Pulmonary metastasectomy: an overview

Abstract

Metastasectomy is the most frequent surgical resection undertaken by thoracic surgeons, being the lung the second common site of metastases. The present oncological criteria for pulmonary metastasectomy are: (I) the primary cancer need to be controlled or controllable; (II) no extrathoracic metastasis-that is not controlled or controllable-exists; (III) all of the tumor must be resectable, with adequate pulmonary reserve; (IV) there are no alternative medical treatment options with lower morbidity. General favourable prognostic features in patients with pulmonary metastases are: (I) one or few metastases; (II) long disease free interval; (III) normal CEA levels in colorectal cancers. Negative predictive features in patients candidate to pulmonary metastasectomies are: (I) active primary cancer; (II) extrathoracic metastases; (III) inability to obtain surgical radicality; (IV) mediastinal lymphatic spread. The lack of controlled trials and studies limited by short follow-up and small cohorts did not allow to overcome some skepticism; moreover, the heterogeneity of these patients in terms of demographic, biologic and histologic characteristics represents a clear limit even in the largest series. On the basis of present knowledge, without results coming from on-going randomized trials, radical resection, histology, and disease free interval seem to be independent prognostic factors identifying a cohort of patients maximally benefitting from lung metastasectomy.

The Society of Thoracic Surgeons Consensus Statements for the Surgical Treatment of Pulmonary Metastases

“…The majority of reports are retrospective, single-institution case studies limited by small cohorts; short follow-up times; the lack of or use of historical controls or comparison survival analyses with other types of therapies, such as systemic chemotherapy and radiation; and the heterogenicity of tumor type, histology, and patient population. 1,3 Other characteristics invalidating the ability to evaluate the role of PM in metastatic disease based on current studies include the low rates of PM, even in large studies, suggesting a selection bias, and the inability to distinguish between prognostic characteristics, such as indolent disease, which does well with any or no therapy. Because patients with favorable prognostic factors can survive longer irrespective of treatments, predictive factors are used instead to determine which patients may benefit from PM.…”

“…THE RESECTION OF pulmonary metastases, known as pulmonary metastectomy (PM), is a frequently performed oncologic surgical procedure because the lung is the second most common site for the development of metastases. 1 The oncologic criteria for PM include a primary cancer that is controlled or controllable, the absence or control of extrathoracic metastases, complete resectability (R0) of the tumor, a patient with adequate cardiopulmonary reserve to tolerate the procedure, and a lack of a systemic therapy that is associated with a lower morbidity. 2 PM most frequently has been performed in patients with metastatic colorectal, sarcoma, malignant melanoma, head and neck, renal cell, germ cell, and breast carcinomas, with the objective of potential cure or improved longterm survival, as measured by the disease-free interval (DFI), which is defined as the time from treatment of the primary cancer or first metastasis to the development of the first metastasis in the case of a primary tumor or subsequent metastasis in the case of PM.…”

“…5 With the knowledge available at this time, radical complete resection, favorable histology, and a prolonged DFI seem to be independent predictive factors identifying a cohort of patients who may benefit from PM. 1 Poor predictive features such as uncontrolled primary malignancy, extrapulmonary metastatic lesions, non-R0 resection, and positive mediastinal lymph nodes usually are considered surgical contraindications. 6 In an attempt to standardize the indications and performance of PM, the Society of Thoracic Surgeons Work Force of Evidence Based Surgery formed a multidisciplinary task force, consisting of thoracic surgeons and both medical and radiation oncologists, to develop a Society of Thoracic Surgeons expert consensus statement on PM.…”

“…Intrathoracic lymph node involvement is associated with reduced survival after PM, especially in colorectal and renal cell cancers, and there are no randomized studies demonstrating whether mediastinal lymphadenectomy improves survival after PM. 1 Despite this prognostic information, mediastinal lymph node dissection in PM is not commonly performed. In a 2008 survey of the European Society of Thoracic Surgeons, 55% indicated that they regularly sample mediastinal nodes at the time of PM, whereas 33% avoided nodal dissection.…”

Management of Intensive Care Unit Process in the Patient with Comorbid Pneumonia and Herpesviralsimplex Encephalitis

“…The prognostic factors affecting DFS include the extent of pulmonary metastasis, duration of disease-free survival, successful radical surgery, and the carcinoembryonic antigen level in colorectal cancers. [7] Most often, patients with pulmonary metastasis are asymptomatic, but occasionally cough or hemoptysis may be seen in centrally located metastases. Most are diagnosed during primary tumor staging or follow-up.…”