Sandy Holland: Pre-Surgery, The Procedure, and Post-Surgery

About eighteen months ago doctors found cancer in Sandy Holland's appendix. Her doctors quickly removed her appendix and Sandy recovered in no time. A few months later, Sandy, who is an elementary school principal in Lompoc, California, began experiencing increasing chest pain, shortness of breath and discomfort. The doctors at the Cottage Hospital in Santa Barbara found fluid on her left lung, which they drained.

In August, Sandy again began to experience discomfort and pain. They performed a second thoracentesis and the cytology tests revealed mesothelioma. In order to confirm the diagnosis, the doctors ordered a biopsy of the pleural tissue and/or tumor. The pathologists confirmed left-sided pleural (epithelial) mesothelioma.

Sandy's oncologist advised that the cell type of her tumor was far less aggressive than sarcomatous mesothelioma. According to her doctor, with a little radiation she could live "three more years." Sandy wondered if perhaps her longevity would be enhanced if she pursued other options beyond radiation alone. She and her husband, Bill, searched the Internet and discovered there was much more that could be done.

Sandy and Bill sought a second opinion. They met with Dr. Robert B. Cameron, Director of Thoracic Oncology, University of California, Los Angeles, on September 19, 1997. Dr. Cameron has operated on several mesothelioma patients at the UCLA Medical School. Sandy and Bill interviewed other thoracic surgeons and were pleased to have chosen Dr. Cameron. Dr. Cameron reviewed her chest films and CT scan films, which showed a small left pleural effusion but no significant tumor.

After analyzing the diagnostic data, Dr. Cameron sat down with Sandy and Bill and explained their treatment options. The first option was to treat only her symptoms and provide her relief from pain with no further treatment or attack on the cancer. This was called "palliative" care -- a concession that the underlying tumor is incurable but medical efforts could be undertaken to minimize pain.

The second choice was multi-modal: pleurectomy / decortication with intraoperative chemotherapy and postoperative radiation therapy. This method is where they make an excision (cutting away) in the pleura (the serous membrane around the lung). They also remove the surface layer of the lung or part of the surface lung tissue, along with any other layers of other organs (such as the diaphragm) where the cancer or tumors may be present. During the surgery chemotherapy is administered, followed by radiation treatments. These radiation treatments are usually directed at the areas of highest risk for recurrence.

Sandy's third option was a more aggressive surgery called Extrapleural Pneumonectomy. This surgery, also known as "EPP", consists of removing the pleural space, the lung itself, intrapleural infusion of chemotherapy during surgery and intense postoperative radiation. Dr. Cameron surmised that since Sandy's disease was found in the earliest stage, this type of surgery would not be of any real benefit to Sandy.

According to Dr. Cameron, experimental approaches using interleukin-4-based immunotoxin therapy and potential photodynamic therapy may be useful in years to come but for now could not be relied upon in Sandy's case. Dr. Cameron was of course aware that clinical trials were ongoing using these and other new therapies.

After thoughtful deliberation and further consultation, Sandy opted for the pleurectomy / decortication. On September 25, 1997, she underwent surgery. After applying general anesthesia, Dr. Cameron used a bronchoscope to inspect the airways of the lung and trachea.

Fortunately, the trachea and bronchi were free of disease. Dr. Cameron made a posterolateral thoracotomy incision starting in the back and encompassing the three previous incisions from the thoracoscopy. These sites were excised (cut away). Using electrocautery, an apparatus that cuts muscle and tissue with electrical current, Dr. Cameron carried the incision down to the latissimus dorsi muscle and detached the serratus muscle from its origin on the rib. The 6th rib was identified and cut from the border of the paraspinal muscle from the back to the costal cartilage (cartilage that joins one rib to another) anteriorly. The fibrous membrane (periosteum) surrounding the rib was elevated and removed.

It was time to focus on the pleura. The pleura was quite thin at the upper part of the chest and showed no significant signs of the disease. Since the pleura was so thin, great care and time was spent stripping the pleura off the lateral posterior and anterior wall of the chest. The pleura was then brought down over the heart, its large vessels, trachea, esophagus, thymus, lymph nodes and connective tissues. Dr. Cameron carefully avoided nicking the vagus and phrenic nerves. This area is known as the "mediastinum." As the pleura was stripped from the front, it was brought down to the diaphragm.

The dissection of the diaphragm took over an hour and was quite difficult. First, the pleura was removed from the superficial part of the diaphragm starting from the front and working toward the back. Dr. Cameron divided the muscles that were attached to the underside of the pleura and down onto the fibrous portion of the diaphragm. The fibrous portion of the diaphragm was then amputated and scraped. An Argon beam coagulator was used to coagulate the fibrous portion of the diaphragm. That part of the diaphragm was not removed because there was no obvious disease.

Dr. Cameron and his team then moved to the esophagus. One nodule was found that looked suspicious. It was removed and sent to pathology. The dissection was then carried up to the inferior part (undersurface) of the hilum (root of the lung), and the entire pleura was brought up to the hilum encircling the lung. The pleura was opened. Dr. Cameron found some adhesions on the lung from previous biopsies. These were carefully dissected from the lung as part of the decortication. Some soft tissue areas in the upper lobe of the lung were removed because they presented a potential breeding ground for tumors.

The pleura from the upper lobe of the lung was dissected. Moving down to the lower lobe, the doctors detected a nodule within the lung parenchyma. They removed this nodule and the other adhesions on the lung. The parietal pleura, visceral decortication and wedge of lung were all sent to pathology for examination.

Dr. Cameron's team then worked on the diaphragm. The 9th rib was moved so that the dissections of the diaphragm could be performed without difficulty. A very small hole was found in the peritoneum, and Dr. Cameron felt it needed to be reinforced. The hole was repaired with a bovine (cow) peritoneum. The diaphragm was plicated (pleated) slightly to keep the phrenic nerve, which had been stripped from the pleura over the pericardium, from being harmed.

After suturing the incisions, the lung was then re-expanded. The chest was irrigated with a sterile antibiotic solution just before it was closed.

Sandy was then placed on her back, awakened, extubated and taken to the recovery room. She was in stable condition. There were no complications during the surgery, and she did not receive any blood products during the operation.

On October 10, 1997, Sandy went in for her routine follow-up care with Dr. Cameron. She was having some complaints of chest pain and had been taking medication every four hours. Her breath sounds were diminished on the left side, but they were clear. Her x-ray showed signs of haziness over the left lung, which is considered normal at this stage of her recovery. Dr. Cameron feels that her left lung will clear up but may have some chronic pleural scarring. Sandy was to begin her radiation treatments approximately four weeks later.

** POSTED DECEMBER 9, 1997 **

Ms. Sandy Holland passed away on January 25, 2000