Pioneers Advance Surgical Management of Lung Cancer

Hippocrates encouraged surgeons wanting to gain hands-on experience to “go to war,” and Ambroise Páre in the 16th century proclaimed war to be the greatest school of surgery.¹ However, without an understanding of pulmonary dynamics, surgeons struggled with chest injuries, uncertain whether to close or leave open full-thickness wounds and, thus, were limited to pulling spears and arrows and suturing lacerations.

A move in the right direction finally came when Dominique-Jean Larrey (1766 1842), a French military surgeon and chief surgeon to Napoleon Bonaparte, closed an open chest wound, which improved the soldier’s breathing. Traumatic lung herniation presented an early opportunity for a limited lung operation as an example from 1499 illustrates. A hesitant Italian physician named Rolandus described his experience: “Called to a citizen of Bologna on the 6th day after his wound I found a portion of the lung issued between two ribs…and it was not possible to reduce it. This compression exercised by the ribs, retained its nutrient from it, and it was so mortified that worms had developed in it…I, yielding to his prayers…made an incision through the skin…Then with a cutting instrument I removed all the portion of the lung, level with my incision.”²

Procedures, such as the one described by Rolandus, which showed a patient could not only survive but also function after the loss of lung tissue, were supplemented in 1861 when Jules-Émile Péan, a renowned French surgeon of the 19th century, found a chest wall tumor invading his patient’s lung and simply excised the involved lung with the tumor, providing more confidence that patients could tolerate some amount of lung loss. These procedures nudged the process forward, but each failed to be an intrathoracic operation, which Block, a Polish surgeon, attempted in 1841. After practicing with rabbits, he resected the lung apex of his cousin for tuberculosis. As observed by author R. H. Meade, “…unfortunately his cousin was not as hearty as the rabbits and died.”¹

Apparently devastated, Block committed suicide soon thereafter. Nonetheless, interest in treating lung infections persisted, especially for tuberculosis and bronchiectasis. These were difficult and typically unsuccessful operations. In 1923, Evarts A. Graham, MD, FACS, former ACS President (1940–1941), found 48 reports of lung resection for bronchiectasis with a 52% mortality rate, and enthusiasm for these procedures waned.

First Successful Pneumonectomy

In 1895, the Scottish surgeon William Macewen, CB, FRS, FRCS, removed a patient’s lung, which was riddled with both tuberculosis and bacterial infection, by essentially shelling it out. There was no attempt to control hilar structures that were presumably buried in an inflammatory mass. The patient survived and, even though it was an inelegant undertaking, Dr. Macewen is credited with performing the first successful pneumonectomy. Dr. Macewen was a formidable individual and had little tolerance for ignorant behavior. He once found himself in a railway carriage with an offensive drunk and “he placed his two thumbs inside the mouth of the drunken fool and dislocated the man’s lower jaw so that he sat absolutely dumbfounded…for the rest of the journey. Then…the jaw was liberated.”³

By declining the chair of surgery position at Johns Hopkins, he opened the door for William S. Halsted, MD, FACS(Hon), to make his seminal contributions. Two other surgeons advanced lung surgery with a focus on infections. Rudolf Nissen, whose eponym is featured in antireflux surgery, reported the first successful “true” pneumonectomy in 1931, when he removed the lung of a 12-year-old girl with chronic bronchiectasis following a chest injury. He suture ligated the hilum but left the lung in situ allowing it, deprived of its blood supply, to eventually slough off. Cameron Haight, MD, FACS, from the University of Michigan in Ann Arbor, repeated this feat a year later in a 13-year-old girl, although he ligated the two left lobes separately. The patients were so hemodynamically unstable that the surgeons had to abort first attempts, necessitating a second and successful operation. Both patients survived, and lung surgery began inching forward.⁴

Lung cancer is now the most frequent reason for lung resection. This all-too-common malignancy received little attention until early in the 20th century following the introduction of x-ray technology in 1895. Dr. Graham, leader of the Empyema Commission during World War I, famously performed the first successful operation for lung cancer with his pneumonectomy in 1933 in St. Louis, Missouri. He was prepared for the challenge. As chair of surgery at Washington University in St. Louis, he was an experienced surgeon, had performed lung resections in animals, and had considerable experience with thoracic procedures such as the infamous operation for bronchiectasis. Dr. Graham chose pneumonectomy for this patient because the tumor was at the orifice of the left upper lobe. He performed a left thoracotomy and occluded the pulmonary artery to assess the patient’s response. Satisfied the patient could tolerate the operation, Dr. Graham ligated the hilum and “mass transfixion (sic) ligatures were placed in the hilum, and the lung was removed.” He implanted radon seeds in the hilar tissues to address possible remaining cancer.⁵

The patient endured postoperative infections, survived, and though several subsequent patients did not, this precedent established surgery for lung cancer. Over time, surgeons have established lobectomy as the operation of choice for localized disease, balancing preservation of lung function and cure. Removal of even less lung by segmentectomy or wedge resection—also known as precision surgery—is now performed for very localized disease.

Following Dr. Macewen’s precedent, Dr. Graham also declined the offer of chair of surgery at Johns Hopkins, in this case opening the door for Alfred Blalock, MD, FACS, former ACS President, and his accomplishments. Strong and bold surgeons developed and advanced chest surgery in general and lung surgery in particular. Thoracic surgery has come a considerable way from primitive and hesitant undertakings during a relatively short time. Fewer than 100 years have passed since Dr. Graham’s milestone operation. But evolution and innovation have not ceased. We will see new techniques that are as revolutionary as the advent of minimally invasive surgery and revised surgical strategies that leverage the power of new chemotherapy and immunotherapy agents.

Dr. Alex Little is a clinical professor at The University of Arizona in Tucson.

References

1. Meade RH. A History of Thoracic Surgery. Springfield, Illinois: Charles C Thomas, 1961.
2. Paget S. The Surgery of the Chest. London, United Kingdom: John Wright & Co.,1896:43-45.
3. Little AG. Cracking Chests: How Thoracic Surgery Got From Rocks to Sticks. Boston, Massachusetts: SDP Publishing,2022:148-149.
4. Nissen R. Total pneumonectomy. Ann Thor Surg. 1980: 29(4):390-394.
5. Mueller CB. Evarts A. Graham: The Life, Lives, and Times of the Surgical Spirit of St. Louis. Memphis, Tennessee: Decker Inc.,2002:117-140.