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 . 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 posttreatment 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.
- Farrell J. Pulmonary metastases: pathological, clinical roentgenological study based on 78 cases at necropsy. Radiology 1935; 24:444.
- Barney JD. Adenocarcinoma of the kidney with metastases to the lung cured by nephrectomy and lobectomy. J Urol 1939; 42:269.
- Srinivas S, Varadhachary G. Spontaneous pneumothorax in malignancy: a case report and review of the literature. Ann Oncol 2000; 11:887.
- Treasure T, Milošević M, Fiorentino F, Macbeth F. Pulmonary metastasectomy: what is the practice and where is the evidence for effectiveness? Thorax 2014; 69:946.
- Treasure T, Russell C, Macbeth F. Re-launch of PulMiCC trial to discover the true effect of pulmonary metastasectomy on survival in advanced colorectal cancer. BMJ 2015; 351:h6045.
- Pastorino U, Buyse M, Friedel G, et al. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg 1997; 113:37.
- Hornbech K, Ravn J, Steinbrüchel DA. Outcome after pulmonary metastasectomy: analysis of 5 years consecutive surgical resections 2002-2006. J Thorac Oncol 2011; 6:1733.
- den Hengst WA, Hendriks JM, Balduyck B, et al. Phase II multicenter clinical trial of pulmonary metastasectomy and isolated lung perfusion with melphalan in patients with resectable lung metastases. J Thorac Oncol 2014; 9:1547.
- National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
- EHRENHAFT JL, LAWRENCE MS, SENSENIG DM. Pulmonary resections for metastatic lesions. AMA Arch Surg 1958; 77:606.
- Martini N, McCormack PM. Evolution of the surgical management of pulmonary metastases. Chest Surg Clin N Am 1998; 8:13.
- Jaklitsch MT, Mery CM, Lukanich JM, et al. Sequential thoracic metastasectomy prolongs survival by re-establishing local control within the chest. J Thorac Cardiovasc Surg 2001; 121:657.
- Kondo H, Okumura T, Ohde Y, Nakagawa K. Surgical treatment for metastatic malignancies. Pulmonary metastasis: indications and outcomes. Int J Clin Oncol 2005; 10:81.
- Quiros RM, Scott WJ. Surgical treatment of metastatic disease to the lung. Semin Oncol 2008; 35:134.
- Todd TR. The surgical treatment of pulmonary metastases. Chest 1997; 112:287S.
- Murthy SC, Kim K, Rice TW, et al. Can we predict long-term survival after pulmonary metastasectomy for renal cell carcinoma? Ann Thorac Surg 2005; 79:996.
- Monteiro A, Arce N, Bernardo J, et al. Surgical resection of lung metastases from epithelial tumors. Ann Thorac Surg 2004; 77:431.
- Reshetov AV, Iablonskiĭ PK, Orlova RV, et al. [The possibility and prognostic value of secondary lymphatic cancer spread in intrapulmonic metastases of solid tumors]. Vestn Khir Im I I Grek 2008; 167:36.
- Ercan S, Nichols FC 3rd, Trastek VF, et al. Prognostic significance of lymph node metastasis found during pulmonary metastasectomy for extrapulmonary carcinoma. Ann Thorac Surg 2004; 77:1786.
- Loehe F, Kobinger S, Hatz RA, et al. Value of systematic mediastinal lymph node dissection during pulmonary metastasectomy. Ann Thorac Surg 2001; 72:225.
- Veronesi G, Petrella F, Leo F, et al. Prognostic role of lymph node involvement in lung metastasectomy. J Thorac Cardiovasc Surg 2007; 133:967.
- Inoue M, Kotake Y, Nakagawa K, et al. Surgery for pulmonary metastases from colorectal carcinoma. Ann Thorac Surg 2000; 70:380.
- Saito Y, Omiya H, Kohno K, et al. Pulmonary metastasectomy for 165 patients with colorectal carcinoma: A prognostic assessment. J Thorac Cardiovasc Surg 2002; 124:1007.
- Pfannschmidt J, Klode J, Muley T, et al. Nodal involvement at the time of pulmonary metastasectomy: experiences in 245 patients. Ann Thorac Surg 2006; 81:448.
- Khan JH, McElhinney DB, Rahman SB, et al. Pulmonary metastases of endocrine origin: the role of surgery. Chest 1998; 114:526.
- THOMFORD NR, WOOLNER LB, CLAGETT OT. THE SURGICAL TREATMENT OF METASTATIC TUMORS IN THE LUNGS. J Thorac Cardiovasc Surg 1965; 49:357.
- Menon A, Milton R, Thorpe JA, Papagiannopoulos K. The value of video-assisted mediastinoscopy in pulmonary metastasectomy. Eur J Cardiothorac Surg 2007; 32:351.
- Welter S, Jacobs J, Krbek T, et al. Prognostic impact of lymph node involvement in pulmonary metastases from colorectal cancer. Eur J Cardiothorac Surg 2007; 31:167.
- Hamaji M, Cassivi SD, Shen KR, et al. Is lymph node dissection required in pulmonary metastasectomy for colorectal adenocarcinoma? Ann Thorac Surg 2012; 94:1796.
- Temple LK, Brennan MF. The role of pulmonary metastasectomy in soft tissue sarcoma. Semin Thorac Cardiovasc Surg 2002; 14:35.
- Robert JH, Ambrogi V, Mermillod B, et al. Factors influencing long-term survival after lung metastasectomy. Ann Thorac Surg 1997; 63:777.
- Kandioler D, Krömer E, Tüchler H, et al. Long-term results after repeated surgical removal of pulmonary metastases. Ann Thorac Surg 1998; 65:909.
- Collie DA, Wright AR, Williams JR, et al. Comparison of spiral-acquisition computed tomography and conventional computed tomography in the assessment of pulmonary metastatic disease. Br J Radiol 1994; 67:436.
- Remy-Jardin M, Remy J, Giraud F, Marquette CH. Pulmonary nodules: detection with thick-section spiral CT versus conventional CT. Radiology 1993; 187:513.
- Parsons AM, Ennis EK, Yankaskas BC, et al. Helical computed tomography inaccuracy in the detection of pulmonary metastases: can it be improved? Ann Thorac Surg 2007; 84:1830.
- Mery CM, Pappas AN, Bueno R, et al. Relationship between a history of antecedent cancer and the probability of malignancy for a solitary pulmonary nodule. Chest 2004; 125:2175.
- Internullo E, Cassivi SD, Van Raemdonck D, et al. Pulmonary metastasectomy: a survey of current practice amongst members of the European Society of Thoracic Surgeons. J Thorac Oncol 2008; 3:1257.
- Franzius C, Daldrup-Link HE, Sciuk J, et al. FDG-PET for detection of pulmonary metastases from malignant primary bone tumors: comparison with spiral CT. Ann Oncol 2001; 12:479.
- Reinhardt MJ, Wiethoelter N, Matthies A, et al. PET recognition of pulmonary metastases on PET/CT imaging: impact of attenuation-corrected and non-attenuation-corrected PET images. Eur J Nucl Med Mol Imaging 2006; 33:134.
- Iagaru A, Chawla S, Menendez L, Conti PS. 18F-FDG PET and PET/CT for detection of pulmonary metastases from musculoskeletal sarcomas. Nucl Med Commun 2006; 27:795.
- Pastorino U, Veronesi G, Landoni C, et al. Fluorodeoxyglucose positron emission tomography improves preoperative staging of resectable lung metastasis. J Thorac Cardiovasc Surg 2003; 126:1906.
- Rusch VW. Pulmonary metastasectomy. Current indications. Chest 1995; 107:322S.
- Chojniak R, Younes RN. Pulmonary metastases tumor doubling time: assessment by computed tomography. Am J Clin Oncol 2003; 26:374.
- Tanaka Y, Maniwa Y, Nishio W, et al. The optimal timing to resect pulmonary metastasis. Eur J Cardiothorac Surg 2008; 33:1135.
- Carballo M, Maish MS, Jaroszewski DE, Holmes CE. Video-assisted thoracic surgery (VATS) as a safe alternative for the resection of pulmonary metastases: a retrospective cohort study. J Cardiothorac Surg 2009; 4:13.
- Nakajima J, Takamoto S, Tanaka M, et al. Thoracoscopic surgery and conventional open thoracotomy in metastatic lung cancer. Surg Endosc 2001; 15:849.
- Nakajima T, Yasufuku K, Iyoda A, et al. The evaluation of lymph node metastasis by endobronchial ultrasound-guided transbronchial needle aspiration: crucial for selection of surgical candidates with metastatic lung tumors. J Thorac Cardiovasc Surg 2007; 134:1485.
- Migliore M, Deodato G. Thoracoscopic surgery, video-thoracoscopic surgery, or VATS: a confusion in definition. Ann Thorac Surg 2000; 69:1990.
- Roth JA, Pass HI, Wesley MN, et al. Comparison of median sternotomy and thoracotomy for resection of pulmonary metastases in patients with adult soft-tissue sarcomas. Ann Thorac Surg 1986; 42:134.
- Migliore M, Jakovic R, Hensens A, Klepetko W. Extending surgery for pulmonary metastasectomy: what are the limits? J Thorac Oncol 2010; 5:S155.
- Casiraghi M, Maisonneuve P, Brambilla D, et al. The role of extended pulmonary metastasectomy. J Thorac Oncol 2015; 10:924.
- Dowling RD, Keenan RJ, Ferson PF, Landreneau RJ. Video-assisted thoracoscopic resection of pulmonary metastases. Ann Thorac Surg 1993; 56:772.
- Saisho S, Nakata M, Sawada S, et al. Evaluation of video-assisted thoracoscopic surgery for pulmonary metastases: 11-years of experience. Surg Endosc 2009; 23:55.
- Goya T, Miyazawa N, Kondo H, et al. Surgical resection of pulmonary metastases from colorectal cancer. 10-year follow-up. Cancer 1989; 64:1418.
- De Giacomo T, Rendina EA, Venuta F, et al. Thoracoscopic resection of solitary lung metastases from colorectal cancer is a viable therapeutic option. Chest 1999; 115:1441.
- Mutsaerts EL, Zoetmulder FA, Meijer S, et al. Long term survival of thoracoscopic metastasectomy vs metastasectomy by thoracotomy in patients with a solitary pulmonary lesion. Eur J Surg Oncol 2002; 28:864.
- Mutsaerts EL, Zoetmulder FA, Meijer S, et al. Outcome of thoracoscopic pulmonary metastasectomy evaluated by confirmatory thoracotomy. Ann Thorac Surg 2001; 72:230.
- Ludwig C, Cerinza J, Passlick B, Stoelben E. Comparison of the number of pre-, intra- and postoperative lung metastases. Eur J Cardiothorac Surg 2008; 33:470.
- 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