Journal Information
Vol. 53. Issue 12.
Pages 661-662 (December 2017)
Vol. 53. Issue 12.
Pages 661-662 (December 2017)
Editorial
Full text access
Current Indications For Surgical Treatment of Lung Metastases
Indicaciones actuales del tratamiento quirúrgico de las metástasis pulmonares
Visits
7213
Jorge Freixineta,
Corresponding author
jfregil@gobiernodecanarias.org

Corresponding author.
, Raúl Embúnb, Pedro Rodrígueza
a Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
b Hospital Universitario Miguel Servet, Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
This item has received
Article information
Full Text
Bibliography
Download PDF
Statistics
Full Text

Surgery for lung metastases continues to raise many questions and spark debate, despite numerous studies and technical advances. The potential of surgery for prolonging survival and even curing disease1 has been emphasized, so the aim of these interventions is curative or to prolong life expectancy. In clinical practice, most metastases treated surgically are colorectal carcinoma, although surgery is an option in kidney tumors, breast cancer, head and neck tumors, malignant melanoma, non-seminomatous germ cell tumors, soft tissue sarcoma, and osteosarcoma.

For years, certain criteria have been required for the resection of lung metastases from extrathoracic tumor disease: feasibility of resecting all visible lesions, reasonable surgical risk, control of the primary tumor, and the absence of other metastatic sites. However, these criteria, specifically the histological type and the site of the primary tumor, now need some refinement. Very limited survival has been reported for melanomas, while for tumors of the colon and rectum, survival rates can be very high, with reports of 5-year survival in some series of up to 60%.2 Criteria regarding control of the primary tumor and the absence of metastasis at other sites have also been revised. Some series have described patients in whom the primary tumor and metastases are discovered simultaneously, and both presentations are treated surgically. Patients with concurrent liver and lung metastases relatively frequently undergo surgery.3

Other prognostic factors include regional lymph node metastasis, which confers a poor prognosis; the number of metastases to be resected; disease-free interval; and the feasibility of resecting all metastases with sufficient margins in a single intervention. Other specific factors apply to certain cancers, such as presence of carcinoembryonic antigen in colorectal tumors, a marker for poor prognosis. In a recent study published by the Spanish Group for Colorectal Lung Metastases Surgery of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), the most important factors were found to be disease-free interval, laterality, carcinoembryonic antigen levels, and the presence of nodal metastases.4 Even so, many patients who undergo surgery are poor candidates for such an intervention, and practitioners must always ensure that the decision to operate is reasonable.

The state of the evidence for this type of surgery has so far been based on non-randomized studies. The PulMiCC study attempts to examine the role of surgery in prolonging survival and to evaluate the possible drawbacks and benefits in terms of quality of life in patients undergoing these procedures.5 While adjuvant chemotherapy is more common, it is also possible to administer induction chemotherapy followed by reassessment of the metastatic lung disease, an approach that may be justified in patients with a poor prognosis. Targeted therapies may also be an option.6 Factors that worsen the prognosis of the patient, but do not rule out surgery, include the need to treat both primary tumor and metastases, and surgery of subsequent relapses. Some cases may undergo repeated interventions on successive occasions. Cases of 2, 3 or even more interventions have been reported.7

With regard to diagnostic studies, several papers have been published comparing the diagnostic safety of conventional computed tomography (CT) with that of high resolution CT and surgical palpation. According to Diederich et al.,8 the sensitivity of helical CT for intrapulmonary nodules measuring more than 5mm with histological confirmation of malignancy was 100%, and 69% for nodules measuring 5mm or less. Only 48% of resected lesions were found to be metastasis, suggesting a high percentage of false positives. The low sensitivity of helical CT in the detection of metastatic nodules measuring less than 5mm has been demonstrated in an experimental model.9

Positron emission tomography has been found to be useful in lesions with a diameter of 10mm or more. However, this technique can sometimes be even less sensitive than helical CT,10 and its value in sarcomas is also questionable. Added benefits include the possibility of detecting other thoracic and extrathoracic lesions, and in particular, mediastinal lymph node involvement or distant disease.11

The standard surgical technique is atypical pulmonary resection,12 where the extent of the resection margin determines to a large extent the prognosis. Small nodules can be difficult to locate, and a thoracotomy may be required to detect them by lung palpation. Sometimes, the size or number of lesions or the site of the metastases may require anatomical lung resection,13 the most common procedures being lobectomy and typical segmentectomy. Other options are enucleation using laser therapy, and non-surgical alternatives, such as radiation therapy, and microwave and radiofrequency ablation.

Years ago, thoracotomy was considered the best approach because it offered the possibility of revealing lesions that had gone undetected on chest CT.14 Now, video-assisted thoracoscopy is increasingly used in this type of surgery, but despite good results,15 no randomized studies of long-term survival are available.

The degree of scientific evidence for the surgical treatment of lung metastases is limited. Helical CT plays an important role in the extension study, while positron emission tomography is useful for lesions measuring more than 10mm. With regard to the surgical technique, video-assisted thoracoscopy and atypical lung resection are the standard procedures, although small nodules may sometimes have to be resected using thoracotomy.

References
[1]
U. Pastorino, M. Buyse, G. Friedel, R.J. Ginsberg, P. Girard, P. Goldstraw, et al.
International Registry of Lung Metastases. Long-term results of lung metastasectomy: prognostic analyses based on 5206 patients.
J Thorac Cardiovasc Surg, 113 (1997), pp. 37-49
[2]
P.J. Villeneuve, P.S. Sundaresan.
Surgical management of colorectal lung metastases.
Clin Colon Rectal Surg, 22 (2009), pp. 233-241
[3]
D. Del Fabbro, M. Alloisio, F. Procopio, M. Cimino, M. Donadon, A. Palmisano, et al.
Surgical treatment of synchronous colorectal liver and lung metastases: the usefulness of thoracophrenolaparotomy for single stage resection.
Hepatobiliary Pancreat Dis Int, 15 (2016), pp. 216-219
[4]
R. Embún, J.J. Rivas, S. Call, B. Olaiz, J. Freixinet, S. Bolufer, Spanish Group of Lung Metastases of Colo-Rectal Cancer (GECMP-CCR) of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), et al.
Casual model of survival after pulmonary metastasectomy of colorectal cancer. A nationwide prospective registry.
Ann Thorac Surg, 101 (2016), pp. 1883-1890
[5]
T. Treasure.
Pulmonary metastasectomy in colorectal cancer: the PullMiCC trial.
J Thorac Oncol, 5 (2010), pp. S203-S206
[6]
S. Renaud, M. Schaeffer, P.E. Falcoz, J. Seitlinger, B. Romain, A.C. Voegeli.
Perioperative bevacizumab improves survival following lung metastasectomy for colorectal cancer in patients harbouring v-ki-ras2 Kirsten rat sarcoma viral oncogene homologue exon 2 codon 12 mutations.
Eur J Cardiothorac Surg, 51 (2017), pp. 255-262
[7]
M.T. Jaklitsch, C.M. Mery, J.M. Lukanich, W.G. Richards, R. Bueno, S.J. Swanson, et al.
Sequential thoracic metastasectomy prolongs survival by re-establishing local control within the chest.
J Thorac Cardiovasc Surg, 121 (2001), pp. 657-667
[8]
S. Diederich, M. Semik, M.G. Lentschiq, F. Winter, H.H. Scheld, N. Roos, et al.
Helical CT of pulmonary nodules in patients with extrathoracic malignancy: CT-surgical correlation.
Am J Roentgenol, 172 (1999), pp. 353-360
[9]
D.J. Waters, F.V. Coakley, M.D. Cohen, M.M. Davis, B. Karmarzyn, R. Gonin, et al.
The detection of pulmonary metastases by helical CT: a clinicopathological study in dogs.
J Comput Assist Tomogr, 22 (1998), pp. 235-240
[10]
W. De Wever, L. Meylaerts, L. de Ceuninck, S. Stroobants, J. Verschakelen.
Additional value of integrated PET-CT in the detection and characterization of lung metastases: correlation with CT alone and PET alone.
Eur Radiol, 14 (2007), pp. 467-473
[11]
D.L. Fortes, M.S. Allen, V.J. Lowe, K.R. Shen, D.A. Wigle, S.D. Cassivi, et al.
The sensitivity of 18-F fluorodeoxyglucose positron emission tomography in the evaluation of metastatic pulmonary nodules.
Eur J Cardiothorac Surg, 34 (2008), pp. 1223-1227
[12]
S. Shiono, T. Okumura, N. Boku, T. Hishida, Y. Ohde, Y. Sakao, et al.
Outcomes of segmentectomy and wedge resection for pulmonary metastases from colorectal cancer.
Eur J Cardiothorac Surg, 51 (2017), pp. 504-510
[13]
J. Hernández, L. Molins, J.J. Fibla, F. Heras, R. Embún, J.J. Rivas, Grupo Español de Metástasis Pulmonares de Carcinoma Colo-Rectal (GECMP-CCR) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR).
Role of major resection in pulmonary metastasectomy for colorectal cancer in the Spanish prospective multicenter study (GECMP-CCR).
Ann Oncol, 27 (2016), pp. 850-855
[14]
P.M.I. McCormack, M.S. Bains, C.B. Begg, M.E. Burt, R.J. Downey, D.M. Panicek, et al.
Role of video-assisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial.
Ann Thorac Surg, 62 (1996), pp. 213-216
[15]
D. Gossot, C. Radu, P. Girard, A. le Cesne, S. Bonvalot, M.S. Boudaya, et al.
Resection of pulmonary metastases from sarcoma: can some patients benefit from a less invasive approach?.
Ann Thorac Surg, 87 (2009), pp. 238-243

Please cite this article as: Freixinet J, Embún R, Rodríguez P. Indicaciones actuales del tratamiento quirúrgico de las metástasis pulmonares. Arch Bronconeumol. 2017;53:661–662.

Copyright © 2017. SEPAR
Archivos de Bronconeumología
Article options
Tools

Are you a health professional able to prescribe or dispense drugs?