Surgical resection of pulmonary metastases: Benefits, indications, preoperative evaluation, and techniques
- Michael T Jaklitsch, MD
Michael T Jaklitsch, MD
- Professor in Surgery
- Harvard Medical School
- Brigham and Women's Hospital
- Bryan M Burt, MD
Bryan M Burt, MD
- Assistant Professor of Surgery
- Baylor College of Medicine
- James R Jett, MD
James R Jett, MD
- Section Editor — Lung Cancer
- Professor of Medicine Emeritus
- National Jewish Health
- Carlos E Bravo Iniguez, MD
Carlos E Bravo Iniguez, MD
- Fellow, Center for Surgery and Public Health
- Brigham and Women's Hospital
- Section Editor
- Joseph S Friedberg, MD
Joseph S Friedberg, MD
- Section Editor — Thoracic Surgery
- Charles Reid Edwards Professor of Surgery
- University of Maryland
Lung metastases from a primary extrapulmonary malignancy are often a manifestation of widespread dissemination; however, some patients have no other evidence of disease [1,2]. Extensive experience with pulmonary metastasectomy in a number of different cancers has confirmed that resection can substantially prolong survival and cure some patients . Based upon these observations, aggressive resection of isolated pulmonary metastases has become a widely accepted treatment for appropriately selected patients.
The benefits of metastasectomy, selection criteria, preoperative evaluation, and techniques for surgical resection are discussed here. Outcomes according to histology are discussed elsewhere, as are issues specific to resection of soft tissue sarcoma lung metastases. (See "Surgical resection of pulmonary metastases: Outcomes by histology" and "Surgical treatment and other localized therapy for metastatic soft tissue sarcoma".)
The integration of surgery into multidisciplinary therapy for patients with specific malignancies is discussed in the appropriate topic reviews.
The majority of pulmonary metastases are asymptomatic. Most are detected incidentally during the initial staging workup of a primary cancer, or from routine post-treatment surveillance radiographic studies, typically chest computed tomography (CT). Symptoms of cough, pain, or hemoptysis may be present in patients with hilar involvement, particularly when the metastases abut or invade the bronchi. Rarely, patients with peripheral metastases present with a spontaneous pneumothorax due to tumor disruption of the visceral pleura .
BENEFITS OF RESECTION
While pulmonary metastasectomy is a commonly performed operation, belief in its effectiveness is based upon registry data and surgical follow-up studies; there are no randomized trials. Until trials are completed, uncertainty will remain about the effectiveness of metastasectomy relative to other forms of treatment (eg, chemotherapy, stereotactic radiotherapy) . One such trial is underway in Great Britain for patients with metastatic colorectal cancer (ie, the PulMiCC trial, NCT01106261 ), in which patients are randomly assigned to pulmonary metastasectomy or active monitoring.
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- BENEFITS OF RESECTION
- Patient selection
- - Criteria for resection
- Influence of prognostic determinants
- - Completeness of resection
- - Disease-free interval
- - Number of lesions
- - Lymph node spread
- Repeat metastasectomy
- PREOPERATIVE EVALUATION
- Computed tomography
- - Differential diagnosis
- PET scans
- Brain imaging
- Need for preoperative tissue diagnosis
- TIMING OF SURGERY
- Operative staging
- Extent of resection and surgical approach
- - Open thoracotomy
- Role for extended resection
- - VATS procedure
- SUMMARY AND RECOMMENDATIONS