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The International Registry of Lung Metastases. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. The International Registry of Lung Metastases
Abstract
Objectives:
The International Registry of Lung Metastases was established in 1991 to assess the long-term results of pulmonary metastasectomy.
Methods:
The Registry has accrued 5206 cases of lung metastasectomy, from 18 departments of thoracic surgery in Europe (n = 13), the United States (n = 4) and Canada (n = 1). Of these patients, 4572 (88%) underwent complete surgical resection. The primary tumor was epithelial in 2260 cases, sarcoma in 2173, germ cell in 363, and melanoma in 328. The disease-free interval was 0 to 11 months in 2199 cases, 12 to 35 months in 1857, and more than 36 months in 1620. Single metastases accounted for 2383 cases and multiple lesions for 2726. Mean follow-up was 46 months. Analysis was performed by Kaplan-Meier estimates of survival, relative risks of death, and multivariate Cox model.
Results:
The actuarial survival after complete metastasectomy was 36% at 5 years, 26% at 10 years, and 22% at 15 years (median 35 months); the corresponding values for incomplete resection were 13% at 5 years and 7% at 10 years (median 15 months). Among complete resections, the 5-year survival was 33% for patients with a disease-free interval of 0 to 11 months and 45% for those with a disease-free interval of more than 36 months; 43% for single lesions and 27% for four or more lesions. Multivariate analysis showed a better prognosis for patients with germ cell tumors, disease-free intervals of 36 months or more, and single metastases.
Conclusions:
These results confirm that lung metastasectomy is a safe and potentially curative procedure. Resectability, disease-free interval, and number of metastases enabled us to design a simple system of classification valid for different tumor types.
... The current criteria for PM, as clearly presented by Kondo [37]. With the appropriate selection of patients, 5-year survival rates, as reported to the IRLM, were 20%-40% in 1997 [38]. A more recent series reported a 5-year survival rate of 50%, demonstrating the potential of reaching a 64% 5-year survival rate [37], [39], [40]. ...
... As previously mentioned, the inability to completely resect all metastatic nodules is globally considered a contraindication to PM. Survival data indicate that complete resection of metastases is linked to better outcomes. According to the IRLM series, for example, the 5-year survival with complete vs incomplete resection was 36% vs 13% [38]. The resection of lung parenchyma in general, or metastatic nodules in this case, can be performed anatomically or nonanatomically (atypical) using different resection or energy devices. ...
... Therefore, the IRLM was founded in 1991 to establish the long-term results of PM. In 1997, an analysis of 5,206 cases of PM from 18 institutes across Europe, the USA and Canada with different pathological entities was published [38]. In this analysis, actuarial 5-, 10-and 15-year survival was 36%, 26% and 22%, respectively. ...
... Lung is the most common metastatic site of various malignancy including colorectal cancer (CRC), osteogenic and soft tissue sarcoma, malignant melanoma, germ cell tumours, breast cancer and renal cell carcinomas [1][2][3]. Pulmonary metastasectomy in carefully selected patients is now widely accepted as a practical curative intervention in the interdisciplinary management of metastatic malignancy. Previous research reported associated improvements in both overall and disease-free survival following pulmonary metastasectomy, with 5-year survival rates ranging between 20% and 40% [1,3]. ...
... Pulmonary metastasectomy in carefully selected patients is now widely accepted as a practical curative intervention in the interdisciplinary management of metastatic malignancy. Previous research reported associated improvements in both overall and disease-free survival following pulmonary metastasectomy, with 5-year survival rates ranging between 20% and 40% [1,3]. Completeness of resection, primary tumour type and histology, disease-free interval, number and laterality of lung metastases and lymph node metastases were reported as prognostic indicators in patients underwent pulmonary metastasectomy [1][2][3][4][5]. ...
... Previous research reported associated improvements in both overall and disease-free survival following pulmonary metastasectomy, with 5-year survival rates ranging between 20% and 40% [1,3]. Completeness of resection, primary tumour type and histology, disease-free interval, number and laterality of lung metastases and lymph node metastases were reported as prognostic indicators in patients underwent pulmonary metastasectomy [1][2][3][4][5]. However, local relapse occasionally happened after wedge lung resection, even after pathologically complete resection. ...
OBJECTIVES
Spread through air spaces (STAS) is a unique pattern of invasion in primary lung cancers. However, little is known about STAS in pulmonary metastases (PMs). This study was to investigate the incidence of STAS among PMs and the association between STAS and clinicopathological characteristics of PMs.
METHODS
A total of 127 patients who underwent metastasectomy at our institution from June 2009 to December 2019 were retrospectively analysed. Survival analysis was performed in 40 patients with PM from colorectal cancer (CRC).
RESULTS
STAS was identified in 33.1% of patients (42 of 127) with PMs. STAS was found in PMs of various primary cancers, including CRC, breast cancer, renal cell carcinoma, cholangiocarcinoma and osteogenic and soft tissue sarcoma, but the incidence varies. PMs originating from epithelial tissue showed higher incidence of STAS than those from mesenchymal tissue (45% vs 11%, P < 0.001). Elder age (P = 0.006) and primary sites (P < 0.001) were significantly correlated with STAS. In patients with PMs from CRC, the presence of STAS was an independent predictor of shorter recurrence-free survival (hazard ratio = 10.25, P = 0.002) and poor overall survival (hazard ratio = 4.75, P = 0.047) by multivariable analysis.
CONCLUSIONS
STAS might be a lung-specific tumour invasion pattern and STAS is commonly observed in PMs of different origins. The incidence of STAS was significantly higher in PMs originating from epithelial tissues than those from mesenchymal tissues. Presence of STAS was an independent predictor of poor prognosis in patients with PM from CRC.
... 4 Six years later, the clinical benefit of systematic lung metastasectomy was confirmed by the results of the International Registry of Lung Metastases (IRLM), which included 5275 patients of all ages and various primary malignancies. 5 The IRLM provided a reliable classification system to predict the probability of survival at 5 and 10 years, based on the time interval from primary tumor, number of resected metastases, and absence of residual disease. 5 Nonetheless, many medical oncologists remained skeptical about the true curative potential of surgery for metastatic cancer, due to the lack of a control group and potential patient selection bias. ...
... 5 The IRLM provided a reliable classification system to predict the probability of survival at 5 and 10 years, based on the time interval from primary tumor, number of resected metastases, and absence of residual disease. 5 Nonetheless, many medical oncologists remained skeptical about the true curative potential of surgery for metastatic cancer, due to the lack of a control group and potential patient selection bias. 6 To address this criticism and provide more solid evidence on the curative potential of lung metastasectomy, we assessed the long-term survival (LTS) of a consecutive series of children and adolescents and young adults (AYA) treated by lung metastasectomy for osteosarcoma. ...
... The present analysis also includes previously reported patients. 4,5,[7][8][9] ...
Introduction
Surgical resection of pulmonary metastases has been associated with increased survival at 5 years for osteosarcoma, but limited information is available on long-term outcome, role of repeated metastasectomies, and surgical sequelae in a pediatric population. We analyzed a consecutive series of children, adolescents, and young adults (AYA) treated by repeated lung metastasectomies during a period >40 years to estimate the clinical benefit and potential cure rate of salvage surgery.
Methods
All patients who underwent lung metastasectomy for osteosarcoma at the IRCCS Istituto Ortopedico Rizzoli of Bologna, University of Modena, and IRCCS Istituto Nazionale Tumori of Milan from May 1973 to January 2014 were included. Overall survival (OS) at 20 years from the first metastasectomy was calculated.
Results
A total of 463 consecutive children and AYA were analyzed. Median age was 15.9 years (range 0.2–23.2 years) and median follow-up 18.6 years. The 5- and 20-year OS were 34.0% and 29.7% (95% CI 25.5–34.0%). Among the 138 (29.8%) alive patients, 42 (30.4%) had disease recurrence cured by repeated metastasectomies. Disease-free interval from primary tumor, number of metastases, and complete resection were the most relevant survival predictors at multivariable model analysis.
Discussion
The extended follow-up of this consecutive series shows that repeated lung metastasectomy can achieve a permanent cure when offered to properly selected patients with metastases from osteosarcoma.
... With the advent of multidisciplinary treatment, pulmonary metastasectomy (PM) is a widely adopted treatment for selected patients with pulmonary metastases. Patients with R0 resection, a disease-free interval (DFI) ≥ 36 months and a solitary pulmonary metastasis may have a better prognosis after PM [1,2]. PM has a low postoperative complication rate (3.6%) and a low 30-day mortality rate (0.7%) [3]. ...
... Among the pulmonary resection options, wedge resection (WR) is a surgical technique considered favorable for pulmonary metastases. It is the most common procedure [1,3,4] used for excision for the following reasons. First, the risk of new pulmonary metastases is high after PM. ...
... For disease-free survival, multiple pulmonary metastases and surgical margin distance were factors for poor prognosis in univariable analysis. Although the number of pulmonary metastases is a well-known factor for poor prognosis [1,2], Davini et al. recently demonstrated that a short surgical margin distance was an independent prognostic factor of poor survival [10]. ...
Background
Pulmonary metastasectomy is a common treatment for selected patients with pulmonary metastases. Among pulmonary resections, wedge resection is considered sufficient for pulmonary metastases. However, a major problem with wedge resection is the risk of local recurrence, especially at the surgical margin. The aim of this prospective study was to explore the frequency of and the risk factors for recurrence at the surgical margin in patients who underwent wedge resection for pulmonary metastases.Methods
Between September 2013 and March 2018, 177 patients (220 lesions) with pulmonary metastases from 15 institutions were enrolled. We studied 130 cases (169 lesions) to determine the frequency of and risk factors associated with recurrence at the surgical margin in patients who underwent wedge resection. Moreover, we evaluated the recurrence-free rate and disease-free survival after wedge resection.ResultsA total of 81 (62.3%) patients developed recurrence. Recurrence at the surgical margin was observed in 11 of 130 (8.5%) cases. The 5-year recurrence-free rate was 89.1%. Per patient, multivariable analysis revealed that the presence of multiple pulmonary metastases was a significant risk factor for recurrence. Per tumor, distance from the surgical margin and tumor/margin ratio were risk factors for local recurrence. The 5-year disease-free survival rate was 34.7%, and the presence of multiple pulmonary metastases and small surgical margin were risk factors for disease-free survival by univariable analysis.Conclusions
Among patients who undergo wedge resection for pulmonary metastasis, patients with multiple pulmonary metastases tend to develop recurrence at the surgical margin.
... результаты одного из таких исследований при метастатическом колоректальном раке указывают, что метастазэктомия значимо повышает общую и безрецидивную выживаемость. общая 5-, 10-и 15-летняя выживаемость составила соответственно 36%, 26% и 22% [55]. В другом исследовании, охватывающем 760 метастазэктомий по поводу легочных метастазов саркомы мягких тканей, 34% пациентов прожили пять лет, а 23% -семь лет [18]. ...
... основной причиной неудовлетворительных результатов метастазэктомий является высокая частота локальных рецидивов в оперированном легком, которая достигает 41% -68% [35,55,56]. Повторное удаление метастатических очагов возможно, но ограничивается допустимым пределом снижения функции внешнего дыхания. ...
... так, 5-летняя общая выживаемость пациентов с легочными метастазами колоректального рака оставалась практически неизменной до конца 20 века и только в последние десятилетия существенно повысилась. При анализе результатов лечения до 2000 года 5-летняя выживаемость составляла около 35%, а после 2000 -более 63% [38,55,56]. ...
The lung is the most commonly attacked organ in metastatic disease. In many patients who were successfully cured of primary cancer, pulmonary metastases for a long time may be the only, and sometimes the final manifestation of the disease. This kind of dissemination is known as isolated lung metastases. The prognosis for untreated patients with pulmonary metastases is unfavorable: 5-year survival does not exceed 5%. This survey considers the evolution of technologies for the treatment of isolated metastatic lung lesions from surgical metastasectomy to combined methods of high-dose regional chemotherapy.
... A few registry articles (eight in total) have largely defined practice. The most influential reported 5,206 patients with multiple pathologies from the International Registry of Lung Metastases (IRLM) [6], without a denominator of cancer patient population from which the metastasectomy patients derived (Table 1). ...
... PM is safe. Accumulated reports totaling 6,122 patients [6,[30][31][32] demonstrate less than lobectomy (wedge resections and segmentectomy) is the most common resection technique, used in 4,644 patients (75%). Lobectomy, and seldom, pneumonectomy, was used in the remaining 25%. ...
... The IRLM included 5,206 patients with varying pathology and reported metastasis to mediastinal or hilar LNs in 5% of patients (11% germ cell tumors, 8% melanomas, 6% epithelial tumors, and 2% sarcomas). Mediastinal LN sampling was discretionary, and LNs were assessed in only 4.6% of patients [6]. Since 1997, more surgical oncologists perform LN assessment during PM, but systematic mediastinal lymphadenectomy remains controversial. ...
... Seven patients were excluded, four with surgical approaches combined sternotomy or ipsilateral thoracotomy and contralateral VATS, and three with diagnostic purposes of suspected metastatic lesions. After exclusion, 43 patients surgically treated with therapeutic intent were divided into two groups, (1) sixteen patients receiving simultaneous bilateral open thoracotomy (open group) and (2) twenty-seven patients receiving simultaneous bilateral VATS (VATS group) (►Fig. 1). ...
... Although the prognosis deteriorates as the number of pulmonary metastases increases, if all lesions are potentially resectable, surgical treatment should be considered. 2,27 Consequently, several studies have suggested that one-stage surgery in managing bilateral pulmonary metastases is as safe as unilateral-side surgery. [18][19][20][21] Despite this, an increased operative time was observed in the bilateral groups compared with the unilateral groups, while the length of postoperative hospital stays and complications were comparable between groups. ...
Background Resection is the current treatment of choice for resectable bilateral pulmonary metastases. This study aimed to compare the differences in outcomes between simultaneous bilateral open and video-assisted thoracic surgery (VATS) for pulmonary metastasectomy.
Methods Forty-three patients underwent pulmonary metastasectomy through one-stage bilateral open thoracotomy (n = 16) and VATS (n = 27) between 2011 and 2020. Perioperative and oncological data were analyzed.
Results The predominant primary tumor histology in both groups was colorectal cancer. The operative time, blood loss, and pain score on postoperative day 1 (POD1) were higher in the open group (p < 0.001, 0.009, and 0.03, respectively). No significant differences in pain score on POD2 and POD3, postoperative length of stay, or complications were found. Notably, numbers of the resected metastatic lung nodules were significantly greater in the open group (median number: 9.5 vs. 3, p < 0.001). Recurrence-free survival (RFS) and overall survival (OS) were comparable. The median RFS was 15 months (interquartile range [IQR], 6–22) in the open group and 18 months (IQR, 8–47) in the VATS group. The median OS was 28 months (IQR, 14–44) and 29 months (IQR, 15–54) in the open group and VATS group, respectively.
Conclusion One-stage bilateral pulmonary metastasectomy is safe and reduces medical expenditures in selected patients regardless of surgical approach. Although the open group harbored a greater number of metastatic foci, perioperative and oncological outcomes were similar to that of the VATS group.
... The boundaries of the oligometastatic entity as well as the optimal modalities of treatment remain uncertain, but it is clear that this patient population has a better prognosis than patients with widespread disease. Early surgical series reporting on metastectomies for oligometastatic disease show durable remission, perhaps even cure, after resection of limited liver metastases in colorectal cancer, adrenal metastases in NSCLC, and solitary lung metastases in a mix of solid tumors [7][8][9]. ...
... With subsequent advances in CT-guided percutaneous lung biopsy and endobronchial ultrasound (EBUS)-guided biopsy, as well as improvements in imaging such as PET/CT, the diagnostic role of resection has decreased. Several large case series have shown that patients who undergo surgical management of limited-volume, isolated pulmonary metastases have favorable survival [9,[13][14][15]. A meta-analysis of sixteen of these series, including 1937 patients, showed a 5-year overall survival of 46%; longer disease-free interval (DFI), complete resection of metastases, solitary metastasis, and hormone receptor-positive disease were favorable prognostic factors [16]. ...
Opinion statement
Oligometastatic breast cancer, typically defined as the presence of 1–5 metastases, represents an intermediate state between locally advanced and widely metastatic disease. Emerging research suggests that oligometastatic cancer has a unique molecular signature distinct from widely metastatic disease, and that it carries a superior prognosis. Owing to its more limited capacity for widespread progression, oligometastatic disease may benefit from aggressive ablative therapy to known metastases. Options for ablation include surgical excision, radiofrequency ablation, and hypofractionated image–guided radiotherapy (HIGRT). The phase II SABR-COMET trial, which enrolled patients with oligometastatic disease of multiple histologies and randomized them to HIGRT vs. standard of care, found a notable survival advantage in favor of HIGRT. Other data suggest that HIGRT may synergize with immunotherapy by releasing powerful cytokines that increase anti-tumor immune surveillance and by recruiting tumor infiltrating lymphocytes, helping to overcome resistance to therapy. There are many ongoing trials exploring the role of ablative therapy, most notably HIGRT, with or without immunotherapy, for the treatment of oligometastatic breast cancer.
We believe that patients with oligometastatic breast cancer should be offered enrollment on prospective clinical trials when possible. Outside the context of a clinical trial, we recommend that select patients with oligometastatic breast cancer be offered treatment with a curative approach, including ablative therapy to all sites of disease if it can be safely accomplished. Currently, selection criteria to consider for ablative therapy include longer disease-free interval from diagnosis to metastasis (>2 years), fewer metastases, and fewer involved organs. Undoubtedly, new data will refine or even upend our understanding of the definition and optimal management of oligometastatic disease.
... Metastasectomy has sometimes been used for removing pulmonary metastases in cases in which the metastases are resectable and limited. 1 There have been many reports on pulmonary metastasectomy and prognostic factors. 2 In those studies, resectability, number of metastases, and disease-free interval (DFI) were used to establish prognostic groups. Although those reports were published before 2000, the use of metastasectomy for various cancers has been increasing since 2000 despite various advances in systemic therapies. ...
... Metastasis-directed therapy has progressed with surgical experience, with widespread recognition of the concept of oligometastasis and with technological developments in radiotherapy. 1,2,4,11 Since SBRT has been used worldwide, many results of SBRT as a metastasis-directed therapy have been reported. 6,[12][13][14] Because SBRT has been mainly performed for patients who were not candidates for surgery, the concern for non-CSD generated the hypothesis of the current study. ...
Cancer-specific death (CSD) and non-cancer-specific death (non-CSD) after stereo-tactic body radiotherapy (SBRT) for pulmonary oligometastases have not been studied in detail. The aim of this study was to determine the cumulative incidences of CSD and non-CSD and to reveal prognostic factors. Data from a large survey of SBRT for pulmonary oligometastases were used for analyses, and patients with unknown cause of death were excluded from current analyses. CSD was primary cancer death and non-CSD was non-primary cancer death including a series of cancer treatment-related deaths. Cumulative incidences were calculated using the Kaplan-Meier method and a stratified Cox regression model was used for multivariate analyses (MVA). Fifty-two patients with an unknown death were excluded and a total of 1326 patients was selected. CSD and non-CSD occurred in 375 and 109 patients, respectively. The median OS period was 53.2 months and the cumulative incidences of 1-, 3-, and
... In 1997, based on these data, Pastorino published a paper based on an analysis of 5206 cases. This allowed him to make recommendations regarding the qualification of patients with metastatic disease for surgical treatment [1]. The disadvantage of this research program was that data about the patients treated came from many medical centers. ...
... Survival after radical metastasectomy is 5 years in 36%, 10 years in 26%, 15 years in 22% of cases. After non-radical metastasectomy, survival is 5 years in 13%, 10 years in 7% of cases [1,8]. In our study, radicalism in the unchanged surgical margin was achieved in 508 patients, which constituted 90.4%. ...
Introduction:
The problem of treating secondary cancer is very controversial. Huge progress in its treatment began in the 1970s with the introduction of chemotherapy. In the surgical aspect Pastorino's work published in 1997 was a milestone. To this day, most authors cite its research results.
Aim:
The task is to answer the question what tactics to follow in the surgical treatment of patients with secondary cancer affecting the respiratory system.
Material and methods:
Retrospective studies were conducted on a group of 577 patients. Men prevailed slightly. The average age was 56 years. Surgical access used in the vast majority of cases was anterolateral thoracotomy. Wedge resection was the most common scope of surgery. Lymph nodes were not removed as standard. Single and multifactorial statistical surveys were conducted (Kaplan-Meier estimator and multifactorial Cox regression analysis).
Results:
A total of 1,058 operations were performed during which 1889 metastases were removed. Negative tissue margins were obtained in 90.4%. The median survival was 47 months. Complications occurred in 76 patients, which constituted 7.1% of performed procedures. There were 3 perioperative deaths.
Conclusions:
It was found that the factors negatively affecting survival were lack of radicalism, size of the metastasis > 3 cm, and number of metastases > 1. The factors positively influencing survival were a longer time than primary surgery and a greater number of operations. Histological diagnosis differentiated patient survival.
... Sekonder pulmoner neoplazmlar, primer malign tümörlerin sistemik metastazlarının bir parçası olmakla birlikte sahip oldukları özellikler bakımından ayrı olarak incelenmesi gereken bir konudur. Primer tümörün lokal olarak kontrolü; cerrahi, kemoterapi (KT) ve radyoterapi ile sağlanabilse de sistemik metastazlar için tedavi şekli hala tartışmalıdır (1)(2)(3). Sekonder pulmoner neoplazmlar için cerrahi rezeksiyon, belli strateji ve kriterler uygulandığında etkin bir tedavi yöntemidir. Bunlar; primer tümörün kontrol altında olması, ekstratorasik metastaz olmaması, lezyonların komplet rezeksiyona uygun olması ve cerrahi sonrası kardiyopulmoner rezervin uygun olmasıdır (4)(5)(6). ...
... Sarkom ve melanomlarda fazla olmak üzere metastazektomi sonrası nüksler görülebilmektedir. Bu olgularda metastazektomi kriterleri sağlanabiliyorsa remetastazektomiler yapılabilir (1,4). Çalışmamızda 4 (%10.6) ...
Amaç: Kliniğimizde opere edilen sekonder akciğer neoplazmları incelenerek, primer tümör kontrol altında ikenyapılan metaztazektominin sağkalım üzerine olan etkilerinin araştırılması. Materyal metod: Bu çalışmada Ocak 2010 ile Ocak 2015 yılları arasında kliniğimizde sekonder pulmoner neoplazm nedeni ile opere edilen 29 olgu retrospektif olarak incelendi. Olgular yaş, cinsiyet, kardiopulmoner değerlendirmeler, primer tümörün histopatolojik tipi, sekonder tümörün evresi ve preoperatif radyolojik bulguları, hastalıksız yaşam süreleri, cerrahi insizyon şekilleri ve rezeksiyonun türü, komplet-inkomplet rezeksiyon sayıları, nodül sayıları, sağkalım süreleri açısından değerlendirildi. Bulgular: Olguların 9’u kadın (%31) 20’si (%69) erkek idi. En küçük yaş 18 en büyük yaş 75 (ortalama 56±12) idi. Olgularımıza toplam 38 cerrahi girişim uygulandı. En sık uygulanan cerrahi girişim 24 olguda (%63,2) posterolateral torakotomi (PLT), 14 olguda (%36,8) video yardımlı torakoskopik cerrahi (VATS) idi. Bir yıllık sağkalım %96, 3 yıllık sağkalım %72 ve 5 yıllık sağkalım % 58 olarak bulundu. Primer tümörün histopatolojik tipine göre en sık karsinom (%79,3) ikinci sıklıkta sarkom (%17,2) tespit edildi.Sarkomlarda pulmoner metastazektominin 5 yıllık sağkalım %40, karsinomlarda %73,5 olarak hesaplandı. Sonuç: Primer malignitesi kontrol altında ve ekstra pulmoner metastazı olmayan sekonder pulmoner neoplazmlı olgularda, metastazektomi, özellikle karsinomlarda sağkalıma önemli ölçüde katkı sağlanmaktadır. Çalışmamızda sekonder tümörün evresinin ve primer tümörün histopatolojik tipinin sağkalımı belirleyen esas faktörler olduğu görüldü.
... 2 Metastasectomy can prolong the survival of patients with RCC, 2 with better prognoses achieved in subjects with a limited number of lesions amenable to complete resection. [2][3][4] Although rare (< 1% of metastatic RCC 5 ), spontaneous regression (SR, defined as the partial or complete disappearance of a malignant tumor in the absence of all treatment or in the presence of therapy that is considered inadequate to exert a significant influence on the growth of neoplastic disease 6 ) can occur in metastatic RCC (mRCC). 7 Most cases of SR of mRCC occur after treatment of the primary tumor. ...
... 2,14,15 It could, in fact, confer a prognostic advantage to some patients and, in rare cases, it can trigger the SR of the remaining lesions. 2,14,16 To our knowledge, this is the first reported case of SR occurring after palliative resection of a limited portion of the disease (approximately 37%) (Figure 4), and in a patient with several predictors of poor outcome (non-radical resection, lymph node involvement, high number of pulmonary lesions, and size of the largest metastasis [2][3][4]9 ). To date, SR of mRCC has been mainly described in association with procedures involving the primary tumor, such as cytoreductive nephrectomy, tumor biopsy, 17 radiotherapy (abscopal effect), 18 and radiofrequency ablation. ...
... Systematic mediastinal lymphadenectomy or sampling is routinely performed for primary neoplasm of the lung, including adenocarcinoma, squamous cell carcinoma and neuroendocrine tumours (1). Despite a paucity of randomized clinical trial data, it is now generally accepted that overall survival for many tumour types is improved with resection of limited metastases in carefully selected patients (2). Nonetheless, controversy exists surrounding the need for assessment of mediastinal lymph nodes during pulmonary metastasectomy (1). ...
... The registry has some limitations, however, for analysing the effect of lymph node involvement on survival (12): data were gathered on patients from 18 countries, preoperative radiological techniques differed between hospitals, as did the indications for preoperative mediastinoscopy, and lymphadenectomy was only performed in 4.6% of cases (2). ...
... Kích thước u phổi trên CT-scan ≥ 3cm thời gian sống thêm trung bình 26,7 ± 6,9 tháng đã được xác định là tiên lượng kém cho thời gian sống thêm toàn bộ. Các nghiên cứu trước đây đã chỉ ra rằng đường kính tối đa nhỏ hơn <3 cm là các yếu tố tiên lượng sống kéo dài [6]. Nghiên cứu của tác giả Kim B (2024) đã chứng minh và kết luận rằng kích thước u phổi lớn là yếu tố nguy cơ cho tiên lượng sống còn kém [5]. ...
Đặt vấn đề: Ung thư biểu mô tế bào gan (UTBMTBG) là loại ung thư phổ biến và tử vong hàng đầu tại Việt Nam, phổi là vị trí phổ biến nhất của di căn ngoài gan. Phẫu thuật nội soi lồng ngực cắt bỏ khối u phổi di căn từ UTBMTBG cho thấy tăng thời gian sống thêm. Mục tiêu: Đánh giá các yếu tố liên quan thời gian sống thêm sau phẫu thuật nội soi điều trị ung thư phổi di căn từ UTBMTBG. Đối tượng và phương pháp nghiên cứu: Hồi cứu mô tả loạt ca tất cả bệnh nhân được phẫu thuật cắt bỏ u phổi di căn từ UTBMTBG qua nội soi lồng ngực tại khoa Ngoại Lồng ngực, Bệnh viện Chợ Rẫy từ 01/2020 đến 08/2024. Kết quả: Tổng cộng có 33 bệnh nhân được phẫu thuật nội soi lồng ngực cắt u phổi di căn với thời gian theo dõi trung bình là 38,8 tháng. Thời gian theo dõi trung bình là 24 tháng (4-56 tháng). Thời gian sống thêm toàn bộ trung bình 38,8 ± 3,9 tháng, tỷ lệ sống thêm sau 1, 2 và 3 năm lần lượt là 87,8%, 68,4%, 55,9%. Các yếu tố liên quan thời gian sống thêm: thời gian di căn phổi ≤12 tháng; kích thước khối u phổi ≥ 3cm; AFP, AFP-L3 và PIVKA-II đồng thời tăng có liên quan đến tiên lượng sống còn. Kết luận: PTNS lồng ngực cắt u phổi thứ phát ở những bệnh nhân bị UTBMTBG di căn mang lại kết quả sống còn khả quan. Tuy nhiên, thời gian di căn phổi ngắn và kích thước u phổi lớn, các chất chỉ dấu sinh học tăng là yếu tố tiên lượng xấu cho người bệnh.
... The predicted survival time in the group with other tumor histology (79 months) was significantly (p < 0.05) higher than in the groups with tumor histology carcinoma (41.4 months) and sarcoma (55.5 months). Our survival rates in cases are higher than those in the literature [16]. Imaging methods allow detailed imaging of the lung parenchyma since it is located within a limited area in the rib cage, thus facilitating early detection of metastases. ...
Introduction
Metastatic disease is one of the main causes of death and factors affecting overall survival. It is known that selected patients with pulmonary oligometastases whose primary tumor is under control and who have adequate respiratory capacity may benefit from metastasectomy by resecting all detected lesions.
Aim
To report our findings on the use of video-assisted thoracoscopic surgery (VATS) for pulmonary metastasectomy, with a focus on identifying suitable candidates.
Material and methods
Between August 2010 and 2023 a total of 532 pulmonary metastasectomy procedures were performed in our institution. Metastasectomy was performed with VATS for 281 of those patients.
Results
VATS metastasectomy was performed in 131 patients with a single lesion on preoperative imaging, while 110 patients underwent metastasectomy for multiple lesions. The rate was significantly (p < 0.05) lower in the group with multiple lesions removed during surgery (38 months) than in the group with only one lesion removed during surgery (60 months). The predicted survival time in the group with other tumor histology (79 months) was significantly (p < 0.05) higher than in the groups with tumor histology carcinoma (41.4 months) and sarcoma (55.5 months).
Conclusions
The best prognosis after metastasectomy is provided in cases with a single nodule. Grade is also an important prognostic factor affecting survival, particularly for grade 1 tumor. The histopathological type of the primary tumor is also a significant prognostic factor affecting survival after pulmonary metastasectomy in secondary pulmonary neoplasms, particularly for sarcoma and carcinoma.
... There remains limited data on metastectectomy for urothelial cancers as compared to that in other tumor types, such as in lung cancers [23]. For example, it is unclear whether the addition of systemic therapy may provide additional benefit over curative treatment, despite most studies incorporating this in the care of these patients. ...
Purpose of Review
To summarize and evaluate the literature on treatment approaches for oligometastatic and locally recurrent urothelial cancer.
Recent Findings
There is no clear definition for oligometastatic urothelial cancers due to limited data. Studies focusing on oligometastatic and locally recurrent urothelial cancer have been primarily retrospective. Treatment options include local therapy with surgery or radiation, and generalized systemic therapy such as chemotherapy or immunotherapy.
Summary
Oligometastatic and locally recurrent urothelial cancers remain challenging to manage, and treatment requires an interdisciplinary approach. Systemic therapy is nearly always a component of current care in the form of chemotherapy, but the role of immunotherapy has not been explored. Consideration of surgical and radiation options may improve outcomes, and no studies have compared directly between the two localized treatment options. The development of new prognostic and predictive biomarkers may also enhance the treatment landscape in the future.
... Complete resection of metastases is linked with better outcomes [7][8][9] . The various advantages of parenchymasparing PM were downsized by the occurrence of local recurrence at the surgical margin 3,10,11 . ...
Pulmonary metastasectomy (PM) is consensually performed in a parenchyma-sparing manner to preserve functionally healthy lung tissue. However, this may increase the risk of local recurrence at the surgical margin. Laser assisted pulmonary metastasectomy (LPM) is a relatively recent innovation that is especially useful to resect multiple metastatic pulmonary nodules. In this study we investigated the rate of local recurrence after LPM and evaluated the influence of various clinical and pathological factors on local recurrence. Retrospectively, a total of 280 metastatic nodules with different histopathological entities were studied LPM from 2010 till 2018. All nodules were resected via diode-pumped neodymium: yttrium–aluminum-garnet (Nd:YAG) 1,318 nm laser maintaining a safety margin of 5 mm. Patients included were observed on average for 44 ± 17 months postoperatively. Local recurrence at the surgical margin following LPM was found in 9 nodules out of 280 nodules (3.21%). Local recurrence at the surgical margin occurred after 20 ± 8.5 months post operation. Incomplete resection (p = < 0.01) and size of the nodule (p = < 0.01) were associated with significantly increased risk of local recurrence at the surgical margin. Histology of the primary disease showed no impact on local recurrence. Three and five-year survival rates were 84% and 49% respectively. Following LPM, the rate of local recurrence is low. This is influenced by the size of the metastatic nodules and completeness of the resection. Obtaining a safety margin of 5 mm seems to be sufficient, larger nodules require larger safety margins.
... Surgical resection represents the treatment of choice for both patients with stage I, stage II, some stage IIIA lung cancer [5] and pulmonary metastases in properly selected cases [6]. ...
Thermal ablation is a minimally invasive technology used to treat many types of tumors, including lung cancer. Specifically, lung ablation has been increasingly performed for unsurgical fit patients with both early-stage primi-tive lung cancer and pulmonary metastases. Image-guided available techniques include radiofrequency ablation, microwave ablation, cryoablation, laser ablation and irreversible electroporation. Aim of this review is to illustrate the major thermal ablation modalities, their indications and contraindications, complications, outcomes and notably the possible future challenges.
... 35 In one large international registry study of cancer patients that was not exclusive to CRC but often extrapolated to metastatic CRC disease, complete resection of lung metastases was associated with a median survival of 36 versus 13 months. 36 In patients undergoing pulmonary metastases resection, 5-year survival rates were generally higher for patients who reached a disease-free interval of greater than 36 months (45% vs. 33% for those with a disease-free interval of less than 1 year). In a multicenter cohort study of 522 patients who underwent pulmonary resection for colorectal metastases, the median survival was 54.9 months and the 5year disease-specific survival was 46.1%. ...
Colorectal cancer (CRC) is the second most common cause of cancer-related death in the United States comprising 7.9% of all new cancer diagnoses and 8.6% of all cancer deaths. The combined 5-year relative survival rate for all stages is 65.1% but in its most aggressive form, stage 4 CRC has a 5-year relative survival rate of just 15.1%. For most with stage 4 CRC, treatment is palliative not curative, with the goal to prolong overall survival and maintain an acceptable quality of life.
The identification of unique cancer genomic and biologic markers allows patient-specific treatment options. Treatment of stage 4 CRC consists of systemic therapy with chemotherapeutic agents, surgical resection if feasible, potentially including resection of metastasis, palliative radiation in select settings, and targeted therapy toward growth factors. Despite advances in surgical and medical management, metastatic CRC remains a challenging clinical problem associated with poor prognosis and low overall survival.
... This approach is supported by the success of surgical series. In cohorts including several histological tumor sites with mostly colorectal cancer or sarcoma patients, surgical removal of liver or lung metastases resulted in 5-year survival rates of up to 50 % depending on the risk constellation [3][4][5][6][7]. In the past, this hypothesis was further supported by several single-arm studies on stereotactic body radiotherapy (SBRT). ...
Evidence from a few small randomized trials and retrospective cohorts mostly including various tumor entities indicates a prolongation of disease free survival (DFS) and overall survival (OS) from local ablative therapies in oligometastatic disease (OMD). However, it is still unclear which patients benefit most from this approach. We give an overview of the several aspects of stereotactic body radiotherapy (SBRT) in extracranial OMD in breast cancer from a radiation oncology perspective. A PubMed search referring to this was conducted. An attempt was made to relate the therapeutic efficacy of SBRT to various prognostic factors. Data from approximately 500 breast cancer patients treated with SBRT for OMD in mostly in small cohort studies have been published, consistently indicating high local tumor control rates and favorable progression-free (PFS) and overall survival (OS). Predictors for a good prognosis after SBRT are favorable biological subtype (hormone receptor positive, HER2 negative), solitary metastasis, bone-only metastasis, and long metastasis-free interval. However, definitive proof that SBRT in OMD breast cancer prolongs DFS or OS is lacking, since, with the exception of one small randomized trial ( n = 22 in the SBRT arm), none of the cohort studies had an adequate control group. Further studies are needed to prove the benefit of SBRT in OMD breast cancer and to define adequate selection criteria. Currently, the use of local ablative SBRT should always be discussed in a multidisciplinary tumor board.
... Lung metastasectomy for colorectal cancer (CRC) is based on surgical follow-up studies since the 1970s, gaining momentum in the 1980s and 1990s [3]. The publication in 1997 of the International Registry of Lung Metastases with data on 5206 patients [4] showed that survival after metastasectomy was better if the metastases were solitary and there was a longer elapsed time since primary resection. There were no RCTs, but there had been 1 comparative study published in 1980 [5]. Å berg and colleagues identified patients in the pre-metastasectomy era whose characteristics would make them candidates for metastasectomy in the 1980s. ...
Objectives:
The objective of this review was to assess the nature and tone of the published responses to the Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) randomized controlled trial.
Methods:
Published articles that cited the PulMiCC trial were identified from Clarivate Web of Science (©. Duplicates and self-citations were excluded and relevant text extracted. Four independent researchers rated the extracts independently using agreed scales for the representativeness of trial data and the textual tone. The ratings were aggregated and summarized. Two PulMiCC authors carried out a thematic analysis of the extracts.
Results:
Sixty-four citations were identified and relevant text was extracted and examined. The consensus rating for data inclusion was a median of 0.25 out of 6 (range 0 to 5.25, IQR 0-1.5) and for textual tone the median rating was 1.87 out of 6 (range 0 to 5.75, IQR 1-3.5). The majority of citations did not provide adequate representation of the PulMiCC data and the overall the textual tone was dismissive. Although some were supportive, many discounted the findings because the trial closed early and was underpowered to show non-inferiority. Two misinterpreted the authors' conclusions but there was acceptance that five-year survival was much higher than widely assumed.
Conclusions:
Published comments reveal a widespread reluctance to consider seriously the results of a carefully conducted randomized trial. This may be because the results challenge accepted practice because of 'motivated reasoning'. But there is a widespread misunderstanding of the fact that though PulMiCC with 93 patients was underpowered to test non-inferiority, it still provides reliable evidence to undermine the widespread belief in a major survival benefit from metastasectomy.
... Sarcomas are among the most common of tumours that metastasize to the lungs [19]. In the absence of lung metastases, 5-year survival ranges from 30% to 80% [20]. ...
OBJECTIVES
This study investigated the outcomes of sarcoma patients with lung metastases who underwent pulmonary metastasectomy (PM), compared to patients who underwent medical management alone. The secondary objective was to compare survival after PM between variables of interest.
METHODS
This was a retrospective review of 565 sarcoma patients with confirmed, isolated pulmonary metastasis identified from the Surveillance, Epidemiology and End Results database between 2010 and 2015. 1:4 propensity score matching was used to select PM and non-PM groups. The multivariable Cox proportional hazards model was used to analyse prognostic factors of disease-free survival (DFS).
RESULTS
Of the eligible 565 patients, 59 PM patients were matched to 202 non-PM patients in a final ratio of 3.4. After propensity matching, there were no significant differences in baseline characteristics between PM and non-PM patients. The median DFS after PM was 32 months (interquartile range 18–59), compared to 20 months (interquartile range 7–40) in patients without PM (P = 0.032). Using a multivariable Cox proportional hazards model, metastasectomy (hazard ratio 0.536, 95% confidence interval 0.33–0.85; P = 0.008) was associated with improved DFS. In a subset analysis of patients who underwent PM only, the median DFS was longer in males compared to females (P = 0.021), as well as in bone sarcoma compared to soft tissue sarcoma (P = 0.014).
CONCLUSIONS
For sarcoma patients with metastatic lung disease, PM appears to improve the prognosis compared to medical management. Furthermore, there may be a survival association with gender and tumour origin in patients who underwent PM. These data may be used to inform the surgical indications and eligibility criteria for metastasectomy in this setting.
... 1 ...
Successes in combined treatment of maxillofacial cancer diseases lead to significant increasing of life expectancy, and as a result to growth of lung metastasis frequency. That’s why one of the steps of these diseases therapy is operative metastasectomy. As you know separate lung ventilation, one lung collapse and accordingly one lung ventilation often has to be in thoracic surgery. Earlier we achieved it by usage double-lumen endotracheal tubes. The review of last scientific publications about anesthesia in cancer thoracic surgery convincingly and authentically shew that current bronchial blockers provided safe lung separation in that cases when it didn’t get to spend one lung ventilation because of impossibility to use double-lumen tube. The medical indications for usage bronchial blockers are maxillofacial deformations, abnormal tracheobronchial anatomy, the morbid obesity and tracheostomy. We have analyzed 40 successful cases of modern bronchial blockers application for providing lung collapse on the operation side, estimated possibilities and shown the results of bronchial blockers usage during operations in thoracic cancer surgery.
... Local therapy might be curative for certain patients with distant metastases. Generally, the lung is regarded as the main organ of metastases derived from various malignancies, and pulmonary metastasectomy (PM) is performed in carefully selected patients with pulmonary-limited metastases in clinical practice (2,3). Because there are no randomized studies that have validated the survival benefit of PM, the surgical outcome of PM is controversial (4)(5)(6). ...
The incidence rate of distant metastasis from head and neck (HN) cancers is 4.2-58.8%. The lung is the most common site of distant metastasis, and pulmonary metastasectomy (PM) can be performed in selected patients with pulmonary metastasis originating from HN cancers. However, due to the small number of study objectives, the knowledge on PM treatment of pulmonary metastasis from HN cancers remains insufficient, and the optimal management of pulmonary metastasis from HN cancer is unclear. Patients with pulmonary metastasis from HN cancer who underwent PM have a better prognosis than those who did not, with reported 5-year overall survival rates after PM of 20.9-59.4%. A histology of squamous cell carcinoma, incomplete resection, a short disease-free interval (DFI), and the oral cancer have been identified as factors predicting a worse prognosis after PM in this patient population. As a systemic therapy, longer overall survival has been achieved using immune check point inhibitors compared with standard single-agent therapies. Since the clinical and morphological diagnoses of pulmonary metastasis from HN cancers are often difficult, molecular techniques can provide useful information for the differential diagnosis between pulmonary metastasis from HN cancers and primary lung cancers. In cases of suspected pulmonary metastasis from HN cancer, the surgical strategy should be determined based on the patient's clinical background.
... Publications report that LNI rate ranges from 5% to 32% (5,18,19). Due to differences in reporting and treatment, a comparison between various publications is difficult. In order to better assess and reach prognostic conclusions, the LNI has to be homogenously reported, and the technique used for LN evaluation must be reported in extent. ...
Lymph node (LN) removal during pulmonary metastasectomy is a prerequisite to achieve complete resection or at least collect prognostic information, but is not yet generally accepted. On average, the rate of unexpected lymph node involvement (LNI) is less than 10% in sarcoma, 20% in colorectal cancer (CRC) and 30% in renal cell carcinoma (RCC) when radical LN dissection is performed. LNI is a negative prognostic factor and presence of preoperative mediastinal disease usually leads to exclusion of the patient from metastasis surgery. Nonetheless, some authors found excellent prognoses even with mediastinal LNI in colorectal and RCC metastases when radical LN dissection was performed (median survival of 37 and 36 months, respectively). Multiple metastases, central location of the lesion followed by anatomical resections are associated with a higher LNI rate. The real prognostic influence of systematic LN dissection remains unclear. Two positive effects were described after radical lymphadenectomy: a trend for improved survival in RCC patients and a reduction of mediastinal recurrences from 23% to 0% in CRC patients. Unfortunately, there is a great number of studies that do not demonstrate any positive effect of lymphadenectomy during pulmonary metastasectomy except a pseudo stage migration effect. Future studies should not only focus on survival, but also on local and LN recurrence.
... Data about postoperative mortality are generally missing but, whenever available, they report no mortality. According to 12 studies, chemotherapy after diagnosis of the primary tumor was utilized at some stage, as neoadjuvant treatment before the redo metastasectomy in 4 papers and as adjuvant therapy following redo resection in 5 (40,111,126,127,130). The prognostic indicators of overall survival at multivariate analysis for this group are summarized in Figure 6. ...
Repeat surgical resection (redo) for pulmonary metastases is a questionable, albeit intriguing topic. We performed an extensive review of the literature, to specifically analyze results of redo pulmonary metastasectomies. We reviewed a total of 3,523 papers. Among these, 2,019 were excluded for redundancy and 1,105 because they were not completely retrievable. Out of 399 eligible papers, 183 had missing information or missing abstract, while 96 lacked data on survival. A total of 120 papers dated from 1991 onwards were finally included. Data regarding mortality, major morbidity, prognostic factors and long-term survivals of the first redo pulmonary metastasectomies were retrieved and analyzed. Homogeneity of data was affected by the lack of guidelines for redo pulmonary metastasectomy and the risks of bias when comparing different studies has to be considered. According to the histology sub-types, redo metastasectomies papers were grouped as: colorectal (n=42), sarcomas (n=36), others (n=20) and all histologies (n=22); the total number of patients was 3,015. Data about chemotherapy were reported in half of the papers, whereas targeted or immunotherapy in 9. None of these associated therapies, except chemotherapy in two records, did significantly modify outcomes. Disease-free interval before the redo procedure was the prevailing prognostic factor and nearly all papers showed a significant correlation between patients' comorbidities and prognosis. No perioperative mortality was reported, while perioperative major morbidity was overall quite low. Where available, overall survival after the first redo metastasectomy ranged from 10 to 72 months, with a 5-years survival of approximately 50%. The site of first recurrence after the redo procedure was mainly lung. Despite the data retrievable from literature are heterogeneous and confounding, we can state that redo lung metastasectomy is worthwhile when the lesions are resectable and the perioperative risk is low. At present, there are no "non-surgical" therapeutic options to replace redo pulmonary metastasectomies.
... Arguably pioneering publications include a report from the International Registry of Lung Metastases in 1997 analyzing more than 5000 cases of lung metastasectomy from 18 centers of excellence. 1 This publication more convincingly demonstrated the efficacy of surgical therapy as well as identified variables predictive of survival, including tumor cell type. Other variables now accepted to impact survival were identified, such as longer diseasefree intervals and small numbers of metastatic lesions. ...
... Pulmonary metastasectomy (PM) is a common treatment for selected patients with pulmonary metastasis. Patients with complete resection without residual lesions, a diseasefree interval (DFI) ≥36 months, and solitary pulmonary metastasis may have a better prognosis after PM (4,5). Because there are no randomized studies validating the survival benefit of PM, its efficacy is controversial (6,7), as is its role in the treatment of pulmonary metastasis of breast cancer. ...
Background:
Pulmonary metastasectomy (PM) for breast cancer-derived pulmonary metastasis is controversial. This study aimed to assess the prognostic factors and implication of PM for metastatic breast cancer using a multi-institutional database.
Methods:
Clinical data of 253 females with pulmonary metastasis of breast cancer who underwent PM between 1982 and 2017 were analyzed retrospectively.
Results:
The median patient age was 56 years. The median follow-up period was 5.4 years, and the median disease-free interval (DFI) was 4.8 years. The 5- and 10-year survival rates after PM were 64.9% and 50.4%, respectively, and the median overall survival was 10.1 years. Univariate analysis revealed that the period of PM before 2000, a DFI <36 months, lobectomy/pneumonectomy, large tumor size, and lymph node metastasis were predictive of a worse overall survival. In the multivariate analysis, a DFI <36 months, large tumor size, and lymph node metastasis remained significantly related to overall survival. The 5- and 10-year cancer-specific survival rates after PM were 66.9% and 54.7%, respectively, and the median cancer-specific survival was 13.1 years. Univariate analyses revealed that the period of PM before 2000, DFI <36 months, lobectomy/pneumonectomy, large tumor size, lymph node metastasis, and incomplete resection were predictive of a worse cancer-specific survival. Multivariate analysis confirmed that a DFI <36 months, large tumor size and incomplete resection were significantly related to cancer-specific survival.
Conclusions:
As PM has limited efficacy in breast cancer, it should be considered an optional treatment for pulmonary metastasis of breast cancer.
... Moreover, prognosis is strongly related to the nature of the primary tumor [8]. Thus, based on surgical and histological series, patients most likely to respond to local treatments are those with [9]: ...
Purpose: To review the available options of percutaneous ablation of lung metastasis.
Methods: General indications, prognostic factors, and image guidance of percutaneous lung ablations were reviewed. Specificities, technical aspects, advantages and limitations of each technic were highlighted. Complications and follow up where also reviewed.
Results: Image-guided, percutaneous ablation is of interest for patients with a limit number (<3–5) small metastases (<2–3 cm). Other predictive factors have been reported such as the disease-free interval, the primary tumor, or the proximity with large vessels or bronchus. Radiofrequency ablation (RFA) is the most reported technic, with local control rate >90% for small tumors, and a very low complication rate. Microwave (MWA) and cryoablation are alternative technics developed in the last 15 years to overcome RFA limitations, with encouraging results. Larger ablations zones and less heat sink effect have been described with MWA. On the other hand, cryoablation allows painless treatments under conscious sedation and/or local anesthesia, high accessibility of difficult locations and promising results on prospective multicenter series. Although irreversible electroporation (IRE) could be used for lesions close to main blood vessels as it is not limited by the heat sink effect and does not have significant effects on connective tissue, allowing to treat lesions near to vital organs, preliminary results for lung metastasis are disappointing.
Conclusion: Percutaneous ablation of lung metastases, whatever technic is used, is feasible, with high local control rate, and acceptable complication rate. Although indications seem clear enough, validation through controlled trials is mandatory.
... The potential benefit of lung metastasectomy in CRC emerged firstly in 1997 from International Registry of Lung Metastasectomy consisting of 5,206 patients from Europe and North America, providing evidence of better survival in radically resected CRC Lung Metastasis (CRCLM) (4). Since this report, a growing number of studies accumulated supporting the potential therapeutic role of CRCLM resection, making it a widely accepted option in the multimodal treatment of metastatic CRC. ...
Background: Adjuvant chemotherapy after resection of colorectal cancer (CRC) lung metastases may reduce recurrences and improve survival. The choice of best candidates for adjuvant chemotherapy in this setting is controversial, especially when a single lung metastases (SLM) is resected. The aim of this study is to evaluate the risk of recurrence after radical resection for single lung metastasis from CRC.
Patients and methods: Demographic, clinical, and pathological data were retrospectively collected for patients radically operated on for single pulmonary metastasis from CRC in 4 centers. Survival was computed by Kaplan-Meyer methods. Chi-square, log-rank test, and for multivariate analysis, Cox-regression and binary logistic regression were used when indicated.
Results: The sample consisted of 344 patients, mean age 65 yrs. Overall 5 yrs survival was 61.9%. Recurrence occurred in 113 pts (32.8%). At univariate analysis, age > 70 (p = 0.046) and tumor size > 2 cm (p = 0.038) were predictive of the worst survival chance, while synchronous lung metastasis (p = 0.039), previous resection of extrathoracic metastasis (p = 0.017), uptake at FDG-PET scan (p = 0.006) and short (<12 months) disease-free interval (DFI) prior to lung metastasectomy (p = 0.048) were risk factors for recurrence. At multivariate analysis, only high CEA (>4 ng/mL) was associated with worst survival (HR: 4.3, p = 0.014), while prior abdominal surgery (HR: 3, p = 0.033), PET positivity (HR: 2.7, p = 0.041), and DFI > 12 months (HR: 0.14, p < 0.001) confirmed to predict recurrence of disease.
Conclusions: Surgical resection of solitary lung metastases from CRC is associated with prolonged survival. High value of CEA, PET positivity, previous extrathoracic resected metastasis, and short (<12 months) DFI were found to be predictive of death or disease recurrence and might identify in this scenario patients at higher risk which could potential benefit of chemotherapy.
... Our rates of OS and PFS are comparable with retrospective reviews of repeat metastasectomy for pulmonary metastases. 30,31 Our study was limited by the retrospective nature of our analysis and acquisition of toxicity information from clinical notes. Patients did not routinely undergo pulmonary function testing prior to and following treatment, so tests such as spirometry or lung diffusion capacity were not available for analysis. ...
Introduction:
Stereotactic ablative radiotherapy (SABR) is highly effective at controlling early stage primary lung cancer and lung metastases. Although previous studies have suggested that treating multiple lung tumors with SABR is safe, post-treatment changes in respiratory function have not been analyzed in detail.
Patients and methods:
We retrospectively identified patients with 2 or more primary lung cancers or lung metastases treated with SABR and analyzed clinical outcomes and predictors of toxicity. We defined a composite respiratory decline endpoint to include increased oxygen requirement, increased dyspnea scale, or death from respiratory failure not owing to disease progression.
Results:
A total of 86 patients treated with SABR to 203 lung tumors were analyzed. A total of 21.8% and 41.8% of patients developed composite respiratory decline at 2 and 4 years, respectively. When accounting for intrathoracic disease progression, 12.7% of patients developed composite respiratory decline at 2 years. Of the patients, 7.9% experienced grade 2 or greater radiation pneumonitis. No patient- or treatment-related factor predicted development of respiratory decline. The median overall survival was 46.9 months, and the median progression-free survival was 14.8 months. The cumulative incidence of local failure was 9.7% at 2 years.
Conclusion:
Although our results confirm that SABR is an effective treatment modality for patients with multiple lung tumors, we observed a high rate of respiratory decline after treatment, which may be owing to a combination of treatment and disease effects. Future studies may help to determine ways to avoid pulmonary toxicity from SABR.
... A hypothesis was postulated that the patient is considered cured if the oligometastases is removed by a local ablative procedure, just like how surgery works for any disease with locoregional recurrences. This was supported by a study where there was a survival rate of 26% and 22% respectively for 10-year and 15-year in a 5000 and more patients analysis in The International Registry of Lung Metastasis [10]. Finley and Shiono et al. have reported respectively 29% and 26.5% of 5 year survival rate in patients with head and neck squamous cell carcinoma who underwent pulmonary resection of metastasis [11,12]. ...
Background
Head and neck cancer has predilection of metastasising to the lung, bones or liver. The site of metastasis usually depends on the primary tumour location, the staging and the regional spread of the tumor. Patients with distant metastasis are predicted to have a poor prognosis with low survival rate. Oligometastasis is the term used for an intermediate biologic state of restricted metastatic capacity with limited number and sites of organ with metastasis. It is also defined by less than or 5 metastatic lesion in a disease with a controlled primary tumor.
Case Reports
In this case series, we have reported three cases of head and neck carcinoma that poses treatment dilemmas because of lung metastases. First case is a gentleman with laryngeal carcinoma with multiple small lung metastases where the treatment options of surgery versus chemoradiation was debated. The second case is a gentleman with low grade mucoepidermoid carcinoma of the parotid gland with suspicious lung spread of disease. Lastly is a patient with papillary thyroid carcinoma with florid lung metastases who completed chemoradiation, where issues of survival rate is discussed.
Conclusion
The presence of lung metastases does not necessarily mean that the prospect of surviving is poor for the patient. It is necessary to determine the best choice of treatment yielding the best quality of life to maximize the survival period for these patients.
... Initially, reports on favorable survival outcomes in oligometastatic cancers largely involved surgery (6). In 1997, the International Registry of Lung Metastases reported a 5-year overall survival (OS) of 36% in patients with lung metastases treated by surgical resection (7). Moreover, a 5-year OS of 40% was reported following liver resection for metastatic colorectal cancer patients with a median survival of 46 months (8). ...
Purpose: The oligometastatic state is a proposed entity between localized cancer and widely metastatic disease, comprising an intermediate subset of metastatic cancer patients. Most data to support locally-directed treatment, such as stereotactic ablative radiotherapy (SABR), for oligometastases are from retrospective institutional reports. Following the success of a recently completed and reported phase II trial demonstrating important clinical outcomes, herein we review the current landscape of ongoing clinical trials in this context.
Materials and methods: A review of currently activated and registered clinical trials was performed using the clinicaltrials.gov database from inception to February 2019. A search of actively recruiting trials, using the key words oligometastases, SABR, and various related terms was performed. Search results were independently reviewed by two investigators, with discrepancies settled by a third. Data abstracted from identified studies included study type, primary disease site, oncologic endpoints, and inclusion/exclusion criteria.
Results: Of the initial 216 entries identified, 64 met our review eligibility criteria after full-text review. The most common study type was a phase II clinical trial (n = 35, 55%) with other study designs ranging from observational registry trials to phase III randomized controlled trials (RCTs). A minority of trials were randomized in design (n = 17, 27%). While most studies allowed for metastases from multiple primary disease sites (n = 22, 34%), the most common was prostate (n = 13, 15%), followed by breast, gastrointestinal, non-small cell lung cancer (NSCLC), and renal (n = 6, 9% each). In studies with a solitary target site, the most common was liver (n = 6, 9%) followed by lung (n = 3, 5%). The most common primary endpoints were progression-free survival (PFS) (n = 20, 31%) and toxicity (n = 10, 16%). A combined strategy of systemic therapy and SABR was an emerging theme (n = 23, 36%), with more recent studies specifically evaluating SABR and immunotherapy (n = 9, 14%).
Conclusion: The safety and efficacy of SABR as oligometastasis-directed treatment is increasingly being evaluated within prospective clinical trials. These data are awaited to compliment the abundance of existing observational studies and to guide clinical decision-making.
... The most influential registry, the International Registry of Lung Metastases, followed-up with 5,206 patients with multiple pathologies who presented with lung metastases and underwent PM, but even this report did not contain a denominator of the total cancer population from which the metastectomy patients were derived. 5 With the knowledge available at this time, radical complete resection, favorable histology, and a prolonged DFI seem to be independent predictive factors identifying a cohort of patients who may benefit from PM. 1 Poor predictive features such as uncontrolled primary malignancy, extrapulmonary metastatic lesions, non-R0 resection, and positive mediastinal lymph nodes usually are considered surgical contraindications. 6 In an attempt to standardize the indications and performance of PM, the Society of Thoracic Surgeons Work Force of Evidence Based Surgery formed a multidisciplinary task force, consisting of thoracic surgeons and both medical and radiation oncologists, to develop a Society of Thoracic Surgeons expert consensus statement on PM. 3 Guidelines could not be established owing to the lack of supporting literature. ...
... Lung metastasectomy remains the most effective approach in this situation; however, the 5-year survival of 20% to 40% associated with this treatment is disappointing. 1 One of the most important factors related to this poor overall survival is the intrathoracic recurrence of resected disease, which is common. 2,3 The presence of micrometastatic disease may be correlated with this local recurrence and in many cases is not properly treated because it cannot be noticed during surgery. ...
... At the present time, no randomized evidence is available, and results of the PulmiCC trial are awaited for. 1 The largest available retrospective series included more than 5000 patients and was published in 1997. 2 Factors proven to be significant were macroscopic complete resection, number of metastases, with a single metastasis having the best survival, and finally, diseasefree interval with a better prognosis for patients with a disease-free interval longer than 3 years. ...
... 1-3 The 5-year survival rate varying between 15 and 52% and recurrence rate of approximately 40% after PM were reported in the literature. [5][6][7] In this study, we aimed to analyze clinical properties of patients who underwent PM for osteogenic and soft tissue sarcomas (STSs) and to investigate the prognostic factors associated with overall survival (OS) and disease-free survival (DFS) after PM. ...
Background Main prognostic factors of improved survival after pulmonary metastasectomy (PM) for osteogenic and soft tissue sarcomas are suggested as histological type, number and size of pulmonary nodules, and disease-free interval (DFI).
Methods Sixty-nine patients who underwent PM between January 1999 and December 2017 were evaluated retrospectively. Relations between parameters and prognostic risk factors for overall survival (OS) and disease-free survival (DFS) were evaluated.
Results Osteosarcoma was the most common histologic type (36.2%) and 21 of 25 cases were seen under the age 20 years (p < 0.001). Comparison of patient groups including osteosarcoma and nonosteosarcoma patients showed significant difference according to age (p < 0.001), nodule size (p = 0.033), ratio of surgical margin to nodule size (p = 0.007), and DFI (p = 0.039). Univariate analysis showed that the number of nodules (p = 0.008), ratio of surgical margin to nodule size (p = 0.001), and localization of nodule (p = 0.039) were significant factors associated with DFS. Also, nodule size (p = 0.042), number of nodules (p = 0.003), ratio of surgical margin to nodule size (p < 0.001), and laterality (p = 0.027) were significant prognostic factors associated with OS. Cut-off values of ratio of surgical margin to nodule size for DFS and OS were calculated as 0.94. Logistic regression analysis determined the ratio of surgical margin to nodule size as the common significant risk factor for DFS and OS.
Conclusions Our study showed that the ratio of surgical margin to nodule size ≥ 1 should be taken as a common risk factor for DFS and OS. Therefore, resection of nodules with the possible widest surgical margin is an important point of PM.
... 10 Demonstra ng the nega ve impact of disease burden, the median survival among pa- ents who were not resected following relapse in one se- ries was 8 months. 16 In a second series, in 39 pa ents who underwent repeat metastasectomy, OS for the 19 pa ents with single-site disease was 65 months, compared with 14 months for the 15 pa ents with two or more sites of re- currence. 10 Although clearly demonstra ng benefi t, these retrospecc ve series are subject to pa ent selecc on bias fa- voring pa ents who are fi t and eligible for metastasectomy. ...
Soft tissue sarcomas (STS) encompass a group of rare but heterogeneous diseases. Nevertheless, many patients, particularly those with oligometastatic disease can benefit from thoughtful multimodality evaluation and treatment regardless of the STS subtype. Here, we review surgical, interventional radiology, radiation, and chemotherapy approaches to maximize disease palliation and improve survival, including occasionally long-term disease-free survival. Surgical resection can include lung or other visceral, soft tissue and bone metastases with a goal of rendering the patient disease free. Staged resections can be appropriate, and serial resection of oligometastatic recurrent disease can be appropriate. Retrospective series suggest survival benefit from this approach, although selection bias may contribute. Interventional radiology techniques such as percutaneous thermal ablation (PTA) and arterial embolization can present nonoperative local approaches in patients who are not medically fit for surgery, surgery is too morbid, or patients who decline surgery. Similarly, radiation therapy can be delivered safely to areas that are inaccessible surgically or would result in excessive morbidity. Currently no randomized trials exist comparing interventional radiologic approaches or radiation therapy to surgery but retrospective reviews show relatively similar magnitude of benefit in terms of disease palliation and survival, although it is felt unlikely that these procedures will render a patient to long-term disease-free status. Chemotherapy has evolved recently with the addition of several new treatment options, briefly reviewed here. Importantly, if a patient sustains a good response to chemotherapy resulting in true oligometastatic disease, consideration of multimodality local therapy approaches can be considered in the appropriate patient.
Третий том руководства охватывает интерстициальные, неопластические, профессиональные заболевания органов дыхания, а также болезни легких сосудистого генеза. В частности, значительно обновлены главы об идиопатических интерстициальных пневмониях, идиопатическом легочном фиброзе и о гиперчувствительных пневмонитах. Переработан и дополнен раздел, посвященный неопластическим заболеваниям. В издание включены главы о нормальной анатомии сосудистого русла, секвестрации и артериовенозных мальформациях легкого. Актуализирована информация об эндоваскулярной окклюзии бронхиальных и коллатеральных артерий легких у пациентов с врожденными цианотическими пороками сердца. Впервые вниманию читателей представлены главы о тяжелых гемодинамических расстройствах – легочном сердце и коагулопатиях – при респираторных заболеваниях. В раздел «Профессиональные и связанные с факторами окружающей среды заболевания легких» добавлены главы о радиационных поражениях органов дыхания и болезнях легких, возникающих при холодовом воздействии.
Objectives:
We seek to identify pre-operative prognostic factors and measure their effect on 5-year survival following Pulmonary Metastasectomy (PM) for Colorectal Cancer (CRC).
Methods:
We systematically reviewed the databases of Cochrane Library, MEDLINE, Embase and Google Scholar from January 2000-April 2021 to identify pre-operative factors that have been investigated for their prognostic effect on survival following PM. Quality assessment was performed using the QUIPS tool. The prognostic effect of each identified factor on 5-year survival post PM was estimated using random-effects meta-analyses.
Results:
We identified 115 eligible articles which included 13,294 patients who underwent PM from CRC. The overall 5-year survival after resection of the lung metastasis was 54.1%. The risk of bias of the included studies was at least moderate in 93% (107/115). Seventy-seven pre-operative factors had been investigated for their prognostic effect. Our analysis showed that 11 factors had favorable and statistically significant prognostic effect on 5-year survival post-PM. These included solitary metastasis, size <2cm, unilateral location, N0 thoracic disease, no history of extra-thoracic or liver metastasis, normal carcinoembryonic antigen levels both before PM and CRC excision, no neo-adjuvant chemotherapy before PM, CRC T-stage < T4 and no p53 mutations on CRC. Disease free interval at 24 months did not appear to affect 5-year survival.
Conclusion:
Despite the considerable risk of bias in the literature, our study consolidates the available evidence on pre-operative prognostic factors for PM from CRC. These findings can complement both clinical practice and the design of future research on the field of PM.
Background:
Resection of all lung metastases in patients with osteosarcoma improves survival. The increased computed tomography (CT) scan quality allows detecting smaller nodules. We aimed to evaluate the prognostic impact of those nodules that do not meet the classical criteria for lung metastases.
Methods:
A central radiology review (CRR) on lung CT scans performed during the treatment of patients included in OS2006 trial and treated with a high-dose methotrexate-based chemotherapy from 2007 to 2013 was realized in three centers.
Results:
At trial enrollment, among 77 patients, six (8%) had nodules meeting the trial's criteria for metastatic disease, 46 (60%) were classified as having localized disease, and 25 (32%) as having doubtful nodules. After CRR, 218 nodules were found at diagnosis (all in patients classified as "metastatic or doubtful" and 13 patients classified as "localized") (median two nodules per patient [1-52]). The 5-year event-free survival/overall survival (EFS/OS) of patients with at least one nodule versus no nodule were similar (67.7%/79.2% vs. 81.8%/91%). After histological analysis, two of 46 (4.3%) "localized" and eight of 25 (32.0%) "doubtful" patients were re-classified as "metastatic," whereas there was no change in patients initially "metastatic." The 5-year OS of confirmed histological metastatic versus nonmetastatic patients were different (56% vs. 92%, p < .01).
Conclusion:
Central review of lung CT scan increased the detection of nodules in osteosarcoma. Patients with small lung nodules classified as doubtful had a quite similar outcome as those with a localized disease. However, patients with confirmed metastatic nodules have a poorer prognosis, even if considered as "localized" at diagnosis.
Background:
Intraoperative molecular imaging (IMI) has been shown to improve lesion detection during pulmonary sarcomatous metastasectomy. Our goal in this study was to evaluate whether data garnered from IMI-guided resection of pulmonary sarcoma metastasis translate to improved patient outcomes.
Study design:
Fifty-two of 65 consecutive patients with a previous history of sarcomas found to have pulmonary nodules during screening were enrolled in a nonrandomized clinical trial. Patients underwent TumorGlow the day before surgery. Data on patient demographics, tumor biologic characteristics, preoperative assessment, and survival were included in the study analysis and compared with institutional historical data of patients who underwent metastasectomy without IMI. p values < 0.05 were considered significant.
Results:
IMI detected 42 additional lesions in 31 patients (59%) compared with the non-IMI cohort where 25% percent of patients had additional lesions detected using tactile and visual feedback only (p < 0.05). Median progression-free survival (PFS) for patients with IMI-guided pulmonary sarcoma metastasectomy was 36 months vs 28.6 months in the historical cohort (p < 0.05). IMI-guided pulmonary sarcoma metastasectomy had recurrence in the lung with a median time of 18 months compared with non-IMI group at 13 months (p < 0.05). Patients with synchronous lesions in the IMI group underwent systemic therapy at a statistically higher rate and tended to undergo routine screening at shorter interval.
Conclusions:
IMI identifies a subset of sarcoma patients during pulmonary metastasectomy who have aggressive disease and informs the medical oncologist to pursue more aggressive systemic therapy. In this setting, IMI can serve both as a diagnostic and prognostic tool without conferring additional risk to the patient.
Background: Increased use of chest computed tomography (CT) scanning and greater awareness among general radiologists has led to
a rise in lung nodule identification. Nodules less than 1 cm in diameter are considered small, and the morphology of such nodules is difficult
to characterize.
Objectives: The aim of our study was to determine the significance of pulmonary nodules that are too-small-to-characterize on CT scan in
patients with extrapulmonary solid tumors and to determine the characteristics that help in distinguishing malignant from benign pulmonary nodules.
Materials and Methods: We conducted a retrospective observational study in the Department of Radiodiagnosis of the Tata Memorial
Hospital, Mumbai, India, and included patients with non‐pulmonary solid malignancies who had obtained baseline CT/positron emission
tomography (PET) scans between January 2010 and December 2014. Demographic information, site of the primary tumor, and histological
diagnosis were recorded. Baseline and follow‐up CT images were read by two radiologists. The significance of associated risk factors was
analyzed using Pearson’s Chi‐square test. A multivariable logistic regression model was used.
Results: Our study included 200 patients and 334 nodules, of which 148 (44.3%) nodules were found to be benign and 127 (38%) were
malignant. The remaining 59 (17.7%) nodules in 32 patients were indeterminate. Most nodules located at a distance of less than 10 mm fromthe pleura were benign, whereas more than 2/3rd of the nodules more than 10 mm away from the pleura were malignant (n = 60/94, 63.8% P = 0.0001). The mean size of the 148 benign nodules (5.3 mm)
was smaller than that of the 127 malignant nodules (9.2 mm).
Nearly 93% of malignant nodules were solid (P = 0.0001). About
83% of malignant nodules were round, while 7 of 10 linear‐shaped
nodules were either benign or indeterminate (P = 0.006). Among the
nodules associated with poorly differentiated primary neoplasms,
63.6% were malignant, 25% were benign, and 11.4% were indeterminate (P = 0.005).
Conclusions: Too‐small‐to‐characterize pulmonary nodules
detected on CT are a common clinical problem and are more
likely to be benign or indeterminate even in patients with known
extrapulmonary neoplasms. Using nodule size, distance from the
Background
A single‐institution experience of pulmonary metastasectomy in soft tissue sarcoma (STS) was retrospectively reviewed. Our specific aim was to examine, whether the resection of pulmonary metastases could be curative. We also compared overall survival (OS) of patients after complete or incomplete pulmonary resection and nonsurgical treatment.
Methods
Between 1987 and 2016, 1580 patients were treated for STS with curative intent by Soft Tissue Sarcoma Group at Helsinki University Hospital, Finland. Three hundred forty‐seven patients (22%) developed advanced disease and 130 STS patients (9%) developed pulmonary metastases as first systemic relapse. Seventy four patients (5%) were operated for lung metastases.
Results
Fifty‐five patients (42%) had a complete and 19 (15%) incomplete resection. Fifty‐six (43%) were unoperated. Median OS after complete or incomplete metastasectomy, chemotherapy, or best supportive care was 22, 18, 8, and 5 months, respectively. Twelve patients (9%) developed no further metastases and are alive with no evidence of disease. Disease‐free survival (DFS) for completely resected patients was 17% at 5 years. All long‐term survivors had oligometastatic disease and they underwent one to three complete metastasectomies.
Conclusions
Complete pulmonary metastasectomy in STS results in 5 years DFS in nearly one‐fifth of patients. Most of these patients are probably cured.
Aim: Lung metastases from an extra-pulmonary origin occasionally present with a limited metastatic disease burden. In cases where metastatectomy is not feasible, stereotactic body radiation therapy (SBRT) represents a non-invasive, efficacious option. We report the outcomes of patients treated with lung SBRT in cases of limited metastatic disease.
Methods: We retrospectively reviewed outcomes in 44 patients with 50 lung nodules from various extra-pulmonary malignancies treated with SBRT. Fifty percent of the patients were male and median age was 64. The median number of nodules was 1 and 90% of patients had oligometastatic disease. Thirty-four percent of patients had extra-thoracic disease.
Results: Fifty lung nodules were treated with SBRT in 44 patients. Median dose was 48 Gy in 5 fractions with a median biological effective dose (BED) of 100 Gy10. Follow-up imaging was available for review in 96% of nodules. Median follow-up was 17.5 months. One year local control was 82%. BED >72 Gy10 predicted improved local control (90 vs. 57% at 1 year). One year overall survival following SBRT was 66%. There was no difference in overall survival if patients had extra-thoracic disease.
Conclusion: Lung SBRT is a safe, effective tool for treatment of limited lung metastases. Dose selection remains important for local control.
Pulmonary metastasectomy for colorectal cancer is an established means of treatment for select patients. This article will highlight the recent evidence published in the literature related to current practices for the surgical management of colorectal lung metastases and propose a diagnostic algorithm for use in clinical practice. It will also discuss controversies related to pulmonary metastasectomy, including the optimal timing of surgery, the extent of lymph node sampling/dissection, and the extent of surgical resection.
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