Curative‐intent treatment of pulmonary metastases from colorectal cancer: A comparison between imaging‐guided thermal ablation and surgery

Abstract

Background: Pulmonary metastases (PM) are the most frequent extra-abdominal metastases from colorectal cancer. Lung resection and imaging-guided thermal ablation (IGTA) are used as curative-intent treatment. We compared the outcomes of patients with PM, treated with resection or ablation.Methods: We retrospectively analyzed data from patients who underwent surgery or IGTA for colorectal PM between April 2011 and November 2020. Surgery was performed for peripheral PM and IGTA for deep-located PM not in contact with major vessels. Patients who had both procedures were excluded. Patients were compared using propensity score matching (PSM) analysis, stratified according to number, size, and unilaterality of PM.Results: One hundred and fourty-six patients were included, 65 (44.5%) underwent surgery and 81 (55.5%) underwent IGTA. After PSM analysis, each group contained 46 patients. IGTA patients had a lower morbidity rate (13.1% vs. 15.2%, p = 0.028) and a shorter length of stay (5.13 vs. 2.63 days, p < 0.001). Oncological outcomes were similar in both groups with 5-year OS of 80% and 5-year progression-free survival (PFS) of 30% (p = 0.657 and p = 0.504, respectively) with similar recurrence patterns. Conclusion:Lung resection and IGTA seem to have similar oncologic outcomes for both OS and PFS. IGTA could be an alternative effective treatment for small PM, whenever technically feasible.

The percutaneous management of pulmonary metastases

“…Another retrospective study looks at curative-intent treatment for colorectal pulmonary metastases including 65 surgeries (open approach or video-assisted thoracic surgery whenever technically possible) for peripheral metastases and 81 thermal ablations for deep-located metastases not in contact with major vessels. 36 After PSM analysis, each group contained 46 patients. Thermal ablation patients had a lower morbidity rate and a shorter length of stay.…”

Finding that outcomes after imaging‐guided thermal ablation and surgery for colorectal lung metastases are similar does not prove a survival benefit from either

“…But such was the strength of the growing consensus about surgical metastasectomy that teams elected to operate on the majority. For the 263 patients, selected for operation, there was 69% 5-year survival 4 (Figure 1 Karam et al 1 chose data to support their argument as we are all inclined to do. They quoted 38% from the preliminary PulMiCC report and deemed it "quite poor compared to previously published 5-year [overall survival] ranging from 40 to 68%" 1 The cited paper 5 was an invited contribution to the European Society of Thoracic Surgeons Lung Metastasectomy Project 6 when PulMiCC was mooted.…”

“…For the 263 patients, selected for operation, there was 69% 5-year survival 4 (Figure 1 Karam et al 1 chose data to support their argument as we are all inclined to do. They quoted 38% from the preliminary PulMiCC report and deemed it "quite poor compared to previously published 5-year [overall survival] ranging from 40 to 68%" 1 The cited paper 5 was an invited contribution to the European Society of Thoracic Surgeons Lung Metastasectomy Project 6 when PulMiCC was mooted. 7 Citing it more fully, Pfanschmidt wrote "For a subset of highly selected patients, the overall results of a 5-year actuarial survival rate after complete resection ranged between 40 and 68%.…”

“…From their propensity score matching analysis, recently published in the Journal of Surgical Oncology, Karam 1 and colleagues draw the conclusion that surgical metastasectomy and image guided thermal ablation (IGTA) may be followed by similar overall survival (OS). This is in line with a now generally held belief that for local treatments of colorectal cancer (CRC) lung metastases, cancer teams can choose between surgery, IGTA and stereotactic radiotherapy techniques according to technical considerations and the availability of expertize.…”

“…10 This applies similarly to surgery and IGTA. 1 PulMiCC indicates that survival is predominantly a feature of expert selection of those with a better prognosis plus the effect of guarantee time bias. As Karam et al 1 have shown IGTA may be as effective as surgery in locally controlling individual lung metastases but this does not mean that either treatment actually prolongs patients' lives.…”