Surgical Management of Lung Cancer: History, Evolution, and Modern Advances.

PURPOSE OF REVIEW: Although surgery for lung cancer was not common before the early twentieth century, it has enjoyed remarkable progress since then both in type of resection and technical approach. This has been coupled with significant technological advances. Here, we will review the history and evolution of this relatively new field of surgery. RECENT FINDINGS: The gold standard of the extent of resection for lung cancer evolved from pneumonectomy to lobectomy to even sublobar resection for select situations. In addition, major advances have occurred in the technical aspect of the surgical procedure. The incisional approach has evolved from rib spreading thoracotomy to thoracoscopic surgery with the latter showing significant improvement in short-term outcomes over open thoracotomy. However, standard video-assisted thoracoscopic surgery or VATS is associated with visual and mechanical limitations, including lack of depth perception and rigid straight instruments. This makes it appropriate only for early-stage peripheral and small tumors. Most of the limitations of VATS can be overcome with the more recently introduced robotic-assisted thoracic surgery (RATS). RATS utilizes wristed instruments that are introduced in the chest through 8-mm ports and can mimic the movements of the human hand. In addition, magnified, three-dimensional and high definition imaging gives the surgeon an image of the lung unlike any other modality. This has allowed surgeons to perform advanced resections such as pneumonectomy or sleeve resection in a minimally invasive fashion. In addition, RATS has become a platform for the addition of other technical enhancements such as incorporating a near infra-red light source into the camera allowing identification of autoflourescent agents, such as indocyanin green. This has allowed localization of small nodules for resection and identification of tissue planes for sublobar resection. However, new technologies also require investments in time and money. Thoracic surgery for lung cancer has evolved to include advanced minimally invasive techniques including video-assisted and robotic-assisted thoracoscopy. RATS in particular may enable surgeons to perform more advanced procedures in a minimally invasive fashion. It is hoped that the higher costs of new surgical technology may be offset by the potential for improved patient outcomes and resultant socioeconomic benefits.

Novel Techniques in Video-assisted Thoracic Surgery (VATS) Lobectomy.

Twenty years ago, thoracic surgery witnessed the leap from thoracotomy to the first video-assisted thoracic surgery (VATS) lobectomy. Gradually VATS lobectomy has become widely accepted and practiced worldwide. As the idea of less-invasive, fewer, and smaller incisions is taken up by surgeons, thoracic surgery has witnessed the progress of the conventional three-port VATS lung resection to two-port VATS and finally the birth of uniportal VATS lobectomy. Incisions have also become much smaller over the years, such as those seen in total port access lobectomy or microlobectomy. A modified version of the uniportal VATS lobectomy through the subxiphoid incision has also recently been used. The movement toward less-invasive surgery has no doubt driven the innovation of sophisticated instruments and technology to cope with the demanding need of working through a restricted incision. Reported outcomes and results of these new developments are encouraging.

The Past, Present and Future of Pulmonary Metastasectomy: A Review Article.

Pulmonary metastases are a sign of advanced malignancy and an omen of poor prognosis. Once primary tumors metastasize, they become notoriously difficult to treat and interdisciplinary management often involves a combination of chemotherapy, radiotherapy, and surgery. Over the last 25 years, the emerging body of evidence has recognized the curative potential of pulmonary metastasectomy. Surgical resection of pulmonary metastases is now commonly considered for patients with controlled primary disease, absence of widely disseminated extrapulmonary disease, completely resectable lung metastases, sufficient cardiopulmonary reserve, and lack of a better alternative systemic therapy. Since the development of these selection criteria, other prognostic factors have been proposed to better predict survival and optimize the selection of surgical candidates. Disease-free interval (DFI), completeness of resection, surgical approach, number and laterality of lung metastases, and lymph node metastases all play a dynamic role in determining patient outcomes. There is a definite need to continue reviewing these prognosticators to identify patients who will benefit most from pulmonary metastasectomy and those who should avoid unnecessary loss of lung parenchyma. This literature review aims to explore and synthesize the last 25 years of evidence on the long-term survival, prognostic factors, and patient selection process for pulmonary metastasectomy.

[Evarts A. Graham (1883-1957)--biography and medical achievements. His input into the knowledge of carcinogenic actions of tobacco]. / Evarts A. Graham (1883-1957)--biografia i osiagniecia medyczne. Wklad do wiedzy o rakotwórczym dzialaniu tytoniu.

Evarts Ambrose Graham (1883-1957) was one of the most prominent American surgeons of the 20th century. Some believe that he belonged, together with William Halsted and Harvey Cushing, to the three most respected American surgeons. Graham was mainly dedicated to thoraco-surgery. He proposed a new treatment for empyema of the chest, based on the physiological understanding of pleural mechanics. He introduced the cholecystography method for the visualization of gall bladder and performed the first total one-stage pneumonectomy. Moreover, he was actively engaged in the studies of carcinogenic influence of tobacco and an association between tobacco smoking and lung carcinoma.

Fundamentals of Standard Sleeve Resection.

Standard sleeve resection refers to the circumferential removal of a segment of the main bronchus in continuity with a lobectomy in order to avoid pneumonectomy. By doing so, surgery can be carried out in patients with compromised pulmonary function while also benefiting those with more normal function. It is most often indicated for malignant tumors located at the origin of the right upper lobe bronchus. Operative mortality is low and in the range of 2% to 3%, and quality of life and long-term survival are better than what is observed after pneumonectomy.

[What place for lung volume reduction surgery for emphysema?] / Quelle place pour la réduction de volume pulmonaire chirurgicale dans l'emphysème ?

Lung volume reduction surgery (LVRS) has been part of the management for the treatment of selected emphysematous patients for two decades. In a large randomized American trial (NETT), lung volume reduction surgery was shown to improve overall survival at 5 years as well as exercise capacity and health-related quality of life, especially in cases of upper-lobe-predominant emphysema and low exercise capacity. Inclusion criteria were pretreatment FEV1≤45 %, TLC≥100 %, RV≥150 %, room air resting PaCO2≤60mmHg and PaO2≥45mmHg. Patients with FEV1≤20 % and either a DLCO<20 % or homogeneous emphysema were at increased risk of mortality following LVRS and should not be considered for this procedure. Despite this evidence base, lung volume reduction surgery is performed infrequently, competing with lung transplantation and new endoscopic volume reduction techniques.

The history of acupuncture anesthesia for pneumonectomy in Shanghai during the 1960s.

The success of acupuncture anesthesia (AA) for pneumonectomy in Shanghai in 1960 was a key event for AA gaining practical clinical application. The effort was a close collaboration between the Shanghai First Tuberculosis Hospital and the Shanghai Institute of Acupuncture and Moxibustion. One of the most important factors of AA success was the great financial and political support provided by the Chinese central government and Shanghai local government. In December1965 the State Science and Technology Commission of China issued a formal document acknowledging AA as an important first-level national achievement of the integration of Chinese and Western medicine, and a collaborative effort of the whole scientific community in China. AA was an important influential factor that helped acupuncture spread across the world.

Evarts Ambrose Graham (1883-1957), doyen of pulmonary surgeons.

Evarts Graham performed the first successful pneumonectomy in 1933. Evarts Ambrose Graham, the son of a Scotch Irish surgeon, was born on 19 March 1883. After early schooling in Chicago, he graduated at Princeton and returned to Chicago to study Medicine, taking his MD at Rush Medical College in 1907. The chemical aspects of pathological changes then occupied him fully until 1919, when he was appointed full-time professor of surgery at the Washington School of Medicine in St Louis. Visualisation of gallstones temporarily took his attention, but bronchogenic carcinoma was seldom far from his thoughts, and he recognised (too late to save himself) the causative association with cigarette smoking by 1950. He died on 4 March 1957.

History of Cardiothoracic Surgery at Washington University in Saint Louis.

The Division of Cardiothoracic Surgery at Washington University evolved a century ago to address what many considered to be the last surgical frontier, diseases of the chest. In addition, as one of the first training programs in thoracic surgery, Washington University has been responsible for educating more thoracic surgeons than nearly any other program in the world. Beginning with Evarts A. Graham and continuing through to Ralph J. Damiano Jr., the leaders of the division have had a profound impact on the field of cardiothoracic surgery.

History of limited resection for non-small cell lung cancer.

A retrospective study of limited resection for lung cancer in a large number of patients was first reported in the 1970s. The reported outcome of segmentectomy was comparable to that of standard lobectomy. The North American Lung Cancer Study Group (LCSG) performed a randomized controlled clinical trial to compare limited resection (segment or wedge) with lobectomy for T1N0 (stage IA) non-small cell lung cancer (NSCLC) in the 1980s. The study revealed a significant excess of intrathoracic recurrence rate and a tendency to poorer survival in the limited resection group. Since then, limited resection has not been considered the standard operation for lung cancer. However, this situation is gradually changing, because the recent introduction of chest computed tomography (CT) to mass surveys has made peripherally located lung cancer detectable at the earliest stage. Several recent non-randomized studies of intentional limited resection from Japan demonstrated good outcomes comparable to those of lobectomy. Organ-sparing wedge resection without systematic dissection of lymph nodes may be suitable for some types of small lung cancers detected only by CT. Our meta-analysis of published data comparing survival rates after limited resection and lobectomy for stage I lung cancer revealed that limited resection was comparable to lobectomy. Further studies are necessary to define precise targets of intentional limited resection for lung cancer.

The King's anaesthetic.

King George VI underwent an operation for pneumonectomy in September 1951. Part of the operation anaesthetic record has survived. With conjecture, on a typical scenario of a 55-year-old male undergoing pulmonary resection for carcinoma in the early 1950s and other facts in the public domain, the King's anaesthetic has been reconstructed to give an approximation of the events that in the last few months of his life caused his speech to change from that achieved by his personal voice coach and recently portrayed on celluloid in the film 'The King's Speech'. The popularity and success of the film 'The King's Speech' brought to mind that King George VI died of bronchogenic carcinoma, a result, not recognised at the time, of the cigarette smoking habit that is a prominent feature of the story in celluloid.

Individual ligation technique for lower lobe lobectomy.

The classic description of the individual ligation technique for lower lobectomy was published in 1940. Doctor Brian Blades and Dr Edward Kent clearly described the anatomy of the bronchus, pulmonary artery, and vein to both the right and left lower lobes based on their dissection of 83 fresh cadaver lungs. They also provided a detailed description of their recommended technique for dissection, transection, and closure of each major structure. This was an important departure from the previously described mass ligation techniques. This cadaver experience was effectively transferred to the operating room. Kent and Blades reported on 18 patients who underwent lower lobectomy without mortality or the dreaded complication of "putrid empyema." They high-lighted several basic thoracic surgical principles necessary for successful lower lobectomy that are as valid today as they were then. This landmark report provided the impetus for thoracic surgeons to accept lobectomy as a safe and standard anatomical resection.

William E. Adams: Thomas Mann and The Magic Mountain.

The lobectomy for carcinoma of the lung performed by William E. Adams in 1946 on Thomas Mann, author of the tuberculosis saga The Magic Mountain, deserves to be added to Harold Ellis's series of "historically famous operations." This lobectomy, by which the surgeon cured his far more famous patient, was only one episode in his 40 eventful years as Chicago's leading pioneer in early thoracic surgery. The historic case is well documented by preoperative, operative, and pathology reports obtained through the courtesy of still-living witnesses and associates, friends of the author. Thomas Mann died 9 years later of an aortoiliac rupture at the University Hospital in Zurich. At autopsy no local recurrence or distal metastasis was found.

Classics in thoracic surgery: Total pneumonectomy. Rudolf Nissen, M.D.

In July, 1931, a 12-year-old girl sustained a crushing injury to the thorax. Tension pneumothorax, which suggested a tear in the left main bronchus, developed. Because of chronic pulmonary suppuration over the next several months, the decision was made to extirpate the left lung. Total pneumonectomy was attempted, but during the operation strong traction on the hilum resulted in temprary asystole. The operation was halted and resumed fourteen days later. The lung was freed and suture ligatures tied around the hilum, central to the bronchial obstruction. Two weeks later the necrotic lung sloughed off. A small bronchial fistula closed spontaneously. The patient lived for several years. Haight and Graham completed successful pneumonectomies in 1933, Traham's procedure being accomplished in one stage. In the 49 years since the first pneumonectomy, little has been added to the technique, save the achievement of superior hemostasis.

Hugh Morriston Davies and lobectomy for cancer, 1912.

The report of a lobectomy for bronchogenic carcinoma in 1912, by Hugh Morriston Davies of London, and without precedent, describes a surgical technique strikingly similar to that of today. Unfortunately, Davies' patient died because postoperative management of the pleural space was not yet well understood. The tumor had been identified by radiographic examination and the diagnosis confirmed by cytological examination of the sputum. The operative technique included individual ligation of hilar vessels and suture closure of the bronchus, neither of which was to be reported again for more than 20 years. More effective management of the pleural space was described, without special emphasis, by Harold Brunn of San Francisco 17 years later.