Bring it on! Kermit Kelley and wife Kerry await final instructions before surgery. UCLA's David Geffen School of Medicine, September 27, 2007.
All Systems Go!
In one hour, 68 year-old Kermit Kelley was about to undergo life-altering
surgery. It was nine a.m. in the pre-op staging area at UCLA's David
Geffen School of Medicine. A steady stream of nurses and doctors had been
visiting Kermit since seven o'clock, hooking him up to this, inserting that.
Since his diagnosis with malignant mesothelioma in July, 2007, Kermit and
his wife Kerry had pored over the medical literature. They asked all the
questions: Should he have chemotherapy? If so, when-before surgery or
after? Should he even have surgery? If so, what surgery? The extra-pleural
pneumonectomy (EPP), in which the diaphragm, tumor and lung are amputated?
Or the pleurectomy / decortication (P/D), in which the doctor removes
only the tumor and spares the lung?
Sifting for a solution
The answers were not clear cut. "We knew that lots of doctors liked
the EPP," said Kerry. "But we hated the idea of losing Kermit's
lung. Why take out the lung if it's healthy and free from cancer?
It just didn't make any sense."
The Kelleys learned that the EPP was widely considered to be the surgical
standard of care. "Sure, it's the standard," said Kerry.
"But what does that mean? The standard for every breast cancer used
to be a radical mastectomy, and now we know how wrongheaded that was.
I'm no doctor, but I've got common sense, and some things just
don't feel right."
They knew that neither operation would cure Kermit's mesothelioma.
Both operations, even if performed by a world-class surgeon like Dr. Cameron,
would leave microscopic malignant cancer cells in the chest cavity. They
learned that recurrence was virtually certain, that it was a matter of
"when" rather than a matter of "if."
"Then we found out that the EPP can sometimes actually speed up the
spread of the disease. That really scared us. Why would we do a surgery
that takes away a healthy lung and helps the cancer grow in other parts
of his body? It didn't add up."
The Kelleys were troubled that if they had the EPP, the risk of cancer
spreading might increase, since the surgeon typically removes the entire
diaphragm, a cutting process which can create holes through which malignant
cells metastasize elsewhere by spilling into the peritoneum.
Since the tumor's recurrence is a virtual certainty, what if it cropped
up in the only good lung after the other lung had been removed? What then?
The evidence began to tilt in favor of Dr. Cameron's pleurectomy /
Dr. Cameron advises Kermit of test results showing the tumor had encased
the lung and locked up the diaphragm. Game plan: liberate the lung, restore
normal lung function.
The Kelleys consulted with Dr. Robert Cameron, director of the Mesothelioma
Program at UCLA.
"I liked him right away," said Kermit. "Forthright. No sugar-coating.
Compassionate. Objective. A man you can respect after the first five words
come out of his mouth."
Adds Kerry, "Dr. Cameron didn't promise a cure or tell us that
his surgery was always better than the EPP. He laid out the facts-because
of all the other parts of therapy and other factors and such, you can't
scientifically say one is better than the other. But he did say he would
try to buy us some time."
If the surgery succeeded, the post-operative period would allow them to
also pursue complementary therapies such as immunotherapy with interferon
alpha. Dr. Cameron explained that the published survival data did not
clearly favor the EPP over the pleurectomy. He advised that more articles
were being published that questioned the presumed merits of the EPP over
the P/D, much as surgeons years ago began to question and later discard
the strategy of performing a radical mastectomy for every breast cancer.
The Kelleys were also impressed with quality of life issues after the surgery.
"I've got a good heart, but I was concerned about putting more
stress on my ticker if I only had one lung," Kermit said.
Kermit, a career water works contractor in the public and private sector
for over thirty years, knew the value of hard work. "Sometimes doing
the job right means working harder and longer. You know that on the job
site, but you don't ever think about it like that with surgeons. You
know, it's true. Sometimes the difference between doing a good surgery
is kind of like doing a good piece of carpentry, the guy who is more patient
and has more experience and knows his tools better and knows his wood
better is the guy who does the better job. You don't think of working
on a lung the same as working on a cabinet, but I suppose when you get
down to it, maybe it is."
Search and destroy.
Dr. Cameron (R) and Dr. Peng (L) opening the chest. The thick rind of
tumor was immediately evident.
The Kelleys learned that the EPP was a simpler procedure that took 3-4
hours, whereas Dr. Cameron's surgery was more complicated, and often
took 4-9 hours, depending on whether the tumor had invaded the chest wall,
heart sac, or diaphragm. Kermit read that each procedure cost about the
same, but that Medicare paid the surgeon more for the easier EPP than
for the longer, more arduous P/D.
Crossing the Rubicon
"That did it for me," Kermit said. "Dr. Cameron is willing
to work twice as long for less money because he believes the pleurectomy
is the way to go. If I'm going to let a doctor stick his hands into
my chest, I want the hands of a skilled craftsmen who's not afraid
of hard work. That's how I was raised."
Kermit decided that he could more effectively pursue the healing process
with two healthy lungs rather than one, quarterbacked by a doctor who
was not afraid of a hard day's work, who was an expert surgeon, and
who was committed to helping his patient from start to finish. "I
didn't want a surgeon who would cut and run. I know this is a long
haul. I wanted a doctor who would help us with options after surgery."
Adds Kerry: "We believe it all came down to quality of life. With
two healthy lungs he has a better chance of recovering from the surgery
and has a better chance of living a high quality of life.
A tumor that slowly suffocates
Thoracic surgery is one of the surgical specialties whose practitioners
are often regarded with awe. These are the men and women who operate on
and around the heart and lungs, the organs that more than any except the
brain symbolize humanity and life. The P/D begins by cutting open the
chest, clipping out a rib, and spreading open the chest wall.
In a healthy person, such a procedure would reveal the lung and diaphragm,
working together to pump air into the oxygen-hungry body. But in Kermit's
case, the open chest revealed a smooth, red, thick rubbery blanket that
encased the entire lung and stuck like cement to the chest wall.
The massive mesothelioma tumor had grown around his lung, compressed it,
and finally collapsed it. He had only one lung working now, and the void
in his chest testified to the power and destructive force of the relentless tumor.
Stripping away the serpent
Dr. Cameron first explored the extent of the tumor with his hand, inserting
it into Kermit's chest. Although the PET scan had depicted the tumor
as small to moderately sized, reality proved far different. As it slowly
strangled his lung, the cancer had also latched onto the lining of his
heart and his diaphragm. Inveigling itself with a complex network of veins
and arteries, the giant tumor had positioned itself so that removing it
might be more dangerous than leaving it alone.
The devil by its horns.
After stripping the tumor off the chest wall and lung apex, Dr. Cameron
holds a flap of tumor. Fours hours to go.
It became clear in an instant why so many surgeons prefer the EPP and eschew
the P/D: patience and skill. Working the tenacious and deadly tumor away
from the organs and arteries had to be done millimeter by millimeter.
The patience, concentration, and methodical repetition required to strip
away the cancerous blanket are monumental. It takes all of that, plus
nimble fingers, which are probably the surgeon's best tumor-stripping device.
Uncertainty was another factor. What if after all the hard work of chiseling
the tumor off the chest wall and diaphragm it turned out the tumor had
trespassed - i.e., contaminated - the actual lung lobes? If the surgeon
simply amputated the entire tumor-encoated lung, without daring to strip
it off, and it later turned out the lungs were tumor free, well, by that
time it would be too late. More risk, more tedious labor were the only
certainties. But, with all big risks comes great pay-offs.
Dr. Cameron's legendary stamina was evident after the first few hours
passed. Never leaving his patient's side for even a second, he carefully
and laboriously performed his delicate work. As other members of the surgical
team finally succumbed to fatigue or shift's end, Dr. Cameron remained
at the helm of his ship, calmly, patiently, firmly guiding the hulk of
his surgical team to its final destination: peeling away the cancer within.
Dr. Richard Peng, an enormously talented young surgeon from Orange County,
worked in tandem with Dr. Cameron, following his guidance and working
with extraordinary care and precision within the narrow confines of the
chest cavity. Dexterously using his surgical tools as he sutured together
a patch of bovine diaphragm to replace the pieces of diaphragm lost to
the tumor, Dr. Peng displayed the same level of focus and complete absorption
as his mentor. They had to, as stripping away tumor off of a 2 mm thick
sheet of muscle is like cutting glue from the surface of a balloon without
puncturing it. Dr. Cameron and Dr. Peng were well aware of the risks of
nicking the diaphragm and thus providing a portal through which the malignant
cells could travel to the gut.
The beating heart
Dr. Cameron holds the thick, rubbery tumor after meticulously scraping
it off the thin diaphragm muscle.
Kermit's tumor, however, had decided to throw Dr. Cameron a curve.
In addition to its insidious growth along the lung and diaphragm, it had
snaked its way up to the pericardium, the delicate sac that encloses the
human heart. Removing the tumor without damaging the pericardium was crucial
to keeping the cancer off of the heart. In a worst-case scenario a patient
can live with only one lung-the same can obviously not be said for the heart.
By now the operation was six hours long, and at a time when most people
would collapse simply from having to stand in one place for so long, Dr.
Cameron was just as focused and fresh as the moment he'd begun-never
mind that he had left the operating room the prior evening at midnight.
Never moving from his patient's side, he and Dr. Peng carefully began
what can only be described as a procedure that is delicate beyond belief.
The attempt succeeded, and the heart was safe.
The home stretch
A full seven hours into the surgery, Dr. Cameron moved to the final part
of the operation: removing the tumor from the lung itself. This part of
the surgery has often been called "impossible" by experienced
thoracic surgeons, since the tumor creeps down into the deep folds and
fissures that separate the different lobes of the lung. With a smile,
Dr. Cameron showed the "impossibility" of this aspect of the
surgery, using the most sophisticated and delicate instrument ever created:
his index finger.
Gently moving his finger into the fissures, he easily lifted out the tumor.
Soon enough the entire cancer was peeled back like the diseased rind of
an orange and removed from Kermit's chest. Beneath the cancerous blanket
lay a big, pink, healthy lung, waiting to step up in its lifelong service
to the body's blood. With a twist of the anesthesiologist's knob
that poured life-giving oxygen into the collapsed lung, the lung filled
with air and swelled up to recapture its former space within the chest.
Dr. Cameron watched for a moment, and then said with a smile, "Look
at that. A perfectly good lung. Why would anyone want to cut that out
and throw it away? I think it looks pretty good right where it is."
Let my lung breathe!
Dr. Peng holding the tumor while Dr. Cameron peels the tumor from the lung.
About nine hours after opening up Kermit's chest, Dr. Cameron and Dr.
Peng removed the four-pound tumor in one piece from the cleaned up chest
cavity. "Fruits of their labor?" Not exactly. The fruit of their
labor was still inside Kermit's chest, where it belonged, a pink plum
of a human lung, ready to return to action. Not a bad pay-off for a few
extra hours of hard labor, especially for Kermit and his family.
Mesothelioma patients giving back
Kermit's desire to educate patients, doctors, and the world about mesothelioma
and its treatment is a common thread that runs among victims of asbestos
John McNamara, a mesothelioma survivor like Kermit who was also treated by Dr. Cameron,
decided that he would lend a hand as well. John and his wife T.C. bought
an apartment in Los Angeles, furnished it, and made it available to any
mesothelioma patient seeking consultation or treatment from Dr. Cameron.
This generous donation made the Kelleys' initial visit and surgery
in Los Angeles possible. Generosity tends to spread. Like the McNamaras,
the Kelleys before and after the surgery expressed their wish to help
educate others about Dr. Cameron's surgery. "We'd like others
to know about the surgery," said Kermit, who agreed to having his
surgery photographed. "I don't think of myself as either a 'guinea
pig' or a 'trailblazer.' I'm just a guy who's making
the best of a bad situation. I've learned a few things from patients
before me, and I hope to contribute my own story."
Working together, and coordinated through the Pacific Meso Center, the
McNamaras and Kelleys have helped turn another page in the treatment and
education about this disease.
*** POSTED OCTOBER 8, 2007 ***