Treatment of isolated pulmonary metastases

Metastatic melanoma: Pathologic characterization, current treatment, and complications of therapy

Metastatic melanoma (MM) has the potential to involve virtually any anatomical site, and it also has a wide spectrum of histological appearances. General clinicopathologic data pertaining to MM are presented in this review, together with a discussion of its differential diagnosis and therapy. "Biological" agents used in the treatment of melanoma are considered, along with the pathological features of the complications that they may cause.

Preoperative imaging of pulmonary metastases in patients with melanoma: implications for minimally invasive techniques

HYPOTHESIS

Preoperative imaging underestimates the number of pulmonary melanoma metastases. Although thoracoscopic resection is less invasive than resection via thoracotomy, it does not allow manual palpation of the lung to identify any metastases not visible on the preoperative scan or at the time of resection.

DESIGN

Retrospective review of a prospectively maintained database.

SETTING

Tertiary referral center.

PATIENTS

A total of 170 patients who underwent preoperative computed tomography of the chest, followed within 30 days by thoracotomy for resection of pulmonary metastatic melanoma.

MAIN OUTCOME MEASURES

Number of pathology-confirmed pulmonary metastases detected by preoperative chest computed tomography vs intraoperative manual palpation.

RESULTS

The mean age of the patients was 49.5 years at initial diagnosis of melanoma and 57.1 years at diagnosis of pulmonary metastases; 69% of patients were male. A total of 334 pulmonary metastases were resected; the mean lesion size was 2.0 cm (range, 0.1-14.0 cm). In 49 of 190 pulmonary resections (26%), manual palpation of the subpleural parenchyma revealed lesions not identified during preoperative imaging. The rate of 5-year overall survival was 33%.

CONCLUSIONS

Preoperative imaging underestimates the number of pulmonary lesions in patients with metastatic melanoma. Because incomplete resection of metastatic disease is associated with worse outcomes, we recommend caution when considering a minimally invasive approach for the resection of pulmonary metastatic melanoma.

Selected benefits of thoracotomy and chemotherapy for sarcoma metastatic to the lung

To determine the benefit of aggressive surgical therapy, we studied 77 consecutive patients presenting to our sarcoma registry with pulmonary metastases. Detailed follow-up was available on all patients; the median follow-up of the 13 long-term survivors was 72 months from the date of diagnosis of the primary tumor. Survival of these 77 patients with metastatic disease was independent of the size, location, and histology of the primary tumor. Once metastases developed, survival of patients with pulmonary metastases was not influenced by the extent of surgical resection of the primary tumor or by the use of radiation therapy. Pulmonary metastases were initially treated with thoracotomy and metastasectomy in 34 patients. The median survival after thoracotomy was 26 months. Seven patients were alive more than 4 years after their diagnosis. Pulmonary metastases were treated with chemotherapy alone in 43 patients. Although the survival was shorter (median survival 14 months) in patients treated with chemotherapy, an objective response to chemotherapy was obtained in 13 (30%) patients. Four of these patients were alive 4 years after their diagnosis. These data demonstrate that both thoracotomy and chemotherapy are associated with long-term survival of patients with sarcoma metastatic to the lung.

Surgery for pulmonary metastasis: a 20-year experience

During a recent 20-year period, 556 patients underwent operation for pulmonary metastasis at the University of Texas M.D. Anderson Hospital and Tumor Institute at Houston. The surgical mortality was 1.5% for 772 resections. A selection of 443 patients was made to evaluate the contribution of operative intervention as a primary treatment, with selective adjunctive therapy when applicable. The success of a surgical approach is dependent primarily on adherence to selection criteria; it is important that only patients in whom all known disease can be completely removed with the planned resection and who have full control of the primary site are treated. The overall survival for the group was 35%. For patients with carcinoma, survival ranged from 24% for those with primary uterine cervix tumors to approximately 54% for urinary tract, male genital tract, and corpus of uterus primary tumors. In the group with sarcoma, patients with skeletal tumors had a 46.4% survival rate (50.7% for those with osteogenic sarcoma), and 33% of the patients with soft tissue tumors had long-term survival. The outcome for patients with melanoma was poor; only 12.1% survived 5 years. If the original criteria apply, multiple and bilateral lesions can be successfully managed. Patients undergoing planned adjuvant treatment had a superior outcome compared with those not so treated. However, a significant survival advantage was shown only for patients with sarcoma. The failure to control all disease in patients in whom pulmonary metastasis is controlled surgically can only be improved on through the use of systemically active adjuvant treatment.

Resection of lung metastases in large bowel cancer

A series of 14 patients had partial or, in one case, total excision of the lung for metastatic tumour originating in the large bowel. Two patients have survived long periods (9 years and 12 years) and are now apparently free of the disease. A third patient shows no recurrence after bilateral lobectomy 2 years ago. Six of the remaining 11 patients developed isolated pulmonary metastases 5 years and 4 months to 11 years and 4 months after the original bowel resection. All 6 survived for 9 months to 11 years after pulmonary resection before succumbing to the disease. In all 11 patients who died, death was caused by systemic metastases in the brain, spinal cord or bone.

Thoracic metastases

One hundred and four patients are reviewed who were found to have thoracic metastases arising from distant primaries. Ninety lesions were intrapulmonary and the remainder involved other thoracic structures, such as chest wall and pleura. The tissue diagnosis was established in all but eight patients. Cases were included only if review of the histology revealed that both primary and secondary tumours were identical. The chest lesion was the presenting feature of the disease in 21 patients. In the remainder, the interval between treatment of the primary and appearance of the thoracic metastasis varied from a few months to 25 years. Twelve patients had metastatic sarcoma. The remainder had metastases from the gastrointestinal tract (29), from the genitourinary tract (32), from breast primaries (18), and a miscellaneous group (13) which included five instances of malignant melanoma and metastases from adrenal, laryngeal, and thyroid primaries. The metastases were treated surgically in 47 patients. In the light of cell type, availability of nonsurgical methods of treatment, site of metastasis, and survival, an attempt is made to evaluate the place of surgery in the management of thoracic metastatic disease.

Rationale for the surgical treatment of pulmonary metastases

In a twenty-six year period, 90 patients underwent surgical treatment for metastatic malignant disease of the lung. The primary tumour had apparently been completely removed and there was no evidence of other metastatic spread. Thirty patients enjoyed a survival of more than five years. In 22 cases of the lung lesion was multiple and in 17, the lesions were bilateral. In patients with pulmonary metastases, but without evidence of other dissemination of the disease, resection of the lesions provided useful palliation, and 33% survived for five years of more.

The effect of metastasectomy: fact or fiction?

Metastasectomy in the treatment of solitary metastases has been recommended almost unanimously. The basis for this recommendation has been that 5-year survival after metastasectomy is around 30%, which is just as good as after operation for bronchial carcinoma. It has been assumed, implied, or claimed that the 5-year survival without operation is nil. Control material is, however, lacking. Seventy surgically treated patients were compared with a small, historical control group of 12 patients. There was no difference in 5-year survival. Because of these findings and after a study of the literature, we postulate that patients with lung metastases fulfilling the criteria for operation constitute a selected group with a favorable natural history. Five-year survival, therefore, is an insufficient way of describing the effect of metastasectomy. However, patients with 10-year survival are rare in the literature. In some patients with a favorable tumor-host relationship or with possibilities for effective chemotherapy, cure or prolongation of life has been achieved. Such patients should undergo operation. Randomized studies are needed in all groups for which we do not have sufficiently strong evidence that metastasectomy contributes to the longevity of the patient.

The role of thoracotomy in the management of pulmonary metastases from malignant melanoma

Thirty-three patients over a 21-year period underwent thoracotomy for resection of suspected pulmonary metastases from malignant melanoma. Eleven patients were found to have nonmalignant disease (Group 1); 10 were found to have unresectable disease (Group 2); and 12 were rendered disease-free (Group 3). Of the patients found to have melanoma, 20 of 22 received post-operative chemotherapy. The median survival of the patients in Group 2 was 10.5 months (3 to 20 months); in Group 3 it was 12 months (3 to 35 months). There were no 5-year survivors. No factors distinguished the three groups preoperatively. Surgical resection still offers the greatest chance for long-term survival, based on reports of patients in the literature who have survived longer than 5 years following resection of pulmonary metastases from melanoma. Thoracotomy is especially useful for staging purposes in those patients found to have no metastatic disease.

Pulmonary resection in metastatic carcinoma

Resection of pulmonary metastases in osteogenic sarcoma has been reported by us to result in a five-year survival rate of 27 percent. A later report of surgical management of pulmonary metastases from all types of sarcomas showed a five-year survival rate of 26%. This report reviews the experience with 188 patients treated surgically for pulmonary metastasis from a variety of carcinomas, demonstrating that a similar rate of survival is obtainable by surgical excision of these metastases. A total of 188 patients underwent 242 thoractomies for metastatic pulmonary carcinomas. The most frequent sites of origin were the colon, melanoma, breast, and testicular carcinoma. Surgical treatment of these metastases is justified when the following criteria are adhered to: (1) primary site controlled or controllable; (2) no extrapulmonary metastatic sites demonstrable; (3) good surgical risk; and (4) no effective treatment available by nonsurgical means.

Testis tumor metastatic to lung: twenty-two-year survivor

A case is presented of a twenty-two-year survivor following pulmonary resection of a solitary embryonal cell carcinoma metastasis from a primary teratocarcinoma of the testis. The literature is reviewed with regard to this problem, and the criteria for pulmonary resection of metastic lesions are presented.

Multiple thoracotomy for metastatic pulmonary neoplasm

Marks, P. (1974).Thorax, 29, 248-251. Multiple thoracotomy for metastatic pulmonary neoplasm. Surgical excision of solitary, metastatic, malignant lesions of the lung is reported as of benefit in certain cases in which the primary tumour apparently has been completely removed and in which there is no evidence of further metastatic spread. It has been shown that in a few instances survival for many years may be expected to follow such a procedure, while at other times the degree of palliation of pulmonary symptoms makes the operation worthwhile.

Two patients who had metastatic lung deposits successfully removed are described. Further pulmonary metastases, without evidence of metastases elsewhere or recurrence of the original lesion, were resected. In both cases remarkable palliation of symptoms was afforded and both are alive at the time of writing (1 November 1973).

Surgical treatment of pulmonary metastases

Isolated pulmonary metastases from many primary sources were treated by surgery in 37 patients. Twenty-one per cent of those with carcinomas and 16% of those with sarcomas survived for five years. Twenty-four patients are now dead, 21 from generalized tumour dissemination. Occasional long-term survivals were obtained which, when related to the low mortality and morbidity attending thoracotomy, make this form of therapy worthy of consideration in selected cases.

Surgical treatment of pulmonary metastases from testicular tumours

Isolated pulmonary metastases from testicular tumours were treated by surgery in nine patients. Six are alive and well with no clinical evidence of recurrence. Three of the survivors were operated on more than 10 years ago. Surgical treatment should be considered in such patients, particularly as the metastases are often solitary and may be better differentiated histologically than the primary tumour. Mortality and morbidity rates after thoracotomy are minimal.