Reply

Abstract

We thank Dr Pramesh and colleagues for their constructive comments regarding our study [1Inoue M. Ohta M. Iuchi K. et al.Benefits of surgery for patients with pulmonary metastases from colorectal carcinoma.Ann Thorac Surg. 2004; 78: 238-244Abstract Full Text Full Text PDF PubMed Scopus (214) Google Scholar]. To the best of our knowledge there is no randomized controlled study that compared the effects of treatment between metastasectomy and the best supportive care in patients with pulmonary metastasis from colorectal carcinoma. Thus, it remains unclear whether the survival of patients with poor prognostic predictors treated with surgery is better than that of those without treatment. As they mentioned, it would be impossible to observe a good risk patient with poor prognostic predictors in the practice. However, we believe that patients with mediastinal involvement proven by mediastinoscopy or transbronchial needle aspiration cytology show no indication for metastasectomy, because of the poor outcome [2Pfannschmidt J. Muley T. Hoffmann H. et al.Prognostic factors and survival after complete resection of pulmonary metastases from colorectal carcinoma experiences in 167 patients.J Thorac Cardiovasc Surg. 2003; 126: 732-739Abstract Full Text Full Text PDF PubMed Scopus (221) Google Scholar, 3Saito Y. Omiya H. Kohno K. et al.Pulmonary metastasectomy for 165 patients with colorectal carcinoma a prognostic assessment.J Thorac Cardiovasc Surg. 2002; 124: 1007-1013Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar]. Lymph node metastasis is not rare in patients with pulmonary metastasis from colorectal carcinoma. We previously studied 25 consecutive cases treated by a metastasectomy with lymph node dissection or sampling and found that 28% of the patients had positive lymph nodes [4Inoue M. Kotake Y. Nakagawa K. Fujiwara K. Fukuhara K. Yasumitsu T. Surgery for pulmonary metastases from colorectal carcinoma.Ann Thorac Surg. 2000; 70: 380-383Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar]. A complete resection is not expected for such patients and systemic chemotherapy should be considered. Although patients with poor prognostic predictors, such as bilateral metastases, Dukes’ B-D, high carcinoembryonic antigen (CEA) level, or multiple lesions, are not always contraindicated for a thoracotomy, they should be preoperatively considered, especially in patients with poor risk. However, from our findings we emphasize that those prognostic factors are more meaningful in good risk patients. Namely, we recommend a lobectomy with lymph node dissection using a standard operation for primary lung cancer in good risk patients with good prognostic predictors (Dukes’ A, unilateral solitary metastasis, normal CEA level, no lymph node swelling) with the aim of curative (not palliative) treatment. Indeed, in our retrospective study we found three 10-year survivors without recurrence in the group that underwent a lobectomy.