A Philly Doctor’s Unique Approach, a 17-Hour Surgery, and a Saved Lung: How a Local Medical Team is Achieving Life-Changing Results

For patients with advanced cancer, there are a lot of complex decisions to be made. In recent years, treatments such as radiation and immunotherapy have become more effective, giving these patients a better chance at living longer, healthier lives. 

As new technologies have changed how we treat advanced cancer, surgical practices have also evolved to help manage, if not cure, these cancers. As a result, determining the appropriate surgical approach to cancer has grown more complex—requiring not only complicated, real-time decision-making and physical stamina at the operating table, but also shared decision-making with the patient about their goals regarding lifespan and quality of life. To get the best overall results for the patient, surgeons often need to weigh removing as much of the cancerous tissue as possible against preserving patients’ bodily function. 

The revolutionary work of Dr. Joseph Friedberg, a thoracic surgeon at the Temple Lung Center and Fox Chase Cancer Center in Philadelphia, aims to make that process less about a decision between the lesser of two evils and more about delivering the best of both worlds. As the thoracic-surgeon-in-chief for Temple Health and Co-Director of the Temple Health Mesothelioma and Pleural Disease Program, Friedberg is a world-renowned expert in pleural disease—conditions that affect the tissue covering the outside of the lungs and the inside of your chest cavity. When disease spreads to this tissue, it becomes increasingly difficult to manage. 

“It’s a very common place for cancers to spread. Lung cancer, breast cancer, thymic, pancreatic–you name it, they can all spread there. It’s also an area where some rare cancers, like mesothelioma, can start. In either case, there are situations where surgically removing the cancer may help the patient,” Friedberg says. 

Because the pleura acts as a lining for the chest cavity, surrounding some of your most critical and complex organs—like the heart—removing it can be extremely challenging. At the same time, the chest cavity provides room for some cancers to grow to shocking size, even to the point of pushing the heart and lungs out of place. Faced with these factors, there is a risk of impact on cardiovascular function in the patient.  

But Friedberg has developed a unique and consistently successful method of removing the cancerous pleura while sparing more critical parts of the body that it surrounds. His approach has helped patients who have been told they would have no choice but to lose function, or lose a lung, as a result of their cancer. It’s a method that has inspired physicians from across the globe, expanding possibilities for how thoracic surgeons can approach cancers that involve the pleura. 

A Treatment for One of the Deadliest Cancers

Friedberg was first exposed to mesothelioma during his thoracic surgical fellowship, where he received training in techniques to remove the cancer, but also in removing the lung. Deeply affected by the severity of the cancer (patients often survive less than a year after diagnosis), he elected to make the primary clinical and research focus of his career an effort to help these patients. Understanding that the goal of surgery for mesothelioma is to extend the patient’s life significantly beyond what would be expected with chemotherapy alone, Friedberg placed quality of life on par with extension of life. “There’s a huge difference in quality of life between having one or two lungs,” he says. “Not only that, but if the cancer recurs after surgery, you’re likely to be a candidate for more and better treatment options if you still have both lungs.” 

“Initially there was a lot of resistance to the lung-sparing approach for mesothelioma,” Friedberg says. “But now, that surgery has developed a lot of momentum, and I would say for the most part it is the preferred technique worldwide. It’s just that not a lot of people do it.” 

A Challenging Task for Any Surgeon

According to Dr. Friedberg, this type of operation doesn’t appeal to a lot of surgeons.   

“It takes me twice as long to remove these cancers when I save the lung; it’s technically challenging, tedious, and definitely requires a lot of stamina and focus,” he says. Friedberg often takes 10 to 14 hours in the operating room to carefully separate the cancerous pleura from the tissues that it surrounds, before washing the chest cavity with heated iodine to kill as many remaining cancer cells as possible. The separation needs to be exhaustive because of the way the cancer spreads through the pleura.  

“The pleura becomes the cancer,” Friedberg says. “People think of cancer like a grape sitting in a Jell-O mold, and some cancers are like that, where you can just cut around it and remove the cancer cleanly and intact. Pleural cancers are different. Here, it’s like someone poured the cancer in and it turned to concrete–there isn’t a square inch in the chest cavity that’s not involved with the cancer.” 

A former engineering student and college athlete, Friedberg notes that the technique demands a high level of focus. It also requires a high degree of collaboration between departments involved in the relevant organs, chiefly the heart and lungs. A successful operation often draws on the unique expertise of Temple Health’s comprehensive team of specialists, including cardiac surgeons, pulmonologists, radiation oncologists, pathologists, radiologists, and medical oncologists.

Temple’s Chief of Cardiovascular Surgery, Yoshiya Toyoda, MD, regularly joins Friedberg for complex cancer operations that involve the heart or may require heart-lung bypass. “I really need a world-class heart surgeon, like Dr. Toyoda, to team up with me on some of these cases,” Friedberg says. 

Finally, in addition to these obstacles, this procedure is still a leading-edge approach—meaning there’s no set way of performing the technique, and it requires a high level of real-time problem-solving due to the intricacy of cancers in the pleura. 

“This operation, it’s always different. No two cases are the same,” Friedberg says. As a result of this complexity, Friedberg not only trains physicians who have come from around the world to observe his rare expertise–but he also receives referrals for patients who cannot receive his kind of help elsewhere. 

A Transformative Result for Patients

Despite the technique’s difficulty, the result, for Friedberg, is worth it because it can change a patient’s life. The cancers that he treats are frequently both tragic and shocking. Cancers of the thymus, which often spread to the pleura, can grow undetected to large sizes in some patients, to the point where it displaces and compresses the heart and lungs.  

“If someone’s young and healthy, and you put a two-liter bottle’s worth [of cancer] in their chest a tablespoon at a time over a year or two, they might only notice it a little bit,” Friedberg says. “I had a 17-year-old patient who went to see the doctor because she was kind of falling behind in soccer practice. And she had a gigantic tumor that replaced her entire right lung, was pushing her heart all the way into the opposite chest cavity, and was pushing her liver down into her pelvis.”  

Friedberg has been able to help patients like these, who are often told that their cancer is either unresectable or that a successful operation would require removing their lung. Friedberg performed one of his longest surgeries on a 30-year-old radiation oncology fellow who sought multiple consultations at top health systems across several states, with the general consensus being that if his cancer could be removed, it would require removing the lung.  

Because of the skillset and experience he has from mesothelioma surgery, Friedberg thought he would be able to remove the cancer and save the lung. He spent 17 hours removing the primary tumor from on top of the heart and the cancerous pleura from all the different organs in the chest, with Dr. Toyoda helping to remove the cancer from the main vein that drains the top half of the body into the heart. Despite the magnitude of the surgery, saving the lung helped this patient exceed expectations. 

“He’s back at work,” Friedberg says. “I spoke to him a couple of weeks ago, and he said he’d gone out for a two-mile run. That’s not happening with one lung.” 

A Longer, Better Life

But the benefits of Dr. Friedberg’s approach may go beyond quality of life–the surgery may offer the best of both worlds and actually extend a patient’s lifespan. First, because preserving the lung gives the patient a better chance to withstand future chemotherapy and radiation, which is highly likely to be necessary with Stage IV cancer. When Friedberg conducted a study to test this idea, he confirmed patients were living longer with the lung than without. 

“When you have one lung, you become more fragile,” he says. “We published a study where we looked at 28 patients–14 where I had removed the lung, and then the next 14 where I had saved the lung. What we found was that the latter not only had a better quality of life, but they were also living longer.”  

Friedberg is currently researching another possible reason behind the longer lifespan, involving the lung’s ability to aid the immune system in its fight against cancer.  

“The lung has to be an immunogenic organ. You’re breathing dust and bacteria and viruses and fungi all the time and your body needs to be able to respond to these threats,” Friedberg says. By leaving the lung in place after killing as many cancer cells as possible, the immune system may learn to better combat these cells–an idea that Friedberg has received several grants to examine more closely.  

In any case, for Dr. Friedberg, the potential positive benefits of saving the lung in these pleural cancers translates into a benefit for the patients that far outweighs the personal toll each of these cases takes on him. 

“These patients are just so courageous, so when you’re standing there for 14 hours you just have to think about the fact that this patient trusted me with their life,” Friedberg says. “They always share their purpose: ‘I want to see my daughter graduate high school.’ Or ‘I want to get to know my granddaughter–she’s due in three months.’ It’s a selfless kind of courage … I always tell them, I can’t tell you 100 percent that I’ll be able to save your lung, but I can promise 100 percent that I will try my hardest.  Someday I may encounter a patient where that’s the only option but, after several hundred of these cases, that has yet to happen.”