— You are dealing with thoracic surgery. What exactly does such a specialist treat?
— All diseases of the thoracic cavity and chest, including malignant tumors. The heart is usually operated on by cardiac surgeons, but in our department we perform unique combined surgeries, including the use of artificial circulation, in lung patients where the heart and great vessels are damaged together.
— Which intra-breast cancers are becoming more common among Russians?
— Over the past few years, lung cancer has become the leading cause of cancer in both men and women. Moreover, the patients became even younger. While previously our patients were over 60 years old, now we are 45-50 years old and women get sick more often.
There are two reasons for this statistic. First of all, early diagnosis has improved; The disease is detected earlier. Second, the overall global stress level has increased. Oncologists identify many reasons why cancer develops, but I lean towards the stress theory.
If we talk about women, stress also plays a role here. It is also believed that female sex hormones may play a role in the development of lung tumors.
There is a theory that during menopause the protective effect of female sex hormones weakens. This may contribute to the development and progression of lung cancer.
— One of the main problems of thoracic surgery is mediastinal tumors. What neoplasms do they include?
— Let’s start with what the mediastinum is. This is the space between the right and left pleural sacs, bounded anteriorly by the sternum with the costal cartilages and posteriorly by the spine. The mediastinum contains the heart with its large vessels, trachea, esophagus, thymus, diaphragm nerves, thoracic lymphatic duct, and bronchial tree.
Mediastinal tumors include a large group of neoplasms arising from various tissues: thymomas (tumors of the thymus), lymphomas (tumors of the lymph nodes), and teratomas (tumors of embryonic cells). There are many of them and they can develop at any age, but most often they are diagnosed in patients aged 30-50.
— Do mediastinal tumors have specific symptoms?
– Yes. Symptoms include pain: pain may radiate to the neck, shoulder and interscapula. Malignant tumors in this area are dangerous because they can grow into neighboring organs, metastasize and spread very aggressively. They often need chemotherapy before surgery.
Mediastinal tumors with left-sided localization can simulate pain resembling angina pectoris. These can be any tumor; it is impossible to single out specific ones.
In malignant mediastinal lymphomas, when a person develops a malignant tumor in the mediastinal lymph nodes, symptoms of compression of the organs in the chest cavity occur: cough, difficulty breathing and swallowing, chest pain, itching of the skin, and night sweats are often observed.
— You have had patients with neurofibroma. Can you tell us about this disease?
– Yes, we really had patients like this. Neurofibromas are nodules of nerve tissue and often occur in the mediastinum. These tumors typically cause pain and functional impairment.
Often patients may complain of changes in skin sensitivity or blurred vision. Also, if such a tumor is located close to the spine and ribs, it can cause various changes in these parts of the bone skeleton, for example, curvature of the spine. In these cases, patients often complain of chest and back pain.
Neurofibromatosis cannot be treated with chemotherapy or radiation therapy, so such nodes need surgery. We had a patient with a very large neurofibroma that completely surrounded the subclavian artery, putting pressure on the left lung and even causing a blood clot in the left ventricle of the heart. It was a difficult case.
— Have you ever encountered thymomas?
– Definitely. Thymomas are characterized by an aggressive course and can metastasize to the lymph nodes, lungs and chest wall, therefore aggressive surgical tactics are adopted: removal of the thymoma along with the fatty tissue in the thymus gland and anterior mediastinum, supported by chemoradiotherapy if necessary.
— Are there any special symptoms?
— It all depends on the type of tumor. Sometimes thymomas cause compression mediastinal syndrome, which is accompanied by chest pain, dry cough, and shortness of breath. Thymoma may also be indicated by a feeling of tightness in the trachea and large bronchi and respiratory failure.
In addition, there is a symptom of compression of venous trunks, in which the outflow of venous blood from the head and upper half of the body is impaired. These are voices in the head, headaches, facial swelling, and increased venous pressure. Compression of the esophagus is accompanied by swallowing disorder – dysphagia. It can be compared to the feeling of a lump in the throat.
In some patients, this tumor is accompanied by myasthenia gravis, which means pathological rapid fatigue of striated muscles. Thymoma can also press on the phrenic nerve, and this is a serious condition. Later, patients also have difficulty breathing.
— What do surgeons do in case of nerve compression?
— They usually remove it, but we performed the first surgery in Russia to reconstruct the phrenic nerve. The patient had a thymoma with metastasis to the chest wall and myasthenia gravis. He successfully completed chemotherapy, but the tumor remained and completely involved the phrenic nerve, so we had to remove the tumor along with resection of the phrenic nerve.
The operation was performed at the height of the pandemic, between waves of COVID-19, and the patient was in an older age group; He was 65 years old. Therefore, we decided not to leave the phrenic nerve without it, we cut and placed a piece of the intercostal nerve, that is, we reconstructed the phrenic nerve by inserting the intercostal nerve. After this surgery, the patient’s diaphragm continued to work.
— Which intrathoracic tumor is the most difficult to operate on?
— The complexity depends on the extent of the cancer: which organs it affects, which vessels it has spread to, whether chemotherapy, radiation therapy or immunotherapy was given before surgery. If so, the cancer is much more difficult to operate on due to multiple adhesions and fusions, meaning we lack anatomical landmarks.
These surgeries can only be performed by the most experienced surgeons.
Additionally, the tumor may be located at the periphery of the lung and not affect anything, or it may be in the center of the lung and affect a vessel, bronchi, pericardium, or mediastinum. In the first case, the tumor can be seen thoracoscopically. (i.e., through puncture of the chest wall using special endoscopic instruments or a robotic system) will work and should obviously work on the second one. If the patient cannot be operated on, he is completely transferred to chemotherapy or radiation therapy.
Elderly patients pose a particular challenge. In my opinion, this patient group is the most difficult group in modern medicine.
– Does this have anything to do with heart disease?
– Yes. Tumors are abundant in older age groups: 60 years, 70 years, 80 years. Cardiovascular diseases are common among them. In particular, similar lesions can be detected in more than 50% of our patients with lung tumors. This is coronary heart disease, damage to the valves, branches of the aortic arch, especially the carotid arteries.
Few clinics can provide complete treatment to such patients because they need specialists experienced in functional diagnosis who can make an accurate diagnosis.
— How are such patients treated?
“Sometimes we operate on both problems at the same time; For example, we remove the tumor and insert a stent. In such cases, we attract the help of surgeons of the relevant profile: cardiac surgeons, neurosurgeons, esophageal surgeons.
In other cases, operations are performed alternately if the situation allows. The problem is that sometimes dividing treatment into phases leads to progression of coronary heart disease; That is, myocardial infarction may occur after surgery. It’s good that the person is still in the hospital and we managed to transfer them to cardiac surgeons, but what if the person is at home?
— You are examining complications after coronavirus. Especially tracheal stenosis. How often does this complication occur after COVID-19?
“This complication does not only occur after coronavirus. It can occur in any situation where the patient remains on mechanical ventilation for a long time. This could be a car accident, traumatic brain injury, stroke, diabetes or even myasthenia gravis can lead to long-term artificial ventilation.
The longer the tube remains in place, the higher the risk of cicatricial tracheal stenosis because the lower end of this tube puts pressure on the mucosal membrane. First, an ulcer appears, then infection occurs and inflammation begins. When everything heals, a scar appears that narrows the lumen.
For an adult whose tracheal lumen is usually 2 x 1.5 cm, narrowing to 2-3 mm is fatal, and many die at home or on the way to the hospital without realizing what has happened to them. There are cases when such patients consult a doctor complaining of lack of air, noisy breathing, and therapists and pulmonologists often confuse this breathing with bronchial asthma, emphysema or bronchitis. These people are treated with inhalation, with mucolytics, until something happens: death or surgery by a thoracic surgeon.
— How do thoracic surgeons deal with this?
— The operation has two options. The first is a circular resection in which a portion of the trachea is completely excised. This surgery may be associated with a number of complications, including restenosis, which may require a tracheostomy. The second type of operation is tracheoplasty, in which a T-shaped tube is inserted into the trachea. On it, the tracheal lumen is formed within 6-8 months. Very good reliable operation, but the process is long.
— Unique operations have been developed and implemented in your department. What are these techniques?
– For example, we were not satisfied with operations on respiratory tract tumors – trachea and bronchi. Typically, surgeons cut out a piece of the trachea or bronchus and then stitch the whole thing together. In this case, the complication rate reaches 30% and even deaths may occur. Additionally, the patient sometimes needs to stay in hospital for up to a month.
We were not satisfied with this technique and put forward our own hypothesis: It is just a tube, we can remove a part of the wall and close the hole with autopericardium. Then the problem of complications is resolved and the patient can be discharged on the eighth day.
— How many patients have you operated on this way?
— All six of us got good results and even patented this technique. Before us, no one in Russia had performed surgery with this method. Additionally, this operation was performed thoracoscopically in four patients; This is often a revolutionary approach. Now we continue to improve surgical techniques. Our area of interest is very broad.