Change of Paradigm in Pulmonary Metastasectomy

Abstract

We read with interest the article by Prenafeta Claramunt and colleagues in The Annals of Thoracic Surgery.1Prenafeta Claramunt N, Hwang D, de Perrot M, et al. Incidence of ipsilateral side recurrence after open or video-assisted thoracic surgery resection of colorectal lung metastases. Ann Thorac Surg. 2020;109:1591–1597.Google Scholar In their retrospective study of 211 colorectal cancer patients undergoing curative surgical resection of pulmonary metastases, they reported similar ipsilateral recurrence rates in a propensity match analysis between video-assisted thoracic surgery (VATS) (23.6%) and open thoracotomy (26.2%). They also reported clinical benefits such as shorter length of stay in the VATS group (median 2 days vs 4 days). Overall, this study adds more evidence on the benefit of VATS in the management of pulmonary metastasectomy,2Perentes J.Y. Krueger T. Lovis A. Ris H.B. Gonzalez M. Thoracoscopic resection of pulmonary metastasis: current practice and results.Crit Rev Oncol Hematol. 2015; 95: 105-113Crossref PubMed Scopus (27) Google Scholar offering a good balance between efficient oncologic treatment and quality of life for these metastatic patients. During many years, the acceptance of VATS was slowed because of the fear of leaving nodules undetected during preoperative radiologic exams, and thoracotomy with bimanual palpation was considered mandatory to detect all lesions.2Perentes J.Y. Krueger T. Lovis A. Ris H.B. Gonzalez M. Thoracoscopic resection of pulmonary metastasis: current practice and results.Crit Rev Oncol Hematol. 2015; 95: 105-113Crossref PubMed Scopus (27) Google Scholar Two major developments have modified this paradigm: (1) the advancement in radiologic imaging with the routine use of 1-mm thin-slice single-breath computed tomography scan, and (2) the development of instrumentation for VATS. Thus, the tradeoff between risks and benefits has progressively shifted towards the lesser invasive approach. Some questions remain, however. Although a VATS approach for a solitary metastasis is widely accepted, the choice of surgery for multiple lesions remains less evident. This element is important with regard to lung-sparing possibilities that, in some situations, can better be achieved by open surgery (ie, precision surgery or laser resections) than by VATS. A cutoff value was arbitrarily set to 3 lesions in the past,2Perentes J.Y. Krueger T. Lovis A. Ris H.B. Gonzalez M. Thoracoscopic resection of pulmonary metastasis: current practice and results.Crit Rev Oncol Hematol. 2015; 95: 105-113Crossref PubMed Scopus (27) Google Scholar but it would be interesting to know whether a more precise value came out of the study of Prenafeta Claramunt and associates.1Prenafeta Claramunt N, Hwang D, de Perrot M, et al. Incidence of ipsilateral side recurrence after open or video-assisted thoracic surgery resection of colorectal lung metastases. Ann Thorac Surg. 2020;109:1591–1597.Google Scholar Another question resides in the importance of lymph node dissection associated to lung resection. Survival benefits for lymph node dissection have been demonstrated in colorectal cancer.3Zellweger M. Abdelnour-Berchtold E. Krueger T. Ris H.B. Perentes J.Y. Gonzalez M. Surgical treatment of pulmonary metastasis in colorectal cancer patients: Current practice and results.Crit Rev Oncol Hematol. 2018; 127: 105-116Crossref PubMed Scopus (28) Google Scholar The latter is thought to better guide adjuvant therapy in these patients. Lymph node dissection or sampling should likely be performed in these patients although, in our experience, it was less frequent in VATS cases than in open cases. It would be interesting to know if the rate of lymph node dissection was comparable between the VATS and open cases in the study of Prenafeta Claramunt and colleagues.1Prenafeta Claramunt N, Hwang D, de Perrot M, et al. Incidence of ipsilateral side recurrence after open or video-assisted thoracic surgery resection of colorectal lung metastases. Ann Thorac Surg. 2020;109:1591–1597.Google Scholar Incidence of Ipsilateral Side Recurrence After Open or Video-Assisted Thoracic Surgery Resection of Colorectal Lung MetastasesThe Annals of Thoracic SurgeryVol. 109Issue 5PreviewThere is still controversy whether full lung palpation is required for patients undergoing pulmonary metastasectomy. We aimed to compare pulmonary ipsilateral recurrence (IR) after video-assisted thoracic surgery (VATS) or open surgery. Full-Text PDF Video-Assisted Thoracic Surgery as the Future of Pulmonary Metastasectomy: ReplyThe Annals of Thoracic SurgeryVol. 110Issue 3PreviewThank you very much for giving us the opportunity to reply to this Letter to the Editor in The Annals of Thoracic Surgery by Perentes and colleagues,1 which we read carefully. In their letter, Perentes and colleagues1 support our study as further evidence of the benefit of video-assisted thoracic surgery (VATS) in pulmonary metastasectomy.2 Full-Text PDF