Complex Thoracotomy
The Glass Half Full
Jim Laucis, 65, of Upton would have never believed that a ruptured appendix was good luck, but thanks to the thorough testing ordered by the Milford Regional emergency staff last summer, he learned about a huge mass that ultimately turned out to be an extremely rare cancer. Since the mass wasn’t causing his symptoms and had likely been there awhile, Jim was told he could wait until after his recovery from appendix surgery to follow up with his primary care doctor.
On Oct. 1, 2018 a few months after the discovery, Thoracic Surgeon Brian Whang, MD, performed a complex thoracotomy to remove the 4.5-pound mass from between Jim’s chest wall and internal organs. Assisting Dr. Whang were his colleagues, Thoracic Surgeon Matthew Rochefort, MD, and Physician Assistant Chris LeSiege, PA-C who see patients on a regular basis at Brigham and Women's Thoracic Surgery located on the second floor of the Hill Health Center at Milford Regional. The Medical Center’s thoracic surgery team provides a wide range of diagnostic and treatment services for patients with benign and malignant disorders of the lung, esophagus and stomach, mediastinum (space between the lungs) and trachea.
According to Dr. Whang, Jim’s tumor originated in his thymus gland. “It arose from what was left of his thymus gland, which serves a role in immunity in childhood, and after that it tends to shrink up,” explains Dr. Whang, the chief of thoracic surgery. “It took years for it to grow, and since it wasn’t very invasive, he got away with it. It took up half his chest and was about the size of a melon. Thymus tumors are unusual to begin with, but this was unusual even for a thymus tumor.”
Jim recalls how his medical issues started in June when he developed a pain in his stomach, which he first attributed to a GI bug. The discomfort made a full circle around his abdomen, and when it reached the bottom, burning set in. He went to urgent care, and they sent him to the emergency room, where he was diagnosed with a ruptured appendix and an infection. To his surprise, a CT scan revealed a portion of a large mass in his chest. After his discharge, Jim pushed the mass to the back of his mind and focused on regaining his strength.
“I was amazed how the appendix knocked my system down,” says Jim. “It took a few weeks to get back to normal. I had a positive outlook about the mass since it wasn't bothering me and I didn’t have symptoms. I felt it was serious, but not life-threatening at the moment.”
Later in the summer, Jim and his wife Debbie were ready to deal with the growth. His primary care doctor referred him to Ryan Shipe, MD, a pulmonary/critical care specialist at Lung, Allergy & Sleep Specialists in Hopedale. Further imaging and a needle biopsy ordered by Dr. Shipe determined that Jim’s tumor was a squamous cell carcinoma, spindle cell type. At this point, Jim was referred to Brigham and Women’s Thoracic Surgery at Milford Regional where he met with Dr. Whang and Chris LeSiege, PA-C. They ordered a PET scan, which uses a special dye containing radioactive tracers to evaluate how the tissues and organs work at the cellular level.
“He felt so good that he had a hard time believing it was cancer and had to come out,” recalls Dr. Whang. “The thing that really got him was the PET scan which showed how intensely metabolically active the tumor was. He saw something glowing like the sun in his chest. It’s useful to us to show whether anything else lights up that we didn’t expect.”
Jim also underwent tests including a brain MRI, echocardiogram, and a lung function test. If the cancer had spread to his brain or liver, surgery wouldn’t be the best option, explains Dr. Whang. Since it was contained to that one area, and his heart and lungs were healthy, he advised Jim to have the surgery.
“My intention was to put it off until winter, but the more I saw the size of it, the more I changed my mind, and I went with their recommendation to do something about it as soon as possible,” Jim says. “My biggest fear was that it could metastasize. I was very impressed with Dr. Whang and liked him a lot. I asked him questions, and he looked me in the eye and answered them. He went through the surgery step-by-step. I felt very confident. I did ask him how many lung surgeries he had done, and his answer was in the 500 range; that made me feel even better as someone who has been there that many times has seen an awful lot. He showed me where they would do the incision. I really liked Chris as well. He’s a great person and answered everything.”
Jim met Dr. Rochefort the morning of the surgery and got to know him during his hospital stay. Although the thoracic surgeons perform many minimally invasive surgeries, Jim’s procedure was mostly open surgery due to the mass’s size. Despite the 15-centimeter incision, Dr. Whang says they were able to preserve the latissimus dorsi, the widest and most powerful muscle of the back, which shaved off a month of recovery time. They were also able to preserve the phrenic nerve, the right lung, and diaphragm, and avoid removing the sac surrounding the heart.
“We put the tumor in a bag in the chest and pulled it out through the incision,” relates Dr. Whang. “We had to cut two ribs as they were guaranteed to break otherwise. If you cut them, it’s controlled and allows for the mobility you need with much less pain. We used video to look around the mass—it helped to have a camera to show what was on the other side.”
Over the 2.5-hour surgery, Dr. Whang says that he, Dr. Rochefort, and Chris were trading roles, working together to do tasks such as retracting the mass, cauterizing, suturing, and maneuvering the camera.
“I got out of surgery at 3 p.m. and they had me walking at 8 p.m., then every day after that,” Jim recalls. “Chris had told me the more I walked, the better I would be.”
According to Dr. Whang, walking drops the diaphragm, allows for better expansion of the lungs, and helps the patient to cough up gunk in the lungs. It also keeps patients from losing their strength and balance as well as minimizes the risks of blood clots and pneumonia.
Jim was kept comfortable in the Progressive Care Unit and stayed in the hospital for three days. The surgical team also biopsied the lymph nodes and found no other signs of cancer. Dr. Whang acknowledges that because the tumor was so rare and slow-growing, it’s hard to know how long it would have taken for the cancer to progress; however, he says that over time it would have made its presence known. “Certainly the tumor would’ve kept growing,” he says. “I would assume that it would have started to press on his right atrium and impeded the venous return to his heart. That could’ve led to passing out, arrhythmias and shortness of breath.”
Jim followed up with an oncologist at Dana-Farber/Brigham and Women's Cancer Center at Milford Regional, who didn’t see the need for chemotherapy or radiation. He will continue to check in with the thoracic surgeon team and have routine CT scans.
“Believe it or not, my appendix was a lot worse than this surgery,” Jim states. “Dr. Whang said it’s because with the appendix I was dealing with infection, and with this I was dealing with incisions. The biggest plus of all was that in ten minutes, my wife could be there, that all the appointments were in Milford, and we had Dana-Farber people there for the cancer end of it.”
He praises the Brigham and Women's Thoracic Surgery team for keeping him informed and all being on the same page. “They all seem to do very well together,” Jim notes. “I couldn’t even suggest anything they could do to be better.”
Read more about Brian Whang, MD or call 857-307-5576 to schedule an appointment with him.
