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Abstract

We have read with interest the comments from Dr Baisi and colleagues [1Baisi A. De Simone M. Raveglia F. Cioffi U. Risk factors for survival in candidates for lung metastasectomy for colorectal cancer.Ann Thorac Surg. 2013; 96 (letter): 740-741Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar] regarding our article addressing the role of lymph node dissection as part of surgical resection for colorectal metastases to the lung [2Hamaji M. Cassivi S.D. Shen K.R. et al.Is lymph node dissection required in pulmonary metastasectomy for colorectal adenocarcinoma?.Ann Thorac Surg. 2012; 94: 1796-1801Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar]. They have raised several important points regarding the difficulty of selecting appropriate patients who are potential candidates for metastasectomy. They also correctly point out that we did not observe a significant correlation with several prognostic factors previously identified in the literature, such as maximum metastasis diameter, number of pulmonary lesions (single or multiple), preoperative CEA, previously resected hepatic metastasis, or stage of primary tumor. Although several these factors demonstrated a trend toward significance in our dataset, none was as strong as the correlation with positive mediastinal lymph nodes and survival. Given these data, we have concluded the presence of metastatic disease in mediastinal lymph nodes to be a powerful predictor of survival after metastasectomy. Despite these findings, our data also demonstrated a limited number of 5-year survivors with N2 level lymph node metastases at the time of metastasectomy, suggesting that despite the poor outcome overall of these patients, it is not an absolute contraindication to a surgical approach. With respect to the utility of computed tomography—positron emission tomography (CT-PET), we agree that its role in detecting mediastinal nodal involvement remains unclear. What is suggested from our data is a sensitivity less than that observed for non-small cell lung cancer, and hence a note of caution in using CT-PET results to guide management. The combination of lymph node metastases as a powerful prognostic indicator, in addition to the relatively poor sensitivity of CT-PET imaging for detecting nodal metastases, strengthens the argument for routine lymph node dissection as part of any metastasectomy for colorectal cancer. While in no way definitive, we believe our data highlight several important points regarding lung metastasectomy for colorectal cancer that are not well addressed in the literature to date. (1) Lymph node metastases are a poor prognostic indicator overall. (2) Lymph node metastases may not be a contraindication to surgical resection. (3) CT-PET has a relatively poor sensitivity for evaluating the mediastinum for nodal metastases in the setting of lung lesions from metastatic colorectal cancer. Although these three points form only part of the equation for surgical decision making as to which patient is a candidate for metastasectomy, we believe these conclusions are an important contribution to the literature, given the scarcity of studies examining this specific subject area. Reports such as the Gonzalez metaanalysis [3Gonzalez M. Poncet A. Combescure C. Robert J. Ris H.B. Gervaz P. Risk factors for survival after lung metastasectomy in colorectal cancer patients: a systematic review and meta-analysis.Ann Surg Oncol. 2013; 20: 572-579Crossref PubMed Scopus (283) Google Scholar] clearly identify which patients benefit most from metastasectomy, but they do not clearly identify the cutoff point as to which patients should be considered for lung metastasectomy versus those who will not achieve any added quantity or quality of life. This remains a challenging question for thoracic surgical oncologists despite the available data in the literature. Risk Factors for Survival in Candidates for Lung Metastasectomy for Colorectal CancerThe Annals of Thoracic SurgeryVol. 96Issue 2PreviewWe have read with interest the article by Hamaji and colleagues [1] focused on prognostic factors for survival in patients who underwent pulmonary metastasectomy for colon adenocarcinoma. Full-Text PDF