Editorial
Current Indications For Surgical Treatment of Lung Metastases
Indicaciones actuales del tratamiento quirúrgico de las metástasis pulmonares
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The potential of surgery for prolonging survival and even curing disease<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> 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.</p><p id="par0015" class="elsevierStylePara elsevierViewall">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%.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> 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.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> 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.</p><p id="par0025" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> 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.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> 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.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">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.,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> the sensitivity of helical CT for intrapulmonary nodules measuring more than 5<span class="elsevierStyleHsp" style=""></span>mm with histological confirmation of malignancy was 100%, and 69% for nodules measuring 5<span class="elsevierStyleHsp" style=""></span>mm 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 5<span class="elsevierStyleHsp" style=""></span>mm has been demonstrated in an experimental model.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Positron emission tomography has been found to be useful in lesions with a diameter of 10<span class="elsevierStyleHsp" style=""></span>mm or more. However, this technique can sometimes be even less sensitive than helical CT,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> 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.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The standard surgical technique is atypical pulmonary resection,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> 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,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> 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.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Years ago, thoracotomy was considered the best approach because it offered the possibility of revealing lesions that had gone undetected on chest CT.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Now, video-assisted thoracoscopy is increasingly used in this type of surgery, but despite good results,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> no randomized studies of long-term survival are available.</p><p id="par0050" class="elsevierStylePara elsevierViewall">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 10<span class="elsevierStyleHsp" style=""></span>mm. 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.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">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.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International Registry of Lung Metastases. Long-term results of lung metastasectomy: prognostic analyses based on 5206 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "U. Pastorino" 1 => "M. Buyse" 2 => "G. Friedel" 3 => "R.J. Ginsberg" 4 => "P. Girard" 5 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 55 | 17 | 72 |
| 2024 September | 55 | 17 | 72 |
| 2024 August | 84 | 37 | 121 |
| 2024 July | 57 | 20 | 77 |
| 2024 June | 71 | 25 | 96 |
| 2024 May | 88 | 33 | 121 |
| 2024 April | 43 | 26 | 69 |
| 2024 March | 57 | 19 | 76 |
| 2024 February | 39 | 26 | 65 |
| 2023 March | 19 | 7 | 26 |
| 2023 February | 85 | 23 | 108 |
| 2023 January | 68 | 29 | 97 |
| 2022 December | 89 | 33 | 122 |
| 2022 November | 102 | 36 | 138 |
| 2022 October | 100 | 35 | 135 |
| 2022 September | 58 | 39 | 97 |
| 2022 August | 77 | 58 | 135 |
| 2022 July | 56 | 39 | 95 |
| 2022 June | 60 | 41 | 101 |
| 2022 May | 71 | 34 | 105 |
| 2022 April | 84 | 26 | 110 |
| 2022 March | 110 | 50 | 160 |
| 2022 February | 82 | 31 | 113 |
| 2022 January | 115 | 50 | 165 |
| 2021 December | 105 | 40 | 145 |
| 2021 November | 88 | 42 | 130 |
| 2021 October | 103 | 48 | 151 |
| 2021 September | 81 | 40 | 121 |
| 2021 August | 109 | 44 | 153 |
| 2021 July | 96 | 37 | 133 |
| 2021 June | 103 | 58 | 161 |
| 2021 May | 106 | 38 | 144 |
| 2021 April | 487 | 128 | 615 |
| 2021 March | 162 | 21 | 183 |
| 2021 February | 79 | 31 | 110 |
| 2021 January | 94 | 32 | 126 |
| 2020 December | 81 | 32 | 113 |
| 2020 November | 103 | 20 | 123 |
| 2020 October | 97 | 30 | 127 |
| 2020 September | 70 | 26 | 96 |
| 2020 August | 57 | 14 | 71 |
| 2020 July | 74 | 37 | 111 |
| 2020 June | 78 | 21 | 99 |
| 2020 May | 95 | 13 | 108 |
| 2020 April | 76 | 43 | 119 |
| 2020 March | 67 | 24 | 91 |
| 2020 February | 62 | 21 | 83 |
| 2020 January | 61 | 31 | 92 |
| 2019 December | 87 | 19 | 106 |
| 2019 November | 75 | 23 | 98 |
| 2019 October | 55 | 17 | 72 |
| 2019 September | 36 | 10 | 46 |
| 2019 August | 51 | 22 | 73 |
| 2019 July | 40 | 18 | 58 |
| 2019 June | 30 | 16 | 46 |
| 2019 May | 41 | 12 | 53 |
| 2019 April | 51 | 15 | 66 |
| 2019 March | 47 | 18 | 65 |
| 2019 February | 49 | 27 | 76 |
| 2019 January | 35 | 25 | 60 |
| 2018 December | 38 | 21 | 59 |
| 2018 November | 53 | 20 | 73 |
| 2018 October | 92 | 26 | 118 |
| 2018 September | 39 | 12 | 51 |
| 2018 May | 4 | 2 | 6 |
| 2018 April | 43 | 16 | 59 |
| 2018 March | 55 | 21 | 76 |
| 2018 January | 1 | 0 | 1 |
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