Pulmonary Metastasectomy: Common Practice But Is It Best
Pulmonary Metastasectomy: Common Practice But Is It Best
Pulmonary metastasectomy is common practice among surgeons, comprising nearly 15% of all lung resections. Pulmonary metastasectomy from a primary tumor elsewhere is widely believed to improve survival in selected patients, although the evidence for the added value of surgery is still weak. Most resections are performed in patients with a long disease-free interval with few metastases limited to one or both lungs from all cancer types. Until results of a randomized trial comparing surgery versus no surgery, such as in patients with colorectal metastases (PulMiCC trial), are published, surgeons will be unable to give an evidence-based answer to patients asking for the benefit of this invasive treatment that jeopardizes their pulmonary function, exercise capacity and quality of life.
Resection of metastases in the lung from a wide range of primary tumors elsewhere has become an important part of the daily clinical practice of a thoracic surgeon. According to the 2014 database report published by the European Society of Thoracic Surgeons (ESTS) on the surgical activities in participating units across Europe, pulmonary metastases accounts for 14.4% of all resected lung pathology. Compared to the 2010 report (15%), this figure has barely changed.
Current practice is based on outcomes published in observational, uncontrolled series with often mixed cancer types. In patients with a solitary or few metastases with intervals longer than 2–3 years from resection of the primary tumor to metastasectomy, 5-year survival rates of 30–50% are recorded. These reports have been criticized, questioning the true survival benefit for the individual patient following surgical removal or ablation of pulmonary metastases at a certain stage in the disease when already spread systemically. Case selection is based on known favorable prognostic indicators. This may create a potential bias for interpretation of the results and questions a causal relation between metastasectomy and survival. No randomized clinical trials, however, exist to guide thoracic surgeons in their clinical decision-making for pulmonary metastasectomy in an individual patient.
Abstract and Introduction
Abstract
Pulmonary metastasectomy is common practice among surgeons, comprising nearly 15% of all lung resections. Pulmonary metastasectomy from a primary tumor elsewhere is widely believed to improve survival in selected patients, although the evidence for the added value of surgery is still weak. Most resections are performed in patients with a long disease-free interval with few metastases limited to one or both lungs from all cancer types. Until results of a randomized trial comparing surgery versus no surgery, such as in patients with colorectal metastases (PulMiCC trial), are published, surgeons will be unable to give an evidence-based answer to patients asking for the benefit of this invasive treatment that jeopardizes their pulmonary function, exercise capacity and quality of life.
Introduction
Resection of metastases in the lung from a wide range of primary tumors elsewhere has become an important part of the daily clinical practice of a thoracic surgeon. According to the 2014 database report published by the European Society of Thoracic Surgeons (ESTS) on the surgical activities in participating units across Europe, pulmonary metastases accounts for 14.4% of all resected lung pathology. Compared to the 2010 report (15%), this figure has barely changed.
Current practice is based on outcomes published in observational, uncontrolled series with often mixed cancer types. In patients with a solitary or few metastases with intervals longer than 2–3 years from resection of the primary tumor to metastasectomy, 5-year survival rates of 30–50% are recorded. These reports have been criticized, questioning the true survival benefit for the individual patient following surgical removal or ablation of pulmonary metastases at a certain stage in the disease when already spread systemically. Case selection is based on known favorable prognostic indicators. This may create a potential bias for interpretation of the results and questions a causal relation between metastasectomy and survival. No randomized clinical trials, however, exist to guide thoracic surgeons in their clinical decision-making for pulmonary metastasectomy in an individual patient.