Resection of pulmonary sarcomatous metastases: Cut to cure?

Abstract

Central MessagePulmonary metastasectomy requires high-level evidence in the context of mounting observational studies, such as the current one, consistently identifying similar reliable surgical prognostic factors.See Article page 319. Pulmonary metastasectomy requires high-level evidence in the context of mounting observational studies, such as the current one, consistently identifying similar reliable surgical prognostic factors. See Article page 319. Soft tissue sarcoma (STS) represents a relatively rare and complex tumor type with an extensive subgrouping of histology that reflects heterogeneous biology.1Quesada J. Amato R. The molecular biology of soft-tissue sarcomas and current trends in therapy.Sarcoma. 2012; 2012: 849456Crossref PubMed Scopus (42) Google Scholar The molecular mechanisms driving metastasis, with a predilection for occurrence in the lungs, of this mesenchymal tumor group are poorly understood.2Chiang A.C. Massague J. Molecular basis of metastasis.N Engl J Med. 2008; 359: 2814-2823Crossref PubMed Scopus (799) Google Scholar, 3Weidle U.H. Birzele F. Kollmorgen G. Ruger R. Molecular basis of lung tropism of metastasis.Cancer Genomics Proteomics. 2016; 13: 129-139Crossref PubMed Scopus (85) Google Scholar Until further innovation in medical treatment of metastatic STS is realized, pulmonary metastasectomy is increasingly accepted as an integral treatment modality, despite the lack of prospective, randomized data to support the optimal management of these patients.4Digesu C.S. Wiesel O. Vaporciyan A.A. Colson Y.L. Management of sarcoma metastases to the lung.Surg Oncol Clin N Am. 2016; 25: 721-733Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar In this issue of the Journal, Chudgar and colleagues5Chudgar N.P. Brennan M.F. Munhoz R.R. Bucciarelli P.R. Tan K.S. D'Angelo S.P. et al.Pulmonary metastasectomy with therapeutic intent for soft tissue sarcoma.J Thorac Cardiovasc Surg. 2017; 154: 319-330.e1Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar present their institutional experience of therapeutic intent pulmonary metastasectomy in more than 500 patients. They reviewed data as far back as 1991 exclusively in those patients with STS, excluding those with osteogenic sarcoma. Multivariate analysis revealed that the leiomyosarcoma subtype, among several other clinicopathologic factors, was associated with improved survival. This study represents one of the largest modern series uniquely focused on identifying practical, clinically relevant factors that can help guide thoracic surgeons in selecting pulmonary metastasectomy candidates who harbor advanced-stage STS. The authors astutely point out the relative logistic barriers in being able to conduct a prospective randomized trial for STS tumors, so their findings are evermore salient. This study highlights that careful patient selection, at least in part, contributes to the perceived extended survival for pulmonary metastasectomy. Thus, for fit patients who meet criteria for safe metastasectomy, the overall expected benefits of prolonged survival regardless of the underlying beneficial factor (specific patient biology or metastasectomy effect) may be an individualized reason to proceed. A secondary and vital benefit of this practice paradigm is access to metastatic tumor tissue that contributes to ongoing research. However, some equipoise is required on this matter. There remains debate and doubt about whether metastasectomy directly improves survival in any solid tumor type. Clinicians await the results of the Pulmonary Metastasectomy in Colorectal Cancer controlled trial using a noninferiority nested randomization to determine the survival effect, if any, of pulmonary metastasectomy per se in colorectal cancer.6Migliore M. Milosevic M. Lees B. Treasure T. Di Maria G. Finding the evidence for pulmonary metastasectomy in colorectal cancer: the PulMicc trial.Future Oncol. 2015; 11: 15-18Crossref PubMed Scopus (20) Google Scholar Patients who have lung metastases cannot wait because this trial, initiated in 2010, is still accruing subjects with an estimated study completion of 2025. Finally, I am curious to ask the authors why specifically they think that the Pulmonary Metastasectomy in Colorectal Cancer trial results “may not be readily extrapolated to STS”? Pulmonary metastasectomy with therapeutic intent for soft-tissue sarcomaThe Journal of Thoracic and Cardiovascular SurgeryVol. 154Issue 1PreviewSoft-tissue sarcoma is a heterogeneous disease that frequently includes the development of pulmonary metastases. The purpose of this study is to determine factors associated with improved survival among patients with soft-tissue sarcoma to help guide selection for pulmonary metastasectomy. Full-Text PDF Open Archive