Sep. 15, 2000 Penn surgeons perform -- and teach -- a once-rare procedure: saving clear portions of cancer-ridden lungs when even a main pulmonary artery is involved in malignancy
Procedure has lower risk and leaves patients with more stamina than complete removal of the lung
When a surgeon opens the chest of a lung cancer patient and finds that the malignancy has spread from one of the lungs to its pulmonary artery, he or she will almost always remove the entire lung.
But doctors at the University of Pennsylvania Medical Center are performing and teaching a surgical procedure that routinely saves part of the affected lung, leaving the patient with more stamina, the potential for normal activity, and the same long-term prognisis.
In fact, when a lung is removed in its entirety, "there is a much greater risk of death after surgery, and certainly more shortness of breath permanently," according to Joseph B. Shrager, MD, PhD, a thoracic surgeon and assistant professor of surgery at the University of Pennsylvania Medical School.
Even though there has been scattered anecdotal evidence (and one other large published study) since the late 1960s that indicate the advantages of the lung-sparing procedure, which is described in medical terminology as a "lobectomy with tangential pulmonary artery resection," very few doctors have been willing to attempt it.
"Ninety-five percent of surgeons who operate for lung cancer are not comfortable with the procedure," said Shrager. "They're afraid of bleeding, and they feel it's too great a technical risk."
But since 1992, Penn's thoracic surgeons, led by Dr. Larry Kaiser, have successfully performed about 40 of the surgeries. They've found, according to Shrager, that "in most cases the procedure is only slightly more difficult than removing the entire lung."
A report of the team's findings based on the first 33 cases was published this summer in the Annals of Thoracic Surgery, and earlier this year, Shrager presented the results of those cases at the meeting of the Society of Thoracic Surgeons in Fort Lauderdale, Fla.
Decision-making in the operating room
In lung cancer, it can take from six months to two years before a malignant tumor is detected. Surgery is a viable treatment only in cases where a non-small-cell malignancy has not yet spread from the lung to the brain, bones, liver or adrenal glands. (Small cell carcinomas are most commonly treated with only radiation and chemotherapy.)
But when surgery is the clear course, even using the most sophisticated medical technology, a doctor still often cannot be sure before opening a patient's chest whether there is involvement of the pulmonary artery.
"We'll tell people, 'We take out only as much as we need to,'" Shrager said.
And so the final choice between a traditional pneumonectomy - the complete removal of the affected lung -- or an attempt to save part of the lung, is one that must be made on the floor of the operating room.
The delicate work of arterial resection
The most daunting part of the combined lobectomy/resection procedure is the pulmonary artery resection: The wall of the artery that is overgrown with malignancy is removed, and then the artery is stitched back together.
But the thoracic surgeons at Penn have found the surgery only slightly more challenging than traditional lung cancer surgery.
"Typically when we're doing the procedure it's a left upper lobe cancer and the tumor is growing into the pulmonary artery," Shrager said. "As long as it's not extensively growing into the artery, basically we clamp the pulmonary artery above and below where the tumor is invading, and then cut out only the side wall of the artery where the tumor is attached, causing a tangential incision, and then repair the artery."
"This is something that can easily be taught," Shrager said. "And it's something we hope to see become a standard procedure, whenever possible. The value of the technique is that patients who undergo this surgery appear to have the same chance of being cured of the cancer as those undergoing complete lung removal, but they will not experience any diminishment in the quality of their life."
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