Video-assisted thoracic surgery (VATS) for resection of metastatic adenocarcinoma as an acceptable alternative

Pulmonary metastases in urogenital cancers: Surgical treatment and outcomes

INTRODUCTION

Metastasis is remaining one of the major problems in cancer treatment. Like many other malignancies, urogenital tumors originating from kidney, prostate, testes, and bladder tend to metastasize to the lungs. The aim of this retrospective study is to evaluate the operative results and prognosis of pulmonary metastasectomy in patients with primary urogenital tumors.

METHODS

This study was approved by the local ethical committee. We retrospectively analyzed the surgical and oncological results of patients who underwent lung resections for urogenital cancer metastases in our department between 2002 and 2018. Demographic data and clinicopathological features were extracted from the medical records. Survival outcomes according to cancer subtypes and early postoperative results of VATS and thoracotomy were analyzed.

RESULTS

22 out of 126 patients referred for pulmonary metastasectomy to our department had metastases from urogenital tumors. These patients consisted of 17 males and five females. Their metastasis originated from renal cell carcinoma (RCC; n=9), bladder tumor (n=7), testis tumors (n=4), and prostate cancer (n=2). There was no intraoperative complication. Postoperative complications were seen in 2 patients.

CONCLUSIONS

Although pulmonary metastasectomy in various types of tumors is well known and documented, the data is limited for metastases of urogenital cancers in the literature. Despite the limitations of this study, we aim to document our promising results of pulmonary metastasectomy in patients with primary urogenital tumors and wanted to emphasize the role of minimally invasive approaches.

Role of subxiphoid uniportal video-assisted thoracoscopic surgery in pulmonary metastasectomy

Optimal management for patients with pulmonary metastasis is still debated. True survival benefit from widely practiced pulmonary metastasectomy (PM) is yet to be proved from high-quality randomized controlled trials. The ideal surgical approach for PM is also not generally agreed. VATS offers enhanced recovery and superior functional outcomes but at the expense of less detection of lung nodules and higher possibility of narrow/positive resection margins. The subxiphoid uniportal VATS (uVATS) approach is an evolving new approach with potential advantages including simultaneous access to both lung fields, less pain and faster rehabilitation. These advantages make it a favorable approach for PM, particularly in the setting of bilateral metastases. However, its use is still limited to case reports of a small number of patients. There is room for improvements in subxiphoid uVATS due to reported technical challenges and limitations. Herein, we aim to publicize a comprehensive review of literature on applications of subxiphoid uVATS in PM.

Role of video-assisted thoracoscopic surgery in pulmonary metastasectomy

Introdcution

There are sparse prospective studies investigating the role of video-assisted thoracoscopic surgery (VATS) in management of pulmonary metastasis.

Aim

To prospectively investigate short-term surgical and pathological outcomes for PM patients operated on by VATS or open thoracotomy (OT) for management of lung secondaries.

Material and methods

Between October 2017 and December 2020, patients undergoing pulmonary metastasectomy were recruited. Patients were assigned to undergo resection with either thoracotomy (group 1) or VATS (group 2) after multidisciplinary team discussions based on the number, size and location of pulmonary metastasis and underlying lung function. All related short-term surgical and pathologic outcomes for both groups were collected for analysis.

Results

Of 58 patients enrolled, 21 were in group 1 and 37 in group 2. Colorectal cancer primary represented 40% of the cases. Patients in the VATS group were more likely to have solitary lesions that are peripherally located and removed by wedge resection, as opposed to patients in the thoracotomy group, who had more anatomical lung resections. More new nodules were likely to be detected during surgery in thoracotomy than VATS cases (p = 0. 027). However, 8 (out of 15) of the newly detected lesions were not malignant. Operative time, blood loss and hospital stay were in favor of VATS procedures.

Conclusions

In a highly selected cohort of pulmonary metastasis patients with favorable criteria (peripherally located, small, solitary/oligo-metastasis and cN0), VATS may provide acceptable onco-pathologic outcomes as compared to the standard open thoracotomy.

Lung Metastases: Current Surgical Indications and New Perspectives

Pulmonary metastasectomy is an established treatment that can provide improved long- term survival for patients with metastatic tumor(s) in the lung. In this mini-review, we discuss the state of the art of thoracic surgery in surgical management of lung metastases which actually occurs for a large part of surgical activity in thoracic surgery department. We describe the principles of surgical therapy that have been defined across the time, and that should remain the milestones of lung metastases treatment: a radical surgery and an adequate lymphadenectomy. We then focus on current surgical indications and report the oncological results according to the surgical approach (open vs. mini-invasive), the histological type and number of lung metastases, and in case of re-metastasectomy. Finally, we conclude with a brief overview about the future perspectives in thoracic surgery in treatment of lung metastases.

Video-assisted pulmonary metastectomy is equivalent to thoracotomy regarding resection status and survival

Background

Surgical resection of pulmonary metastases leads to prolonged survival if strictly indicated. Usually, thoracotomy with manual palpation of the entire lung with lymph node dissection or sampling is performed. The aim of this study was to evaluate the role of video-assisted thoracoscopic surgery (VATS) in pulmonary metastectomy with curative intent.

Methods

In this study, all patients with suspected pulmonary metastasis (n = 483) who visited the Center for Thoracic Surgery in Regensburg, between January 2009 and December 2017 were analysed retrospectively.

Results

A total of 251 patients underwent metastectomy with curative intent. VATS was performed in 63 (25.1%) patients, 54 (85.7%) of whom had a solitary metastasis. Wedge resection was the most performed procedure in patients treated with VATS (82.5%, n = 52) and thoracotomy (72.3%, n = 136). Postoperative revisions were necessary in nine patients (4.8%), and one patient died of pulmonary embolism after thoracotomy (0.5%). Patients were discharged significantly faster after VATS than after thoracotomy (p < 0.001). Complete (R0) resection was achieved in 89% of patients. The median recurrence-free survival was 11 months (95% confidence interval 7.9–14.1). During follow-up, eight (12.7%) patients in the VATS group and 42 (22.3%) patients in the thoracotomy group experienced recurrence (p = 0.98). The median overall survival was 61 months (95% confidence interval 46.1–75.9), and there was no significant difference with regard to the surgical method used (p = 0.34).

Conclusions

VATS metastasectomy can be considered in patients with a solitary lung metastasis. An open surgical approach with palpation of the lung showed no advantage in terms of surgical outcome or survival.

Prognostic Impact of Newly Proposed M Descriptors in TNM Classification of Non-Small Cell Lung Cancer

INTRODUCTION

The International Association for the Study of Lung Cancer recently proposed new M descriptors for the next edition of the TNM classification for NSCLC, subdividing the current M1b category into two subcategories: M1b, which indicates a solitary extrathoracic metastasis in a single organ, and M1c, which indicates multiple extrathoracic metastasis. The purpose of this study was to validate the prognostic value of the newly proposed M descriptors in an independent cohort with multivariate and subgroup analysis.

METHODS

A total of 1024 patients in a consecutive lung cancer database who had stage IV NSCLC treated between 2011 and 2014 were analyzed. Newly proposed M staging was used for classification and comparison of survival. Adjustment for other clinical covariates and subgroup analysis was conducted.

RESULTS

According to the newly proposed M descriptors, 262 patients (25.6%), 152 patients (14.8%), and 610 patients (59.6%) were classified into the subgroups M1a, M1b, and M1c, respectively. The median overall survival times were 22.5, 17.8, and 13.6 months for the M1a, M1b, and M1c groups, respectively (p < 0.001). After adjustment for other covariates, Cox proportional hazards regression revealed statistically significantly shorter overall survival for the M1b group than for the M1a group (hazard ratio = 1.30; 95% confidence interval: 1.03-1.65, p = 0.03) and for the M1c than the M1b group (hazard ratio = 1.57; 95% confidence interval: 1.28-1.93, p < 0.001). These differences showed a consistent tendency regardless of pathologic and molecular subtypes.

CONCLUSIONS

The newly proposed M descriptors have prognostic value in patients with stage IV NSCLC.

Video-assisted thoracoscopic surgery versus open resection of lung metastases from colorectal cancer

This study aimed to compare the short and long-term survival outcomes between video-assisted thoracoscopic surgery (VATS) and open resection of lung metastases from colorectal cancer. Between January 2006 and January 2013, 57 patients underwent VATS of lung metastases from colorectal cancer. These patients were compared with a consecutive matched group of 57 patients who underwent open resection within the same period. The two groups were similar in terms of age, gender, tumor size, number of tumors, tumor laterality and type of pulmonary resections. The operative time was longer in the VATS group, but the estimated blood loss was less in the VATS group than in the open group. Postoperative 30-day mortality, 30-day complications were similar between the groups. More complications were classified as major in patients underwent open resection, though the difference was not significant (P = 0.297). The 5-year overall survival rate was 50% for VATS and 46% for open resection (P = 0.251). The 5-year overall disease-free survival time was similar in two groups (P = 0.457). The findings suggest that VATS is associated with less blood loss than open resection for lung metastases of colorectal cancer. According to our results, VATS for lung metastases from colorectal cancer is equivalent to open resection in terms of long-term survival outcomes.

Simultaneous Laparoscopy-Assisted Resection for Colorectal Cancer and Metastases

With advancement of minimal invasive surgery, a simultaneous laparoscopy-assisted resection for colorectal cancer and metastasis has become feasible. Hence, we report three cases of simultaneous laparoscopic surgery for colorectal cancer with liver or lung metastasis. In the first case, laparoscopic right hemicolectomy and left lateral segmentectomy of liver was performed for ascending colon cancer and liver metastasis. In the second case, laparoscopic right hemicolectomy and wedge resection of right lower lung was performed for cecal cancer and lung metastasis. In the third case, laparoscopic right hemicolectomy and wedge resection of left lower lung was performed for ascending colon cancer and lung metastasis. In the first two cases, patients quickly returned to normal activity. In the third case, postoperative bleeding was observed, but spontaneously stopped. There was no postoperative mortality. Simultaneous laparoscopic surgery represents a feasible option for colorectal cancer with metastases on the other organs.

Video-assisted thoracoscopic surgery versus open thoracotomy for pulmonary metastasectomy: a systematic review

BACKGROUND

Pulmonary metastasectomy has become a popular procedure for patients with pulmonary metastases. It can be achieved via the traditional open thoracotomy or the more recently developed video-assisted thoracoscopic surgery (VATS). However, there has been much debate as to which approach is better in terms of detection of pulmonary metastases and, in turn, survival and recurrence outcomes. We aim to compare the two different approaches in terms of survival and recurrence outcomes.

METHODS

Medline and EMBASE databases were searched for relevant publications dated prior to May 2013. The bibliographies of the included articles were examined for additional relevant articles that were not included in the search. All publications reporting on overall survival and recurrence-free survival were included. The articles were carefully examined and data were extracted. STATA 12L and RevMan5.2 software were used to combine the data using the random effects model.

RESULTS

A total of 1960 studies were identified through the search. Thirty-two articles had extractable data regarding overall survival and recurrence-free survival. However, only eight articles were included in the end as the other 24 articles had incomplete data. From the included articles, we found that the VATS group had slightly higher odds of 1-, 3- and 5-year overall survival with odds ratios of 1.53, 1.69 and 1.41, respectively, and also higher odds of 1-, 3- and 5-year recurrence-free survival with odds ratios of 1.29, 1.54 and 1.54, respectively.

CONCLUSION

VATS offers a suitable alternative to open thoracotomy for the treatment of pulmonary metastases.

Outcomes of Hybrid Video Assisted Thoracoscopic Surgery for Pulmonary Metastasectomy

BACKGROUND

Pulmonary metastasectomy is an acceptable treatment option in various metastatic lesions. The role of minimally invasive surgery for metastasectomy remains controversial. We report on a recently described hybrid video-assisted thoracoscopic surgery (hVATS) technique in the community hospital setting.

METHODS

Using a retrospective study design, data on 61 patients undergoing 67 resections between April 2000 and January 2008 was collected at a single institution. Patient demographics, pathology, and clinical outcome data were recorded. Kaplan Meier estimates and multivariate Cox regression were used to assess survival and prognostic factors, respectively.

RESULTS

Mean patient age was 61.7 years. The majority of lesions were solitary, unilateral, and genitourinary or gastrointestinal in origin (69%). R0 resection was achieved in 97% of cases with the most common operation being lobectomy. Mean length of stay was 4.4 days. Mean follow-up was 39.7 months and 5-year overall survival was 63.2% for the cohort; median survival was not reached. The number of lesions (univariate only) and tumor size over 4 cm influenced overall survival.

CONCLUSIONS

Hybrid VATS is a safe and feasible technique in the community medical center setting and warrants additional investigation as an alternative strategy in the management of pulmonary metastases.

Thoracoscopic versus open pulmonary metastasectomy: a prospective, sequentially controlled study

BACKGROUND

Patients with limited metastatic disease in the lung may benefit from metastasectomy. Thoracotomy is considered the gold standard, and video-assisted thoracoscopic surgery (VATS) is controversial because nonimaged nodules may be missed when bimanual palpation is restricted. Against guideline recommendations, metastasectomy with therapeutic intent is now performed by VATS by 40% of thoracic surgeons surveyed. The evidence base for optimal surgical approach is limited to case series and registries, and no comparative surgical studies were observer blinded.

METHODS

Patients considered eligible for pulmonary metastasectomy by VATS prospectively underwent high-definition VATS by one surgical team, followed by immediate thoracotomy with bimanual palpation and resection of all palpable nodules by a second surgical team during the same anesthesia. Both surgical teams were blinded during preoperative evaluation of CT scans and during surgery. Primary end points were number and histology of nodules detected.

RESULTS

During a 12-month period, 37 patients were included. Both surgical teams observed exactly 55 nodules suspicious of metastases on CT scans. Of these, 51 nodules were palpable during VATS (92%), and during subsequent thoracotomy 29 additional nodules were resected: Six (21%) were metastases, 19 (66%) were benign lesions, three (10%) were subpleural lymph nodes and one was a primary lung cancer.

CONCLUSIONS

Modern VATS technology is increasingly used for pulmonary metastasectomy with therapeutic intent, but several nonimaged, and therefore unexpected, nodules are frequently found during subsequent observer-blinded thoracotomy. A substantial proportion of these nodules are malignant, and, despite modern imaging and surgical technology, they would have been missed if VATS was used exclusively for metastasectomy with therapeutic intent.