Risk factors for impaired lung function after pulmonary metastasectomy: a prospective observational study of 117 cases

Pulmonary laser-assisted metastasectomy is associated with prolonged survival in patients with colorectal cancer

Background

Pulmonary metastases develop in 10-15% of patients with colorectal cancer. Surgical metastasectomy currently provides the only hope for a cure for these patients. The aim of this study was to analyze the expanding role of pulmonary metastasectomy in the context of laser-assisted surgery (LAS) vs. non-laser-assisted surgery (NLAS).

Methods

We performed a single-center retrospective analysis of 204 patients who underwent curative pulmonary metastasectomy for colorectal cancer between 01/2005 and 12/2016. The main endpoint was survival. The Kaplan-Meier method was applied for statistical analysis and survival rates were compared with the log rank test.

Results

Median follow-up was 53 months. A total of 267 metastases were resected in 154 operations in the NLAS group (median: 1) vs. 438 metastases in 122 operations in the LAS group (median: 5; P<0.0001). The interval between treatment of the primary tumor and the first pulmonary metastasectomy was significantly shorter in the LAS group (19 vs. 32 months; P=0.008). Anatomical resections were significantly reduced using LAS, 8% vs. 23% respectively. Despite more negative predictors in the LAS group, there was no statistically significant difference in overall disease-specific 5-year survival (70% LAS vs. 58% NLAS; P=0.18).

Conclusions

Survival after pulmonary metastasectomy has previously been shown to correlate with a low number of metastases and a longer disease-free interval. However, with the tissue-saving LAS technique complete resectability can be achieved in patients with more metastases and long-term survival is possible for selected patients.

Management of Sarcoma Metastases to the Lung

For decades, surgical resection of pulmonary metastases has been performed; despite limited randomized data, surgery is increasingly accepted as an integral part in the management of metastatic disease. Long-term results indicate resection is potentially curative with significantly improved survival following complete resection. Recurrence, however, is not uncommon with many patients undergoing repeat resection. With advancing surgical technique and adjuvant therapies, patients with high or recurrent tumor burden are increasingly afforded disease control and potential cure. In this review, the prognostic characteristics of pulmonary metastases from sarcoma, preoperative evaluation, operative technique, long-term outcomes, and management of complex patients are highlighted.

Pulmonary metastasectomy for sarcoma-Essen experience

Background

Pulmonary metastasectomy is an established treatment modality for patients with soft as well as bone tissue sarcomas. Aim of this study is to describe the Essen experience in the surgical management of patients with pulmonary sarcoma metastases.

Methods

This is a retrospective single center analysis of perioperative outcome of patients undergoing pulmonary metastasectomy for sarcoma metastases from 1997-2017 and a summary of published papers on this topic.

Results

During the observation period 327 patients (49.23% female) underwent pulmonary metastasectomy for metastases of extrathoracic sarcomas in curative intent. The number of resected metastases was 1-3 in 283 cases (86.54%), 4-9 in 31 cases (9.48%) and 10 or more lesions in 14 cases (4.28%). Wedge resections or precision excisions with laser or electrocautery were performed in 278 cases (85.02%), anatomical segmental resections in 16 patients (4.89%) and lobectomies in 33 patients (10.09%). Bilateral procedures were performed in 98 cases (29.96%). Lymphadenectomy was performed in 122 patients. Positive lymph nodes were found only in 6 cases. All of these cases were patients with soft tissue sarcoma as primary tumor. Preoperative neoadjuvant treatment was performed in 79 patients (24.15%) with chemotherapy, in 54 patients (16.51%) with radiochemotherapy and in 10 patients (3.05%) with radiotherapy. Major postoperative complications were observed in 2.75% of all patients. Thirty-day mortality was 0%.

Conclusions

Pulmonary metastasectomy in sarcoma patients is a feasible and safe treatment strategy even in patients with bilateral metastases and multiple lesions. Thoracic lymph node metastases are rare and did not influence survival in our cohort.

Multi-reoperations for lung metastases

In this study, we investigated role and results of multi-reoperations for lung metastases. From 1986 to 2010, 113 consecutive patients (61 men and 52 women; mean age: 53.2 ± 12.8 years) underwent repeated lung metastasectomy with curative intent in our institution. Two procedures were performed in 113 patients, three in 54, four in 31, five in eight and six in three. There was no perioperative mortality. Cumulative 5-year survival was 65% and this was significantly higher than the value recorded for patients undergoing only one metastasectomy (42%; p = 0.021). Size, number of resections and probability of recurrence increased by number of operation whereas disease free interval reduced. At any metastasectomy both short disease-free interval and multiple metastases resulted in the most significant negative prognosticators. In conclusion, redo metastasectomy is worthwhile for the initial procedures, afterwards both disease-free and overall survivals decrease and surgery lose its efficacy.

History and present status of pulmonary metastasectomy in colorectal cancer

Clinical practice with respect to metastatic colorectal cancer differs from the other two most common cancers, breast and lung, in that routine surveillance is recommended with the specific intent of detecting liver and lung metastases and undertaking liver and lung resections for their removal. We trace the history of this approach to colorectal cancer by reviewing evidence for effectiveness from the 1950s to the present day. Our sources included published citation network analyses, the documented proposal for randomised trials, large systematic reviews, and meta-analysis of observational studies. The present consensus position has been adopted on the basis of a large number of observational studies but the randomised trials proposed in the 1980s and 1990s were either not done, or having been done, were not reported. Clinical opinion is the mainstay of current practice but in the absence of randomised trials there remains a possibility of selection bias. Randomised controlled trials (RCTs) are now routine before adoption of a new practice but RCTs are harder to run in evaluation of already established practice. One such trial is recruiting and shows that controlled trial are possible.

Role of segmentectomy for pulmonary metastases

Pulmonary metastasectomy has not been proven by randomized trials to be more effective than non-operative management, but currently has a well-accepted role for certain primary cancers, in particular colorectal cancer and sarcoma. One of the principal tenets for pulmonary metastasectomy is that all lesions are resected. A major technical difference compared to surgical management of primary lung cancer is that management of metastatic disease frequently requires the resection of multiple and possibly bilateral lesions. In addition, surgeons and patients must often consider repeat surgery for management of metachronous lesions that develop some time after a previous resection, given the nature of metastatic cancer. Therefore, surgeons must ensure complete resection of lesions with negative margins but also must be cognizant of minimizing resection of functional lung tissue as much as possible, in order to ensure that both current and future lesions can be resected while leaving patients with adequate pulmonary function. Segmentectomy is generally infrequently utilized for pulmonary metastasectomy, but has a role for lesions for which a wedge resection is technically not possible but a lobectomy is not required. Segmentectomy can be an important tool in achieving the dual goals of complete resection and impacting pulmonary function as little as possible. Using minimally invasive techniques with thoracoscopy to perform segmentectomy is associated with less short-term morbidity than thoracotomy. Although the use of minimally invasive techniques limits manual palpation and therefore potential resection of small lesions not identified by pre-resection imaging, the current literature does not suggest that these procedures should be done via thoracotomy.

Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC International)

SUMMARY Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) is a randomized controlled trial. Patients with resected colorectal cancer found to have one or more pulmonary metastases are randomized to have a metastasectomy or not. Both arms include active monitoring. Patients considered possible candidates for pulmonary metastasectomy are asked to first give consent to be assessed according to protocol after which a decision to have or not have metastasectomy may be made. If there is uncertainty, patients are invited to consent to randomization, including minimization for known prognostic factors: the number of metastases, the interval since primary resection, carcinoembryonic antigen levels and the TNM stage of the primary cancer. The primary outcomes are survival and quality of life. The trial is open in England, and in Serbia and Italy as PulMiCC International.