vinci robot in 2017 changed lung cancer surgery again. Previous versions had been used, but the latest robot is better suited for chest surgeries. Now, Dr. Soukiasian says most of the incisions he makes are the size of a pencil tip to insert robotic instruments.
“I’m able to do an entire operation looking at a three-dimensional image,” he says. “Whatever I do is imitated by the robot. It’s like having four arms instead of two.”
These changes open options to patients who may not have been able to undergo surgery in the past.
“The innovations have taken it to a different level in our ability to deliver advanced surgical options for people who may not have been candidates in the past,” Dr. Soukiasian says.
The ability to make three-dimensional models of the lungs using advanced imaging is another amazing advance that has improved surgeries.
These models of a patient’s lungs help Dr. Soukiasian and his colleagues perform a procedure known as a navigational bronchoscopy, allowing them to find their way through the pulmonary labyrinth directly to the tumor. They program a robot fitted with a bronchoscope—a flexible tube with a camera that goes down the airway—and then they can sample the tumor to perform a biopsy.
Technology and teamwork can allow lung cancer to be diagnosed and removed in the same day
Dr. Soukiasian says working as a team with oncologists, pathologists and pulmonologists as a cardiothoracic surgeon is one of the most satisfying and meaningful aspects of his job.
That teamwork and the advances in technology have combined in a powerful way in just the last year. Using the 3D models and new robotic technology available through the navigational bronchoscopy, Dr. Soukiasian and his team can diagnose and remove lung cancer in one surgical session.
Dr. Soukiasian takes the sample of the tumor and hands it off to pathologists who determine if it is lung cancer or not. If it is cancerous, in some cases, he can remove the cancer—sparing the patient going under anesthesia again, monitoring CT scans and a long wait between diagnosis and surgery.
“It’s very immediate and very rewarding,” he says. “Someone comes in with a lung mass, you make the diagnosis, take the lung cancer out and they go home.”
It’s an excellent marriage of precision medicine to diagnose the tumor, identify if it has any mutations that will respond to the growing number of targeted therapies available, surgical advances and the know-how of a team of lung cancer care experts.
The American Cancer Society, Centers for Disease Control and Prevention and the National Cancer Institute reported in 2021 an overall decline in the number of cancer deaths—good news that is attributed to declines in deaths from lung cancer and melanoma. The advances in treating these diseases as well as preventive efforts are saving lives, experts say.
“It’s an amazing time to be helping people who have lung cancer,” Dr. Soukiasian says. “Seeing these changes that have helped to cure so many people, helping to prolong their lives with their loved ones, is why I’m so glad to be a cardiothoracic surgeon.”