“And when we were removed is the 40th metastasis, assisting me the head of children’s section said: “What we do from a light, almost nothing remains, what are we doing?” To understand I can say – in Europe a patient who has more than 10 metastases were considered inoperable” for the salvation of the doomed love of surgery and the wonders, which is not the case, says oncologist Eugene Levchenko, head of the surgical thoracic Department of SMRC Oncology. N. N. Petrov.
Photo: Evgeny Levchenko / Facebook
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In search of metastases every millimeter of light – fingered
– Widely known your surgery when you removed the girl about 70 of lung metastases. The complexity was in their number?
– Exclusivity in this case is not the number of distant metastases, I know in other clinics were removed and larger number of them. The uniqueness is that this patient lives nine and a half years without a relapse. In March, we are ready to celebrate 10-year anniversary of surgery. And just want to say that it is not only our surgeons success. It is the success of our Institute! In the treatment of this patient participated in a huge number of doctors of various specialties, primarily pediatric oncologists.
Returning to our stage, the stage of surgical intervention: generally, these operations neither in our country nor in Europe, nor in America is not widely implemented. To date we have made about 180 such operations. What is metastatic cancer? Stage IV is when tumor cells from the blood are carried throughout the body.
And there is a narrow category of patients, where the cells grew, realized only in the lungs. These patients need system-that is, chemotherapy, treatment. But sometimes chemotherapy is not effective, and at a certain stage chemiotherapeutic say – we have nothing we can. And it is this category of patients we can help with our technique.
In 2007 we had the first patient with bilateral metastatic lung, and she had an increase in lesions in the lungs on the background of the conducted treatment. I read that there is a certain method, it has Europe’s only cardiac surgeon Paul Van a Shil, it was written off, he “blessed” us for such an operation.
The technique is easy off from the circulation, it then adjusted its own blood circulation with high doses of cytostatic drugs, which must overcome the resistance to chemotherapy and the highest dose can affect the micrometastases, to prevent metastasis. The first patient we performed the operation on the one hand, but she was still two lesions in the other lung.
We weren’t sure of the technique – it’s experimental, so two months later, just extracted it in the second lung metastasis, without chemoperfusion. And 11 months later the second light has relapsed metastatic process. We went to surgery again – removed recurrent lesions with perfusion. And this patient since 2007 lives without progression and without the need for chemotherapy.
After this incident, we have improved the technique by adding an additional anticancer agent, and began more extensive use of this technology.
Two years after introducing the adults to the children’s Department of our center was hospitalized a girl 16 years old with osteosarcoma stage IV. First she made a prosthetic to save the leg, but then had it completely removed.
Despite many courses of chemotherapy, the lung metastases remained. And they were more than we expected to start the operation. And you need to remove everything, and it’s not just took scissors and cut.
The metastases can be removed with electrocautery precision – within healthy lung tissue, and then each hole in the lung need to take. And that’s when we have removed already 40 metastasis, assisting me the head of children’s section said: “What we do from a light, almost nothing remains, what are we doing?” To understand I can say – in Europe a patient who has more than 10 metastases were considered inoperable, conduct intervention – is inappropriate.
You at that moment wasn’t scared, didn’t want to stay?
– Well, my colleague tried to stop me. Problem: metastasis metastasis hatred, sometimes it occupies the whole of one lobe, and it was small metastases, however, if not removed, the point is lost. We removed 42 of metastasis on the one hand, but on the other hand, they were – through two cycles of chemotherapy, we removed 28 from the second lung metastasis. Then she had a relapse, the pulmonary ligament on the right is not the lung tissue and lymph node, we again operated the girl. And now this girl lives without progression for more than nine and a half years. I want to repeat this figure.
– How laborious such an operation?
Very, it can take three to five or six hours, depending on the number and localization of metastases. Sometimes the metastases grow in larger bronchi, and then there is the need to use bronchoplastic is resection with subsequent suture of the bronchial tubes.
Easy, it is air, and therefore got this name. During the surgery, the patient due to anesthesiology breathing with one lung, and then the operated – collapses, and it is necessary to palpate each mm – all with your fingers. The CT scan shows, say, 10 metastases, and when velperweg is more is more small pockets that were on the CT for shadow of the bronchus, vessel.
– And where is the guarantee that something won’t miss?
– That metastasis will not remain in the lung? There are no guarantees. And you asked the right question. This feeling is very complicated. When we go on such an operation, we have a chart for every metastasis in three planes, so we all found them.
Print, a kind of “passport” for each metastasis are hanging in the operating room as soon as I removed the cards are taken one after the other. But sometimes, when multiple lesions are very small and very soft to the touch metastases, when the tissue of the metastasis is no different from lung tissue, can be a hearth and miss. This happens in about one case out of 30.
But now we have a little sigh because we have a cyber sword with a telescopic sight – it allows you to sum up disastrous for metastases radiation dose. Unfortunately, it is possible to do with only 1-2 foci in the lung, but if more than three already there.
– This was the maximum number of metastases, 42 and 28?
Was more 61 metastasis in one lung, and two 106, at the young man. Chemiotherapeutic come and say: we conduct therapy, but he has a malignant giant cell tumor with destruction of the cervical and thoracic vertebrae, the risk of fracture of the spine. We worked together with the spine, it was a very bloody two-stage operation, we have three vertebrae removed, raised all of the elements that supply blood to the arms and head, trachea, and separated from all of the spine to remove a tumor and protezirovanie body remote vertebrae. Then removed the 45 metastases of the right lung with hemiberlesia, and after 2 months the remaining 61 lesion of the left lung with perfusion.
Two years this guy lived absolutely fine, rode a Bicycle, opened his own business – a hotel for cats, then it was a progression – we removed one metastasis, now he is on targeted therapy and feels well, everything is under control. And the tumor is destroyed the body of the vertebrae, the spine would be broken, there was a palsy, passed out fully his feet and not only.
We must understand that we do not take patients just on a “have metastasized” it is not a universal surgery. Our patients are insensitive to chemotherapy, or those who have already carried out three lines and there is no possibility of further systemic treatment, or patients who have achieved some sort of control and residual tumor to be removed.
Now our youngest patient is four years old, he has 10 of metastases in each lung.
He calls himself Alexei Maximovich, the four-year. Every morning the Director of the Institute does bypass patients are in intensive care, all heads report to patients. Alexey Maksimovich lies on the first day after surgery, watching the whole thing and says: what are you doing here all together? Then he looks at the Director and says: what are the most important? Director: well, Yes. And he said: no, I’m the main.
– In General, everyone understands.
– If you look, he’s right, and the Director agreed with this, for all we work at the forefront of the patient. When they brought him in for a second surgery, the staff left him with the words: “Alex, look, mom said that you’re not supervised”. He had osteogenic sarcoma of the right shoulder, now he has a temporary spacer until the knob is not raised, but ready for the prosthetics – he’s currently made an individual prosthesis that is planned reconstructive surgery.
It is very typical, that my mom sent me pictures of him recently. These patients tie. He’s thinking something quite different, I said dad I died and I die. I met him at CT, he’s come to visit me, I live near here.
– And other clinics are trying to do such operations?
In Europe they are made in 3-4 clinics in Germany, Holland and Belgium. We have also tried. This operation is very, I would say, “technology-intensive”, and when we started, the assistants were just afraid – nobody wanted to go with me and help. Very intense and risky operation, the requirements for assistants is high, the understanding should be complete, if there is any misunderstanding – this is not a plus. But now a day on the table can be two perfusion.
One day, I was in Spain, call a local number, I thought the hotel phone. It turned out, Russian-speaking the lost girl: a huge tumor, left lung all of it is filled. The tumor compresses the superior Vena cava, the blood from my head not coming out, therefore, a cyanotic hue of the face and hands, the patient can not even lie – last week this girl was sleeping while sitting. She is originally from Uzbekistan, working in a modeling Agency – they organized a festival to raise money for her treatment by air ambulance was transporting her to us, operated. Left it on my legs, but I can’t say that everything is fine – there are metastases in the brain. But at that stage – a week, and she’d be gone, we completely removed the tumor, she had opportunities for therapy.
We put the house box, the inside of the webcam, picked up discarded tools began to sew-knitting
– Besides easy you still operate the esophagus?
– Yes, and mesothelioma of the pleura, which is also in the country, unfortunately, no one is operating. Alas, when tumors of the mucosa of the esophagus, the median survival after surgery – 13 months. This is the most difficult operation in surgery of the gastrointestinal tract, and shortly thereafter patients are progressing and everything ends.
– Patients in this case do not refuse to carry it out?
But it’s the median, that is, someone can live five years and some die after two months. Before surgery we began to carry out chemoradiation therapy our results show that this increases the median survival rate is already up to 26 months. Constantly need to move forward.
The next stage of minimally invasive surgery, we also became one of the first to do laparoscopic surgery on the esophagus and thoracoscopically. I am generally very “open” surgeon doing the traditional surgery, and when I was told about the laparoscopic surgery on the esophagus, every time I spoke – but not for Oncology.
And how long have you been thus operating?
2012. The trend became visible, I realized that if I do not begin, start the other. Another motive which has induced me to do this reorganizationist my words against minimally invasive technologies in surgery of the esophagus. I believed that my arguments “against” professional community are not perceived, because I don’t operate that way. I set myself a task: learn how to operate thoracoscopically then tell you that the esophagus should not be – and will hear me. We put the house box, the inside of the webcam, picked up discarded tools began to sew, to knit.
Head of abdominal Department of our center Alexey Karachun I was told: “let’s do esophagus oracleparameter, let’s do it”. And he is a great expert, and I understand that he wants his influence, and in the esophagus to spread that I was operated on in an open way. That is, the threat is real (laughs).
And I started on weekends and evenings to prepare, then Alexis says – did the patient with cancer of the esophagus, let’s do it. Came the day X, he also washed, comes and sees that I’m starting thoracoscopic stage – looked, dropped the gloves and said, OK, here I go. But the second laparoscopic stage of this patient he had.
Then he went on a business trip for a week, and we have more sick, and I myself have made and the laparoscopic stage. He came back with me: I know! Told me everything! (laughs). Now I do it all by myself, performed about 200 such operations and I do not dare to say that oracleparameter intervention – not a subject for discussion for cancer of the esophagus.
And about pleural mesothelioma: imagine that light is like a ball lying in the bag, the outer ball shell and the lining in the bag is the pleura covered with mesothelium. And if a tumor arises in this part, it affects the lining, and the upper shell of the lung.
Operations in this case can be two: the large spread of total removal of the lung along with the shell on the chest wall. The second – more complicated: shell “lining bag” – detachable from the chest, and then another, in millimeters discharge the entire shell is easy.
It’s like a thinly, thinly to peel away the skin from the green Apple, not with a knife, and tweezers, with the same thoroughness with easy all you need to remove, but there is also interlobar fissure, mediastinal structure.
Very time consuming process, we now have two such patients preparing for surgery. And I know this one patient for the whole day – the operation may take 8-9 hours. After lung completely “cleansed” in the pleural cavity there are two drainage. Two hours before suturing the surgical wound, intravenous even introduced a special drug to tumor cells it accumulate, then the lamp is supplied with laser beams, and those cells which are “grabbed” this drug die.
After wound closure, the patient remains on the operating table in one drainage served warmed high-dose cytostatic, from the other he poured. This is done in case where something left a malignant cell.
– How wash out?
– Yes, lavage of the pleural cavity at a temperature of 42 degrees Celsius for two hours – the tumor cells are very sensitive to increases in temperature, it is fatal to them.
I say about the bleeding, the traffic police asked: how to prove?
And after such an intervention feel you and your team?
– Fatigue? Yes! But there is a sense that covers it in spades is a sense of satisfaction. I after such operations driving very slowly – I stopped a couple of times, the traffic police to check drunk if I say no, sometimes people just get tired. With the cops, by the way, was the case – to their credit, I must say.
They called me last night – postoperative bleeding in a patient, and I’m a 20-minute drive from the Institute. I woke up my son – he’s a doctor, too, and we raced. The time was 2am, we looked at the one intersection, ran a red light, and then again, and traffic cops. I roll down the window and blurts out about the bleeding, they ask: how will that prove? I show SMS from colleagues in the office, they immediately say – no problem, sir. A second employee reviewed the documents of the son, managed to shout after you have the insurance ends, don’t forget! At five in the morning I was returning home with the patient all is well, went to see him, gave a bottle of brandy.
Your son is also a thoracic surgeon?
Yes. And I, honestly, tried to dissuade him from going. His grandfather was also a thoracic surgeon. My wife’s oncologist.
Grandma – she’s a psychologist, too, tried to dissuade him: look upon the lives of their parents, the mother calling in the midnight white blood cells low, dad is worn with complications that you want that life? As it stands, 16-year-old, and said: well, I always wanted to be a doctor.
He just didn’t know another life.
We tried to find easier specialty, he had a rotation, we sent him to mammology, gynecology, and he likes thoracic surgery, well, like, like. This is important.
In Stavropol, in residency, my first teacher Yuri S. Gilevich, by the time he is already doomed and, as a doctor, it’s understood – he had a malignant tumor, two of nephrostomy tube, and in this state, he asked me: “Zhenya, do you like surgery?” I started something incoherent reply, and he, without waiting for the end: “And you love her, and she’ll give you a hundredfold.”
He didn’t teach me to knit knots, to operate against the patients – it gave me my next teacher, but he gave me the formula for a happy life – doing things you love that you are still paying money. If you do not love – there will be trouble. Without love in the perestroika period, residency, lack of money, I think I would have been gone a long time from surgery.
In General, I wanted to be a therapist, just was interested in went from five clubs, including surgery, which then won.
– In the end it turned out thoracic surgery?
– When I was a teenager, I had a dream – I remove lung cancer. Well, dreamt and dreamed, I thought, but the other dreams about a medicine I had. When I after graduation he studied in residency, I was first put in septic abdominal surgery is a nightmare, peritonitis, pancreatitis, fistula. By the end of the year, I come to the head of the Department, my second teacher albert Shakirovich Vafina, and say: I like it purulent abdominal surgery, leave me here. And he said: no, you will now go in vascular surgery. Well, I gritted his teeth, went.
End of the second year, I go and say: I liked it so much, I have so many ideas on possible reconstructions, anastomoses, shunts, leave me in vascular surgery. By the time I had entered graduate school. Me again: no, go to the thoracic. That’s it, I stayed. But now, if during the operation meet to the border situation, and esophagus confirmation, I was not afraid of the need to go into the abdominal cavity.
If the tumor grows into the superior Vena cava, usually called vascular surgeons and I performed vascular reconstruction in bronhosekretoliticheskie operations, and the insertion of the superior Vena cava. And I am very grateful to the head of the Department, through which I passed, and feel comfortable in any situation. I can’t say that perform coronary artery bypass grafting, that’s not my Department, but the same chemoperfusion, I think, without knowledge of vascular surgery would have been impossible.
Or the bifurcation of the trachea is a place of separation. If the tumor goes to the bifurcation of the trachea, any thoracic surgeon can say that it is inoperable situation. And 20 years ago, I was in Stavropol, was invited to the cardio – they decided to change the patient’s pacemaker and found the lung tumor, which passed into the trachea. I say: there is one operation, but I have only read. I have not had the opportunity to see these operations, the Internet and YouTube did not exist.
I mail-ordered a cassette tape for VCR – recording operations that were carried out by the academician Mikhail Davydov. And I have watched hours of these operations, all the nuances, scrolled back and forth hundreds of times. The eldest son, then a boy, came to my room with the question: again, the bifurcation of the trachea?
Yes, bifurcation. And I decided on this surgery. Head of the cardio said, you do not mind that the patient has two pacemaker already? No, not confused. And before you go into surgery, I the priest asked for blessings.
I read the “our father”, has thrown hands, and heart – beats
Really? What was it like?
– Yes, our family was then a difficult situation – the relatives a malignant tumor that was the extreme unction. After I went to the priest – this is the situation, never in the region of such transactions was not, I never did, but I’m ready. He has blessed me. Before surgery this patient said to me: if all goes well, I will tell you that today I dreamed…
After surgery, the patient had pneumonia of the only lung, severe postoperative period, but we managed to cope. Before discharge, he tells me – you know, doctor, I’m absolutely not a believer, a Communist, and so I dream: the bypass before surgery, you, other doctors, my friend somehow and a priest. And you say – in General, the operation is very complex and such transactions can only believers patients. And I say: but I am an atheist, not a believer! A friend of mine: you tell me what I believe! I said that I believe, and the priest crossed me!
– But doctors, as people of science, religion…
– Indifferent? Yes. It was the only time – that is, on the occasion when I found myself in this situation and turned to the priest. But in Stavropol was another case. I finished the transaction, and then cardiac arrest. Anesthesiologists in shock, but in the pleural cavity than plus immediately reveal the heart shirt, put the heart on one hand and the other hand begin to massage. It is called direct cardiac massage. I begin to swing – 20 minutes, start 30 minutes – will not start. I’m tired, another surgeon stood to swing. I relaxed a little, started again… 50 minutes. Anesthesiologists said there are no miracles.
I’m not a believer, but mom was very religious and told us that at least one of the prayers children should know.
I begin to read silently, “our father” from despair. Generally, if cardiac activity is not resumed after 30 minutes you can stop massaging the cerebral cortex dies. And I read on 55 minutes, throw hands, and heart – beats.
However, following my phrase – Mat when I on emotion returned anesthesiologists in the operating room – I think the whole effect is undermined.
Anesthesiologists ran back, we’re overextended, and I think the same will happen to patients after 55 minutes. Came home, drank a glass of brandy, to sleep – otherwise it is simply impossible, nerves. Come in the morning to the intensive care unit, bypassing the start with the other patients, leave this for last. Nurses and orderlies look and smile, I think – well, what’s the matter? I go in the house, and this sick, imagine sitting in bed reading “Roman-Gazeta”. I’ve never seen. He looks up and asks: doctor, what is everybody looking at me strange somehow? Nothing, say so, simple. Checked out, everything is fine.
But there were cases when that did not help. Each surgeon has these tragedies – when all done, but. It’s a loss and it always sits, is not forgotten. You know, the surgeons did their best, twisted, so many emotional experiences, and the patient dies from post-operative complications – I have not met a single surgeon, which it would be anyway. You keep on replaying it in my head – why, how, is versed at conferences on death – appointed external expert, all analyses to minimize any further risks. Dead teach the live, I say.
– Your patients are not afraid of such complex operations?
– I have not met one who would not be afraid. I never insist. If you have a large, complex and hazardous operation, the surgeon always weigh the desirability – is there a chance that the patient with my transaction will live longer.
And the patient needs to be configured, it must want to be treated. We don’t know, don’t know how the internal mechanisms, mediators affect the course of tumor process.
Will tell you a story. I started the operation for pulmonary cancer, but after the cut I realized that the operation is pointless. Stopped.
The patient was a pilot, and to care for the son, a boy 14 years old – took him all over the chair, all the procedures were carried by the ship. Me is the attitude of the son to the father just bribed it with a healthy wife! And this pilot came to my office every day after I stitched him up and said that the operation does not make sense: “I want my son graduated from high school and enrolled in flight school, I want to bring.” I say, spread of the tumor is such that I have no guarantee, and if from the other side as well? And he continues to come to the chair, “Do something”.
We went on a non-standard scheme, examined the tumor on all biological markers known to us, seems to be not very aggressive tumor, despite the prevalence. We performed thoracoscopy – looked more easy, there is no such dissemination. Performed two cycles of chemotherapy, and then removed the lung with hyperthermic perfusion and photodynamics, as I first told. For five years he has greeted me every holiday. Then he brought his son, who graduated College and became a civil aviation pilot. Then we found metastases in the cervical spine irradiated. He lived for more than six years, although such prevalence, this does not happen.
Recently we had the first patient with mesothelioma of the pleura, which we operated in 2007 – announced scheme, with the complete removal of a lung, photodynamics and hemiberlesia. Without surgery, such patients do not live more than 13 months. Then a call from an unknown number – the patient’s son – father-Highlander told him to find me and thank you: 15 years ago I performed an operation with resection of the bifurcation of the trachea, he’s alive, thanks for the gift of life and a lot of love to the children, grandchildren and even great-grandchildren!
It’s great when you see the history of the people before the treatment is considered clearly doomed. Like, you not in vain life you live is not in vain “treading the earth”.