Management Of Pulmonary Metastases Research Articles

The role of minimally invasive approaches in the management of pulmonary metastases

The role of minimally invasive approaches in the management of pulmonary metastases

Multisocietal European consensus on the terminology, diagnosis, and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE.

Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases, with a focus on terminology, diagnosis, and management. This project was a multiorganizational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis, and management. Statements were refined during an online Delphi process, and those with 70 per cent agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising 12 key statements. Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term 'early metachronous metastases' applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour, the term 'late metachronous metastases' applies to those detected after 12 months. 'Disappearing metastases' applies to lesions that are no longer detectable on MRI after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards, and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways, including systemic chemotherapy, synchronous surgery, and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

The multi-societal European consensus on the terminology, diagnosis and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE

BackgroundContemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases with a focus on terminology, diagnosis and management. MethodsThis project was a multi-organisational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis and management. Statements were refined during an online Delphi process and those with 70% agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising twelve key statements. ResultsSynchronous liver metastases are those detected at the time of presentation of the primary tumour. The term “early metachronous metastases” applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour with “late metachronous metastases” applied to those detected after 12 months. Disappearing metastases applies to lesions which are no longer detectable on MR scan after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways including systemic chemotherapy, synchronous surgery and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. ConclusionsThe recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

Management of pulmonary metastases: a narrative review on the oncologist’s perspective

Background and Objective: In a large proportion of patients affected by solid tumors, metastatic disease is identified at diagnosis; alternatively, cancer patients might develop metastases during their follow up after treatment of the primary tumor. Among distant metastases, pulmonary lesions are particularly relevant, as they are frequent in many solid malignancies. While the management of disseminated tumors relies mainly on systemic treatments with palliative intent, the interest in local treatments of single or limited pulmonary metastases (oligometastatic disease) has developed throughout years, either with curative intent or with the intent of prolonging survival. In spite of this growing interest, published scientific data on the oligometastatic setting are relatively limited, and randomized trials are particularly scarce; hence, the available evidence mostly relies on retrospective patient series. The aim of this review is to summarize the currently available data on the management of pulmonary metastases, with specific reference to oligometastases from the oncologist’s point of view.

The role of stereotactic body radiation therapy in the management of pulmonary metastases: a systematic review

AbstractWhile pulmonary metastases are often managed through metastasectomies, stereotactic body radiation therapy (SBRT) is a relatively novel treatment that has shown promise for this disease. This review aimed to summarize the current findings of SBRT in the treatment of pulmonary metastases. MEDLINE, EMBASE, and CENTRAL were searched for articles that examined the use of SBRT for patients with pulmonary metastases. Primary outcomes included overall survival, disease‐free survival, and progression‐free survival. Results were pooled where appropriate. Risk of bias was assessed through the Methodological Index for Non‐Randomized Studies tool. After screening, 13 studies with 545 patients conducted between 2006 and 2020 were included in this review. Primary tumor localizations included gastrointestinal, pulmonary, and bone, among others. Pooled overall survival at 1 year was 81%, 41% at 3 years, 34% at 4 years, and 26% at 5 years. Pooled progression‐free survival at 1, 2, and 3 years was 60%, 41%, and 31% respectively. Local control at 1, 2, and 3 years were 90%, 79%, and 77%, respectively. Preliminary evidence regarding SBRT for treatment of pulmonary metastases shows promising benefits for overall survival and local control. Further high‐quality prospective trials are required to investigate the effectiveness and treatment‐related adverse effects of SBRT, and should compare it with metastasectomy.

Role of video-assisted thoracoscopic surgery in pulmonary metastasectomy.

There are sparse prospective studies investigating the role of video-assisted thoracoscopic surgery (VATS) in management of pulmonary metastasis. To prospectively investigate short-term surgical and pathological outcomes for PM patients operated on by VATS or open thoracotomy (OT) for management of lung secondaries. Between October 2017 and December 2020, patients undergoing pulmonary metastasectomy were recruited. Patients were assigned to undergo resection with either thoracotomy (group 1) or VATS (group 2) after multidisciplinary team discussions based on the number, size and location of pulmonary metastasis and underlying lung function. All related short-term surgical and pathologic outcomes for both groups were collected for analysis. Of 58 patients enrolled, 21 were in group 1 and 37 in group 2. Colorectal cancer primary represented 40% of the cases. Patients in the VATS group were more likely to have solitary lesions that are peripherally located and removed by wedge resection, as opposed to patients in the thoracotomy group, who had more anatomical lung resections. More new nodules were likely to be detected during surgery in thoracotomy than VATS cases (p = 0. 027). However, 8 (out of 15) of the newly detected lesions were not malignant. Operative time, blood loss and hospital stay were in favor of VATS procedures. In a highly selected cohort of pulmonary metastasis patients with favorable criteria (peripherally located, small, solitary/oligo-metastasis and cN0), VATS may provide acceptable onco-pathologic outcomes as compared to the standard open thoracotomy.

Management of pulmonary metastases: the surgeon’s perspective

Management of pulmonary metastases: the surgeon’s perspective

Overall survival after perioperative chemotherapy in the management of pulmonary metastasis in osteosarcoma.

e23508 Background: Pulmonary metastasectomy is performed on a select cohort of patients with advanced osteosarcoma with the potential for long term survival. However, evidence on peri-operative chemotherapy at time of metastasectomy is not completely understood and difficult to summarize without a systematic examination of existing literature. The purpose of this project is to perform a meta-analysis of existing studies to determine overall survival (OS) and prognostic factors in adults and children with advanced and recurrent osteosarcoma receiving chemotherapy around time of metastasectomy. Methods: We reviewed survival studies conducted in children and adults with advanced and recurrent osteosarcoma who undergo pulmonary metastasectomy published in English with more than 5 patients. The primary outcome was overall survival. Literature searches were performed in multiple electronic databases including Ovid MEDLINE (1946 to present), Ovid EMBASE (1974 to present), Web of Science, and Cochrane Library. Two investigators independently screened all citations, abstracts, and full-text articles. Results: 24 out of 80 observational studies between 1977 to 2018 were included. 2146 patients were studied of which 987 underwent pulmonary metastasectomy for osteosarcoma. 822 patients received perioperative chemotherapy in this setting. No randomized controlled trials were identified. Studies included patients from Asia, Africa, Europe, and North America. The median OS ranged between 20 to 90 months. 5-year OS ranged between 15 to 63%. Factors associated with survival included: age, number of lesions, disease free interval, time of development of metastases, number of lesions and laterality of pulmonary disease. Conclusions: Overall survival in study has a significant range. Factors influencing survival included intrinsic factors such as patient age and disease characteristics, as well as extrinsic factors such as evolution of chemotherapy regimen over the past four decades. The main limitations are related to the inherently low-quality evidence as a result of lack of randomized controlled trials. More comprehensive data is needed to guide shared decision making in this area.

Simvastatin Possesses Antitumor and Differentiation‐Promoting Properties That Affect Stromal Cells in Giant Cell Tumor of Bone

Giant cell tumor of bone (GCTB) is a locally aggressive destructive bone lesion. The management of pulmonary metastasis and local recurrence after the surgical treatment of GCTB remains a challenge. Pathologically, stromal cells in GCTB are known as primary neoplastic cells and are recognized as incompletely differentiated preosteoblasts. Therefore, inducing GCTB stromal cells to differentiate into cells with a mature osteoblastic phenotype may stop tumor growth and recurrence. In this study, we aimed to investigate how simvastatin, a clinically approved and commonly used statin that has been known to promote the maturation of cells of the osteogenic lineage, affects GCTB stromal cells. We found that simvastatin effectively inhibited cell viability by suppressing proliferation and by inducing apoptosis in GCTB stromal cells. Moreover, simvastatin treatment upregulated the expression of genes related to osteogenic maturation, such as runt-related transcription factor 2, osteopontin, and osteocalcin, and increased the mineralization of the extracellular matrix in GCTB stromal cells. Ingenuity pathway analysis was used to discover that the vitamin D receptor pathway was involved in the simvastatin-induced osteogenic differentiation of GCTB stromal cells by upregulating the 1,25-dihydroxyvitamin D metabolism. Taken together, this in vitro study demonstrates the antitumor and differentiation-promoting effects of simvastatin on GCTB stromal cells and suggests the possibility of using simvastatin as an adjuvant therapy for GCTB. These findings support further clinical investigation of the efficacy of using simvastatin as an adjuvant therapy for GCTB to reduce recurrence and distant metastasis after surgical treatment. © 2019 Orthopedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:297-310, 2020.

Advancement in the surgical treatment of pulmonary metastasis

The management of pulmonary metastases is a target in constant movement. Historically, it has been assumed that patients have a very poor survival when a primary tumour invades other organs, particularly the lungs. Some preliminary works have demonstrated that a substantial number of patients undergoing lung metastasectomy enjoy complete remission, thus benefit of prolonged survival. Initially proposed for highly selected patients with specific cancers, the indication of metastasectomy has expanded to various primary solid tumors and is now proposed in daily practice for a large number of patients, accounting for almost 10% of our surgical activity.

Surgical management of lung metastases.

Management of pulmonary metastases has evolved considerably over the last few decades but is still controversial. The surgical management of lung metastases is outlined, discussing the preoperative management, indications for surgery, the surgical approach and outcomes according to the primary histology.

Abstract 4045: Pediatric osteosarcoma lung metastasis: variations in clinical management

Abstract Background: Nearly 20% of patients with newly diagnosed osteosarcoma have detectable metastatic disease at presentation, most of which is located in the lungs. These patients have a poor prognosis with survival of generally less than 30%. NCCN guidelines as well as many osteosarcoma clinical trials endorse resection of metastases as part of standard treatment. There are limited recommendations as to the timing or method of resection. Methods: An anonymous online questionnaire was distributed to establish practice patterns among members of the Connective Tissue Oncology Society, a multi-disciplinary sarcoma focused organization. Participants were asked about management of lung metastases in 3 clinical scenarios (2 cm unilateral, 0.5 cm unilateral, and multiple bilateral lung nodules). Questions evaluated timing of management, decision to resect, technique of resection, and decision to explore the contralateral lung. Results: 183 individuals completed the survey. Most report initiating nodule management after neoadjuvant therapy. If the nodule disappeared after neoadjuvant therapy or definitive surgery, most report not performing surgical resection. Among nodules resected after neodjuvant therapy or definitive surgery that were unchanged in size, thoracotomy is the most commonly reported surgical technique. When only unilateral nodules were present on imaging, few choose to explore the contralateral lung (11% in 2.0cm and 10% in 0.5cm, compared to 70% in multiple bilateral nodules). Pediatric Oncologists were more likely to initiate management earlier than Medical Oncologists for 2.0cm nodule (90% vs 63%, p<0.001), 0.5 cm nodule (77% vs. 47%, p <0.005), and multiple bilateral nodules (79% vs. 51%, p =0.008). Conclusion: There is marked heterogeneity among treating clinicians in their management of pulmonary metastases in osteosarcoma. Variation was also noted between medical specialties. Prospective trials are needed to evaluate if these differences have significant implications on outcomes for patients with newly diagnosed metastatic osteosarcoma. Citation Format: Andrea T. Vo, Onita Bhattasali, Michael Roth, Jonathan Gill, David Geller, Lor Randall, Richard Gorlick. Pediatric osteosarcoma lung metastasis: variations in clinical management. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4045. doi:10.1158/1538-7445.AM2014-4045

Integration of stereotactic ablative radiotherapy in the management of pulmonary metastases from salivary adenoid cystic carcinoma

In this teaching case, we use the example of a woman with pulmonary metastases from a parotid gland adenoid cystic carcinoma (ACC) to illustrate the optimal use of stereotactic ablative body radiotherapy (SABR) in the context of other aggressive treatment options.

The management of the advanced colorectal cancer: management of the pulmonary metastases.

Pulmonary metastases from colorectal cancer present as systemic manifestation of the disease. As a general principle, the presence of metastases predispose to a poor prognosis. However, the application of some criteria of "operability" permitted the surgical resection resulting in prolonged survival (reported 5-year survival up to 50%), in better quality of life and in the cure of some patients. When the primary tumor site is controlled, and the metastatic disease is limited in lungs without extrapulmonary location (except for resectable or resected hepatic lesion) surgical removal is indicated. As significant prognostic factors in metastasectomies have been reported the synchronous or metachronous caracter of the metastases, the disease free survival, the complete removal of the metastases, the thoracic lymph node invasion, the CEA level before metastasectomy and 1 month after, the solitary vs. multiple pulmonary metastatic locations, the induction chemotherapy, the histological type and differentiation grade, as well as the vascular emboli in histopathological examination. Thorough preoperative evaluation of the patient includes oncological assessment and respiratory functional tests. Alternatively, when the patient is not a good surgical candidate, radiofrequency ablation is an option. Many surgical accesses have been validated, as posterolateral or lateral or even posterior thoracotomy, sternotomy, clamshell incision, and thoracoscopic techniques that offer the advantages of less pain, fast recovery, and less morbidity. Though thoracoscopic metastasectomies have been questioned concerning to the completeness of metastatic removal, no statistical difference in survival has been revealed in many series comparing thoracotomy to thoracoscopic techniques. As a conclusion, there are many advances in the management of pulmonary metastases from colorectal cancer during last decade, the results have been essentially optimized, the role of surgery has been established, and the multimodality approach has been recognized as the cornerstone of a successful outcome.

The evolution of the role of surgery in the management of breast cancer lung metastasis.

Breast cancer is the second leading cause of cancer death among women in the United States. Patients with metastatic disease have a median survival of 12 to 24 months and most present with disseminated disease; however, some present with isolated pulmonary metastases which may benefit from surgical resection. Although the initial experience with resection of pulmonary metastases in the late 19th and early 20th centuries produced some encouraging results, patient selection criteria for resection were strict until the mid-1960's when a significant improvement in survival resulted from aggressive management of pulmonary metastasis in osteosarcoma patients. The application of this approach to breast cancer patients similarly produced encouraging results, with five year survival rates in select patients ranging from 36-54%, but this was not without controversy. In this review, we discuss the evaluation of the breast cancer patient with a pulmonary nodule, the historical evolution of the role of surgery in the management of pulmonary metastasis, as well as the latest evidence to guide patient selection and management.

Progress of the diagnosis and treatment of pulmonary metastasis of gestational choriocarcinoma

妊娠绒毛膜癌（简称绒癌）是最常见的妊娠滋养细胞肿瘤，极易发生血行转移，常出现肺转移。自一系列有效化疗药物用于绒癌治疗之后，绒癌已成为可治愈的恶性肿瘤之一，但耐药及复发仍是治疗失败的主要原因，特别是肺转移灶的处理。如何掌握手术指征和时机成为治疗难点。本文就绒癌肺转移的诊断、化疗、手术指征及时机、手术方式等治疗进展进行综述。

Optimal management of pulmonary metastases from colorectal cancer

The incidence of colorectal cancers is rising worldwide and pulmonary metastases were seen in approximately 10–15% of all patients. Surgical metastasectomy is a widely accepted procedure in selected patients and is considered as the only curative option in patients with secondary pulmonary malignancy. But surgical resection remains controversial due to the lack of randomized trials, comparing pulmonary metastasectomy to control, either medical therapy, or observation. This article will discuss the differentiated therapeutic strategies for patients with pulmonary metastases of colorectal cancer, focusing on surgical resection, patient evaluation, prognostic factors, interdisciplinary therapeutic approaches and current trials.

Prognostic factors and outcome for 99 osteosarcoma patients with pulmonary metastases

Objective To identify prognostic factors and imply the appropriate management of pulmonary metastases from osteosarcoma. Methods Data were obtained retrospectively from 99 osteosarcoma patients with pulmonary metastases who received systemic treatments and followed up in Department of Orthopedic Oncology of Peking University People's Hospital from January 2000 to July 2008. The mean followup time was 24.45 months (range, 13-91 months). The average age of the patients at diagnosis was 20.39 years (range, 7-68 years); the male female ratio was 65:34. All the patients had undergone resection of tumors, and 93 of them had received neoadjuvant chemotherapy. Pulmonary metastases were found in 16 patients at diagnosis of osteosarcoma, in 47 patients during chemotherapy and 36 patients after the whole treatment. The age of patients, the number of pulmonary metastases, the time of appearance of pulmonary metastases,extrapulmonary metastases, the response of primary tumor to chemotherapy and management of pulmonary metastases were analyzed. Results The interval between the diagnosis of osteosarcoma and pulmonary metastases ranged from 0 to 74 months with the mean time of 9.05 months. The 1-year, 2- and 5-year cumulative survival rates were 87.4%, 56.8% and 23.4% respectively in the study, with the median survival time of 25 months. Univariate analysis showed the significant factors included the time of appearance and the management of pulmonary metastases. Cox regression analysis revealed that the time of appearance of pulmonary metastases was the only prognostic factor. There was no significant difference between age, number of pulmonary metastases, extrapulmonary metastases and response of primary tumor to chemotherapy.Conclusion Characteristics related to the time of appearance of pulmonary metastases and surgical management especially as pulmonary resection appear to be more predictive of a successful outcome. Key words: Osteosarcoma; Neoplasm metastasis; Lung neoplasms; Treatment outcome

Cost-effectiveness analysis of FDG PET-CT in the management of pulmonary metastases from malignant melanoma

Objectives. Most guidelines consider FDG PET-CT to detect occult extra-pulmonary disease prior to lung metastasectomy. A cost-effectiveness analysis, using a Markov model over a 10 year period, was performed to compare two different surveillance programs, either PET-CT or whole-body CT, in patients with suspected pulmonary metastasised melanoma. Methods. Data from published studies provided probabilities for the model. Complication and care costs were obtained from standardised administrative databases from 19 hospitals identified by DRG codes (reported in 2009 Euros). For the cost calculation of PET-CT we performed a microcosting analysis. All costs and benefits were yearly discounted at respectively 3% and 1.5%. Outcomes included life-months gained (LMG) and the number of futile surgeries avoided. Cost-effectiveness ratios were in Euros per LMG. Univariate and probabilistic sensitivity analyses addressed uncertainty in all model parameters. Results. The PET-CT strategy provided 86.29 LMG (95% CI: 81.50–90.88 LMG) at a discounted cost of €3 974 (95% CI: €1 339–12 303), while the conventional strategy provided 86.08 LMG (95% CI: 81.37–90.68 LMG) at a discounted cost of €5 022 (95% CI: €1 378–16 018). This PET-CT strategy resulted in a net saving of €1 048 with a gain of 0.2 LMG. Based on PET-CT findings, 20% of futile surgeries could be avoided. Conclusion. Integrating PET-CT in the management of patients with high risk MM appears to be less costly and more accurate by avoiding futile thoracotomies in one of five patients as well as by providing a small survival benefit at 10 years.

Diagnosis and management of pulmonary metastasis from recurrent respiratory papillomatosis

Objective We sought to review the current and proposed management, as well as bring about discussion, of managing the patient with distal tracheal and pulmonary parenchymal involvement by recurrent respiratory papillomatosis (RRP). Design, setting, and patients We conducted a review of 6 patients with pulmonary metastasis from RRP at 3 academic tertiary care hospitals. Interventions included surgical and medical management with antiviral, chemotherapeutic, and/or immune-modulating agents. Results Although treatment with α–2-β interferon, isotretinoin, and methotrexate have not proved to eradicate pulmonary involvement by RRP, possible epithelial stabilization and slowing of disease progression are noted. Conclusions The rates of distal tracheal and pulmonary metastasis as seen in our cohort were higher than previously reported. Approximately 12% of our patients with RRP have distal tracheal spread and as many as 7% of all patients with RRP at our institutions have pulmonary dissemination. Also, high suspicion for malignant conversion to squamous carcinoma in the patient with pulmonary spread should be maintained. In addition, aggressive treatment, although not proved to eradicate the pulmonary disease, should be undertaken due to the high morbidity and mortality associated with pulmonary dissemination of RRP in our cohort.