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Mahfuz v. Philip Morris and R.J. Reynolds

Dr. David Mannino Outlines Lung Surgery and Links Smoker’s Cancer to Cigarettes in $37M Tobacco Trial

The Expert: Dr. David Mannino, a pulmonologist at the University of Kentucky, details the cancer surgery in the smoker at the heart of the case, as well as his belief the cancer was caused by smoking.

By Dr. Gary F. Gansar, MD, FACS
Senior Physician Medical Director, AMFS

In a 2019 tobacco trial, plaintiffs contended that respiratory disease and loss of lung capacity following treatment for smoking-related lung cancer combined to cause the death of a woman who smoked for more than 30 years. In support of that claim, Dr. David Mannino, a pulmonologist and critical care specialist at the University of Kentucky, testifies about the surgery that was performed and his belief that the cancer was caused by smoking.

The expert begins by discussing the procedures that helped determine the extent of the ultimately definitive pneumonectomy operation that had been performed in 1992. In testifying, the pulmonologist refers to the operative report, the written record of the details of an operative procedure. First, he explains, the surgeon performed a bronchoscopy, where a narrow, flexible bronchoscope is passed through the nose and vocal cords into the lung. Since the lesion was present in the upper part of the right lung, this requires a sharp bending of the instrument. If the tumor is in the periphery of the lung, it cannot be reached, or examined and biopsied due to the physical limitations of the bronchoscope. That was the case here.

The surgeon therefore proceeded with a mediastinoscopy, a procedure requiring an incision in the lower part of the neck. A rigid mediastinascope is passed through that incision into the central chest cavity called the mediastinum to allow biopsy specimens to be taken of the lymph nodes on both sides of the trachea, or windpipe, which leads to the lungs. These specimens were sent for “frozen section” analysis. This would allow a pathologist to determine in real time whether there had been a spread of the lung cancer, either locally to the regional lymph nodes on the side of the tumor, or distantly to the lymph nodes on the side opposite to the tumor.

The determination of this spread or lack of spread would help the surgeon to decide on the extent of surgery that needed to be performed. In this case, the evidence of metastatic disease led the surgeon to not proceed with further surgery at that time and to instead reevaluate her.

Later, a pneumonectomy was ultimately performed on this patient. This surgery removes the entire lung on one side. Other types of resection would remove less than an entire lung, and doctors ideally would like to leave as much of the lung behind as possible, but in this case that was apparently not advisable.

The patient had metastatic large cell type carcinoma of the lung. It was able to be staged as a locally metastatic lesion. Staging helps explain how advanced a cancer is. Stage 1 is a better prognostic stage as opposed to Stage 4 which implies an aggressive, distantly spread carcinoma. In this case, the pulmonology expert estimates that the patient had a Stage 3A cancer which implies metastatic spread to the lymph nodes on the same side as the tumor. A large cell cancer is part of a group of cancers included as non-small cell cancers. This is important because at the time that this diagnosis was made [in 1992] a small cell cancer would be considered widely metastatic by nature when it was first discovered. A large cell lesion would be considered more amenable to surgical intervention.

Finally, Mannino expresses without reservation that this type of lung cancer is caused by cigarette smoking and that specifically, this patient’s lung cancer was caused by her smoking cigarettes.

The testimony was key to a $37.05 million jury verdict.

About the Author Dr. Gary F. Gansar, MD, FACS

Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.

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