Completion pneumonectomy for lung metastases: is it justified?

The role of extended pulmonary metastasectomy

BACKGROUND

The role of extended pulmonary resection for lung metastases is still unclear, and little information is available in the literature. This study was performed to analyze the outcomes and prognostic factors of patients who underwent extended resections for pulmonary metastases.

METHODS

From 1998 to 2013, 1027 patients underwent lung metastasectomy procedures. Twenty-nine patients had extended pulmonary resections: three resections of the chest wall, one azygos, one diaphragm, four vascular resections/reconstructions, six sleeve resections, and 14 pneumonectomies.

RESULTS

Extended resection was performed for metastatic disease mainly from epithelial (62.1%) and sarcomatous (20.7%) tumors. Complete resection was obtained in all patients. Thirty-day operative morbidity and mortality rates were 38% (11 of 29) and 0%, respectively. Only one patient had a major complication due to a bronchopleural fistula. Mean hospital stay was 6.3 days. After a median follow-up of 27 months, 16 patients (55%) had died. At univariate analysis, survival was determined by primary tumor histology (p = 0.03); the number of metastases, nodal status, disease-free interval or extension of surgery (pneumonectomy vs. lobar resection) were not related to survival probably due to the low number of patients. Overall survival after a complete extended metastasectomy was 66% at 2 years, 42% at 5 years, and 36% at 10 years.

CONCLUSIONS

Extended resections performed during pulmonary metastasectomies are associated with low mortality and morbidity rates and an acceptable long-term survival when performed in selected patients susceptible to complete resection.

Pulmonary metastasectomy: outcomes and issues according to the type of surgical resection

According to a recent report by the Committee for Scientific Affairs of the Japanese Association for Thoracic Surgery, pulmonary metastasectomy accounted for as many as 10.2 % of all entry cases of general thoracic surgery, and its use is increasing year by year. Accordingly, many studies have examined the surgical procedures used during pulmonary metastasectomy for metastases from primary tumors affecting various organs as well as the outcomes of and indications for such procedures, but some problems remain. In this article, the following questions related to the surgical approach and the type of resection used during pulmonary metastasectomy are reviewed: (1) Wedge resection--what is a safe margin for preventing local recurrence? (2) What is the clinical significance of node sampling/dissection during pulmonary metastasectomy? and (3) When is segmentectomy necessary? In addition, we discuss: (4) open thoracotomy vs. video-assisted thoracoscopic surgery (VATS), (5) repeated metastasectomy for pulmonary metastases, (6) the surgical approach for bilateral pulmonary metastasectomy, (7) pneumonectomy, and (8) pulmonary metastasectomy combined with resection of the neighboring organs.

Experience with Thoracoscopic Pneumonectomies at a Single Institution

Objective

The aim of this study was to review a single-institution experience with video-assisted thoracoscopic pneumonectomy (VATP).

Methods

From July 2008 through December 2012, the medical records of all patients undergoing pneumonectomy (total and completion) for lung cancer were reviewed. Clinical parameters were recorded and analyzed.

Results

During this period, 16% (7/45) of pneumonectomies for malignancy were performed thoracoscopically. Patient selection was performed in the context of a multidisciplinary tumor board. Of the seven VATPs, five were standard (Video 1, available at http://links.lww.com/INNOV/A40 ) and two were completion pneumonectomies (Video 2, available at http://links.lww.com/INNOV/A41 ). Indications were primary lung cancer in six (three adenocarcinoma, one squamous carcinoma, one large cell neuroendocrine carcinoma, and one mixed adenocarcinoma cell and small cell lung carcinoma) and metastatic esophageal cancer in one patient. Preoperative selection was based on unfavorable location of the primary tumor, which excluded the possibility of a lesser resection such as sleeve resection while permitting an R0 resection by pneumonectomy. Pathologic staging was consistent with clinical staging except for one patient who was upstaged. There were four complications: atrial fibrillation, pneumonia, and two bronchopleural fistulas. The median length of stay was 4 days (excluding one outlier). Distant disease recurrence occurred in one patient. Kaplan-Meier survival at 24 months was 75%.

Conclusions

Introduction of VATP into the armamentarium of the experienced thoracoscopic surgeon is feasible with acceptable outcomes and a complication profile that is not dissimilar to the open pneumonectomy experience. Greater experience with this approach should provide additional data to more objectively evaluate the merits of this approach.

Completion pneumonectomy in patients with cancer: postoperative survival and mortality factors

OBJECTIVE

To describe postoperative complications and long-term outcomes of completion pneumonectomy and highlight prognostic factors.

METHOD

We retrospectively reviewed the records of 46 patients (38 men, 8 women) who underwent completion pneumonectomy for lung cancer between 1995 and 2009 in one of two thoracic surgery departments. Most were current or former smokers (n = 41; 89%) and did not undergo chemotherapy (n = 38; 83%) or radiotherapy (83%) before surgery.

RESULTS

Complications after surgery were respiratory failure (n = 11; 24.4%), bronchopleural fistula (n = 6; 13%, with no side preference), and empyema (n = 6; 13%). Blood transfusion was necessary for 43% of the cases (n = 20). The day 90 death rate was 15.2% (n = 7). Postoperative staging showed mostly limited disease. Ten patients (21.7%) underwent operation for a second primary cancer, 25 for local recurrence (54.3%), five for microscopically incomplete resection, and six for other reasons. Median overall survival after completion surgery was 30 months (median follow-up: 46.5 months). Among the 15 living patients (33%), 11 are free of disease (24%). In a Cox regression model, factors negatively influencing overall survival were: age older than 65 years (odds ratio [OR] = 2.47; p = 0.012), current smoker status (OR = 2.285; p = 0.033), postoperative pulmonary (OR = 5.144; p = 0.004), cardiac (OR = 3.404; p = 0.033), or parietal wound complications (OR = 5.439; p = 0.016).

CONCLUSION

Despite its increased postoperative complications and mortality compared with standard pneumonectomy, completion pneumonectomy offers encouraging long-term results. Five main factors seem predictive of shorter overall survival.

Completion pneumonectomy for lung cancer treatment: early and long term outcomes

Background

To analyze the experience of completion pneumonectomy for lung cancer at a single institution in China.

Methods

From January 1988 to December 2007, 92 patients underwent completion pneumonectomy for the treatment of lung cancer. The indications were second primary lung cancer (n = 51), Local metastasis (n = 37) and Lung metastasis (n = 4). The median interval between the primary operation and CP was 24.4 months (1.5-145 m).

Results

There was no intraoperative deaths. The CP procedure lasted 4.3 h (1.5-8 h). Blood loss in the CP performance was 1854.5 ml (200-9100 ml) 9 (9.78%) patients died in the postoperative period: pulmonary embolism (n = 2), disseminated intravascular coagulation (DIC) after the multisystem failure (n = 1), respiratory failure after contralateral pneumonia (n = 5), bronchopleural fistula (BPF) with acute respiratory distress syndrome (ARDS) (n = 1) 31(33.7%) patients had at least one major nonfatal complication. The 1, 3 and 5 year survival rates were 81%, 26% and 14% respectively.

Conclusions

Completion pneumonectomy for lung cancer is a safe surgical procedure for the skilled surgeon though it has a relatively higher complications and the long-term survival is acceptable.

Surgical management of colorectal lung metastasis

Colon cancer is a systemic disease in 19% of patients and metastasizes most frequently to the liver and the lung. Survival is enhanced with complete surgical resection of pulmonary metastases. Comprehensive restaging and verification of preoperative fitness must precede resection. The operative approach is dictated by the anatomic location of the metastases, whereas the extent of resection remains a balance between complete removal of metastatic deposits while preserving as much lung parenchyma as possible. The presence of metastatic involvement of hilar and mediastinal lymph nodes is ominous. Multidisciplinary care is highly recommended. An evidence-based algorithm for the identification assessment and treatment of patients with pulmonary metastases is proposed.

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.

Surgical and Nonsurgical Therapy for Lung Metastasis: Indications and Outcomes

The management of pulmonary metastasis is a broad and multifaceted topic. Because of the filtration function and the favorable microenvironment of the lung, most malignancies cause pulmonary metastases. This article focuses on recent experience with secondary lung malignancies and their newer treatment options, indications, and technical aspects.

Sekund�re Pneumonektomien

Completion pneumonectomy (CP) is widely known to be associated with high morbidity and lethality. However, in certain instances, it offers the only chance for cure. The results of the following CPs (N=86) were investigated: progressive or recurrent benign disease (N=6, group I), recurrence of a malignant tumor (N=41, group II), and complication after lung resection (N=39, group III). Right completion pneumonectomy was carried out in 48 cases and left completion pneumonectomy in 38. The overall 30-day lethality of CP was 20.2%, 0% in group I, 10% n group II, and 33.3% n group III. This lethality was significantly higher on the right side (29.8%) than on the left (7.7%; P=0.014). Differentiation between emergency and urgent indications resulted in 30-day lethalities of 54% and 23%, respectively. This difference is significant (P=0.002). The 30-day lethality for patients with anastomotic or stump insufficiency was 41% (P=0.002). Five-year survival was 26% in the group of patients with malignant disease and 32% in those with complications after lung resection. The results show: the lethality of CP remains high, especially after complications from operating in emergency conditions. However, considering the long-term survival, CP is certainly justified.

Long-Term Survival After Salvage Surgery for Colorectal Lung Metastases

We report the case of a patient with an extended pneumonectomy for colorectal lung metastases after the failure of multimodal treatment. Salvage surgery may be useful in highly selected patients to achieve local control, resulting in long-term disease-free survival.

Completion pneumonectomy for lung metastases

OBJECTIVE

Completion pneumonectomy (CP) for malignant disease is generally accepted but controversial for lung metastases. The data available show a high perioperative morbidity and mortality with a poor long-term prognosis. We analysed the postoperative outcome and long-term results of our patients undergoing CP.

PATIENTS AND METHODS

Between January 1986 and May 2003, nine patients underwent completion pneumonectomy for lung metastases. This represents 10% (9/86) of all CPs performed and 1.7% (9/525) of all pneumonectomies.

RESULTS

One to three metastasectomies in the form of wedge resection (16), segment resection (5) and lobectomies (3) were performed prior to CP. The mean time interval between the operation of the primary tumour and the first metastasectomy was 38 months, the first and second metastasectomy 12 months, the second and third metastasectomy 14 months, and the third metastasectomy and CP 25 months. Six patients had an extended completion pneumonectomy. Operative morbidity and mortality was 0%. One patient is still alive and recurrence-free 9 months after CP. Two patients have recurrent pulmonary contralateral metastases under chemotherapy and six patients died of metastatic disease. Actual survival is 33%, recurrence-free survival (RFS) is 11%. The 3-year survival is 34%.

CONCLUSION

Since there was no morbidity and mortality in our series, CP for lung metastases seems to be justified but the long-term survival is limited by the occurrence of contralateral or extrapulmonary metastatic disease. Multiple resections of metastases have a positive influence on survival, but the last step of resection in the form of CP does not seem to improve long-term survival.

Surgical resection of lung metastases from epithelial tumors

BACKGROUND

One of the main characteristics of malignant tumors is the capability to disseminate, giving rise to local or distant metastases. Pulmonary metastases occur in almost 30% of all oncology patients, and secondary lung tumors are more frequent than primary ones. Surgical resection of metastases is now a well-established procedure, but the results vary with the histologic type of the primary tumor. We wished to identify factors affecting late survival after pulmonary metastasectomy for epithelial tumors.

METHODS

We have reviewed retrospectively data for 78 patients who underwent 101 curative resections of epithelial pulmonary metastases between January 1988 and December 2000 at our department. Potential prognostic factors affecting late survival, namely histology of the primary tumor, disease-free interval, number and size of resected lung metastases, involvement of lymph nodes, use of nonsurgical adjuvant therapy, and relapse of pulmonary metastases, were investigated.

RESULTS

There was no operative mortality, and the postoperative course was uneventful in 91.1% of the procedures. The mean disease-free interval was 48.2 +/- 59.8 months, and the mean follow-up after the first pulmonary metastasectomy was 40.8 +/- 31.5 months. Mean overall survival was 81.0 +/- 10.0 months, and 5-year and 10-year survival rates were 47.4% and 37.7%, respectively. By univariate and multivariate analyses, the disease-free interval and the prognostic grouping system proposed by the International Registry of Lung Metastases were found to significantly influence the long-term survival. Presence of symptoms also showed an important influence.

CONCLUSIONS

Resection of epithelial pulmonary metastases is safe and effective, and is associated with very low perioperative morbidity and mortality and a reasonable 5-year and 10-year survival. In the present study, the disease-free interval influenced significantly the long-term survival. Our results did not differ significantly from (and in many cases compared favorably with) those described in the literature.

Pulmonary medicine and palliative care

Gynaecological malignancies affect the respiratory system both directly and indirectly. Malignant pleural effusion is a poor prognostic factor: management options include repeated thoracentesis, chemical pleurodesis, symptomatic relief of dyspnoea with oxygen and morphine, and external drainage. Parenchymal metastases are typically multifocal and respond to chemotherapy, with a limited role for pulmonary metastatectomy. Pulmonary tumour embolism is frequently associated with lymphangitic carcinomatosis, and is most common in choriocarcinoma. Thromboembolic disease, associated with the hypercoagulable state of cancer, is treated with anticoagulation. Inferior vena cava filter placement is indicated when anticoagulation cannot be given, or when emboli recur despite adequate anticoagulation. Palliative care has a major role for respiratory symptoms of gynaecological malignancies. Treatable causes of dyspnoea include bronchospasm, fluid overload and retained secretions. Opiates are effective at relieving dyspnoea associated with effusions, metatases, and lymphangitic tumour spread. Non-pharmacological therapies include energy conservation, home redesign, and dyspnoea relief strategies, including pursed lip breathing, relaxation, oxygen, circulation of air with a fan, and attention to spiritual suffering. Identification and treatment of gastroesophageal reflux, sinusitis, and asthma can improve many patients' coughs. Chest wall pain responds to local radiotherapy, nerve blocks or systemic analgesia. Case examples illustrate ways to address quality of life issues.