Preoperative Evaluation and Indications for Pulmonary Metastasectomy

Surgical management of colorectal lung metastases

“…Importantly, the patient must be able to tolerate resection of the affected area of the lung. In addition, the likelihood of the patient obtaining a survival benefit from metastasectomy is low if their primary tumor is not controlled, and control of the primary site should be achieved before pulmonary resection . In most malignancies with pulmonary metastases, extrathoracic disease is a contraindication to lung resection for curative intent.…”

“…The generally accepted rule for resection is if all of the lesions can be completely removed and the patient will be left with adequate lung function, then it may be appropriate to proceed with cases involving numerous and/or bilateral sites of disease. In cases of questionable resectability, particularly those involving a potential pneumonectomy, a comprehensive, multidisciplinary evaluation should be undertaken to examine alternative treatment options before proceeding with surgery …”

“…An in‐depth history and physical should be performed in all patients, with a particular focus on cancer history, respiratory symptoms, medical comorbidities, substance/tobacco use, and functional status. While up to 90% of patients with lung metastases will not have respiratory symptoms (hemoptysis, dyspnea, pleuritic chest pain, and wheezing), in those patients with symptoms, it may be an indication of endobronchial or pleural involvement, significant disease burden, or a central tumor . Symptoms of metastases to other sites, such as new fractures, bone/back pain, headaches, vision changes, or other neurologic complaints, should also be solicited, and if found, would be a contraindication to PM.…”

“…However, it does provide additional prognostic information that may change the risk‐benefit ratio for proceeding with surgery in some cases. Moreover, as CRC is known to spread to the brain, any patient with neurologic symptoms warrants either an MRI or CT with and without contrast to rule this out as a site of extrathoracic disease …”

Looking forward lung metastasectomy—do we need a staging system for lung metastases?

“…Unfortunately, most patients with pulmonary metastases will not be candidates for LM because the presence of comorbidities or the need of extended surgery (5,6). In these patients new approaches are available such as radiotherapy, radiofrequency and microwave ablation, and immunotherapy, but these treatments are in search of evidence (7).…”