Carcinoma Cancer

[dr. ochsner:] carcinoma of the lung is a serious disease, we are all very much concerned about it, not only because it is the most frequent of all cancers, but also because the prognosis is so bad. the reason the prognosis is bad, is that carcinoma of the lung is early [?] invasive. we found that of all the patients going through our pulmonary function laboratory, in whom we find a cancer of the lung,

that 40 percent of them have tumor cells in their peripheral arterial blood. in those in which the lesion is in the periphery it's 70 percent, whereas in those in which the lesion is in the hilar portion of the lung, it's 30 percent. the other tragic thing about cancer of the lung is that it is largely preventable. with the exception of adenocarcinoma, which is a rare disease,

and is proportionately becoming rarer all the time, and which has no relationship to the etiologic factor i'm going to discuss in a moment, all other cancers of the lung are caused by cigarette smoking. so this is a disease which has become the most frequent of all cancers, which is preventable, and which is one of our great public health hazards today. as i mentioned previously, the results from the treatment of cancer of the lung are not good.

as shown in this graph of all the patients that we've seen, now representing over 3500, only 50 percent are operable. in other words 50 percent of them, the lesion is already extended beyond the lung at the time we see them. only 30 percent of the entire group are resectable, and only six percent of the entire group are alive and apparently free from disease at the end of five years. this is a man 52 years of age

who began with some mild discomfort in his left chest. an x-ray was taken. it showed a shadow in his lung. this increased rather rapidly within a very short period of time. as one can see here in the left, uhh, chest is a shadow, apparently attached to the chest wall. from this we can't tell whether it's in the lung, or whether it originated from the parietes. in the [?] roentgenogram or the black rather,

one can see that this is in the parenchyma. this man was a very heavy smoker, and because of his heavy smoking, we feel that quite definitely this is a bronchogenic carcinoma. we feel that a history of smoking is the most positive method of making a diagnosis of cancer of the lung. cytology here showed tumor cells in the sputum. incision is made over the left fifth rib.

it begins anteriorly, curves around the angle of the scapula, and then extends up superiorly. the patient is in the right lateral decubitus, so that the left chest is up. one can either do the operation through an intercostal incision or one can resect the rib. now i'm going to resect the rib in this case, because of the lateral area,

the position of it. now i'm counting the ribs, because before the incision it's impossible to tell just which is the fifth rib. but beginning above i am counting them, and now here is the fifth rib, and i am going to resect this. because of the lateral position of the tumor, i think that it is probably adhered to the parietes, and i think there's less danger of my getting into tumor

if i resect the rib than if i make an intercostal incision. also i think they'll have less pain if their rib is resected rather than an intercostal incision. periosteum is pulled away from the rib. the resection is done sub-posteriorly and this helps to stabilize the chest later. beginning posteriorly on the upper side and anteriorly on the lower side,

we separate the periosteum. the periosteum is further separated from the rib with this instrument we call a joker. and then using the doyen periosteal elevator, the periosteum is separated from the rib. costotome is used to divide the rib both anteriorly and posteriorly. now i'm incising through the bed of the rib, and as i feared the lung is adhered in this area. i'm going to try and get an area where it is free,

because i want to be able to tell more about just what this attachment is due to. now i'm in the free pleural cavity posteriorly, and as i feared the lung is adhered to the parietes, and because this adherence may be neoplastic, i'm going to do an extra-pleural dissection of the lung. now using this periosteal elevator, i'm separating the pleura from the uhh, chest wall, and in this way, if the pleura is involved with neoplastic lesion,

there is not much likelihood of implantation of tumor. now i've separated it; one can see how the parietal pleura is adhered to the lung. now dividing the pleura away from the chest wall above, now we're dividing it inferiorly; this is a part that we separated away from the parietes. one can see the tumor... this is the attachment of the pleura to the lung and tumor. of course now we can't tell whether it's neoplastic or not.

i'm inclined to believe that it's only inflammatory. the ribs are separated by means of the finochietto retractor. one can see this is a mediastinum. there is a phrenic nerve lying about the mid-portion of the frame. we're now freeing the mediastinum partly by blood dissection, partly by sharp dissection. we'll get up and isolate the pulmonary artery. there are a number of small branches here, the pulmonary plexus, which are nerve fibers but there are small vessels along with them,

and we are now getting a semb ligature carrier around the pulmonary artery. this is the main branch of the pulmonary artery. the reason we do this is because although we don't know yet whether we are going to do pneumonectomy or lobectomy, is that by isolating the pulmonary artery and getting a ligature on it, we can control any bleeding if it might occur in severing the branches of the pulmonary artery. this is another small branch, uh, vessel in the mediastinum,

which we are ligating to prevent troublesome bleeding. this is another branch of the pulmonary plexus [?] dividing, this will be ligated also. freeing the mediastinum...so far i haven't encountered any large nodes which appear to be involved. the uh, node under the, the nodes under the arch of aorta apparently are uninvolved. this is a pulmonary artery again which i'm putting the ligature around. this is simply a precautionary measure,

because as i said, i don't know whether we are going to do a lobectomy or a pneumonectomy. i'm now separating the individual branches of the pulmonary artery because uhh, i am going to do a lobectomy if it seems feasible and i can remove it. the reason for this is, as i mentioned earlier, the curability incidence in carcinoma of the lung is low, and we've learned by sad experience that the best way to, the best way to treat cancer of the lung

is to do as little resection as one can and remove the tumor grossly. dividing the superior branch of the pulmonary artery... it has been ligated, i'll transfix this. because it's important to transfix these vessels since they are large vessels in diameter. as a matter of fact, their diameter is actually larger than their length. and it's almost like uh, ligating a funnel. so that unless one transfixes it one will uh, there's likely to be bleeding.

now i'm getting some bleeding from the inferior branch of the pulmonary artery. at this stage i didn't know what was causing this, but we subsequently found out that this was due to involvement of the artery by the tumor. because of this, we decided to do a pneumonectomy, because we felt that we would not cure this man if we didn't do a pneumonectomy. so now the pulmonary artery which i previously,

around which i previously put a ligature, is now being ligated. we put one on medially and distally, and then we put two transfixion sutures medially. these are placed in such a way that four quadrants of the vessel are caught. one goes superiorly inferiorly and the other goes anteriorly posteriorly. so that we have four quadrants of the vessel caught.

as i previously mentioned, this is necessary because of the large diameter of the vessel, and if one doesn't catch the four quadrants, there is likelihood of slippage of the vessel, the diameter of the vessel being actually larger than the length of the vessel. using this technique, however, there is little or no danger of hemorrhage, and this i found through the years to be a very valuable method

of handling the pulmonary vessels. both the artery and the two pulmonary veins. the first one, first transfixion ligature went superiorly and inferiorly, and this one, the second one, goes anteriorly posteriorly, so that the four quadrants are caught. after tying it anteriorly, the suture is pulled around and tied posteriorly so as to get the entire segment. we now divide the vessel leaving a relatively long segment. now we're going to free the inferior pulmonary ligament

from the mediastinum. this is done by sharp dissection. there is some bleeding, we catch the, the small vessels as we encounter them. we free this up to, to the inferior pulmonary vein, which is the most inferior and posterior of the structures. now we're coming up to the inferior pulmonary vein. you can see it here exposed. there is a node distally which seems soft

and i don't believe is involved. a ligature is placed around the inferior pulmonary vein. it is held laterally. another one is placed medially. both these are tied, one laterally and one medially. and then, as in the pulmonary artery, we will put two transfixion sutures medially on the cardiac side. this one goes superiorly inferiorly. it's tied anteriorly and then will be pulled around

and tied posteriorly. this is pulling the suture around and tying it posteriorly. one should give sufficient time the ligature to seat, because this is a big vessel and it must be pulled down tautly. now this is another suture. this one goes posteriorly anteriorly so that the four quadrants of the vessel are caught. a munion clamp has been applied to the vessel distally. the ligatures are divided,

and then the inferior pulmonary vein is divided immediately adjacent to the munion clamp, leaving a relatively long segment on the cardiac side. now it's divided, and one can see the sutured end of the inferior pulmonary vein. we next go up and isolate the superior pulmonary vein and do the same thing. we put two ligatures on, one medially, one distally,

two transfixion sutures medially, a munion clamp distally, and then division of the superior pulmonary vein. same technique is used for all three vessels. now the superior pulmonary vein has been divided, the vascular structures are now separated from the lung, with exception of the bronchial arteries. we now go back and isolate and free the bronchus. the left mainstem bronchus up to the region of the bifurcation, because we don't want to leave a long stump.

we are now freeing the bronchus from areolar tissue and any nodes that might be in the hilar area. apparently there are none. a bronchial clamp is placed across the bronchus, relatively high behind the carina. a second one is placed distal to it, because we don't want any spillage from the lung. and then the bronchus is divided by means of this right-angled knife. now we have to close the bronchus.

whereas previously we used mattress sutures, now we use plastic sutures and this is a, these are multiple sutures. the first one is placed at one end of the clamp and tied. now because this is plastic, one must use many throws. it's one of the disadvantages of the plastic suture but the main advantage is that it is well-tolerated, and since we've been using this technique we've had no trouble with the bronchial stumps. it is important that these sutures be brought up tautly enough

just to approximate the, the edges of the bronchus but not too tightly to cut through. one can cut through the bronchus if one pulls too tightly. now a suture is placed at the other end of the bronchus, which is tied around the end of the bronchus, in the same way the first suture was tied. then we put in a row of sutures proximal to the clamp, but these are not tied until after the clamp is removed. they are tagged by means of small hemostats,

so that we won't get them mixed up. as i said previously, at one time we used mattress sutures, but we don't anymore because we feel that interfered with the blood supply. now the clamp is removed and the sutures which been placed are held taut and in this way there is little danger of leakage from the bronchus while we ligate the sutures. again i want to emphasize that these are tied only tight enough to approximate the walls of the bronchus

without cutting through them. they are all tied individually. the fact that they have been tagged with hemostats before makes it easy for us to identify them and not get them mixed up with one another. this is of importance, i think. now they've all been tied and one can see that the closure is very good. now we're putting in saline because we want to be sure that this is watertight.

the anesthetist is now asked to increase the intrabronchial pressure by increasing the pressure on the bag and you can see there is no leak. this is absolutely necessary because if there is any leak, we must put additional sutures in to close it. since there is no leak we can now remove the sutures, leaving them relatively long since they are plastic. and now we close over the bronchial stump by suturing the flaps of pleura

both anteriorly and posteriorly over it. this i think is extremely important because it tends to protect the bronchial stump and prevent a blowout. i think as a result of this, uh, serous fluid is kept trapped in this area, which becomes deposited as fibrin and then ultimately organized so that it's actually like a cap over the bronchial stump. we're now ready to close the chest.

since we've done a pneumonectomy we do not drain the chest, but we put a tube in anteriorly until the chest has been closed. and the reason for this is that with the patient in the right lateral decubitus, the mediastinum gravitates toward the right side, and if this were allowed to continue, there would be accumulation of air in the left hemothorax. the dressing is applied, the patient is then placed back in the supine position,

the anesthetist is then asked to inflate the opposite lung, which brings the mediastinum back to the midline, and then this tube which we put in temporarily is removed. this brings the mediastinum back in the position that it should be, and the chest is now sealed. we want the cavity to fill up with serous fluid. fibrin will become deposited and then ultimately there will be organization of this area. of course, if this were a lobectomy

we would use tubes to evacuate the cavity. now here is the lung, you can see it's a large tumor. i'm cutting through the attachment of the pleura and we're coming down to the mass, and now we can see why this tumor increased in size. on our right is a, one can see the neoplasm. on the left is a hematoma. and this increase in size that was noticed within a relatively short period of time is due to the hemorrhage within the neoplasm.

it'd be impossible for our tumor to grow that fast. i'd like to again emphasize that the results from the treatment of carcinoma of the lung are not good. as i said, only six percent of them are alive and well at the end of five years. it is for this reason that it behooves all of us to use the one weapon we have, namely the prevention of cancer of the lung. which is preventable almost entirely by absence of smoking. because as i mentioned before with the exception of adenocarcinoma.

the the uh, all cancers of the lung are due to cigarette smoking.