Lung Cancer Resection | Dr. Wang Qun (Thoracic Surgery) | CMCS Shanghai

About Dr. Wang Qun

Dr. Wang Qun is Chief of Thoracic Surgery at Zhongshan Hospital, Fudan University — one of China's highest-volume thoracic surgical centres and a national reference institution for minimally invasive lung cancer surgery. He is a nationally recognised leader in video-assisted thoracoscopic surgery (VATS), oesophageal surgery, and mediastinal tumour resection, with particular expertise in anatomical segmentectomy for early-stage lung cancer, simultaneous bilateral VATS for synchronous multiple primary lung cancers, and the integration of Enhanced Recovery After Surgery (ERAS) protocols into complex thoracic procedures. Dr. Wang's practice is defined by the philosophy that precision, minimal invasiveness, and rapid recovery are not competing goals but inseparable components of modern thoracic oncology — that the best cancer operation is one that removes the tumour completely, preserves the maximum functional lung tissue, and returns the patient to full activity in the shortest possible time. His high-volume VATS programme at Zhongshan Hospital has established one of China's most comprehensive thoracic oncology platforms, integrating 3D thoracoscopy, indocyanine green fluorescence guidance, and multidisciplinary perioperative care into a unified surgical pathway.

Case Overview

Ms. Claire Beaumont, a 58-year-old French business executive based in Shanghai with no smoking history, presented following a routine health screening that identified two pulmonary nodules on chest CT — a mixed ground-glass opacity (mGGO) in the right upper lobe and a solid nodule in the left lower lobe. PET-CT confirmed bilateral low-level FDG uptake with no mediastinal involvement or distant metastasis. Pulmonary function testing demonstrated adequate cardiopulmonary reserve. The multidisciplinary team led by Dr. Wang Qun concluded that both lesions represented synchronous multiple primary lung cancers (SMPLC) and recommended simultaneous bilateral VATS resection in a single anaesthetic session.

Dr. Wang performed a right upper lobe posterior segmentectomy (S2) with systematic lymph node sampling using a 3D thoracoscopic system and ICG fluorescence guidance to delineate the intersegmental plane, followed by left lower lobe wedge resection — total operative time 150 minutes, blood loss 30 mL. Final pathology confirmed right upper lobe invasive adenocarcinoma (acinar-predominant, 1.6 cm, clear margins, EGFR Exon 19 deletion) and left lower lobe adenocarcinoma in situ (AIS). All 15 sampled lymph nodes were negative. The patient was mobilised at four hours, commenced oral intake at six hours, had her chest drain removed on day two, and was discharged on day four. At one-month follow-up, pulmonary function had recovered to 90% of pre-operative baseline with no chronic pain.

Patient Background

• Name / Nationality: Ms. Claire Beaumont (pseudonym) — French; senior business executive based in Shanghai; high functional demands and strong quality-of-life priorities
• Age / Sex: 58-year-old female
• Chief Complaint: Bilateral pulmonary nodules identified on routine health screening CT — right upper lobe mixed GGO and left lower lobe solid nodule; asymptomatic
• Smoking history: Never-smoker; no occupational dust or carcinogen exposure
• Tumour markers: CEA and CYFRA21-1 within normal limits
• Past medical history: Hypertension for 5 years — well controlled on medication; no prior thoracic surgery or lung disease
• Functional status: ECOG Performance Status 0 — fully active; no cardiorespiratory symptoms

Imaging and Functional Assessment

High-Resolution Chest CT (HRCT)

• Right upper lobe (RUL): Mixed ground-glass opacity (mGGO) measuring 1.8 cm × 1.5 cm in the posterior segment (S2); solid component approximately 30% of total nodule volume; lobulated margin with pleural traction — highly suspicious for minimally invasive adenocarcinoma (MIA) or invasive adenocarcinoma
• Left lower lobe (LLL): Pure solid nodule measuring 0.8 cm × 0.7 cm; well-defined margins; location in the basal segment — primary lung cancer versus metastasis to be excluded
• No pleural effusion, no mediastinal lymphadenopathy, no chest wall involvement

PET-CT

• Right upper lobe nodule: Mild FDG uptake — SUVmax 2.1; no surrounding satellite lesions
• Left lower lobe nodule: Mild FDG uptake — SUVmax 1.8; no regional nodal hypermetabolism
• Mediastinum and supraclavicular regions: No lymph node enlargement or hypermetabolism — distant metastasis excluded
• Interpretation: Bilateral primary lung malignancy most likely; metabolic activity consistent with early-stage disease

Pulmonary Function Testing

• FEV1: 88% of predicted — normal; adequate reserve for bilateral resection
• DLCO: 85% of predicted — normal diffusion capacity; no interstitial lung disease
• Conclusion: Cardiopulmonary reserve sufficient to tolerate simultaneous bilateral VATS resection without staged approach

Dr. Wang's pre-operative assessment: The CT tells us two things that define the entire surgical strategy. First, the right upper lobe lesion has a 30% solid component with pleural traction — this is not a pure GGO that we can watch. It needs to come out, and it needs a proper anatomical resection with lymph node sampling to stage it correctly. Second, the left lower lobe lesion is small and solid — the differential is primary lung cancer versus metastasis, but the PET activity is too low for a metastasis from an aggressive primary. These are almost certainly two independent primaries. The question is not whether to operate — it is how to operate on both sides in a way that preserves the maximum lung function and gets this patient back to her life as quickly as possible.

Multidisciplinary Team Discussion and Pre-operative Strategy

The MDT convened by Dr. Wang Qun included thoracic radiology, respiratory medicine, and pathology. The consensus diagnosis was synchronous multiple primary lung cancers (SMPLC) — two independent primary tumours arising simultaneously in different lobes, a distinct entity from intrapulmonary metastasis. The distinction is clinically critical: SMPLC carries a significantly better prognosis than metastatic disease and is managed with curative surgical intent for both lesions.

The surgical strategy was designed around three principles: oncological completeness (adequate margins and lymph node staging for both lesions); functional preservation (anatomical segmentectomy rather than lobectomy for the right upper lobe lesion, preserving the anterior and apical segments); and single-session efficiency (simultaneous bilateral VATS to avoid a second general anaesthetic and reduce total recovery time).

Right side: Anatomical posterior segmentectomy (S2) of the right upper lobe with systematic lymph node sampling — Groups 2R, 4R, 7, 10, and 11. Segmentectomy rather than lobectomy was selected because the lesion was less than 2 cm with a significant GGO component, meeting the criteria established by the JCOG0802 trial for non-inferiority of segmentectomy versus lobectomy in terms of overall survival, with superior pulmonary function preservation.

Left side: Wedge resection of the left lower lobe basal segment nodule — appropriate for the small solid lesion given its peripheral location and the need to preserve left lower lobe function.

Technical platform: 3D thoracoscopic system for enhanced depth perception during vascular dissection; single utility port plus camera port technique; ICG fluorescence guidance for intersegmental plane delineation; no rib spreader — muscle-sparing approach throughout.

Operative Procedure

Anaesthesia and Positioning

Anaesthesia: Double-lumen endotracheal intubation with single-lung ventilation — right lung deflated for right-side surgery, left lung deflated for left-side surgery. Total intravenous anaesthesia (TIVA) protocol to minimise post-operative nausea and facilitate early mobilisation.

Positioning: Left lateral decubitus for right-side surgery; repositioned to right lateral decubitus for left-side surgery — sequential bilateral approach in a single anaesthetic session.

Phase 1 — Right Upper Lobe Posterior Segmentectomy (S2)

Port placement: Primary utility port (approximately 3 cm) at the anterior axillary line, fourth intercostal space; camera port at the mid-axillary line, seventh intercostal space. No additional ports — single utility port technique minimises chest wall trauma and post-operative pain.

Exploration: Right lung deflated; posterior segment nodule confirmed by direct palpation — firm consistency consistent with invasive adenocarcinoma. No pleural adhesions, no pleural effusion, no unexpected additional lesions.

Vascular dissection — 3D thoracoscopic guidance: Under 3D visualisation providing stereoscopic depth perception, the posterior segmental artery (A2) and posterior segmental vein (V2) were precisely identified and dissected free from surrounding structures. Anatomical variants were confirmed against pre-operative CT reconstruction before any vascular division. The posterior segmental artery was divided using an ultrasonic scalpel for small branches and an Endo-GIA vascular stapler for the main trunk. Blood loss from vascular dissection: less than 10 mL.

Dr. Wang's operative note: The 3D system changes the vascular dissection completely. In 2D thoracoscopy, you are estimating depth from motion parallax and tissue tension. In 3D, you see the spatial relationship between the artery, the vein, and the bronchus as clearly as in open surgery. For a posterior segment resection, where the A2 can have two or three branches with variable origins from the truncus posterior, that depth perception is not a luxury — it is a safety requirement.

Bronchial division and intersegmental plane identification: The right lung was re-inflated to identify the inflation-deflation boundary between the posterior segment and the adjacent anterior and apical segments. ICG fluorescence was administered intravenously; under near-infrared imaging, the perfused anterior and apical segments fluoresced brightly while the devascularised posterior segment remained dark — providing a precise, real-time map of the intersegmental plane that anatomical landmarks alone cannot reliably define. The posterior segmental bronchus (B2) was divided with an Endo-GIA stapler along the fluorescence-defined plane. Intraoperative frozen section of the bronchial margin: negative.

Intersegmental plane division: The intersegmental plane was divided along the ICG-defined boundary using an Endo-GIA stapler — preserving the maximum volume of anterior and apical segment parenchyma while ensuring an adequate margin around the posterior segment tumour.

Lymph node sampling: Systematic sampling of mediastinal and hilar lymph node stations — Groups 2R, 4R, 7, 10, and 11 — performed after segmentectomy. All nodes sent for intraoperative frozen section: all negative.

Phase 2 — Left Lower Lobe Wedge Resection

Repositioning: Patient repositioned to right lateral decubitus; left lung deflated. Port placement mirrored right-side approach — single utility port plus camera port.

Nodule localisation: Left lower lobe basal segment nodule identified by palpation — firm, well-circumscribed, consistent with the CT appearance. ICG fluorescence confirmed nodule location relative to the visceral pleural surface.

Wedge resection: Endo-GIA stapler applied to excise the nodule with a 1.5 cm margin of surrounding parenchyma — appropriate for a peripheral solid nodule of this size. Intraoperative frozen section: adenocarcinoma in situ (AIS) — no invasive component; margins clear.

Operative data — bilateral total: Total operative time 150 minutes (right side 110 minutes, left side 40 minutes); total blood loss approximately 30 mL; one 28 Fr chest drain placed on the right side; no drain placed on the left side given minimal air leak and negligible fluid output.

Post-operative Course and ERAS Outcomes

Pain Management

• Intraoperative: Bilateral intercostal nerve blocks performed under direct thoracoscopic vision before port closure — providing 12–18 hours of post-operative analgesia without systemic opioids
• Post-operative: Intravenous patient-controlled analgesia (PCA) with non-opioid analgesics; no high-dose opioid requirement throughout admission
• Outcome: Pain scores consistently below 3/10 on visual analogue scale; no pain-related mobilisation delay

ERAS Milestones

• 4 hours post-operatively: Oral fluids commenced; assisted ambulation to chair — no orthostatic hypotension
• 6 hours post-operatively: Liquid diet commenced; urinary catheter removed
• Post-operative day 1: Chest drain output less than 200 mL; no air leak on water-seal assessment; patient ambulating independently in corridor
• Post-operative day 2: Chest drain removed; chest X-ray confirmed full right lung re-expansion; patient eating normal diet
• Post-operative day 4: Discharged home; wound check scheduled at one week

One-Month Follow-up

• Pulmonary function: FEV1 recovered to 90% of pre-operative baseline — consistent with the predicted functional preservation advantage of segmentectomy over lobectomy
• Symptoms: No chronic chest pain, no dyspnoea on exertion, no wound complications
• Imaging: Chest CT confirmed no residual disease, no pneumothorax, no pleural effusion
• Oncology referral: Referred to thoracic oncology for adjuvant osimertinib (third-generation EGFR tyrosine kinase inhibitor) per ADAURA trial protocol — given EGFR Exon 19 deletion in the right upper lobe invasive adenocarcinoma

Final Pathology

• Right upper lobe posterior segment: Invasive adenocarcinoma, acinar-predominant subtype; tumour size 1.6 cm; all surgical margins negative; visceral pleural invasion absent; lymphovascular invasion absent — pT1bN0M0, Stage IA2
• Left lower lobe: Adenocarcinoma in situ (AIS); tumour size 0.7 cm; margins clear — pTisN0M0; no adjuvant therapy required for this lesion
• Lymph nodes: 0/15 nodes positive — Groups 2R, 4R, 7, 10, 11 all negative; complete pathological nodal staging confirmed
• Molecular profiling (right upper lobe): EGFR Exon 19 deletion mutation — sensitising mutation; ALK rearrangement negative; ROS1 negative; PD-L1 TPS less than 1%

Expert Commentary — Dr. Wang Qun

1. Synchronous Multiple Primary Lung Cancers: Surgical Strategy Over Systemic Compromise

Synchronous multiple primary lung cancers present a strategic challenge that has no single correct answer — only a correct process. The first question is always diagnostic: are these two independent primaries, or is one a metastasis from the other? The distinction determines everything. Metastatic disease is managed systemically; SMPLC is managed surgically with curative intent for each lesion. In this case, the combination of different lobe locations, different CT morphologies (mGGO versus solid), different SUVmax values on PET, and ultimately different pathological subtypes (invasive adenocarcinoma versus AIS) confirmed independent primary origin. Once the diagnosis of SMPLC is established, the surgical strategy must be designed to achieve R0 resection of both lesions while preserving the maximum functional lung tissue — because the patient needs enough lung reserve to tolerate adjuvant therapy, to recover from any future pulmonary event, and to maintain quality of life for the decades ahead. Lobectomy of both lobes would have been oncologically adequate but functionally excessive. Segmentectomy on the right and wedge resection on the left achieved the same oncological result with a fraction of the functional cost.

2. Anatomical Segmentectomy: The Evidence Has Arrived

For two decades, lobectomy was the standard of care for early-stage lung cancer regardless of tumour size, because the randomised evidence for segmentectomy was absent. The JCOG0802 trial changed that. For tumours less than 2 cm with a consolidation-to-tumour ratio greater than 0.5 — the category that includes this patient's right upper lobe lesion — segmentectomy is non-inferior to lobectomy in overall survival and superior in pulmonary function preservation. The mechanism is straightforward: segmentectomy removes the tumour-bearing segment with its bronchus and vessels while preserving the adjacent segments and their function. For a patient who needs to tolerate adjuvant targeted therapy, maintain exercise capacity, and potentially face future pulmonary challenges, that preserved function is not a cosmetic benefit — it is a clinical asset. At Zhongshan Hospital, anatomical segmentectomy for appropriately selected early-stage lung cancers is now the standard approach, not an experimental alternative.

3. ICG Fluorescence and 3D Thoracoscopy: Technology in Service of Precision

The intersegmental plane is the most technically demanding aspect of anatomical segmentectomy. The plane between adjacent segments does not follow a visible anatomical boundary — it must be inferred from the vascular and bronchial anatomy, confirmed by the inflation-deflation technique, and then divided with sufficient margin to ensure oncological clearance without sacrificing adjacent segment function. ICG fluorescence resolves this problem definitively. After intravenous ICG injection, the perfused segments fluoresce under near-infrared light while the devascularised target segment remains dark — providing a real-time, patient-specific map of the intersegmental plane that is more accurate than any pre-operative reconstruction. The 3D thoracoscopic system addresses a different problem: vascular dissection in a confined space where depth perception is critical. The posterior segment of the right upper lobe has the most variable arterial anatomy in the lung — the A2 can arise from the truncus posterior as a single trunk, as two separate branches, or in combination with the A6 from the interlobar artery. In 2D thoracoscopy, identifying these variants requires extensive experience and carries real risk of inadvertent vascular injury. In 3D, the spatial relationships are immediately apparent. Together, ICG fluorescence and 3D thoracoscopy do not make the operation easier — they make it safer and more precise.

4. ERAS in Thoracic Surgery: The Protocol Is the Operation

Enhanced Recovery After Surgery is not a post-operative nursing protocol. It is a perioperative philosophy that begins with anaesthetic selection, continues through surgical technique, and extends through every post-operative decision. The reason this patient was mobilised at four hours, eating at six hours, and discharged at four days is not because we moved quickly — it is because every decision from the pre-operative assessment through the final drain removal was made with early recovery as an explicit goal. Intercostal nerve blocks performed under direct thoracoscopic vision before port closure eliminate the first 12–18 hours of post-operative pain without systemic opioids — and it is opioid-related sedation, nausea, and ileus that delay mobilisation and oral intake in conventional thoracic surgery. A single small-bore drain rather than two large-bore drains reduces pain and allows earlier removal. TIVA anaesthesia reduces post-operative nausea. Each decision is individually small; collectively, they transform the post-operative trajectory. The four-day discharge in this case is not exceptional — it is the expected outcome of a correctly executed ERAS pathway for uncomplicated bilateral VATS resection.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Ms. Beaumont from initial screening alert through adjuvant therapy initiation, including: urgent review of external HRCT images and radiology reports with bilingual summary for the patient and her family physician in France; specialist referral to Dr. Wang Qun at Zhongshan Hospital's Department of Thoracic Surgery with priority MDT scheduling; coordination of PET-CT, high-resolution chest CT with 3D reconstruction, pulmonary function testing, and pre-operative cardiac evaluation; bilingual interpretation throughout all MDT discussions, surgical consent, and anaesthetic assessment sessions; coordination of EGFR, ALK, ROS1, and PD-L1 molecular profiling with results translation and oncology referral; real-time surgical updates to the patient's husband and her oncologist in Paris during the 150-minute bilateral procedure; post-operative daily bilingual updates covering drain output, air leak assessment, mobilisation progress, and discharge planning; coordination of one-month follow-up CT, pulmonary function testing, and wound assessment with results communicated to the patient's respiratory physician in France; adjuvant osimertinib initiation coordination with thoracic oncology, including drug access, tolerability monitoring schedule, and long-term surveillance protocol; and establishment of a direct communication channel between Dr. Wang's team and the patient's treating physicians in France for ongoing co-management.

For international patients with pulmonary nodules, early-stage lung cancer, or complex bilateral thoracic disease requiring expert surgical evaluation in Shanghai, Dr. Wang Qun's team at Zhongshan Hospital represents thoracic surgical expertise at the international frontier — combining 3D-VATS precision, ICG fluorescence guidance, and comprehensive ERAS protocols to achieve complete oncological resection with the fastest possible return to full function. CMCS ensures that expertise is accessible: in the patient's language, with overseas physicians informed at every step, from the first screening CT through long-term surveillance.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.