Photo by Chris Ware
Imagine a tumor slowly amassing in your chest. Eventually, it balloons to such an enormous size that it begins to compress a lung, making it difficult for you to catch your breath. At least one surgeon refuses to take your case because extracting the abnormal glob of tissue promises to be a very risky proposition. That was the dilemma that one Bronx resident faced…until he met Avraham D. Merav, MD (on right in photo), medical director of the Thoracic Center at Phelps Memorial Hospital Center and a thoracic surgeon.
In August 2010, Alberto (not his real name) was 59 years old and in poor health, with a history of minor strokes and at least three prior heart attacks. He had developed chest pain and shortness of breath. A CT scan revealed a large tumor pressing against his left lung and compressing his spleen and left kidney. It was not the first time Alberto had received such news. In 1995, a surgical team at Jacobi Medical Center in the Bronx removed a benign, 4-pound, 11½-ounce fibrous tumor of his pleura (the lining of the chest cavity). While the tumor’s cause was unknown, it’s a type that tends to recur. Unfortunately, though, Alberto, had failed to obtain the proper follow-up care that would have detected the new lesion much earlier in its development.
The surgeon who performed his first surgery had retired, so Alberto’s cardiologist referred him to another thoracic surgeon in the Bronx. When that surgeon declined to take the case, fearing that the tricky operation would kill the patient, the cardiologist sent Alberto to Dr. Merav, who agreed to operate—but not before careful preparation. The type of tumor that Alberto had—a “giant solitary fibrous tumor of the pleura”—is very rare. A literature search revealed only about 100 cases.
Dr. Merav performed the four-hour operation in June, assisted by his colleague Rocco Lafaro, MD (on left in photo), a thoracic surgeon at Westchester Medical Center. Extracting the tumor completely required a large incision from the chest through the diaphragm and into the abdominal cavity. The team also needed to remove the patient’s eighth rib. Rarely does such surgery require entering the chest and abdominal cavities, Dr. Merav notes, but that just illustrates the tumor’s immensity. At more than 5 pounds, 2 ounces, “this was the size of a big watermelon—a big, oval watermelon,” says Dr. Merav. “I needed both hands to hold it up once we got it out.”
Tumors that recur tend to “adhere” or stick to healthy tissue, Dr. Merav says. In Alberto’s case, the challenge was to separate the tumor from surrounding structures, especially the lung, to which it had adhered. That required “special skill and time and effort,” he says. Alberto had some bleeding during the procedure, requiring a blood transfusion. Since that is a common complication, the surgical team was prepared to intervene quickly. Afterward, the surgeons repaired the patient’s diaphragm and closed the gaping incision. Although an abdominal surgeon was standing by in case his services were needed, the thoracic team managed the entire operation on their own.
While the mass had not spread to other organs, pathologists determined that it had some characteristics of a low-grade malignant tumor. As a result, additional genetic testing is underway to determine whether Alberto might benefit from Gleevec, a prescription medication that may prevent the tumor from recurring.
With the pressure of the tumor off of his lung, Alberto, now 61, is doing fine. Once the mass was removed, his “lung re-inflated to its normal capacity, and everything down in the abdomen moved back up,” Dr. Merav says. “He was basically returned to normal.”