Just 4 months into his first permanent job, surgeon , has been thrust into the after removing a massive tumor from an 81-year-old patient's neck.
Milton Wingert's tumor grew from the size of an egg about six months ago – when Khan was wrapping up a fellowship in Toronto – when he was operated on at Mount Sinai Hospital in New York last week. The tumor was estimated to weigh 5-7 pounds.
"I didn't foresee it getting this much , but it just draws a lot of people in," Khan said. "The visible shock of seeing a tumor that large intrigues people."
The 37-year-old surgeon was hired at Mount Sinai in July, and while this is "probably the biggest tumor I've ever operated on," he said, it certainly hasn't been his toughest case.
"We do complex surgeries like this on a weekly basis," Khan told 鶹ý.
That's not to say this wasn't a challenging procedure. One surgical team at a different hospital had already passed on doing the surgery. A second team was willing to take it on, but ultimately decided Wingert would be better off at a tertiary care center with more resources. That's when they called Khan, already known for his expertise, who said he'd be happy to do the procedure.
The tumor pathology was poorly differentiated, and on imaging, it seemed that the carotid artery and the brachial plexus nerve cluster were pushed back by the large growth -- "but you don't really know what you're going to find until you get in there," Khan said.
The carotid, subclavian, brachial plexus, spinal accessory nerve, hypoglossal nerve – "all of these were just at the boundaries of his tumor, so anything could have been involved," he said.
Key members of the surgical team were called to be on standby: a thoracic surgeon could break the clavicle if needed; a vascular surgeon could reconstruct the carotid or other arteries; a second head-and-neck oncological surgeon could lend an additional hand.
Khan started on the contralateral side, opening up the neck as an apron incision. He first found all of the critical structures on the contralateral side in order to get landmarks and have a sense for the patient's normal anatomy.
He then worked his way from the medial to lateral side, carefully finding and removing the tumor from critical anatomy. He found the thyroid cartilage, then the thyroid, making sure the tumor hadn't invaded the organ. Then he worked the tumor off the carotid artery, then off the jugular vein. He found the hypoglossal nerve, and worked it off that, and then dissected it off the clavicle. Khan worked until it was "just tethered on the muscles," then severed it completely.
The whole procedure took about 7 hours, which Khan said was a long time given that he didn't have to do a reconstruction. Instead, he rotated a piece of muscle from the same side to cover the patient's carotid artery before closing everything up with the patient's own skin, since he had enough left even after all the extra skin surrounding the tumor was removed.
"I moved relatively slow given the fact that I wanted to be very careful about not getting into anything critical," he told 鶹ý. "He'd had a carotid artery study the day before that showed he did not have good collateral flow from the contralateral side, so getting into his carotid artery would have been catastrophic."
This surgery was just the beginning of the road for 81-year-old Wingert. The poorly differentiated tumor certainly has an aggressive pathology, and is likely to be a sarcoma or an anaplastic thyroid cancer; the full pathology report will be available later this week. Indeed, it had grown quickly, from the size of an egg six months ago, to grapefruit-sized, and finally soccer ball-sized at the time of the surgery.
Fortunately, PET scans were negative for distant metastasis, but the plan is for Wingert to see medical and radiation oncology this week and determine the course of treatment – likely chemotherapy or radiation or some combination of the two.
The biggest obstacle will be transportation, since Wingert lives across the Hudson River in Jersey City. But Mount Sinai may be able to provide Access-A-Ride services to help bring him back and forth to treatment.
Khan is awaiting final pathology before searching the case report literature for similar surgeries, though he said he's seen something similar while doing his fellowship in Toronto. He'd also done his residency at Mount Sinai, another "advantage" in taking on the case so early in his career.
"This is what I trained to do," he said. "The sheer size made this a unique story, but we do complex surgeries in complicated neurovascular areas on a regular basis."