Value of systematic mediastinal lymph node dissection during pulmonary metastasectomy

Lymph node dissection in small-sized pulmonary metastasectomy: Impact on the long-term survival

INTRODUCTION

Pulmonary metastasectomy has been clarified in improving long-term survival in most primary malignancies with pulmonary metastasis, while the role of additional lymph node dissection remained controversial. We aimed to investigate the prognosis of lymph node involvement and identify the role of lymph node dissection during pulmonary metastasectomy in a real-world cohort.

METHODS

We identified patients diagnosed with pulmonary metastases with ≤3 cm in size and received pulmonary metastasectomy between 2004 and 2017 in the Surveillance, Epidemiology, and End Results database. We compared the survival via Kaplan-Meier analysis and propensity score matching method, and the multivariable analysis was conducted by cox regression analysis.

RESULTS

A total of 3452 patients were included, of which 2268(65.7%) received lymph node dissection, and the incidence of node-positive was 11.3%(256/2268). In total, the median overall survival was 62.8 months(interquartile range, 28.6-118.9 months), and the lymph node involvement was referred to an impaired survival compared to node-negative diseases(5-year overall survival rate, 58.0% versus 38.6%), with comparable survival between N1 and N2 diseases(P = 0.774). Lymph node dissection was associated with improved survival(HR = 0.80; 95%CI, 0.71-0.90; P < 0.001), and the survival benefits remained regardless of age, sex, the number of metastases, and surgical procedures, even in those with node-negative diseases. At least eight LNDs might lead to a significant improvement in survival, and additional survival benefits might be limited with additional dissected lymph nodes.

CONCLUSIONS

Lymph node involvement was associated with impaired survival, and lymph node dissection during pulmonary metastasectomy could improve long-term survival and more accurate staging.

Radiofrequency ablation versus surgical resection for the treatment of oligometastatic lung disease

PURPOSE

The purpose of this study was to compare efficacy and tolerance between radiofrequency ablation (RFA) and surgery for the treatment of oligometastatic lung disease.

MATERIALS AND METHODS

This retrospective study reviewed patients treated in two institutions for up to 5 pulmonary metastases with a maximal diameter of 4cm and without associated pleural involvement or thoracic lymphadenopathy. Patient demographics, tumor characteristics, treatment outcome, and length of hospital stay were compared between the two groups. Efficacy endpoints were overall survival (OS), progression-free survival (PFS) and pulmonary or local tumor progression rates.

RESULTS

Among 204 patients identified, 78 patients (42 men, 36 women; mean age, 53.3±14.9 [SD]; age range: 15-81 years) were treated surgically, while 126 patients (59 men, 67 women; mean age, 62.2±10.8 [SD]; age range: 33-80 years) were treated by RFA. In the RFA cohort, patients were significantly older (P<0.0001), with more extra-thoracic localisation (P=0.015) and bilateral tumour burden (P=0.0014). In comparison between surgery and RFA cohorts, respectively, the 1- and 3-year OS were 94.8 and 67.2% vs. 94 and 72.1% (P=0.46), the 1- and 3-year PFS were 49.4% and 26.1% vs. 38.9% and 14.8% (P=0.12), the pulmonary progression rates were 39.1% and 56% vs. 41.2% and 65.3% (P>0.99), and the local tumour progression rates were 5.4% and 10.6% vs. 4.8% and 18.6% (P=0.07). Tumour size>2cm was associated with a significantly higher local tumor progression in the RFA group (P=0.010). Hospitalisation stay was significantly shorter in the RFA group (median of 3 days; IQR=2 days; range: 2-12 days) than in the surgery group (median of 9 days; IQR=2 days; range: 6-21 days) (P<0.01).

CONCLUSION

RFA should be considered a minimally-invasive alternative with similar OS and PFS to surgery in the treatment of solitary or multiple lung metastases measuring less than 4cm in diameter without associated pleural involvement or thoracic lymphadenopathy.

Lymphadenectomy during pulmonary metastasectomy: Impact on survival and recurrence

Background and Objectives: Lymphadenectomy during pulmonary metastasectomy (PM) is widely carried out. We assessed the potential benefit on patient survival and tumor recurrence of this practice.

Methods: One hundred eighty‐one patients undergoing a first PM were studied. Eighty‐six patients (47.5%) underwent lymphadenectomy (L+ group) whereas 95 (52.5%) did not undergo nodal harvesting (L−group). Main outcomes were overall survival (OS) and disease‐free survival (DFS). Median follow‐up was 25 months (interquartile range [IQR], 13‐49).

Results: At follow‐up 84 patients (46.4%) died, whereas 97 (53.6%) were still alive with recurrence in 78 patients (43%). There was no difference in 5‐year survival (L+ 30.0% vs L− 43.2%; P = .87) or in the 5‐year cumulative incidence of recurrence (L + 63.2% vs L−80%; P = .07) between the two groups. Multivariable analysis indicated that disease‐free interval (DFI) less than 29 months (P < .001) and lung comorbidities (P = .003) were significant predictors of death. Metastases from non‐small–cell lung cancer increased the risk of lung comorbidities by a factor of 19.8, whereas the risk of DFI less than 29 months was increased nearly 11‐fold. Competing risk regression identified multiple metastases (P = .004), head/neck primary tumor (P = .009), and age less than 67 years (P = .024) as independent risk factors for recurrence.

Conclusion: Associated lymphadenectomy showed not to give any additional advantage in terms of survival and recurrence after PM.

An overview on clinical, pathological and molecular features of lung metastases from colorectal cancer

Introduction: Lung metastases occur in 10-20% of patients with colorectal cancer (CRC). Most of them are treated with palliative intent and have a poor prognosis. Pulmonary metastasectomy may be a curative option for carefully selected patients with 5-year survival rates ranging from 25% to 60%. However, up to 70% of patients develop recurrence after pulmonary metastasectomy. Therefore, the identification of prognostic factors is essential in CRC patients with resectable lung metastases. Areas covered: This review aims at summarizing the actual body of knowledge available on lung metastases from CRC focusing on their clinical, pathological and molecular profile. Moreover, we provide an update on experts' attitudes towards lung metastasectomy, adjuvant or perioperative chemotherapy. Expert opinion: Traditional clinical prognosticators such as the total number of pulmonary metastases, carcinoembryonic antigen (CEA) serum levels before surgery, and presence of lymph node metastases cannot provide reliable criteria to predict survival after lung metastasectomy. Indeed, research efforts have been directed in recent years toward studying the biological characteristics of lung lesions to better define prognosis and response to treatment, and ultimately shed new light on their proper local and systemic management.

Lymphadenectomy During Pulmonary Metastasectomy

Pulmonary metastasectomy continues to be an effective approach to prolong survival in appropriately selected patients. The incidence of lymphatic spread is more common than previously recognized, with an estimate of 20% to 25% across multiple tumor types. The presence of metastatically involved lymph nodes adversely affects survival. What remains unclear is whether N1 vs N2, or the number of stations involved affects survival differently. The role of surgery for pulmonary metastasectomy in the patient with nodal metastases will likely expand with ongoing improvements in targeted and immunotherapies.

Is manual palpation of the lung necessary in patients undergoing pulmonary metastasectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether manual palpation of the lung is necessary in patients undergoing pulmonary metastasectomy. In total, 56 articles were found using the described search strategy. After screening these articles and their references, 18 publications represented the best evidence to answer the clinical question. No randomized controlled trial addressing the three-part question was available. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers were tabulated. The studies reported on 1472 patients with different primary cancers. The patients underwent more than 1630 pulmonary metastasectomies between 1990 and 2014 after the treatment of primary cancer. Almost three quarters of patients underwent open procedures like thoracotomy or sternotomy. Most frequently, helical CT with a slice thickness ranging between 1 and 10 mm was used for preoperative imaging. The sensitivity in detecting pulmonary nodules ranged from 34 to 97%. The corresponding sensitivity rates for PET-CT were 66-67.5 and 75% for high-resolution CT. The positive predictive value for lesions detected by helical CT varied from 47 to 96%. Helical CT reached a specificity between 54 and 93% in detecting pulmonary nodules. The surgeons identified more nodules by meticulous palpation than helical CT. It is noteworthy that up to 48.5% of these palpated nodules were benign lesions (false-positive). Patients with smaller imaged nodules, multiple imaged nodules or primary mesenchymal tumour are more likely to have occult pulmonary nodules. We conclude that not all palpable pulmonary nodules can be imaged preoperatively. Thoracotomy allows the manual palpation of the ipsilateral hemithorax and might be superior to video-assisted thoracic surgery regarding radical resection. However, not all palpable nodules are malignant, and the impact of non-resected pulmonary metastases on patient survival is not clearly evaluated.

Thoracoscopic Management of Pulmonary Metastases

In appropriately selected patients, resection of pulmonary metastases from various primary tumors can lead to improved survival. Metastasectomy has traditionally been performed by open thoracotomy; however, thoracoscopic resection offers the important benefits of a less invasive approach with more expeditious recovery. Concerns regarding missed lesions during thoracoscopy have not been realized in analyses of survival and may be offset by a policy of repeat metastasectomy for pulmonary recurrences. Despite the relative paucity of prospective trials, the preponderance of data supports the use of video-assisted thoracic surgery for pulmonary metastasectomy, which represents our preferred strategy for these patients.

Increased lymphangiogenesis in lung metastases from colorectal cancer is associated with early lymph node recurrence and decreased overall survival

Pulmonary metastasectomy (PM) is an accepted treatment modality in colorectal cancer (CRC) patients with pulmonary tumor spread. Positive intrathoracic lymph nodes at the time of PM are associated with a poor prognosis and 5-year survival rates of <20 %. Increased lymphangiogenesis in pulmonary metastases might represent an initial step for a subsequent lymphangiogenic spreading. We aimed to evaluate the presence of lymphangiogenesis in clinically lymph node negative patients undergoing PM and its impact on outcome parameters. 71 patients who underwent PM for CRC metastases were included in this dual-center study. Tissue specimens of pulmonary metastases and available corresponding primary tumors were assessed by immunohistochemistry for lymphatic microvessel density (LMVD) and lymphovascular invasion (LVI). Results were correlated with clinical outcome parameters. LMVD was 13.9 ± 8.1 and 13.3 ± 8.5 microvessels/field (mean ± SD) in metastases and corresponding primary CRC; LVI was evident in 46.5 and 58.6 % of metastases and corresponding primary CRC, respectively. Samples with high LMVD had a higher likelihood of LVI. LVI was associated with early tumor recurrence in intrathoracic lymph nodes and a decreased overall survival (p < 0.001 and p = 0.029). Herein, we present first evidence in a well-defined patient collective that increased lymphangiogenesis is already present in a subtype of pulmonary metastases of patients staged as N0 at the time of PM. This lymphangiogenic phenotype has a strong impact on patients' prognosis. Our findings may have impact on the post-surgical therapeutic management of CRC patients with pulmonary spreading.

Pulmonary metastasectomy: role of pulmonary metastasectomy and type of surgery

OPINION STATEMENT

Patients with untreated metastatic disease have a less than 5 % to 10 % 5-year survival, and for the patient who has metastatic disease isolated to the lungs, pulmonary metastasectomy remains the best hope for cure. Pulmonary metastasectomy has been performed for decades. However, despite hundreds of studies spanning several decades, randomized control data in support of pulmonary metastasectomy is still lacking, and the evidence upon which we base this commonly accepted surgical practice is for the most part weak. While well-accepted surgical selection criteria exist, controversies related to pulmonary metastasectomy abound. Unanswered and clearly debatable are questions related to: optimal preoperative imaging, if mediastinal staging should be performed and if so when, is video-assisted thoracic surgery (VATS) equivalent to open thoracotomy, is finger palpation of the lung mandatory, is repeat pulmonary metastasectomy justified, and what is the interrelationship of pulmonary metastasectomy to other treatments. Current practice to the surgical approach to pulmonary metastasectomy remains quite variable.

The prognostic impact of lymph-node dissection on lobectomy for pulmonary metastasis

OBJECTIVES

The prevalence and characteristics of lymph-node metastasis have not been thoroughly investigated in patients with pulmonary metastases from various primary neoplasms. The necessity of performing lymph-node dissection with pulmonary metastasectomy is unknown.

METHODS

We retrospectively reviewed the database of the Metastatic Lung Tumor Study Group of Japan. Between November 1980 and June 2013, 4363 patients underwent resection of pulmonary metastases. After selecting for patients who underwent lobectomy, 683 patients (16%) were analysed. The presence of lymph-node metastasis, outcomes and prognoses were investigated.

RESULTS

The primary tumour site was colorectal in 350 patients, head and neck in 73 patients, kidney in 41 patients, uterus in 41 patients and bone/soft tissue in 31 patients. The overall 5-year survival rate after pulmonary metastasectomy was 50.1%, and the 10-year survival rate was 36.4%. Lymph-node metastasis was more frequently found in uterine (27%) and head and neck cancers (29%). Five-year survival rates were 53.8% in patients without lymph-node metastasis, 39.4% in patients with hilar lymph-node metastasis and 30.8% in patients with mediastinal lymph-node metastasis. The extent of lymph-node dissection was not related to survival. Univariate analysis revealed that tumour size, the presence of lymph-node metastasis, the presence of multiple lesions, a disease-free interval of 24 months or less and incomplete resection were significant predictors of poor prognosis. Multivariate analysis confirmed these prognostic factors.

CONCLUSIONS

Retrospective analysis of lobectomy for pulmonary metastasis demonstrated that lymph-node metastasis is a significant prognostic factor predicting poor outcome. Lymph-node sampling or dissection is therefore warranted to predict patient prognosis.

Endobronchial ultrasound-guided transbronchial needle aspiration is a sensitive method to evaluate patients who should not undergo pulmonary metastasectomy†

OBJECTIVES

Pulmonary metastasectomy is considered an effective treatment in selected patients with extrapulmonary cancer and oligometastatic disease. We know that the presence of mediastinal lymph node metastases reduces survival significantly, but the mediastinum is rarely evaluated before metastasectomy in these patients. We prospectively evaluated how endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) could identify metastases to the mediastinal lymph nodes in patients referred for pulmonary metastasectomy.

METHODS

All patients with extrapulmonary cancer and oligometastatic disease confined to the lungs on positron emission tomography-computed tomography, and who were considered eligible for pulmonary metastasectomy, routinely underwent EBUS-TBNA of the mediastinal lymph nodes. If EBUS-TBNA did not reveal malignant spread, the patient subsequently underwent pulmonary metastasectomy with systematic sampling of mediastinal lymph nodes for histological evaluation.

RESULTS

One hundred and three eligible patients were referred for EBUS-TBNA during a 4-year period. The primary cancers were located in the colon/rectum (n = 64), kidney (n = 16) and other sites (n = 23). EBUS-TBNA sampled 248 lymph nodes and adequate cytology was obtained in 93 patients (90%). EBUS-TBNA found lymph node metastases in 17 patients (16.5%) and during subsequent pulmonary metastasectomy in the remaining 86 patients 1 (1.0%) had a lymph node metastasis. The sensitivity, specificity, NPV and PPV of EBUS-TBNA for diagnosis of mediastinal lymph node metastasis were 94.4, 100, 98.8 and 100%, respectively.

CONCLUSIONS

EBUS-TBNA is a sensitive minimally invasive modality for evaluation of mediastinal lymph node metastases in patients with oligometastatic pulmonary disease. It allows surgeons to select patients who will not benefit from pulmonary metastasectomy.

Unexpected lymph node disease in resections for pulmonary metastases

BACKGROUND

Pulmonary metastasectomy is widely accepted for different malignant diseases. The role of mediastinal lymph node (LN) dissection in these procedures is discussed controversially. We evaluated our results of LN removal at the time of pulmonary metastasectomy with respect to the frequency of unexpected LN disease.

METHODS

This was a retrospective analysis of 313 resections performed in 209 patients. Operations were performed in curative intention. Patients with known thoracic LN involvement and those without lymphadenectomy (n = 43) were excluded. Patients were analyzed according the type of LN dissection. Subgroups of different primary cancers were evaluated separately.

RESULTS

Sublobar resections were performed in 256 procedures with lymphadenectomy, and 14 patients underwent lobectomy. Patients underwent radical lymphadenectomy (n = 158) or LN sampling (n = 112). The overall incidence of unexpected tumor in LN was 17% (radical lymphadenectomy, 15.8%; sampling, 18.8%). Unexpected LN involvement was found in 17 patients (35.5%) with breast cancer, in 120 (9.2%) with colorectal cancer, and in 53 (20.8%) with renal cell carcinoma. The 5-year survival was 30.2% if LN were tumor negative and 25% if positive (p = 0.19). LN sampling vs radical removal had no significant effect on 5-year survival (23.6% vs 30.9%; p = 0.29).

CONCLUSIONS

Dissection of mediastinal LN in resection of lung metastases will reveal unexpected LN involvement in a relevant proportion of patients, in particular in breast and renal cancer. Routine LN dissection appears necessary and may become important for further therapeutic decisions. On the basis of our data, LN sampling seems to be sufficient.

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.

Risk factors for lymph node metastases and prognosticators of survival in patients undergoing pulmonary metastasectomy for colorectal cancer

BACKGROUND

Systematic lymph node dissection is not routinely performed in patients undergoing pulmonary metastasectomy (PM) of colorectal cancer. The aim of the study was to identify risk factors for lymph node metastases (LNM) and to determine prognosticators for survival in colorectal cancer patients with pulmonary metastases.

METHODS

We retrospectively reviewed our prospective database of 165 patients with colorectal cancer undergoing PM and systematic lymph node dissection with curative intent from 1999 to 2009. The χ(2) test, regression analyses, Kaplan-Meier analyses, log rank tests, and Cox regression analyses were used to determine prognosticators for LNM and survival.

RESULTS

The prevalence of LNM was 22.4%. Lymph node metastases were more often detected in case of rectal cancer and if anatomic resections in term of segmentectomy or lobectomy had to be performed for PM. The number of pulmonary metastases showed a nonlinear association with the risk of positive postoperative LNM. For 1 to 10 pulmonary metastases, each additional pulmonary metastasis conferred a 16% increase in risk for LNM. Rectal cancer, M-status of the primary tumor, number of pulmonary metastases, and disease progression during pre-PM chemotherapy were independent prognosticators for survival. Lymph node metastases were not an independent prognosticator.

CONCLUSIONS

Rectal cancer, required anatomic resections, and multiple metastases were risk factors for LNM. Rectal cancer, M-status of the primary tumor, number of pulmonary metastasis, and disease progression during pre-PM chemotherapy were independent negative predictors of survival, stratifying patients with poor prognosis who may benefit from chemotherapy before or after PM.

Metastasectomy with standardized lymph node dissection for metastatic renal cell carcinoma: an 11-year single-center experience

BACKGROUND

Pulmonary metastasectomy (PM) for metastatic renal cell carcinoma is an established method of treatment for selected patients. The incidence of intrathoracic lymph node metastases (ITLNM) and outcomes remain controversial. The purpose of this study was to determine the incidence of ITLNM and long-term outcome of PM for metastatic kidney cancer.

METHODS

From January 1999 to December 2009, 116 patients (82 men, age 61.7 ± 9.0 years) with metastases from kidney cancer underwent PM and systematic lymph node dissection with curative intent. Kaplan-Meier analyses, log-rank test, and Cox regression analyses were used to estimate survival and to determine prognosticators of survival.

RESULTS

Overall survival rates were 49% at 5 years and 21% at 10 years (median survival, 56.6 ± 9.2 months). Complete resections could be achieved in 108 patients (93.1%). Forty patients (34.5%) had systematic therapy before metastasectomy. Partial regression was observed in 11 patients (27.5%). Surgical morbidity and mortality rates were 13.8% (16 of 116) and 0.9% (1 of 116), respectively. ITLNM were found in 54 (46.6%). Patient age (≥ 70 years; p = 0.003), female gender (p = 0.016), and number of metastases (≥ 2 metastases; p = 0.012) were associated with inferior survival after PM in the univariate analysis. The presence of ITLNM and type of lung resection did not significantly affect survival. Patient age remained the only significant prognostic factor when a multivariate Cox proportional hazards model was applied.

CONCLUSIONS

PM and systematic lymph node dissection can be performed safely with low morbidity and mortality. Long-term survival is achievable in selected patients even with ITLNM. We recommend that systematic lymph node dissection should be demanded in every patient due to the high prevalence of ITLNM. Patients aged 70 years or older should be selected carefully for PM.

Optimal management of pulmonary metastases from colorectal cancer

The incidence of colorectal cancers is rising worldwide and pulmonary metastases were seen in approximately 10-15% of all patients. Surgical metastasectomy is a widely accepted procedure in selected patients and is considered as the only curative option in patients with secondary pulmonary malignancy. But surgical resection remains controversial due to the lack of randomized trials, comparing pulmonary metastasectomy to control, either medical therapy, or observation. This article will discuss the differentiated therapeutic strategies for patients with pulmonary metastases of colorectal cancer, focusing on surgical resection, patient evaluation, prognostic factors, interdisciplinary therapeutic approaches and current trials.

Evaluation of a new prognostic score (Munich score) to predict long-term survival after resection of pulmonary renal cell carcinoma metastases

BACKGROUND

The aim of this single-center study was to analyze factors predicting long-term outcomes following surgical resection of pulmonary metastases in patients with renal cell carcinoma.

METHODS

Two hundred two consecutive patients entered the study. Overall survival was analyzed by the Kaplan-Meier method. Multivariate analysis was performed using Cox regression models.

RESULTS

In 175 cases (87%), curative resection of the pulmonary metastases was achievable, with median survival of 43 months. Multivariate analysis revealed complete metastasectomy (R0), metastasis size >3 cm, positive nodal status of the primary tumor, synchronous metastases, pleural infiltration, and tumor-infiltrated hilar or mediastinal lymph nodes as independent prognostic factors for survival. On the basis of these findings, a new scoring system (the Munich score) was established to predict survival, which discriminates 3 groups with low, intermediate, and high risk for poor outcomes (median survival, 90, 31, and 14 months, respectively, P < .001).

CONCLUSIONS

The aim of the Munich score is to define patients with low, intermediate, and high risk for poor survival and will help identify patients who may benefit from further adjuvant therapy.

Imaging requirements in the practice of pulmonary metastasectomy

The primary imaging modality for the detection of pulmonary metastases is computed tomography (CT). Ideally, a helical CT scan with 3- to 5-mm reconstruction thickness or a volumetric thin section scanning should be performed within 4 weeks of pulmonary metastasectomy. A period of observation to see whether further metastases develop does not seem to allow better patient selection. If positron emission tomography is available, it may identify the extrathoracic metastatic sites in 10 to 15% of patients. Despite helical CT scan, palpation identifies the metastases not detected by imaging in 20 to 25% of patients and remains the standard. No data define the optimal interval for follow-up surveillance imaging.

Thoracic lymphatic involvement in patients having pulmonary metastasectomy: incidence and the effect on prognosis

Mediastinal and hilar lymph node involvement are rarely reported in the literature concerning pulmonary metastasectomy. The first problem is to determine with accuracy the incidence and location of thoracic lymph node involvement in patients with lung metastases. Determination of the impact on survival of this type of lymphatic spread may contribute to assessing whether metastatic nodal disease identified preoperatively is an absolute contraindication to metastasectomy. Systematic mediastinal lymph node dissection has revealed a statistically significant difference in survival between patients with lymph node involvement and those without lymph node metastases. Videomediastinoscopy to identify involved mediastinal lymph nodes can be safely performed and may have a role in a more accurate staging of the metastatic disease. The authors conclude that attention should be paid to ensuring that we do not operate on patients in whom we will leave behind diseases that we cannot reach. The discovery of mediastinal lymph node involvement may also influence decisions with respect to postresection adjuvant therapy.

Tumor infiltrated hilar and mediastinal lymph nodes are an independent prognostic factor for decreased survival after pulmonary metastasectomy in patients with renal cell carcinoma

PURPOSE

Surgical resection remains the most effective treatment in patients with pulmonary metastasis of renal cell carcinoma. To our knowledge the prognostic significance of mediastinal and hilar lymph node metastasis during pulmonary metastasectomy in patients with renal cell carcinoma is unknown. We analyzed the value of computerized tomography to predict mediastinal/hilar lymph node involvement as well as the impact of systematic lymphadenectomy on survival in patients with pulmonary renal cell carcinoma metastasis.

MATERIALS AND METHODS

We analyzed survival in 110 patients who underwent resection of pulmonary metastasis of renal cell carcinoma using the Kaplan-Meier method. Multivariate analysis was done by Cox regression analysis.

RESULTS

Lymph node metastasis was histologically proved in 35% of patients. Metastasis was not associated with initial tumor grade, lymph node status, the number of pulmonary metastases or recurrent pulmonary metastasis. Computerized tomography had 84% sensitivity and 97% specificity to predict lymph node metastasis. Sensitivity was markedly better for detecting mediastinal than hilar lymph node metastasis (90% vs 69%). Patients with lymph node metastasis had significantly shorter median survival than patients without lymph node metastasis (19 vs 102 months, p <0.001). Multivariate analysis revealed that tumor infiltrated mediastinal lymph nodes were an independent prognostic factor for patient survival. Match paired analysis showed that after lymph node dissection patients showed a trend toward improved survival.

CONCLUSIONS

Mediastinal and hilar lymph node metastases significantly correlate with decreased survival. Systematic lymphadenectomy provides valuable information on staging and prognosis in patients with pulmonary metastasis of renal cell carcinoma, and may prolong survival.

Current status of pulmonary metastasectomy from primary epithelial tumors

The resection of pulmonary metastases can prolong the survival of selected patients and its therapeutic value is now accepted. The criteria for eligibility have also evolved. We reviewed the recent literature on pulmonary metastasectomy for various epithelial primary tumors and tried to establish better prognostic indicators for its surgical application. In addition to the welldefined requisites for pulmonary metastasectomy, other requirements include the absence of mediastinal lymph node involvement, a limited number of pulmonary metastatic lesions, a long disease-free interval, small metastasis, and no elevation of tumor markers, although the clinical importance of each factor varies among the primary tumors. On the other hand, with the development of video-assisted thoracoscopic surgery (VATS) and advances in thoracic imaging technology, VATS metastasectomy might become an accepted treatment for metastatic nodules located in the periphery of the lung, which can be easily removed by a wedge resection. Repeat surgery is also possible during follow-up after VATS.

Pulmonary metastasectomy: a survey of current practice amongst members of the European Society of Thoracic Surgeons

OBJECTIVE

Currently, no randomized trials exist to guide thoracic surgeons in the field of pulmonary metastasectomy. This study investigates the current clinical practice among European Society of Thoracic Surgeon (ESTS) members.

METHODS

A Web-based questionnaire was created exploring the clinical approach to lung metastasectomy. All ESTS members were surveyed.

RESULTS

One hundred forty-six complete responses were received from the 494 consultant ESTS members surveyed (29.6%). For most respondents (68%), lung metastasectomy represents a minor proportion (0-10%) of their clinical volume. Approximately 90% of respondents always/usually review their lung metastasectomy cases within a multidisciplinary meeting. Helical computed tomography is most commonly used (74%) for the detection of metastases, while positron emission tomography is used additionally in less than 50%. Most of respondents (92% and 74%, respectively) consider unresectable primary tumor and predicted incomplete metastasectomy as absolute contraindications to lung metastasectomy. The most frequently performed resection is wedge excision (92%). Palpation of the lung is considered necessary by 65%, while 40% use a thoracoscopic approach with therapeutic intent. Though 65% consider pathologically positive nodes a contraindication to metastasectomy, a similar number rarely/never perform mediastinoscopy before metastasectomy. At the time of metastasectomy 55% perform mediastinal lymph node sampling whereas 33% perform no nodal dissection whatsoever.

CONCLUSIONS

The survey provides a large, time-sensitive database summarizing the clinical practice of pulmonary metastasectomy by members of the ESTS. Responses demonstrate a remarkable consistency of practice patterns, though certain areas of potential controversy showed greater variance. Conceivably, these divergent approaches will encourage future collaborative studies aimed at identifying evidence-based practices for patients with pulmonary metastases.

Surgical treatment of metastatic disease to the lung

The presence of distant metastases usually implies disease not amenable to cure through surgical resection. In such cases, chemotherapy is the mainstay of treatment, with surgery or radiation reserved for palliative measures. However, metastases limited to the lung may be resected with resultant prolonged patient survival compared to unresectable, widely disseminated metastases. Isolated pulmonary metastases should therefore not be considered untreatable. In this review, we discuss the pathophysiology of pulmonary metastases. We outline prognostic factors associated with metastases, and propose criteria to help select patients for metastasectomy. Surgical approaches, including various open techniques and video-assisted thoracoscopy, are covered. Surgical issues, including the need for unilateral versus bilateral exploration, the extent of resection to achieve cure, the need for lymph node dissection, and the benefit of repeat operations, are discussed. Finally, we review some of the more common tumors that metastasize to the lungs, and the role of metastasectomy in their treatment. Resection of pulmonary metastases confers a survival benefit to a select group of patients so long as the primary tumor is controlled, metastases are limited to the lungs, the patient can tolerate the operation from a cardiopulmonary standpoint, and the metastases are completely resected.

Prognostic factors and analysis of microsatellite instability in resected pulmonary metastases from colorectal carcinoma

BACKGROUND

In this study, we analyze our experience with pulmonary resection for metastases from colorectal carcinoma. The aims were to search for factors influencing prognosis and to investigate the presence of microsatellite instability in the primary tumors and the corresponding lung metastases.

METHODS

We identified 81 patients who underwent surgical resection between 1991 and 2004. The microsatellite instability was determined by immunohistochemical evaluation of MSH2 and MLH1 in 117 lesions (41 primary tumors and 76 lung metastases).

RESULTS

Overall 3-, 5-, and 10-year survival rates were 50%, 42%, and 30%, respectively. Univariate analysis showed that stage of the primary tumor (p = 0.037), radicalness of the resection (p = 0.019), and stratification into groups according to the International Registry of Lung Metastases classification (p = 0.039) were prognostic factors. Multivariate analysis showed that stage of the primary tumor (p = 0.030) and the radicalness of the resection (p = 0.014) were independent prognostic factors. All tumors displayed preserved expression of MSH2 and MLH1 and were considered microsatellite stable lesions.

CONCLUSIONS

Pulmonary resection of metastases from colorectal carcinoma results in long-term survival in selected patients. Complete resection, stage of the primary tumor and stratification into groups according to the International Registry of Lung Metastases classification were prognostic factors. All the metastases and the corresponding primary tumors were microsatellite stable lesions. This finding seems to demonstrate that pulmonary metastases are infrequent in colorectal carcinomas with microsatellite instability.

The value of video-assisted mediastinoscopy in pulmonary metastasectomy

OBJECTIVE

To assess the role of video-assisted mediastinoscopy (VAM) in identifying involved mediastinal lymph nodes in patients undergoing pulmonary metastasectomy.

METHODS

Over a 4-year period (2002-2005) a retrospective study was carried out in 57 patients (44 men, 13 women, mean age 59 years) undergoing isolated, unilateral or bilateral metastasectomy. Following staging CT scan, VAM was performed prior to open thoracotomy, median sternotomy or VATS resection of the metastasis. Follow-up was complete in all patients.

RESULTS

Fifty-seven patients underwent 62 operations for metastatic disease. The majority had colorectal cancer (39) followed by renal (11), sarcoma (9), liver (2) and miscellaneous (8). Six patients (10.5%) had positive mediastinal nodes on VAM. There was no perioperative morbidity or mortality. At a median follow-up of 25 months, 63 patients (68.5%) were still alive.

CONCLUSIONS

Mediastinal lymph node involvement has been reported to occur in up to 14% of patients with pulmonary metastasis. In our study, 10% of patients treated for pulmonary metastasis had positive nodal disease at metastasectomy. We believe our results confirm that VAM can be safely performed and may have a role in more accurate staging of metastatic disease and influence the decision for post-resection adjuvant therapy.

Long-term survival after repeated resection of pulmonary metastases from colorectal cancer

BACKGROUND

The purpose of this study was to evaluate the outcome of patients undergoing repeated resection of pulmonary metastases from colorectal cancer and specify factors promising long-term survival.

METHODS

From January 1993 to December 2003, 175 patients were diagnosed and resected for pulmonary metastases of colorectal cancer. Follow-up information was collected for 169 patients, and 33 (19.5%) had had recurrent metastasectomies up to three times. Their follow-up information was updated in August 2006. The first repeated resection was performed for up to six bilateral metastases, the second and third metastasectomies were each unilateral and for a single metastasis only. Lymph node involvement was present in 5 patients who underwent repeat resections.

RESULTS

The overall (n = 169) median survival was 47.2 months after the first metastasectomy. The 33 patients with repeated resections had a median survival of 72.6 months, with survival of 53.8% at 5 years and 20.6% at 10 years. After reoperation, age, sex, primary tumor stage, preoperative carcinoembryonic antigen, disease-free interval, prior resection of liver metastases, and lymph node involvement were not found to be of prognostic importance. The only factor that significantly influenced survival was the number of metastases (hazard risk, 1.299). Perioperative mortality even for repeated resections was 0%.

CONCLUSIONS

Repeated resection of pulmonary metastases secondary to colorectal cancer is safe and can provide long-term survival for highly selected patients.

Prognostic role of lymph node involvement in lung metastasectomy

OBJECTIVE

The impact of lymph node involvement in lung metastasectomy from extrapulmonary malignancies is uncertain. We assessed the prognostic value of lymph node status in lung metastasectomy and the prevalence of unexpected mediastinal lymph node involvement after lymph node sampling or dissection.

METHODS

From May 1998 to October 2005, 388 patients underwent 430 pulmonary metastasectomies with curative intent. The clinical records of all patients who underwent radical lymph node dissection or sampling were reviewed retrospectively. Survival was evaluated using the Kaplan-Meier method and comparison of survival curves by log-rank test.

RESULTS

A total of 124 patients (61 men, mean age 59 years) underwent 139 pulmonary metastasectomies (56 wedge resections, 30 segmentectomies, 49 lobectomies, and 4 pneumonectomies with radical lymph node dissection [88] or sampling [51]). Means of 9.4 lymph nodes and 2 lung metastases per intervention were removed. The median disease-free interval from primary treatment to lung metastasectomy was 49 months. Lymph node involvement was present in 25 patients (20%), in 10 (8%) at N1 stations (hilar or peribronchial) and in 15 (12%) at N2 stations (mediastinal), and in 7 (12.5%) after atypical resection and in 19 (23%) after typical resection. In 15 patients (12%) (60% of N+ patients), lymph node involvement was unexpected. Estimated overall 5-year survival was 46%: It was 60% for subjects with no lymph node metastasis and 17% and 0% for those with N1 and N2 disease, respectively (P = .01).

CONCLUSIONS

Lymph node involvement heavily affects prognosis after pulmonary metastasectomies. In most patients, lymph node involvement was not revealed by preoperative workup.

Lymphadenectomy in Metastasectomy

Although surgery for pulmonary metastases does not benefit a significant number of patients, PM should continue to be offered to patients whose primary tumor is controlled and who have acceptable operative risks. For a survival benefit to be achieved, all extrathoracic and pulmonary metastases must be amenable to complete surgical resection. We have shown that the presence of metastatically involved lymph nodes discovered during PM adversely effects survival in patients undergoing curative PM. We therefore continue to recommend complete mediastinal lymphadenectomy at the time of PM to define the patient's prognosis and perhaps to guide adjuvant therapy.

Solitary Metastases: Illusion Versus Reality

"Suddenly a solitary horseman appeared on the horizon, then another, then another...in a few moments a whole crowd of horsemen swooped down upon him."-Leacock The illusion of solitary metastases is counterintuitive but has generated a sizable literature on the subject. The reality is that there are more metastatic deaths each year than the total number of true long-term survivors of solitary metastases combining all organ sites in the literature of the past century up to the present time. The largest number of solitary metastases survivors had metastases primarily in the lung and/or liver. With innovations in molecular imaging and advances in molecular oncology, the stage is set to detect truly solitary metastases early. Then, aggressive treatment by surgical excision, stereotactic body radiosurgery, targeted chemotherapy, or immunotherapy could eradicate the lesion. A comprehensive review of solitary metastases in a large variety of anatomic sites is presented. A broader staging system is recommended to encompass a solitary metastasis (M1) and oligometastases (M2) as distinct from multiple metastases (M3).

Can we predict long-term survival after pulmonary metastasectomy for renal cell carcinoma?

BACKGROUND

The purpose of this study is to identify factors associated with time-related survival after pulmonary metastasectomy for renal cell carcinoma and to confirm the safety of metastasectomy.

METHODS

From January 1986 to July 2001, 417 patients were diagnosed with pulmonary metastases from renal cell carcinoma; 92 underwent pulmonary metastasectomy. Median disease-free interval after nephrectomy was 3.0 years. Half the patients had 1 or 2 pulmonary nodules; 37% had 5 or more. Median size of the largest nodule (pulmonary metastasis) was 15 mm. Complete resection was obtained in 63 patients (68%). Twenty-nine patients received preoperative immunotherapy. Multivariable hazard function analysis was used to identify continuous, ordinal, and true dichotomous risk factors.

RESULTS

PREDICTORS

The strongest risk factor for time-related mortality was incomplete resection. Five-year survival was 8% for incomplete and 45% for complete resection. Other risk factors included the following continuous and ordinal variables: larger nodule size (p = 0.0001), increasing number of involved lymph nodes (p = 0.01), and decreased preoperative 1-second forced expiratory volume (p = 0.02). Immunotherapy did not improve survival. For completely resected patients, shorter disease-free interval was a risk factor (p = 0.01). Fewer pulmonary nodules predicted higher probability of complete resection (p < 0.0001).

SAFETY

No operative deaths occurred. Nine patients (10%) experienced a total of 12 complications, with persistent air leak and atrial arrhythmia accounting for 5 (42%).

CONCLUSIONS

Because pulmonary metastasectomy for renal cell carcinoma is safe, survival depends on complete resection of pulmonary disease and adequate pulmonary reserve. Preoperative determination of resectability is thus critical, and computed chest tomography and mediastinoscopy are valuable tools for optimizing patient selection.

Prognostic significance of lymph node metastasis found during pulmonary metastasectomy for extrapulmonary carcinoma

BACKGROUND

The prognostic significance of lymph node metastasis in cancer patients is well documented. Pulmonary metastasectomy in selected patients is associated with improved survival. Little is known about the prognostic significance of lymph node metastases found during pulmonary metastasectomy for extrapulmonary carcinoma metastatic to the lung.

METHODS

The records of all patients who underwent pulmonary metastasectomy and complete mediastinal lymph node dissection for extrapulmonary carcinomas at our institution from November 1985 through July 1999 were reviewed.

RESULTS

Eight hundred eighty-three patients underwent pulmonary metastasectomy. Of these, 70 patients (7.9%) (44 men, 26 women) had concomitant complete lymphadenectomy. Median age was 64 years (range, 33 to 83 years). Median time interval between primary tumor resection and metastasectomy was 34 months (range, 0 to 188 months). Wedge excision was performed in 46 patients, lobectomy in 16, both in 7, and pneumonectomy in 1. Lymph node metastases were found in 20 patients (28.6%) and were classified as intrapulmonary or hilar (N1) in 9, mediastinal (N2) in 8, and both in 3. There were no operative deaths. Median follow-up was 6.6 years (range, 1.1 to 14.6 years). Three-year survival for patients with negative lymph nodes was 69% as compared with only 38% for those with positive lymph nodes (p < 0.001).

CONCLUSIONS

The presence of lymph node metastases at the time of pulmonary metastasectomy for extrapulmonary carcinoma has an adverse effect on prognosis. Complete mediastinal lymph node dissection should be considered at the time of pulmonary metastasectomy for carcinoma to improve staging and guide treatment.

Fluorodeoxyglucose positron emission tomography improves preoperative staging of resectable lung metastasis

OBJECTIVE

F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is now a procedure of proven clinical value in the staging of primary lung cancer. This study evaluated the role of PET in the preoperative assessment of resectable lung metastases.

METHODS

Eighty-six patients with previously treated malignancy and proven or suspected lung metastases, deemed resectable at computed tomography scan, were investigated with 89 preoperative PET procedures. Primary tumor sites were: gastrointestinal in 32 cases, sarcoma in 13, urologic in 14, breast in 8, head and neck in 7, gynecologic in 5, thymus in 5, other in 5. Seventy lung resections were performed in 68 patients of whom only 54 proved to be lung metastasis, 7 were primary lung tumors, and 9 were benign lesions.

RESULTS

In 19 cases (21%) lung surgery was excluded on the basis of PET scan results due to extrapulmonary metastases (11 cases), primary site recurrence (2), mediastinal adenopathy (2), or benign disease (4). All mediastinal node metastases (7 cases) were detected by PET with a sensitivity, accuracy, and negative predictive value for mediastinal staging of 100%, 96%, and 100%, respectively, versus 71%, 92%, and 95% of the computed tomography scan. In the group of patients who underwent lung resection, PET sensitivity for detection of lung metastasis was 87%.

CONCLUSIONS

PET scan proved to be a valuable staging procedure in patients with clinically resectable lung metastasis and changed the therapeutic management in a high proportion of cases.

Prognostic factors and survival after complete resection of pulmonary metastases from colorectal carcinoma: experiences in 167 patients

OBJECTIVE

Surgical resection is an important form of treatment for pulmonary metastases from colorectal carcinoma. We analyzed the clinical course, outcome, and prognostic factors after surgery.

METHODS

Between 1985 and 2000, 167 patients (103 men, 64 women) underwent complete pulmonary resection of metastatic colorectal carcinoma. Only patients who met the criteria for potentially curative operation, in particular, control of the primary tumor, ability to resect all metastatic disease, and no other extrapulmonary metastases, were included.

RESULTS

The overall 5-year survival was 32.4%. A significantly longer survival was observed in multivariate analysis in patients without lymph node involvement compared with patients with pulmonary or mediastinal lymph node metastases or both. The number of pulmonary metastases significantly influenced survival. In patients with a solitary metastasis, we observed a 5-year survival of 45%, whereas the rate was 19.8% in patients with more than a single metastasis. In multivariate analysis, we also found the prethoracotomy carcinoembryonic antigen serum level to be an independent significant prognostic factor for survival. In patients with a serum carcinoembryonic antigen level exceeding 5 ng/mL and in patients with a serum carcinoembryonic antigen level in the normal range, the 5-year survivals were 22.7% and 48.3%, respectively.

CONCLUSIONS

We conclude that pulmonary resection of metastatic colorectal carcinoma is safe and results in long-term survival. Thoracic lymph node metastases, serum carcinoembryonic antigen level before metastasectomy, and the number of pulmonary metastases were identified as prognosis-related criteria for surgery.

[Surgical treatment of pulmonary metastases from renal cancer]

Based on a large single-center follow-up database, we evaluated the long-term results after curative resection of pulmonary metastases from renal cancer. During a 20-year period, 105 patients underwent a total of 150 resections with curative intention. Hospital mortality was 0.95%, 5- and 10-year survival rates were 40% and 33%, respectively. Significant prognostic relevance was shown for complete pulmonary resection, lymph node involvement upon primary resection as well as size of the resected lung metastasis. Our findings of low perioperative morbidity and mortality rates lead us to propose that in patients without additional metastases curative resection of pulmonary lesions should be considered. Moreover, recurrent pulmonary metastases should also be considered for surgical treatment since resection for cure significantly improves survival in these patients.

Pulmonary metastasectomy for 165 patients with colorectal carcinoma: A prognostic assessment

OBJECTIVE

The purpose of this study was to analyze our entire experience with pulmonary resection for metastatic colorectal carcinoma to determine prognostic factors and critically evaluate the potential role of extended metastasectomy.

METHODS

We analyzed the postoperative survival of 165 patients who underwent curative pulmonary surgery at eight institutions in the Kansai region of western Japan (Kansai Clinical Oncology Group) from 1990 to 2000.

RESULTS

Overall survivals at 5 and 10 years were 39.6% and 37.2%, respectively. Cumulative survival of patients who underwent simultaneous bilateral metastasectomy was significantly lower than that of the patients who underwent unilateral metastasectomy or sequential bilateral metastasectomy (P =.048). Five-year survival was 53.6% for patients without hilar or mediastinal lymph node metastasis, versus 6.2% at 4 years for patients with metastases (P <.001). Five-year survival of patients with a prethoracotomy carcinoembryonic antigen level less than 10 ng/mL was 42.7%, versus 15.1% at 4 years for patients with a carcinoembryonic antigen level 10 ng/mL or greater (P <.0001). Twenty-one patients underwent a second or third thoracotomy for recurrent colorectal carcinoma. Overall 5-year survival from the date of the second thoracotomy was 52.1%. The 34.1% 10-year survival for the 26 patients with hepatic metastasis resected before thoracotomy did not differ significantly from that of patients without hepatic metastases (P =.38).

CONCLUSIONS

The status of the hilar or mediastinal lymph nodes and prethoracotomy carcinoembryonic antigen level were significant independent prognostic factors. Patients with pulmonary metastases potentially benefit from pulmonary metastasectomy even when there is a history of solitary liver metastasis. Careful follow-up is warranted, because patients with recurrent pulmonary metastases can undergo repeat thoracotomy with acceptable long-term survival. Simultaneous bilateral metastasectomy confers no survival benefit. Prospective studies may determine the significance of this type of pulmonary metastasectomy.