Thoracic Oncology Update — June 2026

Welcome to our latest Thoracic Oncology Update from Mr Apostolos Nakas, Consultant Thoracic Surgeon at Spire Leicester Hospital and Glenfield Hospital NHS. This week's update covers important developments across the main areas of chest cancer care — from new treatment approaches in lung cancer to advances in the management of pleural disease, thymoma, and chest wall tumours. Our aim, as always, is to give patients, families, and referring clinicians a clear and accessible overview of what is happening at the forefront of thoracic oncology.

Lung Cancer

Lung cancer remains the leading cause of cancer-related death in the UK, but the outlook for patients is improving steadily thanks to earlier detection and more targeted treatments. The NHS Targeted Lung Health Check programme continues to expand, offering low-dose CT screening to people aged 55–74 who have a history of smoking. Early detection through this programme is making a real difference — cancers found at an earlier stage are far more likely to be treatable with curative intent, including surgical removal.

At our practice, we are committed to offering the surgical option suitable for each individual patient, always with the goal of achieving complete tumour removal.

In advanced lung cancer, the combination of immunotherapy and targeted molecular treatments continues to transform what is possible. Patients whose tumours carry specific genetic mutations — such as EGFR, ALK, or ROS1 — may be eligible for highly effective targeted therapies that can control the disease for extended periods. We work closely with our oncology colleagues to ensure every patient has access to molecular profiling and the most appropriate treatment pathway.

Guideline‑level documents and perioperative trials are reshaping how surgery sits within multimodality care for more advanced disease. The 2026 American Association for Thoracic Surgery (AATS) Expert Consensus on N2+ NSCLC underscores that surgery retains a role within combined‑modality treatment—typically after induction chemotherapy or chemo‑immunotherapy—in well‑staged, fit patients, with strict emphasis on invasive mediastinal staging and MDT adjudication. In parallel, a narrative review describes how VATS and RATS are increasingly being used for locally advanced NSCLC (including post‑induction stage III), reporting acceptable oncologic surrogates and the expected reductions in length of stay and peri‑operative morbidity when MIS is performed in experienced units.

Digital planning is advancing quickly. A 2026 review of artificial‑intelligence–driven 3D reconstruction reports that deep‑learning pipelines can now generate detailed patient‑specific bronchovascular and parenchymal models from CT within 5–10 minutes, compared with hours for manual segmentation. These models have been shown to improve pre‑operative planning and intra‑operative orientation for segmentectomy and sublobar resections—especially in anatomically complex cases or after prior treatment—although performance degrades with poor‑quality CT or distorted post‑treatment anatomy.

At the interface with interventional oncology, a 2026 Cancers review concludes that image‑guided thermal ablation (particularly MWA and cryoablation) and bronchial artery chemoembolisation have become increasingly precise, repeatable lung‑sparing options for both primary and metastatic lung tumours, with early data suggesting good local control and tolerability, and potential synergy when combined with immunotherapy. Meanwhile, a contemporary Chinese review of ctDNA‑defined MRD in NSCLC summarises accumulating evidence that peri‑operative ctDNA dynamics stratify relapse risk and could, in time, guide intensity of local therapy and adjuvant systemic treatment, though this is not yet practice‑changing.

Prospectively, the JCOG2317 (NATCH‑ICI) phase III trial—initiated in 2025—directly compares neoadjuvant nivolumab plus platinum‑doublet chemotherapy followed by surgery versus upfront surgery followed by adjuvant cisplatin‑based chemotherapy (with adjuvant ICI for PD‑L1–positive disease) in clinical stage II–III resectable NSCLC. Its primary endpoint is overall survival, and its results will likely define the practical “default” peri‑operative strategy for this population once mature.

**Unresolved lung cancer surgery questions**

- Long‑term oncologic equivalence of MIS versus open surgery in heavily pretreated N2+ disease remains incompletely defined, particularly regarding margin status and nodal clearance after bulky induction responses.

- How best to integrate ctDNA MRD, advanced imaging and systemic therapy choices into decisions about extent of resection, repeat local therapy and duration of adjuvant immunotherapy is still uncertain and largely trial‑driven.

- The optimal allocation of patients between surgical resection, advanced endobronchial therapies and percutaneous ablation in oligometastatic/oligoprogressive settings in the immunotherapy era is not yet established.

Mesothelioma

Mesothelioma is a cancer of the lining of the lung (pleura) most commonly caused by past exposure to asbestos. It is a complex condition that requires careful assessment and a highly specialised team approach. Diagnosis often involves a combination of imaging, pleural fluid analysis, and biopsy, and our team has extensive experience in performing these procedures safely and accurately.

Treatment options for mesothelioma have improved in recent years. The introduction of immunotherapy combinations — in particular nivolumab and ipilimumab — has provided a meaningful improvement in survival for many patients with unresectable disease. For carefully selected patients, surgery in combination with chemotherapy, immunotherapy and/or radiotherapy may offer the best chance of long-term control. Every case is discussed at our specialist multidisciplinary team (MDT) meeting to ensure the most appropriate plan is put in place.

We are also committed to helping patients and their families understand their legal rights. Many mesothelioma patients have grounds to make a compensation claim related to occupational asbestos exposure, and we are happy to provide the necessary medical reports and documentation to support this process.

Recent work has crystallised the consensus that if surgery is offered, it should almost always be lung‑sparing and embedded in multimodality care. The 2026 Society of Thoracic Surgeons (STS) Expert Consensus on pleural mesothelioma recommends that any surgical resection be part of a multidisciplinary plan after rigorous staging (including CT and PET/CT) and adequate pleural biopsy, and explicitly “strongly favours” pleurectomy/decortication (P/D) or extended P/D over extrapleural pneumonectomy (EPP). The document emphasises that candidates should have primarily epithelioid histology, locoregional disease and be treated at experienced, high‑volume centres.

A contemporary Mount Sinai series of 71 P/Ds (2015–2021), published this year, reported 0% 30‑day and 4.2% 90‑day mortality—less than half the 9% 90‑day mortality seen in MARS2—supporting the safety of lung‑sparing surgery when performed with careful selection and technique. This cohort was predominantly epithelioid and managed within a structured, multidisciplinary programme, which the authors highlight as key to reconciling their outcomes with the more pessimistic MARS2 results.

Perioperative innovation has focused heavily on pain control and functional recovery. A high‑volume regional centre introduced intraoperative intercostal nerve cryoablation (4th–8th spaces, −60 °C for 2 min) during P/D and, in a retrospective comparison of 2024 cases versus a 2015–2023 historical cohort, found significantly reduced inpatient opioid consumption without a signal for increased complications or length of stay, suggesting a role for protocolised, opioid‑sparing analgesia in these large operations. Parallel observational data support thoracic epidural block during P/D as associated with lower rates of major complications, likely via suppression of intraoperative nociception and inflammatory response.

There is also movement toward formalising palliative, symptom‑directed surgery. A University of Chicago trial is enrolling 30 patients with borderline‑resectable or unresectable epithelioid mesothelioma who have completed systemic therapy, testing a limited partial P/D that focuses on removing chest‑wall pleura and decorticating only compressive tumour to improve pain, pleural effusion control and lung expansion; diaphragm, mediastinum and pericardium are purposefully left untouched. The goal is quality of life and enabling continuation of systemic therapy rather than macroscopic complete resection, effectively codifying “palliative P/D” in a prospective protocol.

On the systemic side, ongoing early‑phase trials (e.g. a UC Davis phase I pilot) are combining atezolizumab with pemetrexed/cisplatin around surgery—with pre‑operative cycles to downsize disease and post‑operative atezolizumab as consolidation—in stage I–III pleural mesothelioma, reflecting a broader move to integrate immune checkpoint blockade into surgical pathways.

**Unresolved mesothelioma questions**

- We still lack randomised data comparing modern P/D at expert centres against optimal non‑surgical regimens in rigorously staged epithelioid disease; evidence for surgery in non‑epithelioid subtypes remains very sparse.

- Selection criteria for limited/palliative P/D, standardisation of multimodal analgesia (epidural vs cryoablation vs other regional techniques), and the optimal sequencing of immunotherapy relative to surgery and radiotherapy are all poorly defined and heterogeneous across centres.

Pulmonary Metastasectomy

When cancer from another part of the body — such as the bowel, kidney, breast, or sarcoma — spreads to the lungs, surgery to remove these secondary deposits (metastases) can sometimes offer a real chance of cure or long-term remission. This procedure, known as pulmonary metastasectomy, requires careful patient selection to ensure the potential benefits outweigh the risks.

Many patients with a small number of resectable pulmonary metastases — especially when the primary cancer has been well controlled — continue to benefit from surgical removal. Our team reviews each case thoroughly, considering the number and size of deposits, the biology of the primary tumour, and the patient's overall fitness.

Where possible, we use minimally invasive (keyhole) surgery to remove lung metastases, allowing patients to recover more quickly and return to their everyday lives sooner. We are also pioneers in the use of a medical laser to remove metastases thus enabling sparing of as much lung as possible whilst achieving oncologically appropriate resections. In selected cases, stereotactic ablative radiotherapy (SABR) may be an alternative to surgery and is discussed at our MDT.

A 2026 systematic review of outcomes and prognostic factors for pulmonary metastasectomy (PM) across multiple primaries synthesises contemporary data and confirms that, in selected cohorts, 5‑year survival can range from approximately the mid‑30% range up to beyond 70% depending on tumour type—for example, about 35–72% in breast cancer series and around 40% or more for some other solid tumours. The review reinforces that favourable histology, limited number of lesions, longer disease‑free interval and absence of intrathoracic nodal disease are consistently associated with better outcomes, and that complete (R0) resection and parenchyma‑sparing techniques are key surgical principles.

However, the same review stresses that nearly all available data are retrospective, without randomised comparisons to non‑surgical management, so any apparent survival advantage is vulnerable to selection bias—echoing earlier critiques from Thorax and other sources that PM still fails classical causality tests despite its widespread adoption. Newer registry and institutional data on repeated PM show that second and even third metastasectomies can be performed with low peri‑operative risk and non‑trivial long‑term survival; for example, a large 2026 series of over 1100 patients (1503 operations) reported a 30‑day mortality of 0.1% and 10‑year overall survival of 35.5% after systematic multiple and repeated resections. These findings support considering re‑metastasectomy in patients with favourable biology and adequate reserve.

Equity and access have come into sharper focus. An AATS abstract analysing lung‑limited colorectal metastases found that older patients, those treated in low‑volume hospitals and those living closer to their treating institution were significantly less likely to receive pulmonary metastasectomy, and that patients who had primary‑site surgery without PM had worse overall survival even after adjustment for patient, tumour and hospital factors. This underscores that who actually gets offered PM is as important as whether PM “works,” and that service configuration and referral patterns are modifiable levers.

**Unresolved pulmonary metastasectomy questions**

- There are still no completed randomised trials directly comparing PM with optimised systemic or ablative therapies in most tumour types; the field relies on observational data with inherent selection bias.

- Optimal integration of surgery with stereotactic radiotherapy and percutaneous ablation—particularly for patients who might otherwise undergo multiple repeat thoracotomies—remains unclear, as do the best endpoints (overall survival vs systemic‑therapy‑free interval vs patient‑reported outcomes).

- More work is needed on standardising indications and ensuring equitable access, especially given evidence that age, geography and institutional volume strongly influence whether PM is offered.

Thymoma and Thymic Tumours

Thymomas are tumours that arise from the thymus gland, a small organ in the chest involved in the immune system. They are relatively rare but are the most common tumours of the anterior mediastinum (the front part of the chest). Many thymomas grow slowly and are discovered incidentally on a chest scan, though some can be associated with conditions such as myasthenia gravis — a condition causing muscle weakness.

Complete surgical removal of the thymus (thymectomy) is the cornerstone of treatment for thymoma and, when performed by experienced surgeons, carries an excellent long-term prognosis for most patients. We offer minimally invasive approaches including VATS and robotic thymectomy, which avoid the need for a large chest incision (sternotomy) in suitable patients. This results in less postoperative pain, a shorter hospital stay, and a faster return to normal activities.

For patients with myasthenia gravis, thymectomy can lead to a significant improvement in symptoms or even complete remission, even in the absence of a visible thymoma. Our team works in close collaboration with neurology colleagues to manage these patients safely and effectively throughout the surgical journey.

Newer data continue the trend toward MIS as the preferred approach for early‑stage thymoma in experienced centres. A 2026 study explicitly asking whether MIS should be standard for early‑stage disease documents a major shift over two decades from open median sternotomy to MIS (VATS and RATS) for stage I–II thymomas, with MIS associated with shorter hospital stay and similar rates of complete resection and oncologic outcomes when compared with open surgery. These findings build on prior national registry analyses that found MIS thymectomy for stage I–III thymoma to be safe and to offer peri‑operative advantages without compromising margin status.

A recent review on optimising individualised treatment in locally advanced thymic epithelial tumours notes that MIS approaches are being cautiously extended to select stage III cases, but repeatedly emphasises that achieving an en bloc, margin‑negative resection with appropriate nodal assessment is more important than the incision, and that open approaches remain appropriate whenever MIS would jeopardise oncologic quality. For stage IVa thymoma with pleural dissemination or pleural relapse, small series have adapted mesothelioma‑style lung‑sparing pleurectomy/decortication combined with extensive thymothymectomy and intraoperative photodynamic therapy, reporting encouraging local control in highly selected patients, although data remain limited and from specialist centres.

**Unresolved thymoma surgery questions**

- Firm size and invasion thresholds beyond which MIS becomes unsafe or oncologically suboptimal are not fully defined, and there is no consensus on MIS use for large, invasive or Masaoka‑Koga stage III tumours.

- Optimal management of pleural implants (including the role of mesothelioma‑type P/D, photodynamic therapy and intrapleural chemotherapy) is not standardised, and evidence is confined to small retrospective series.

- Integration of modern systemic and biologic therapies with surgery, and the design of prospective registries or trials with long‑term follow‑up, are needed to strengthen the evidence base beyond current heterogeneous observational data.

Chest Wall Tumours

Tumours arising from the chest wall — whether from bone, cartilage, soft tissue, or skin — present a unique surgical challenge. These include both primary tumours (such as sarcomas and chondrosarcomas) and secondary deposits from other cancers. A thorough assessment with cross-sectional imaging (CT and MRI) is essential to plan the correct surgical approach.

Surgery for chest wall tumours often requires the removal of one or more ribs, and in some cases a portion of the sternum. Where significant structural defects are created, chest wall reconstruction using prosthetic meshes or custom-made implants is necessary to maintain respiratory function and protect the underlying organs. Our team has considerable experience in planning and performing these complex reconstructive procedures.

We work closely with plastic surgeons, oncologists, and rehabilitation specialists to provide comprehensive care for patients with chest wall tumours, from diagnosis through to recovery and long-term follow-up.

Pleural Disease

A pleural effusion — a collection of fluid around the lung — can be one of the first signs of thoracic cancer, or it may develop as the disease progresses. Accurate diagnosis of the cause of a pleural effusion is essential for planning treatment. Procedures such as ultrasound-guided pleural aspiration, medical thoracoscopy, and video-assisted thoracoscopic biopsy allow us to obtain tissue or fluid safely for analysis.

For patients with recurrent malignant pleural effusions that keep coming back and causing breathlessness, we offer two main options: talc pleurodesis (a procedure to stick the two layers of the lining together and prevent fluid re-accumulating) or insertion of an indwelling pleural catheter (IPC), which allows patients to drain the fluid themselves at home. The choice between these options depends on the patient's prognosis, lung function, and personal preferences, and is always discussed in a shared decision-making conversation.

Contact Us

If you or a loved one has been diagnosed with a thoracic condition, or if you are a clinician wishing to refer a patient, we would be very happy to help. Mr Nakas offers prompt consultations at Spire Leicester Hospital , with access to diagnostic and surgical services.

To make an appointment or referral, please contact us:

• Phone: +44 116 265 3614

• Email: apostolos@chestsurgery.net

• Website: www.chestsurgery.net

We look forward to hearing from you and to providing the highest standard of thoracic surgical care.