Pulmonary metastasectomy: outcomes and issues according to the type of surgical resection

Abstract

According to a recent report by the Committee for Scientific Affairs of the Japanese Association for Thoracic Surgery, pulmonary metastasectomy accounted for as many as 10.2 % of all entry cases of general thoracic surgery, and its use is increasing year by year. Accordingly, many studies have examined the surgical procedures used during pulmonary metastasectomy for metastases from primary tumors affecting various organs as well as the outcomes of and indications for such procedures, but some problems remain. In this article, the following questions related to the surgical approach and the type of resection used during pulmonary metastasectomy are reviewed: (1) Wedge resection--what is a safe margin for preventing local recurrence? (2) What is the clinical significance of node sampling/dissection during pulmonary metastasectomy? and (3) When is segmentectomy necessary? In addition, we discuss: (4) open thoracotomy vs. video-assisted thoracoscopic surgery (VATS), (5) repeated metastasectomy for pulmonary metastases, (6) the surgical approach for bilateral pulmonary metastasectomy, (7) pneumonectomy, and (8) pulmonary metastasectomy combined with resection of the neighboring organs.

Surgical management of colorectal lung metastases

“…Though the most appropriate surgical approach and resection type are controversial, it is generally accepted that parenchymal sparing resections should be performed for PM when considering all histologic types. However, a higher rate of local recurrence at the surgical margin has been described with CRC metastases following PM compared with other malignancies . To decrease the risk of margin recurrence, wedge resections should be performed with at least a 10‐mm margin of normal lung tissue …”

“…Historically, evaluation of the mediastinal and hilar lymph nodes was not routinely performed or performed only for suspicious nodes based on preoperative imaging or intraoperative findings . The incidence of mediastinal lymph node metastases in CRC patients with pulmonary metastases has been reported between 8% and 24% and is a known negative prognostic factor for overall survival . The pathological identification of lymph node involvement may be as high as 44% when radical mediastinal lymphadenectomy is routinely performed .…”

“…The pathological identification of lymph node involvement may be as high as 44% when radical mediastinal lymphadenectomy is routinely performed . Several authors advocate for the routine performance of mediastinal lymph node evaluation to provide better prognostic information, as the therapeutic effect of removal of these nodes is unknown . An analysis of 522 patients from 32 thoracic surgery departments in Spain undergoing first lung metastasectomy for CRC identified that lymph node assessment was performed in 48% of cases and nodal metastases were identified in 10% of those patients, with 20% having systematic nodal dissection, 35% having systematic nodal sampling, and 45% having minor lymphadenectomy .…”

“…Repeat PM has been reported to occur in up to 24% of patients with metastases from CRC . The indications for repeat surgery are the same as for a first‐time surgery.…”

Preoperative Evaluation and Indications for Pulmonary Metastasectomy

“…They found spiral CT to have higher sensitivity, specificity, and accuracy than FDG-PET in detecting pulmonary metastases from malignant primary bone tumors. 14,15 Thus chest, abdomen, and pelvic CT scans are frequently the only imaging used in evaluating patients with a history of sarcoma; however, it is not unreasonable to use PET also.…”