Resection Of Metastatic Lesions Research Articles

Resected case of carcinoid tumor of the liver metastatic from the breast

Carcinoid tumor metastatic to the liver from the breast is very unusual. We report a rare case in which the patient underwent curative resection for metastatic lesions to the liver. She had undergone a modified radical mastectomy more than 1 year previously for breast cancer. Recently, it was found that plasma levels of carcinoembryonic antigen (CEA) was elevated, and abdominal ultrasonography detected a liver tumor. The patient underwent a lateral segmentectomy of the liver, resulting in normalization of plasma CEA levels. The resected specimen was diagnosed as carcinoid tumor by histological, immunohistochemical, and ultrastructural microscopic studies. Re-examination of the breast tumor proved it to be the primary carcinoid.

Hepatic resection for noncolorectal nonneuroendocrine metastases.

The experience with hepatic resection for metastatic lesions, exclusive of colorectal and neuroendocrine tumors, is anecdotal. The reduction in operative mortality leads to a reconsideration of the subject. A review of the literature suggests a selective approach. There is little improvement to be anticipated for resection of metastases from tumors of the esophagus, stomach, small intestine, or pancreas. Resection of metastases from primary renal cell carcinoma, Wilms' tumor, and adrenocortical carcinoma is indicated. There is little to recommend resection of metastases from gynecologic or breast primary carcinomas. Resection as palliation is to be considered for all lesions, particularly bulky metastases from ocular melanomas.

Morphological study of the parotid lymph nodes

The surgical resection of metastatic lesions of the parotid gland is controversial. The present anatomical study has been carried out to determine whether or not lymph nodes are present in the deep lobe of the gland and to assess their number in different age groups. We found a substantial number of lymph nodes in the deep lobe of the parotid gland independently of the subject's age. It can be concluded that from a strictly morphological point of view, superficial parotidectomy does not appear adequate when radical neck dissection including the parotid gland is to be done.

One hundred consecutive patients undergoing video-assisted thoracic operations

Video-assisted thoracic surgery is a new modality that allows visualization of and access to the intrathoracic organs without making a thoracotomy incision. One hundred consecutive patients underwent 113 thoracic procedures using this technique. Eight wedge resections for metastatic lesions, 6 pericardial windows, 1 bronchogenic cystectomy, 4 explorations of the aortopulmonary window, 1 decortication, 5 pleural scleroses, 8 bullous ablations, 25 lung biopsies, 19 wedge resections for carcinoma, 9 explorations of the thorax, 3 lobectomies, 1 esophageal cystectomy, 14 wedge resections for benign lesions, 4 pleurectomies, 1 excision of a neurogenic tumor, 3 mediastinal explorations, and 1 imaged axillary dissection were performed. There was no mortality. Ten patients had complications from which they recovered completely. Patients undergoing video-assisted thoracic operations seem to have reduced post-operative pain, shorter hospitalization, and quicker recovery times. Currently, this new modality appears to have beneficial value for patients; however, only further experience will determine its true merits.

Clinical and pathological evaluations of methotrexate, vinblastine, adriamycin and cisplatin chemotherapy for advanced urothelial cancers.

We have treated advanced transitional-cell carcinoma of the urothelial tract with methotrexate, vinblastine, Adriamycin, and cisplatin (M-VAC) chemotherapy since July of 1985. We analyzed the effect of that chemotherapy in 26 patients with advanced urothelial cancer who were treated in our hospital and followed up. They were divided into two groups. Group 1 consisted of 15 patients with distant metastases. In all, 11 of them received M-VAC as adjuvant chemotherapy for metastatic lesions after surgical removal of the primary lesion, and the remaining 4 patients were not operable since they had very advanced-stage tumors; they received only M-VAC chemotherapy. Group 2 contained 11 patients who received M-VAC neo-adjuvant chemotherapy. In group 1, the overall response rate was 57.1% and the mean duration of response was 12.6 months. In the 11 patients who had received M-VAC as adjuvant therapy after surgical removal of the primary tumor, the mean duration of response was 14.1 months. After M-VAC chemotherapy, six patients underwent surgical resection of metastatic lesions and restaging was done pathologically in these cases. The clinical response coincided with the pathological response in all six cases. In group 2, 5 of 11 patients experienced histological downstaging of the resected bladder. M-VAC chemotherapy combined with surgical resection of residual tumors has proved to be an effective option against advanced urothelial cancer.

Surgical Resection of Pulmonary Metastases From Colorectal Adenocarcinoma

Pulmonary resection of metastatic lesions from colorectal adenocarcinoma was performed in 35 patients. The cumulative 5-year survival was 38%. The primary site of cancer was the colon in about half of the patients. Patients with a solitary metastasis or tumors smaller than 3 cm in diameter survived longer than did patients with multiple metastases or tumors larger than 3 cm but the differences were not significant. Other factors, including age, sex, histologic grade of tumor, location and stage of primary carcinoma, location of pulmonary metastases, disease-free interval, and type of pulmonary resection, had no apparent influence on survival time. The lung was the major site of recurrence following pulmonary resection. Seven patients underwent two or more pulmonary resections for metastasis from a colorectal carcinoma. At the time of last follow-up, four patients were alive and free of recurrent disease at 5, 34, 39, and 58 months after the second pulmonary resection. These data suggest that some patients will survive for a long time following pulmonary resection of colorectal metastases, and for highly selected patients, repeated pulmonary resection may further extend survival.

CLINICAL STUDY OF BORRMANN TYPE 4 GASTRIC CANCER

A clinicopathological study was undertaken in 44 patients with Borrmann type 4 gastric cancer. The male: female ratio was 1.10:1 and the average age was as high as 53.8 years. Total gastrectomy was performed in 77.3%, lymphadenectomy (R2 and above) done in 67.4% and combined resection of adjacent organs done in 56.8%. Peritoneal dissemination and liver metastasis occurred at rates of 31.0% and 4.8%, respectively. Histological examination revealed poorly differentiated adenocarcinoma and the depth of gastric wall invasion exceeded “se” in many cases. The incidence of histological lymph node metastasis was 73.1%. Cross-sections of the ends of excised tissue specimens disclosed a high incidence of tumor infiltration (20.9%). The overall prognosis of Borrmann type 4 gastric cancer was exceedingly poor. The 1, 3 and 5 year survival rates were 55.1%, 19.1% and 13.5%, respectively. In the comparison of curative resection and non-curative resection, significant differences were found in survival rates of the 1 and 3 years. One P1 patient who received total gastrecotmy with combined resection of metastatic lesion survived more than 5 years. From the above, extended radical operation is necessary to improve the prognosis in Borrmann type 4 gastric cancers.

TWO RESECTABLE CASES OF SYNCHRONOUS METASTASES OF COLORECTAL CARCINOMA TO THE LIVER AND LUNG

We report 2 cases of synchronous metastases of colorectal carcinoma to the liver and lung in which the metastatic lesions could be radically resected. Case 1 A 59-year-old man underwent adominoperineal excision of rectum for lower rectal carcinoma (well-defferentiated adenocarcinoma in stage III; absolute curative resection). After 2 years and 3 months postoperatively, synchronous metastases to the liver and lung were found. Right lobectomy folloed by partial penumonectomy were carried out, each metastatic lesions being radically resected. As of 5 years and 3 months after the initial operation or one year and 11 months after resection of metastatic lesions, the patient is in health without recurrence. Case 2 A 57-year-old woman had a carcinoma of the ascending colon with synchronous metastatic lesions in the liver and lung. In the first step operation, right hemicolectomy (well-differentiated adenocarcinoma; absolute curative resection for the primary lesion) and catheter intubation into thehepatic artery were done, and postoperative chemotherapy by artrial injection was added. After 7 months, the metastasized lesions in the liver and lung were radically resected. At present as of 4 months after the resection no recurrence occurs. From these experiences, surgical appropriateness for synchronous metastases to the liver and lung was considered.

Major Hepatic Resection: An Update

In 1981, we reported a series of 75 major hepatic resections done over a ten-year period; 58 were for hepatic trauma, nine were for benign disease, and eight were for malignant disease. Since that report, the indications for major hepatic resection have changed, with a more conservative approach to hepatic trauma and a more aggressive approach toward hepatic tumors. In this update, we report 88 hepatic resections from Vanderbilt University Hospital and Metropolitan Nashville General Hospital; 32 were for trauma, 25 were for benign disorders, and 31 were for malignant disease. Since 1977, nine adults and four children have had hepatic resection for primary malignant tumors; there were six hepatocellular lesions, three hepatoblastomas, two malignant hemangioendotheliomas, one malignant hepatoma, and one intrahepatic cholangiocarcinoma. At the time of this writing, the four children have survived for 7.3, 6, 6, and 3.8 years (mean 5.7), and all are alive without evidence of recurrence. For the nine adults, survival has averaged 1.7 years, excluding one postoperative death. Three adult patients are alive at this writing, one of whom is a five-year survivor without evidence of disease. Seventeen adults and one child had hepatic resection for metastatic lesions. In the adults, the primary tumor was in the colon in 14 cases and in the small bowel, stomach, and an unknown site in one case each. The one child had a metastatic Wilms' tumor. Survival has averaged two years, with two long-term survivors (nine years). Six patients are alive at this time. Operative mortality for elective resection has decreased from 12% (2/17) in our earlier report to 3% (1/31) in this series, which has encouraged us to assume a more aggressive approach to the resection of malignant primary and metastatic liver tumors.

Surgical resection of pulmonary metastases from colorectal cancer. 10-year follow-up.

Pulmonary resection of metastatic lesions from colorectal cancer was performed in 62 patients, and their cumulative 5-year and 10-year survival rates were 42% and 22%, respectively. The overall median survival was 24 months. The survival curve decrease even after 5 years after pulmonary resection; four of 13 patients who survived more than 5 years subsequently died of metastatic disease and only two patients survived more than 10 years. The number and size of the pulmonary metastases were significantly correlated with postthoracotomy survival. Solitary metastases less than 3.0 cm in diameter were good indicators of favorable postthoracotomy survival. There were no significant differences in survival based on Dukes' classification or location of the primary lesion. Sex, age, disease-free interval between the primary tumor and appearance of metastasis, and extent of pulmonary resection had no influence on survival. It is impossible to say from our experience that surgical resection of pulmonary metastases increased the cure rate. Presumably a good 5-year survival rate after thoracotomy would be a reflection of a length bias caused by the biologic behavior of the metastatic pulmonary lesions.

Surgery of Pulmonary Metastases

From 1954 to 1985, 150 metastases were removed in 80 patients (55 males, 25 females) with an age range from 8 to 82 years. The role of pulmonary resection for metastatic lesions of the period 1954 to 1975 (group I) was compared to the period 1976 to 1985 (group II). In group I, 48 metastases were resected in 35 patients and in group II, 102 metastases in 45 patients. The surgical mortality in the total population was 1%. The average interval from diagnosis of the primary neoplasm to diagnosis of thoracic metastases was 4 years in both groups. Primary neoplasm localization did not differ in the 2 groups. In both groups approximately 50% of the patients were without symptoms. Wedge resection and lobectomy were the most frequent procedures followed by segmentectomy and pneumonectomy. The median post thoracotomy survival was 21 months in group I and 36 months in group II. Although the tumor-free interval, presenting symptoms and surgery did not differ in the 2 groups, the actuarial 5-year survival in group I was 31%, and 53% for group II. Neither sex, age nor the lung resection type significantly affected the therapeutic results. Good prognostic factors were a non-seminomatous testicular tumor as the primary tumor, a tumor-free interval longer than 60 months and a tumor-doubling time longer than 136 days. Poorer results were obtained in the presence of N2 metastases, and of a large tumor volume. It seems that with the increased effectiveness of chemotherapy, especially in non-seminomatous testicular tumor, the role of surgery is changing. Surgery is now also indicated to resect metastases unresponsive to chemotherapy and to obtain histology of stabilized lesions after chemotherapy.

CLINICAL STUDY OF HEPATIC RESECTION FOR LIVER METASTASES FROM GASTRIC AND COLORECTAL CANCERS

Fourteen patients with metastatic liver cancers underwent hepatic resection during the 5-year period 1980-1985 at the Department of Surgery, School of Medicine, Gunma University, Tone Central Hospital and Gunma Cancer Center Hospital. Metastatic gastric cancers were present in four patients (three males and one female; average age, 66 years) and metastatic colorectal cancers in ten patients (eight males, two females; average age, 56 years). Distant liver metastases from gastric cancers were present in two patients but in the other two patients the primary gastric cancers invaded the liver directly. Five patients had primary cancer and synchronous liver metastases, and of these, four cases were metastasized from cancers of the right colon but one was from cancer of the left colon. Five patients had metachronous liver metastases from colorectal cancer, all of which were metastasized from cancer of the left colon. One year 4 months to 3 years 10 months was the period from primary operation to the resection of liver metastases. Serum CEA examination proved most useful in monitoring the patients, and ultrasonography, computed tom-mography and angiography were useful in evaluating the metastatic tumors. During the 5-year period 1975-1980 gastric cancers and colorectal cancers with liver metastases numbered 35 cases (15% of 231 cases) and 12 cases (10% of 116 cases), respectively, and of these patients only one lived for more than an additional 16 months (26 months). In each group there were three cases that might have had the metastatic concers resected. If we had tried resection, the period of survival could have been prolonged. We concluded that excision or resection of metastatic lesions could be justified on the basis of low operative risk, prolonged survival and good quality of life.

Metastatic Processes and a Potential Indication of Treatment for Metastatic Lesions of Renal Adenocarcinoma

Renal adenocarcinoma findings from 307 autopsied cases with metastasis to 1 and 2 organs were investigated concerning the mode of metastasis. The lung was the most frequent site of metastasis to 1 organ, although the frequency was rather low (30 per cent), followed by bones (over-all), lymph nodes (over-all) and brain, and involving frequently the thoracic spine and retroperitoneal lymph nodes. In patients with metastases to 2 organs a significant correlation was found between the pulmonary-tracheal lymph nodes and those to the lungs. Potential indications for treatment of metastatic lesions were 1) lymphadenectomy and/or radiation therapy for the retroperitoneal and para-aortic lymph nodes and 2) resection of metastatic lesions in the lungs combined with lymphadenectomy and/or radiation therapy for the pulmonary-tracheal lymph nodes. In patients without lung metastasis lymphadenectomy and/or radiation therapy for the pulmonary-tracheal lymph nodes is not always necessary.

Results of pulmonary resection for metastatic lesions

We reviewed the role pulmonary resection for metastatic pulmonary lesions in our institution. Over a 22 year period, 142 patients underwent 153 thoracotomies. The operative mortality was 0.7%. Complete follow-up was obtained on 140 hospital survivors (99.3%). The actuarial 5 year survival rate for carcinoma was 24% (70% confidence limit 0% to 52%) and for sarcoma was 29% (70% confidence limit 0% to 61%). The survival rate to the end of the follow-up for patients with short disease-free intervals (less than 3 months) was 30%; with free intervals of 3 to 30 months, the survival rate was 27%; with long intervals (greater than 30 months), it was 24% (p = 0.8). Six of 29 lobectomy or pneumonectomy specimens has secondary metastases in the regional nodes, but actuarial 5 year survival rates following lobectomy, pneumonectomy, or segmental or wedge excision were not statistically different. Long-term follow-up revealed an overall survival rate of 26%, which was not influenced by tumor histology, disease-free interval, or extent of pulmonary excision. In view of these findings, we continue to advocate conservative excision of pulmonary metastases when the primary tumor is controlled and other organ systems are not involved, regardless of the tumor histology or the disease-free interval.

Testis tumor metastatic to lung: Twenty-two-year survivor

A case is presented of a twenty-two-year survivor following pulmonary resection of a solitary embryonal cell carcinoma metastasis from a primary teratocarcinoma of the testis. The literature is reviewed with regard to this problem, and the criteria for pulmonary resection of metastatic lesions are presented.

Readings in Modern Surgery

In this well-balanced anthology of 57 new and noteworthy publications, Egdahl and Mannick have focused on those areas of clinical surgery undergoing recent change or introspection. For example, some articles introduce new operative approaches (myocardial revascularization for cardiogenic shock, ileostomy and colostomy for toxic megacolon, total pancreatectomy for ductal carcinoma), or improvements in postoperative management (rabbit antilymphocyte serum treatment in clinical transplantation, prevention of tracheal injury during intubation). Others critically reevaluate established operations like carotid endartectomy, sphincterotomy vs choledochoduodenostomy, and hiatus hernia repair. The results of surgery for parathyroid tumors, recurrent hiatus hernia repair, and pulmonary resection for metastatic lesions are updated, and recommendations for alterations in technique or patient management are presented—eg, conservative surgery for papillary thyroid carcinoma, needle aspiration for breast cysts, and transperitoneal drainage of subphrenic abscess. Investigative or controversial topics like tumor immunology, local excision for breast carcinoma, prophylactic portacaval shunts, and ischemic colitis are also

Pulmonary resections for metastatic lesions.

The thought that a localized metastasis in the lungs may represent the only tumor remaining in the patient has led surgeons to carry out pulmonary resections with some expectation of cure in an otherwise hopeless disease. Even if the patient eventually dies of his disease, prolongation of life or relief of any distressing symptoms may be achieved. There has been considerable difference of opinion regarding the advisability of this course of action. Certainly the low mortality of pulmonary resection should not encourage the use of a futile operation. Therefore, periodic reevaluation of results is certainly indicated to enable us to state with more accuracy whether or not such surgical intervention is justified. A previous report of nine patients by one of us (J. L. E.)¹was preceded by publications on the same subject by Seiler, Clagett, and McDonald⁴and by Eschapasse.²The latest, and by far the most extensive, review

Pulmonary resections for metastatic lesions.

THE RENEWED interest in the controversial subject of excision of pulmonary metastatic lesions has prompted us to report nine additional cases and to give our experience in selecting and handling them. The hopelessness in the prognosis for patients in whom pulmonary metastatic lesions are found, even though the primary extrapulmonary malignant growth has been totally removed, has brought about many attempts at surgical removal of the metastatic lesion or lesions and some successes. We shall try to demonstrate that the low mortality and the increased safety of pulmonary resection as practiced today justify a more radical approach to occasional surgical resection of metastatic malignant tissue. There have been previous case reports by others, and reviews by Seiler, Clagett and McDonald¹and by Eschappase²have recently been published. The presence of a lung lesion either as a peripheral parenchymal mass or as evidenced by involvement of a major bronchus,