Dilemma in Pulmonary Metastasectomy: Video-Assisted Thoracoscopic Surgery or Thoracotomy?

Abstract

We read with interest the report by Eckardt and Licht 1 in a recent issue of CHEST (December 2012). Although we congratulate them for their effort in clarifying the potential superiority of open pulmonary metastasectomy for treatment of patients with resectable pulmonary metastases, we want to share some signifi cant concerns. Both preoperative imaging and procedure via video-assisted thoracoscopic surgery (VATS) might miss some small metastatic nodules. 2 The authors argued that the missed metastases might lead to higher recurrence rate and more mediastinal lymph node involvement, both of which might be detrimental to prognosis of those patients. However, VATS has been shown to be less invasive, with minor pain, trauma, and immune disturbance, and to better preserve quality of life and compliance with subsequent adjuvant therapy. 3 In addition, metastasis of malignance is a systematic disease. Some recurrent pulmonary metastases may come from another micrometastasis other than the possibly missed lesions. Also, whether the mediastinal lymph node involvement is due to the pulmonary metastases or other lymphatic micrometastasis is still controversial. 4 Moreover, a few retrospective case-control studies concluded that survival after metastasectomy by VATS was not inferior to open surgery. 4 Several studies also reported that repeated metastasectomy was performed in 10% to 20% of patients who had undergone metastasectomy for the fi rst time, and the survival curves were equal between the fi rst and the fi rst repeated metastasectomy (24.0% to 56.0% vs 23.0% to 53.8%). 4 With regard to this report, VATS should be technically comparable to open thoracotomy in resection of those 55 imaged nodules, even though some of them might not be palpable. Speculatively, we presumed that the four nonpalpable nodules via VATS were not metastatic lesions. Then the ratio of improper resection caused by VATS and thoracotomy was 18.2 (10 of 55) and 35% (28 of 80), respectively ( P , .05). Therefore, we have several concerns: (1) Can the total recurrence rate be actually reduced by the relatively radical resection the fi rst time? (2) Is it defi nitely benefi cial at the cost of more invasiveness and such a high rate of excessive treatment caused by open thoracotomy? (3) If resectable recurrent metastases do happen, what can we do for a patient who has undergone an open thoracotomy? We argue that factors such as effi cacy, invasiveness, compliance, and preservation of quality of life should be all taken into consideration when planning a palliative treatment strategy such as pulmonary metastasectomy. We are also looking forward to more prospective randomized trials with more cases included to elucidate all confusions .