Survival after lung metastasectomy for colorectal cancer: importance of previous liver metastasis as a prognostic factor. Eur J Surg Oncol. 2011;37:786-790. [PMID: 21723689 DOI: 10.1016/j.ejso.2011.05.014]

Pulmonary metastasectomy for colorectal cancer: How many nodules, how many times?

Colorectal cancer (CRC) is one of the most common cancers worldwide, with 5%-15% of CRC patients eventually developing lung metastasis (LM). Despite doubts about the role of locoregional therapy in the management of systemic disease, many surgeons have performed pulmonary metastasectomy (PM) for CRC in properly selected patients. However, the use of pulmonary metastasectomy remains controversial due to the lack of randomized controlled studies. This article reviews the results of surgical treatment of pulmonary metastases for CRC, focusing on (1) current treatment guidelines and surgical techniques of PM in patients with LM from CRC; (2) outcomes of PM and its prognostic factors; and (3) controversial issues in PM, focusing on repeated metastasectomy, bilateral multiple metastases, and combined liver and lung metastasectomy.

The Presence of Mutations in the K-RAS Gene Does Not Affect Survival after Resection of Pulmonary Metastases from Colorectal Cancer

Introduction. Our objective was to identify mutations in the K-RAS gene in cases of pulmonary metastases from colorectal cancer (CRC) and determine whether their presence was a prognostic factor for survival. Methods. We included all patients with pulmonary metastases from CRC operated on between 1998 and 2010. K-RAS mutations were investigated by direct sequencing of DNA. Differences in survival were explored with the Kaplan-Meier method log-rank tests and multivariate Cox regression analysis. Results. 110 surgical interventions were performed on 90 patients. Factors significantly associated with survival were disease-free interval (P = 0.002), age (P = 0.007), number of metastases (P = 0.001), lymph node involvement (P = 0.007), size of the metastases (P = 0.013), and previous liver metastasis (P = 0.003). Searching in 79 patients, K-RAS mutations were found in 30 cases. We did not find statistically significant differences in survival (P = 0.913) comparing native and mutated K-RAS. We found a higher rate of lung recurrence (P = 0.040) and shorter time to recurrence (P = 0.015) in patients with K-RAS mutations. Gly12Asp mutation was associated with higher recurrence (P = 0.022) and lower survival (P = 0.389). Conclusions. The presence of K-RAS mutations in pulmonary metastases does not affect overall survival but is associated with higher rates of pulmonary recurrence.

Does nodal status influence survival? Results of a 19-year systematic lymphadenectomy experience during lung metastasectomy of colorectal cancer

OBJECTIVES

Resection of pulmonary metastases originating from colorectal cancer is increasingly considered. While several adverse risk factors for long-term outcome are known, the selection of patients who may benefit from surgery remains unclear. In particular, few studies have addressed the impact of lymph node involvement, and signification of the hilar or mediastinal level of extent.

METHODS

We retrospectively reviewed the data of 320 patients operated in two thoracic departments between 1992 and 2011. Appropriate statistical tests were used to compare groups at risk.

RESULTS

There were 105 women and 215 men with a mean age of 63.3 years (range: 27-86) at the time of metastasectomy. Lymph node involvement appeared as a significant prognostic factor in both the univariate and multivariate analyses [median survival: 94 months N0 vs 42 months N+, P < 0.0001; OR = 0.573 (0.329-1), P = 0.05]. Survival was similar for hilar and mediastinal locations (median survival: 47 months vs 37 months, respectively, P = 0.14). Associated hepatic metastases had a negative impact on survival in both univariate and multivariate analyses [median survival: 74 months vs 47 months, P < 0.01; OR = 0.387 (0.218-0.686), P = 0.001]. Multiple lung metastases significantly decreased survival in univariate analysis only (median survival: 81 months vs 55 months, P < 0.01). Disease-free survival and preoperative carcinoembryonic antigen had no impact on survival.

CONCLUSIONS

While lymph node involvement was associated with decreased survival, the impact of mediastinal location on survival did not differ from that of hilar location. Consequently, these patients should not be excluded from surgical treatment.

The results of surgery for colorectal hepatic metastases following expansion of the indications in 2005

AIM

Safety and survival were investigated in patients treated according to expanded surgical indications for colorectal hepatic metastases.

METHOD

A retrospective analysis of all consecutive patients who underwent resection of colorectal hepatic metastases at Zhongshan Hospital from 2000 to 2010 was conducted. The patients were divided into two groups based on a change in the surgical indications introduced in 2005. Patients in Group I underwent hepatic surgery between 2000 and 2004 and those in Group II between 2005 and 2010. The clinicopathological data and survival rates of both groups were analysed.

RESULTS

There were 530 patients who underwent hepatic surgery between 2000 and 2010. After the expansion of surgical indications, the rate of surgical resection rose from 25.1 to 35.1% (P < 0.05). There was no significant difference in perioperative mortality (2.2% vs 0.9%) or morbidity (20.9% vs 29.8%). Recurrence occurred in 27.5% and 36.7% in Groups I and II, respectively, and 5-year overall survival was 43% and 49%, respectively (not significant).

CONCLUSION

Expanding the indications for surgical resection of hepatic metastases increased the resection rate but had no significant effect on survival.

What to choose as radical local treatment for lung metastases from colo-rectal cancer: surgery or radiofrequency ablation?

BACKGROUND

Long-term survival can be obtained with local treatment of lung metastases from colorectal cancer. However, it is unclear as to what the optimal local therapy is: surgery, radiofrequency ablation (RFA) or stereotactic radiotherapy (SBRT).

METHODS

A systematic review included 27 studies matching with the a priori selection criteria, the most important being ≥50 patients and a follow-up period of ≥24months. No SBRT studies were eligible. The review was therefore conducted on 4 RFA and 23 surgical series.

RESULTS

Four of the surgical studies were prospective, all others were retrospective. No randomized trial was found. The reporting of data differed between the studies, which led to difficulties in the analyses. Treatment-related mortality rates for RFA and surgery were 0% and 1.4-2.4%, respectively, whereas morbidity rates were reported inconsistently but seemed the lowest for surgery.

CONCLUSION

Due to the lack of phase III trials, no firm conclusions can be drawn, although most evidence supports surgery as the most effective treatment option. High-quality trials comparing currently used treatment modalities such as SBRT, RFA and surgery are needed to inform treatment decisions.

Pulmonary metastasectomy in colorectal cancer: a prospective study of demography and clinical characteristics of 543 patients in the Spanish colorectal metastasectomy registry (GECMP-CCR)

OBJECTIVES

To capture an accurate contemporary description of the practice of pulmonary metastasectomy for colorectal carcinoma in one national healthcare system.

DESIGN

A national registry set up in Spain by Grupo Español de Cirugía Metástasis Pulmonares de Carcinoma Colo-Rectal (GECMP-CCR).

SETTING

32 Spanish thoracic units.

PARTICIPANTS

All patients with one or more histologically proven lung metastasis removed by surgery between March 2008 and February 2010.

INTERVENTIONS

Pulmonary metastasectomy for one or more pulmonary nodules proven to be metastatic colorectal carcinoma.

PRIMARY AND SECONDARY OUTCOME MEASURES

The age and sex of the patients having this surgery were recorded with the number of metastases removed, the interval between the primary colorectal cancer operation and the pulmonary metastasectomy, and the carcinoembryonic antigen level. Also recorded were the practices with respect to mediastinal lymphadenopathy and coexisting liver metastases.

RESULTS

Data were available on 543 patients from 32 units (6-43/unit). They were aged 32-88 (mean 65) years, and 65% were men. In 55% of patients, there was a solitary metastasis. The median interval between the primary cancer resection and metastasectomy was 28 months and the serum carcinoembryonic antigen was low/normal in the majority. Liver metastatic disease was present in 29% of patients at some point prior to pulmonary metastasectomy. Mediastinal lymphadenectomy varied from 9% to 100% of patients.

CONCLUSIONS

The data represent a prospective comprehensive national data collection on pulmonary metastasectomy. The practice is more conservative than the impression gained when members of the European Society of Thoracic Surgeons were surveyed in 2006/2007 but is more inclusive than would be recommended on the basis of recent outcome analyses. Further analyses on the morbidity associated with this surgery and the correlation between imaging studies and pathological findings are being published separately by GECMP-CCR.

Repeated resection of colorectal cancer pulmonary oligometastases: pooled analysis and prognostic assessment

BACKGROUND

Repeated resection of colorectal cancer pulmonary metastasis is associated with long-term survival. Nevertheless, very limited data addressing the best candidates for repeated pulmonary resection is available.

PATIENTS AND METHODS

We searched the PubMed database for retrospective studies evaluating lung metastasectomy for metastatic colorectal cancer (CRC). We included studies with available data about repeated pulmonary metastasectomy. Potential prognostic factors were analyzed for possible impact on survival following the second metastasectomy through univariate and multivariate analysis.

RESULTS

Between 1983 and 2008, 944 lung metastasectomies were carried out on 759 patients. Of those, 148 patients had a second metastasectomy. The 5-year survival rate was 52 % for patients who had 1 metastasectomy and 57.9 % from the second metastasectomy for patients who had repeated resection. More than 2 metastatic pulmonary nodules and maximum diameter of largest pulmonary nodule ≥3 cm were the only independent factors associated with inferior survival following repeated pulmonary resection.

CONCLUSIONS

In selected patients with metastatic CRC, repeated pulmonary metastasectomy offers an excellent chance for long-term survival and is associated with a quite low operative mortality. Patients with more than 2 metastatic nodules and a maximum diameter of the largest metastatic lung nodule of ≥3 cm have a significantly inferior survival.

Risk factors for survival after lung metastasectomy in colorectal cancer patients: a systematic review and meta-analysis

BACKGROUND

Resection of lung metastases (LM) from colorectal cancer (CRC) is increasingly performed with a curative intent. It is currently not possible to identify those CRC patients who may benefit the most from this surgical strategy. The aim of this study was to perform a systematic review of risk factors for survival after lung metastasectomy for CRC.

METHODS

We performed a meta-analysis of series published between 2000 and 2011, which focused on surgical management of LM from CRC and included more than 40 patients each. Pooled hazard ratios (HR) were calculated by using random effects model for parameters considered as potential prognostic factors.

RESULTS

Twenty-five studies including a total of 2925 patients were considered in this analysis. Four parameters were associated with poor survival: (1) a short disease-free interval between primary tumor resection and development of LM (HR 1.59, 95 % confidence interval [CI] 1.27-1.98); (2) multiple LM (HR 2.04, 95 % CI 1.72-2.41); (3) positive hilar and/or mediastinal lymph nodes (HR 1.65, 95 % CI 1.35-2.02); and (4) elevated prethoracotomy carcinoembryonic antigen (HR 1.91, 95 % CI 1.57-2.32). By comparison, a history of resected liver metastases (HR 1.22, 95 % CI 0.91-1.64) did not achieve statistical significance.

CONCLUSIONS

Clinical variables associated with prolonged survival after surgery for LM in CRC patients include prolonged disease-free interval between primary tumor and metastatic spread, normal prethoracotomy carcinoembryonic antigen, absence of thoracic node involvement, and a single pulmonary lesion.

Colorectal cancer pulmonary oligometastases: pooled analysis and construction of a clinical lung metastasectomy prognostic model

BACKGROUND

Although resecting colorectal cancer (CRC) pulmonary metastasis is associated with long-term survival, identification of prognostic groups is needed for future randomized trials, and construction of a lung metastasectomy prognostic model (LMPM) is warranted.

PATIENTS AND METHODS

We searched the PubMed database for retrospective studies evaluating prognostic factors following resecting CRC lung metastasis. Individual patient data were analyzed. Independent prognostic factors were used to construct an LMPM.

RESULTS

Between 1983 and 2008, 1112 metastasectomies were carried out on 927 patients included in eight studies. Five-year survival rate was 54.3% following the first lung resection. Multivariate analysis identified three independently poor prognostic factors: pre-thoracotomy carcinoembryonic antigen ≥5 ng/ml, disease-free interval <36 months, and more than one metastatic lesion. Patients with good-, intermediate-, and high-risk groups according to the LMPM had a 5-year survival of 68.2%, 46.4%, and 26.1%, respectively (P < 0.001). Perioperative chemotherapy and previously resected liver metastasis had no influence on survival.

CONCLUSIONS

The low- and intermediate-risk groups have a good chance of long-term survival following metastasectomy. However, more studies are needed to investigate whether surgery offers any advantage over systemic therapy for the poor-risk group.