Surgical Resection Of Lung Metastases Research Articles

Survival Analysis of Resection of Lung Metastases From Colorectal Cancer

Introduction The publication of the International Registry of Lung Metastases (IRLM) in 1997 was a turning point in favor of surgical resection of lung metastases. Prognostic groups were defined according to resectability, number of metastases, and disease-free interval. The objective of this study was to determine survival in patients who underwent resection of lung metastases from colorectal carcinoma and to evaluate how applicable the prognostic factors established by the IRLM are in this specific patient group. Patients and Methods Patients with lung metastases from colorectal carcinoma who underwent resection between January 1, 2000, and November 30, 2006, were retrospectively analyzed. Survival was calculated using the Kaplan-Meier method, with log-rank comparisons between groups. Results Survivals at 1, 3, 5, and 6 years was 92%, 75%, 54%, and 43%, respectively. The main finding was that 3-year survival was better in patients who underwent atypical resection of the metastasis (75%) than those who required lobectomy (55%). There were no significant differences in survival in terms of number of lung metastases resected or disease-free interval. Conclusions Survival in patients requiring lobectomy for resection of lung metastases from colorectal carcinoma was worse than in those who underwent atypical resection. The number of metastases and disease-free interval may be questionable prognostic factors in the case of lung metastases from colorectal carcinoma.

Análisis de supervivencia de la cirugía de resección de metástasis pulmonares de cáncer colorrectal

Introduction The publication of the International Registry of Lung Metastases (IRLM) in 1997 was a turning point in favor of surgical resection of lung metastases. Prognostic groups were defined according to resectability, number of metastases, and disease-free interval. The objective of this study was to determine survival in patients who underwent resection of lung metastases from colorectal carcinoma and to evaluate how applicable the prognostic factors established by the IRLM are in this specific patient group. Patients and Methods Patients with lung metastases from colorectal carcinoma who underwent resection between January 1, 2000, and November 30, 2006, were retrospectively analyzed. Survival was calculated using the Kaplan-Meier method, with log-rank comparisons between groups. Results Survivals at 1, 3, 5, and 6 years was 92%, 75%, 54%, and 43%, respectively. The main finding was that 3-year survival was better in patients who underwent atypical resection of the metastasis (75%) than those who required lobectomy (55%). There were no significant differences in survival in terms of number of lung metastases resected or disease-free interval. Conclusions Survival in patients requiring lobectomy for resection of lung metastases from colorectal carcinoma was worse than in those who underwent atypical resection. The number of metastases and disease-free interval may be questionable prognostic factors in the case of lung metastases from colorectal carcinoma.

Clinical outcome after surgical resection of lung metastases from melanoma

Surgical therapy plays an important role in the management of selected patients with metastatic melanoma. A retrospective review of 13 patients who underwent surgical resection of lung metastases from melanoma from 1996 to 2003 was performed. The aim of the study was to analyze the clinical outcome and survival time. Mean age was 45 years old (range: 31-64). Complete tumour resection was confirmed histologically. Nine patients presented one single pulmonary lesion, two lesions (n = 3) and three lesions (n = 1) but in all cases confined in the same pulmonary lobe. Median survival time (MST) for the entire group was 20 months (95% confidence interval (CI): 16-24 months). The median time to disease progression after lung metastasectomy was 5 months (95% CI: 3-7 months). MST, according to the prognostic groups proposed by the International Registry of Lung Metastases, was 17 months (95% CI: 6-28 months) for group I (n = 6), MST of 20 months (95% CI: 16-24 months) for group II (n = 5) and MST of 4 months for group III (n = 2), without differences statistically significant (log-rank p = 0.423). MST regarding the time of disease free interval from diagnostic of primary tumour and lung metastases (< 36 months [n = 5] vs > 36 months [n = 8]) was 20 months and 17 months respectively, without differences statistically significant (log rank p = 0.222). Surgical resection when feasible provides survival rates superior to any available nonsurgical therapy. In carefully selected patients, when the resection is performed with curative intent, it may result in improved survival.

Resection of recurrent pulmonary metastases in patients with osteosarcoma

Surgical resection of lung metastases is widely accepted in osteosarcoma patients. Few data exist on treatment of recurrent pulmonary metastases. The authors of the current study retrospectively analyzed patients with osteosarcoma who received surgery for recurrent lung metastases. From 1980 to 2001, 127 metastasectomies were performed on 94 patients. Criteria of eligibility were no metastases beyond the lung, no local recurrence, possibility of achieving complete resection of metastases without causing respiratory insufficiency, acceptable operative risk. Data were statistically elaborated with survival analysis according to Kaplan-Meier method of univariate analysis, life tables and Gehan statistic model, and multivariate analysis using Cox regression test. Results were considered in terms of time from first (DFI1) and second (DFI2) metastasectomy. Of 94 patients operated upon twice, 59 (62.7%) died. Thirty-five (37.3%) are alive; 31 (32.9%) of these are continuously disease-free. The 3- and 5-year event-free actuarial survival curve from first metastasectomy was 45%, and 38%, respectively, whereas from the second metastasectomy, it was 33% and 32%, respectively. According to a Cox regression model, DFI1 has a risk of death of 0.974 times and DFI2 of 0.972 times for every additional month of survival. In multivariate analysis, Cox regression test showed the best predictive model of local recurrence and number of metastases (P = 0.0014). The authors concluded that patients persistently free of the primary osteosarcoma who developed recurrent resectable metastatic disease of the lung should be considered for reoperation a second, third, or fourth time, as these patients had similar DFI curves after five-years.

Isolated Lung Perfusion With Melphalan for Resectable Lung Metastases: A Phase I Clinical Trial

Background Current 5-year survival after complete resection of pulmonary metastases is 20% to 40%, and many patients develop intrathoracic recurrences. Isolated lung perfusion is an experimental technique to deliver high-dose chemotherapy to the lung without systemic exposure. A phase I trial of isolated lung perfusion with melphalan (MN) combined with pulmonary metastasectomy for resectable lung metastases was conducted to define the dose-limiting toxicity and maximum tolerated dose. Methods From May 2001 to August 2003, 16 patients underwent isolated lung perfusion with MN, followed by surgical resection of lung metastases. Patients were treated with increasing MN doses (15, 30, 45, and 60 mg). For each dose level, normothermia (37°C) and hyperthermia (42°C) were evaluated (n = 3 per level). Serum samples were obtained during the procedure. Pulmonary, hematologic, and nonhematologic toxicities were recorded. The primary tumor was colorectal in 7 patients, renal in 5, sarcoma in 3, and salivary gland in 1. Isolated lung perfusion was performed unilaterally in 11 patients, and staged bilaterally in 5. Results In total, 21 procedures of isolated lung perfusion with complete metastasectomy were performed without technical difficulties. Operative mortality was 0%, and no systemic toxicity was encountered. Grade 3 pulmonary toxicity developed at a dose of 60 mg of MN at 37°C in 2 of 3 patients at this dose, terminating the trial. Conclusions Isolated lung perfusion with MN combined with pulmonary metastasectomy is feasible. Dose-limiting toxicity occurred at a dose of 60 mg of MN at 37°C, and the maximum tolerated dose was set at 45 mg of MN at 42°C.

Retrospective study of resection of pulmonary metastases in patients with advanced colorectal cancer: the development of a preoperative chemotherapy strategy.

Considerable data are available to support the resection of hepatic metastases in patients with colorectal cancer, but there are relatively few studies on the role of pulmonary metastectomy. The small number of such studies is mainly noncontemporaneous and predates the use of preoperative neoadjuvant chemotherapy. A retrospective analysis of 31 patients with pulmonary metastases from colorectal cancer treated with surgery and perioperative chemotherapy between 1995 and 2003 was performed. Twenty patients (65%) proceeded directly to surgery and 5 of these received postoperative chemotherapy. Eleven patients (35%) received preoperative chemotherapy, which consisted of a fluoropyrimidine in combination with oxaliplatin or mitomycin-C, except for 1 patient who received single agent irinotecan. Nine of 11 patients (82%) had a partial response and 2 patients (18%) had stable disease. A total of 39 thoracic surgeries (6 bilateral and 1 incomplete) were performed. There were no postoperative deaths. Four of 20 patients (20%) who had initial surgery had postoperative complications, compared with 18% of the preoperative chemotherapy group. Overall 3- and 5-year survival rates after the first thoracic surgery were 65.2% (95% CI, 35.1%-83.9%) and 26.1% (95% CI, 4.3%-56.2%), respectively. Based on the limited data from this study, disease-free interval, number of pulmonary metastases, previous resection of hepatic metastases, prethoracotomy carcinoembryonic antigen levels, and preoperative chemotherapy were not found to be significant prognostic factors for survival. Therefore, surgical resection of lung metastases is associated with low morbidity and mortality and results in long-term survival for 20%-30% of patients. Moreover, preoperative chemotherapy produced a high response rate, with no patients experiencing disease progression before surgery.

Surgical resection of lung metastases from epithelial tumors

Background One of the main characteristics of malignant tumors is the capability to disseminate, giving rise to local or distant metastases. Pulmonary metastases occur in almost 30% of all oncology patients, and secondary lung tumors are more frequent than primary ones. Surgical resection of metastases is now a well-established procedure, but the results vary with the histologic type of the primary tumor. We wished to identify factors affecting late survival after pulmonary metastasectomy for epithelial tumors. Methods We have reviewed retrospectively data for 78 patients who underwent 101 curative resections of epithelial pulmonary metastases between January 1988 and December 2000 at our department. Potential prognostic factors affecting late survival, namely histology of the primary tumor, disease-free interval, number and size of resected lung metastases, involvement of lymph nodes, use of nonsurgical adjuvant therapy, and relapse of pulmonary metastases, were investigated. Results There was no operative mortality, and the postoperative course was uneventful in 91.1% of the procedures. The mean disease-free interval was 48.2 ± 59.8 months, and the mean follow-up after the first pulmonary metastasectomy was 40.8 ± 31.5 months. Mean overall survival was 81.0 ± 10.0 months, and 5-year and 10-year survival rates were 47.4% and 37.7%, respectively. By univariate and multivariate analyses, the disease-free interval and the prognostic grouping system proposed by the International Registry of Lung Metastases were found to significantly influence the long-term survival. Presence of symptoms also showed an important influence. Conclusions Resection of epithelial pulmonary metastases is safe and effective, and is associated with very low perioperative morbidity and mortality and a reasonable 5-year and 10-year survival. In the present study, the disease-free interval influenced significantly the long-term survival. Our results did not differ significantly from (and in many cases compared favorably with) those described in the literature.

Isolated lung perfusion for the treatment of pulmonary metastases current mini-review of work in progress.

Surgical resection of lung metastases is a widely accepted procedure but long-term results are disappointing with a 5-year survival rate of approximately 40%. Pulmonary metastasectomy is only indicated when complete resection can be achieved. A better survival is reported in patients with a single metastasis or a disease-free survival of more than 3 years. Intravenous chemotherapy has no major impact on survival because high-dose therapy is limited by systemic side-effects. Isolated lung perfusion has the advantage of both selectively delivering an agent into the lung while diverting the venous effluent. This allows the drug to be given in a significantly higher dose compared to intravenous therapy, while drug levels in critical organs are kept low enough to avoid significant morbidity. Isolated lung perfusion has proven to be effective for the treatment of lung metastases in animal models while the procedure is technically safe in humans. However, the real clinical value and survival benefit remain to be determined in ongoing clinical trials.The aim of this paper was to update the literature on isolated lung perfusion for the treatment of lung metastases. Furthermore, some proposals are made in order to improve the ultimate prognosis of these patients.

Surgical resection of unilateral lung metastases: is bilateral thoracotomy necessary?

Surgical resection of lung metastases is routine procedure for selected patients with pulmonary nodules and solid tumors. In some cases, patients present with unilateral pulmonary metastases amenable to surgical resection. Surgeons are still divided between unilateral approach directed to the radiologically detected nodules, or bilateral exploratory thoracotomy. This study evaluates the need for bilateral thoracotomy in patients diagnosed with unilateral lung metastases. A retrospective evaluation was made of a prospective database from a single institution (1990-1997) of all consecutive patients (n = 267) diagnosed on admission with unilateral (n = 179) or bilateral (n= 88) lung nodules. Ipsilateral thoracotomy was performed on all patients with unilateral disease. Bilateral thoracotomy was performed on all patients with bilateral lung metastases. adenocarcinoma (25%), osteosarcoma (23%), squamous cell carcinoma (18%), soft-tissue sarcoma (18%), and other (16%). Median follow-up was 17 months. Contralateral disease-free survival and overall survival were determined. Univariate and multivariate analyses were performed to determine prognostic factors for overall and contralateral disease-free survival. The two groups of patients with confirmed bilateral metastases (synchronous or metachronous) were compared. Actuarial overall 5-year survival was 34.9%. Contralateral recurrence-free 6-month, 12-month, and 5-year survival were 95%, 89%, and 78%, respectively. Patients who experienced recurrence in the contralateral lung within 3, 6, or 12 months had an overall 5-year survival rate of 24%, 30%, and 37%, respectively. When patients with recurrence in the contralateral lung were compared to patients with bilateral metastases on admission, there was no significant difference in overall survival. Only histology and the number of pathologically proven metastases significantly (p < 0.05) predicted recurrence in the contralateral lung. Bilateral exploration of unilateral lung metastases is not warranted in all cases. Most patients will have only unilateral disease, and delaying contralateral thoracotomy until disease is detected radiologically does not appear to affect outcome.

Results of aggressive resection of lung metastases from colorectal carcinoma detected by intensive follow-up.

Although outcome of resection for colorectal carcinoma has improved, about 30 percent of patients develop metastatic lesions. Small pulmonary metastases 1 cm or less in diameter now can be detected by diagnostic tests including chest radiography and computed tomography. We evaluated results of our strategy for intensive follow-up after resection of colorectal cancer and aggressive resection of lung metastases disclosed by these periodic examinations. Our follow-up program for lung metastasis includes a serum carcinoembryonic antigen assay every two months and chest radiography every six months. Surgical resection of lung metastases was performed if the primary and any nonpulmonary metastases had been controlled, lung metastases numbered four or fewer, and pulmonary functional reserve was adequate. Standard operation for lung metastasis was lobectomy, and lymph node dissection was added in cases of tumor size over 3 cm. Forty-two patients underwent 50 lung resections for metastatic colorectal cancer between 1992 and 1999. Long-term survival was assessed in terms of clinical variables. Overall five-year survival rate after resection of lung metastases from colorectal cancer was 63.7 percent. Variables significantly affecting postthoracotomy survival were primary tumor histology, number of nodules, and disease-free interval up to appearance of the lung metastases, and primary tumor histology was an independent prognostic factor. Intensive follow-up for lung metastases after resection of colorectal cancer and aggressive resection improved postoperative survival rate. Patients with well-differentiated adenocarcinoma of primary tumor, a solitary metastatic nodule, and disease-free interval of at least two years after initial surgery are likely to be long-term survivors.

Long-Term Results of Surgical Resection of Lung Metastases

.Between 1990 and 2000, 56 consecutive patients underwent lung resection for removal of metastatic disease. Mortality, disease-free interval, and overall survival were studied. Only patients with a complete follow-up were included and data were collected conform the protocol of the International Registry of Lung Metastases. The primary tumour in our series was an epithelial tumour in 25 patients (45%), sarcoma in 15 (27%), germ cell tumours in 11 (19%) and melanoma in 5. Operative mortality was 1.4% (1 out of 73 procedures). Germ cell tumours had the best survival (76% at 5 years), and melanoma the worst (0% at 5 years). Multivariate analysis showed that survival for patients who underwent 2 or more metastasectomies was surprisingly good with a 5-year survival rate of 46%. Survival was not related to disease-free interval, multiple lung metastases, or pneumonectomy. It is in accordance with some reports that a short disease-free interval, numerous lung metastases, or recurrence after the first metastasectomy should not preclude patients from operation.

Surgical treatment of metastatic disease: are the number of metastases a limit for surgical resection of lung metastases

Surgical treatment of metastatic disease: are the number of metastases a limit for surgical resection of lung metastases

Surgical treatment of lung metastases: prognostic factors for long-term survival.

Surgical resection of lung metastases is an established therapy for a large number of primary tumors, but there is some controversy about prognostic factors for long-term survival. From 1968 to 1996, we performed a retrospective review of a series of 85 patients (100 operations) that have been operated for resection of lung metastases. The Kaplan-Meier method was used to estimate the probabilities of survival, the log-rank test for the univariate analysis of prognostic factors for survival, and the Cox model in the subsequent multivariate analysis. The operative mortality was 4% and the morbidity 18%. The mean follow-up after lung resection was 22.13 months (1-146). The actuarial 5-year survival rate was 29.2%. By univariate analysis, the following factors were associated with survival after resection: location and histology of the primary tumor, greatest dimension of the largest metastasis, radicality of the resection, involvement of the resection margins, and use of adjuvant therapy (P < 0.05). After multivariate analysis, only the dimension of the metastases and involvement of surgical margins have been found to be independently associated with survival. Surgical excision is a safe and effective therapy for lung metastases from a large number of primary tumors, provided a complete resection is feasible.

Giant-cell tumour of bone metastasising to the lungs

We reviewed 23 patients with a giant-cell tumour (GCT) of bone and histologically-proven lung metastases at a mean of 11.9 years (3 to 24.5) after the original diagnosis. The mean age of the patients at diagnosis was 27.3 years (9 to 61); the male to female ratio was 0.9:1. The most common primary site was the distal radius. The mean interval between the onset of the tumour and the detection of lung metastases was 4.1 years (0 to 24). There had been local recurrence in 19 (83%) either before or at the time of diagnosis of lung metastasis. Surgical resection alone was the preferred treatment for lung metastases in 70% and resulted in 18 patients (76%) being free from disease when last reviewed. One patient had the spontaneous regression of lung metastases and was free from recurrence 16 years later. Sixteen patients (69.7%) have survived and four (17.4%) have died from progression of the tumour. Three other deaths were not related to the tumour. Local recurrence and a primary lesion at the distal radius seem to be associated with an increased risk of lung metastases. Repeated surgical resection of lung metastases gave a high rate of survival.

Giant-cell tumour of bone metastasising to the lungs. A long-term follow-up.

We reviewed 23 patients with a giant-cell tumour (GCT) of bone and histologically-proven lung metastases at a mean of 11.9 years (3 to 24.5) after the original diagnosis. The mean age of the patients at diagnosis was 27.3 years (9 to 61); the male to female ratio was 0.9:1. The most common primary site was the distal radius. The mean interval between the onset of the tumour and the detection of lung metastases was 4.1 years (0 to 24). There had been local recurrence in 19 (83%) either before or at the time of diagnosis of lung metastasis. Surgical resection alone was the preferred treatment for lung metastases in 70% and resulted in 18 patients (76%) being free from disease when last reviewed. One patient had the spontaneous regression of lung metastases and was free from recurrence 16 years later. Sixteen patients (69.7%) have survived and four (17.4%) have died from progression of the tumour. Three other deaths were not related to the tumour. Local recurrence and a primary lesion at the distal radius seem to be associated with an increased risk of lung metastases. Repeated surgical resection of lung metastases gave a high rate of survival.

Pulmonary metastases—Principles principles and strategies of surgical treatment

Surgical therapy of pulmonary metastases has become an established concept in tumor treatment as therapeutic alternatives are often missing and risks are acceptably low. Reviewing literature and analysing own experience the challenge for an oncological surgeon pursuing a multimodal concept in the treatment of pulmonary metastases is demonstrated. Between August 1989 and December 1993 155 patients had been operated on pulmonary metastases from extrapulmonary malignomas, with 125 of them having a carcinoma as primary malignanyy. Among them most had colorectal cancer (n=37), cancer of the kidney (n=32), the testicles (n=17) and the breast (n=14). In the 209 operations performed the mortality is zero. In case of multiple and/or centrally sited metastases unilateral thoracotomy one by the other seems an appropriate operative management. Prognosis after surgical resection of lung metastases is in general better for carcinoma than for sarcoma patients. Within the group of carcinomas patients with testicular carcinoma show a good prognosis (all our 17 patients are still alive). Important prognostic factors are completeness of surgery and hilar lymph nodes free of tumor in colorectal and kidney cancer metastases of the lung. Median survival time in patients with metastases of colorectal-, kidney-and breast carcinoma is 48 months, 51 months respectively 61 months. Surgical resection is the importance of a curative therapeutic attempt in the treatment of pulmonary metastases. To value the importance of the several therapeutic approaches in a multimodal treatment concept and to adapt them to the different tumor classes, prospective trials with a sufficiently large number of cases are required. With this it might be possible to derive tumor dependent concepts for a multimodal therapy, like the ones which already exist for the treatment of pulmonary metastases of germ cell tumors.

Surgical Resection of Lung Metastases in Renal Cell Carcinoma

The Authors report their experience with surgical treatment of lung metastases from renal cell carcinoma. From June 1986 to July 1991, 19 patients were submitted to contemporary or subsequent lung metastasectomy. Histological examination confirmed the presence of lung metastases due to renal cell carcinoma in 16 cases (6 synchronous and 10 metachronous with a mean disease-free interval of 23 months). In the other 3 cases, histological examination revealed tuberculomas, chondroid hamartoma and foci of anthracosis. To date, among the 6 patients with synchronous lung metastases, 3 have died, 2 are in progression and 1 is NED after a mean-time survival of 74 months. Among the 10 patients who underwent surgical resection of lung metachronous metastases, 1 has died, 3 are in progression and 6 are NED (mean-time survival of 43 months). In conclusion, while the presence of synchronous lung metastases is an unfavourable prognostic factor even after surgical removal (5 out of 6 patients died or are in progression shortly after metastasectomy), the results after surgery of metachronous lung metastases are encouraging, but the real efficacy of this treatment is still to be confirmed.

Resection of pulmonary metastases in osteosarcoma. A retrospective analysis of 44 patients.

Between 1977 and 1985, 44 patients with osteosarcoma and pulmonary metastases were treated at Institut Curie and Marie-Lannelongue. Twenty patients were able to undergo operations according to our criteria. Of 17 patients who immediately after surgery were clinically and radiologically free of disease, six are alive with no evidence of disease and one suffered recurrent pulmonary disease; their 5-year survival is 37%. In 24 patients, various schemes for aggressive chemotherapy for measurable lung disease could be assessed. Only one patient had a complete response; there was one partial response, and three patients experienced stabilization of their disease for 6 to 8 months. Of five patients who had second line postoperative adjuvant chemotherapy, four relapsed within 2 months of stopping treatment. Surgical resection of lung metastases appears definitely to improve the outcome in osteosarcoma patients. Chemotherapy offers no advantage in treating bulk disease, but the prevention of new micrometastatic disease remains a possibility and should be assessed in randomised multicenter trials.

How to Recognize and Treat Parathyroid Carcinoma

Parathyroid carcinoma is a rare tumor and its clinical course is variable. Differentiation of patients with parathyroid carcinoma from those with parathyroid adenoma is often difficult both preoperatively and at operation. For good results, the surgeon must recognize this disorder and perform an en bloc resection at the initial surgery. A neck dissection is necessary only when there is evidence of regional node metastases. After surgery, periodic follow-up of the serum calcium and iPTH levels is essential. When hypercalcemia recurs or the serum iPTH increases, localization studies with the use of thallium-201 scanning help detect local recurrence and regional lymph node metastases, but unfortunately, this method often fails to localize pulmonary metastases. Chest radiographs and CT scanning are useful for delineating pulmonary metastases. A wide excision of locally recurrent tumor, an en bloc radical neck dissection and mediastinum dissection for lymphatic metastases, and an aggressive surgical resection of lung metastases are recommended. Although these operations are rarely curative, they usually offer definite palliation of the marked hypercalcemia, often for a considerable period. Drugs to lower the serum calcium level and systemic chemotherapy are currently of only limited benefit, and radiation therapy is generally ineffective.