Surgical resection of pulmonary metastases from colorectal cancer: a systematic review of published series

Prognostic Factors for Survival after Resection of Pulmonary Metastases from Colorectal Carcinoma

PURPOSE

As chemotherapy has improved, the survival of patients with metastatic colorectal carcinoma has reached up to 2.5 years. Many of these patients experience pulmonary metastases; however, the prognosis after pulmonary metastasectomy is not satisfying. In this study, we analyzed the prognostic factors for survival in patients who underwent pulmonary metastasectomy.

METHODS

Eighty-seven patients with colorectal carcinoma received pulmonary metastasectomy. The pathological status of the primary tumor, outcome of the pulmonary metastasectomy, disease-free interval, perioperative carcinoembryonic antigen (CEA) level and history of liver metastases were assessed.

RESULTS

The five-year survival was 42.5% after pulmonary metastasectomy. A univariate analyses revealed that the CEA level (p = 0.043) and the number of pulmonary metastases (p = 0.047) were prognostic factors for survival. The CEA level was an independent prognostic factor in a multivariate analysis (relative risk = 2.01, p = 0.037). Among cases with elevated preoperative CEA levels, those whose CEA level normalized after metastasectomy had a better prognosis compared with those whose CEA level decreased but was still high, or whose level increased after metastasectomy (median survival time of 41.8 months compared with 28.1 or 15.7 months, respectively p = 0.021).

CONCLUSION

The CEA level can be a predictive marker for the prognosis in patients with pulmonary metastases from colorectal carcinoma.

Pulmonary metastasectomy in uterine malignancy: outcomes and prognostic factors

OBJECTIVE

The aim of this study was to investigate outcomes in uterine cancer patients undergoing pulmonary metastasectomy and prognostic factors associated with survival after the procedure.

METHODS

A retrospective study was performed in 29 uterine cancer patients who underwent surgical resection of pulmonary metastatic lesions at Samsung Medical Center between June 1995 and December 2011.

RESULTS

Histopathology showed carcinoma in 17 patients (58.6%) and sarcoma in 12 patients (41.4%). Of the 29 patients, 17 (58.6%) had less than three pulmonary metastatic lesions. Eight (27.6%) had symptoms related to lung metastasis. The 5-year survival rate after pulmonary metastasectomy for the entire cohort was 48.2%. On univariate and multivariate analysis, the presence of pulmonary symptoms and more than three lesions of metastasis were associated with poor survival after pulmonary metastasectomy.

CONCLUSION

Pulmonary metastasectomy for uterine cancer is an acceptable treatment in selected patients. Patients with more than three pulmonary metastatic lesions and pulmonary symptoms related to lung metastasis could expect to have worse prognosis after pulmonary metastasectomy.

Intensified follow-up in colorectal cancer patients using frequent Carcino-Embryonic Antigen (CEA) measurements and CEA-triggered imaging: Results of the randomized "CEAwatch" trial

AIM

The value of frequent Carcino-Embryonic Antigen (CEA) measurements and CEA-triggered imaging for detecting recurrent disease in colorectal cancer (CRC) patients was investigated in search for an evidence-based follow-up protocol.

METHODS

This is a randomized-controlled multicenter prospective study using a stepped-wedge cluster design. From October 2010 to October 2012, surgically treated non-metastasized CRC patients in follow-up were followed in eleven hospitals. Clusters of hospitals sequentially changed their usual follow-up care into an intensified follow-up schedule consisting of CEA measurements every two months, with imaging in case of two CEA rises. The primary outcome measures were the proportion of recurrences that could be treated with curative intent, recurrences with definitive curative treatment outcome, and the time to detection of recurrent disease.

RESULTS

3223 patients were included; 243 recurrences were detected (7.5%). A higher proportion of recurrences was detected in the intervention protocol compared to the control protocol (OR = 1.80; 95%-CI: 1.33-2.50; p = 0.0004). The proportion of recurrences that could be treated with curative intent was higher in the intervention protocol (OR = 2.84; 95%-CI: 1.38-5.86; p = 0.0048) and the proportion of recurrences with definitive curative treatment outcome was also higher (OR = 3.12, 95%-CI: 1.25-6.02, p-value: 0.0145). The time to detection of recurrent disease was significantly shorter in the intensified follow-up protocol (HR = 1.45; 95%-CI: 1.08-1.95; p = 0.013).

CONCLUSION

The CEAwatch protocol detects recurrent disease after colorectal cancer earlier, in a phase that a significantly higher proportion of recurrences can be treated with curative intent.

The impact of pleural disease on the management of advanced ovarian cancer

Malignant pleural effusion is the most common site of stage IV ovarian cancer. A positive cytology is required for a stage IVA diagnosis. Unfortunately, the accuracy rate of pleural cytology remains low. A number of factors have been identified as prognostic for clinical outcomes in patients with epithelial ovarian cancer (EOC), the International Federation of Gynaecology and Obstetrics (FIGO) stage and residual tumor after debulking surgery being the most widely reported. Thereby careful selection of patients is crucially important, yet no preoperative predictor has proven sufficiently reliable to predict surgical outcome. The authors present a review of the literature on stage IV ovarian cancer specifically focusing on prognostic value of FIGO stage, preoperative workup, role of video-assisted thoracic surgery and maximal cytoreductive surgery.

[Analysis of the Choice of Operation Mode and Prognosis Factors of Patients with Tumors of the Lung Metastasis]

背景与目的

肺部转移性肿瘤的治疗观念有所改变，外科手术的治疗价值及影响预后的因素值得探讨。

方法

回顾性分析2006年1月-2009年12月经手术治疗的57例肺部转移性肿瘤患者的临床资料，随访1年、3年、5年生存率，比较胸腔镜和常规开胸两种手术方式的差别，探讨患者性别、年龄、手术方式、无瘤生存间隔期（disease-free interval, DFI）、转移瘤数目、转移瘤大小及术后是否化疗与预后的关系。

结果

全组患者围手术期无死亡，患者术后1年、3年、5年生存率分别为81.3%、46.5%、29.2%，中位生存时间为33.8个月。多因素分析显示DFI、转移瘤数目和直径是影响预后的独立因素。

结论

合理选择手术治疗，能够提高肺部转移性肿瘤患者的生存期，胸腔镜是优选的手术方式，孤立性肺转移瘤及直径 < 4 cm的患者手术效果更佳。

Indeterminate pulmonary nodules in colorectal cancer

AIM: To investigate the clinicopathologic parameters of pulmonary metastasis in colorectal cancer (CRC) patients after lung operation of indeterminate pulmonary nodules (IPNs).

METHODS: From a prospective database of CRC patients, 40 cases that underwent lung operation between November 2008 and December 2012 for suspicious metastatic pulmonary nodules on chest computed tomography (CT) were enrolled. The decision to perform a lung operation was made if the patient met the following criteria: (1) completely resected or resectable primary CRC; (2) completely resectable IPNs; (3) controlled or controllable extrapulmonary metastasis; and (4) adequate general condition and pulmonary function to tolerate pulmonary operation. Lung operation was performed by a thoracic surgeon without CT-guided biopsy for pathologic confirmation.

RESULTS: A total of 40 cases of lung resection was performed in 29 patients. Five patients underwent repeated lung resection. The final pathology result showed metastasis from the CRC in 30 cases (75%) and benign pathology in 10 cases (25%). The primary tumor site was the rectum in 26/30 (86.6%) cases with pulmonary metastasis, but only 3/10 (30%) cases in the benign group had a primary rectal cancer (P = 0.001). Positron emission tomography (PET)-CT was performed for 22/30 (73.4%) patients in the lung metastasis group and for 6/10 (60.0%) patients in the benign group. PET-CT revealed hot uptake of ¹⁸fluorine 2-fluoro-2-deoxy-D-glucose with all IPNs in both groups. The group with pulmonary metastasis had a higher incidence of primary rectal cancer (P = 0.001), a more advanced tumor stage (P = 0.011), and more frequent lymphatic invasion of tumor cells (P = 0.005). Six cases with previous liver metastasectomy were present in the lung metastasis group. Serum carcinoembryonic antigen levels before lung operation were not elevated in any of the patients.

CONCLUSION: The stage and location of the primary tumor and tumor cell infiltration of lymphatics provide useful indicators for deciding on lung resection of IPNs in CRC.

Clinical features and prognosis in hepatectomy for colorectal cancer with centrally located liver metastasis

BACKGROUND

Hepatic metastasectomy for patients with primary colorectal cancer offers better long-term outcome, and chemotherapy can increase the rate of hepatic resectability for patients with initially inoperable disease. The pattern of liver metastasis and status of the primary tumor are rarely discussed in the analysis of long-term outcome. In this report, we evaluate the influence of the pattern of metastasis on clinical features and prognosis.

METHODS

One hundred and fifty-nine patients who underwent hepatic metastasectomy with curative intent for liver metastasis of colorectal cancer between October 1991 and December 2006 were enrolled. Patients were grouped according to whether liver metastasis was centrally or peripherally located, based on imaging and operative findings. Patient demographics, characteristics of the primary and metastatic tumors, and surgical outcomes were analyzed for long-term survival.

RESULTS

A greater proportion of patients with centrally located metastases were male, as compared with those with peripherally located metastases. Compared with patients with peripherally located metastases, patients with centrally located metastases were more likely to have multiple lesions (P = 0.016), involvement of multiple segments (P = 0.006), large metastases (P < 0.001), and bilobar distribution of metastases (P < 0.001). The estimated 5-year recurrence-free and overall survival rates were 22.4% and 34.2%, respectively. Univariate analysis revealed that centrally located metastasis, primary tumor in the transverse colon, metastasis in regional lymph nodes, initial extrahepatic metastasis, synchronous liver metastasis, multiple lesions, poorly differentiated tumor, and resection margin <10 mm were significant poor prognostic factors for recurrence-free survival and overall survival. Cox regression analysis showed that inadequate resection margin and centrally located liver metastasis were significant predictors of shorter overall survival.

CONCLUSIONS

In colorectal cancer, centrally located liver metastasis represents a poor prognostic factor after hepatectomy, and is associated with early recurrence. Neoadjuvant chemotherapy may be used to downstage centrally located liver metastases to improve outcome.

Development of a claims-based algorithm to identify colorectal cancer recurrence

PURPOSE

To examine the validity of claims data to identify colorectal cancer (CRC) recurrence and determine the extent to which misclassification of recurrence status affects estimates of its association with overall survival in a population-based administrative database.

METHODS

We calculated the accuracy of claims data relative to medical records from one large tertiary hospital to identify CRC recurrence. We estimated the effect of misclassifying recurrence on survival by applying these findings to the linked Surveillance, Epidemiology, and End Results-Medicare data.

RESULTS

Of 174 eligible CRC patients identified through medical records, 32 (18.4%) had a recurrence. A claims-based algorithm of secondary malignancy codes yielded a sensitivity of 81% and specificity of 99% for identifying recurrence. Agreement between data sources was almost perfect (kappa: 0.86). In a model unadjusted for misclassification, CRC patients with recurrence were 3.04 times (95% confidence interval: 2.92-3.17) more likely to die of any cause than those without recurrence. In the corrected model, CRC patients with recurrence were 3.47 times (95% confidence interval: 3.06-4.14) more likely to die than those without recurrence.

CONCLUSIONS

Identifying recurrence in CRC patients using claims data is feasible with moderate sensitivity and high specificity. Future studies can use this algorithm with Surveillance, Epidemiology, and End Results-Medicare data to study treatment patterns and outcomes of CRC patients with recurrence.

Endobronchial ultrasound-guided transbronchial needle aspiration is a sensitive method to evaluate patients who should not undergo pulmonary metastasectomy†

OBJECTIVES

Pulmonary metastasectomy is considered an effective treatment in selected patients with extrapulmonary cancer and oligometastatic disease. We know that the presence of mediastinal lymph node metastases reduces survival significantly, but the mediastinum is rarely evaluated before metastasectomy in these patients. We prospectively evaluated how endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) could identify metastases to the mediastinal lymph nodes in patients referred for pulmonary metastasectomy.

METHODS

All patients with extrapulmonary cancer and oligometastatic disease confined to the lungs on positron emission tomography-computed tomography, and who were considered eligible for pulmonary metastasectomy, routinely underwent EBUS-TBNA of the mediastinal lymph nodes. If EBUS-TBNA did not reveal malignant spread, the patient subsequently underwent pulmonary metastasectomy with systematic sampling of mediastinal lymph nodes for histological evaluation.

RESULTS

One hundred and three eligible patients were referred for EBUS-TBNA during a 4-year period. The primary cancers were located in the colon/rectum (n = 64), kidney (n = 16) and other sites (n = 23). EBUS-TBNA sampled 248 lymph nodes and adequate cytology was obtained in 93 patients (90%). EBUS-TBNA found lymph node metastases in 17 patients (16.5%) and during subsequent pulmonary metastasectomy in the remaining 86 patients 1 (1.0%) had a lymph node metastasis. The sensitivity, specificity, NPV and PPV of EBUS-TBNA for diagnosis of mediastinal lymph node metastasis were 94.4, 100, 98.8 and 100%, respectively.

CONCLUSIONS

EBUS-TBNA is a sensitive minimally invasive modality for evaluation of mediastinal lymph node metastases in patients with oligometastatic pulmonary disease. It allows surgeons to select patients who will not benefit from pulmonary metastasectomy.

Risk factors for survival after lung metastasectomy in colorectal cancer patients: systematic review and meta-analysis

ABSTRACT 

Despite the lack of randomized trials, lung metastasectomy is currently proposed for colorectal cancer patients under certain conditions. Many retrospective studies have reported different prognostic factors of poorer survival, but eligibility for pulmonary metastasectomy remains determined by the complete resection of all pulmonary metastases. The aim of this review is to clarify which pre-operative risk factors reported in systematic reviews or meta-analysis are determinant for survival in colorectal metastatic patients. Different criteria have been now identified to select which patient will really benefit from lung metastasectomy.

Predictors of recurrence after a first hepatectomy for colorectal cancer liver metastases: a retrospective analysis

BACKGROUND

Surgical resection is considered the standard therapy in the treatment of liver metastases from colorectal cancer (CRCLM); however, most patients experience tumor recurrence after curative hepatic resection. The objective was to determine potential prognostic factors for tumor recurrence after an initial hepatectomy for CRCLM.

METHODS

A study population of 101 patients who had undergone a first curative hepatectomy for CRCLM was retrospectively analyzed. Selected biological tumor markers, and clinical and pathological features were then tested by Cox regression.

RESULTS

Synchronous liver metastases occurred in 38 patients (37.6%) and 63 patients (62.3%) presented with metachronous liver metastases. In a median follow-up time of 68 months, recurrence was observed in 64 patients (63.3%). The 5-year cumulative risk of recurrence was 56.7%. The median survival after recurrence was 24.5 months (range 1 to 41 months) and 5-year cumulative overall survival was 31.8%. Of all variables tested by Cox regression, intra- and extrahepatic resectable disease, CEA levels≥50 ng/mL and bilobar liver disease remained significant as predictors of recurrence in the multivariate analysis.

CONCLUSIONS

Independent risk factors for recurrence after an initial hepatectomy for CRCLM, such as intra- and extrahepatic resectable disease, CEA levels≥50 ng/mL and bilobar liver disease, can eventually help in making decisions in this very complex scenario.

SBRT for lung oligometastases: Who is the perfect candidate?

AIM

To analyze the literature data about lung oligometastatic patients who underwent SBRT with regard to doses, fractionation, outcomes, response assessment and prognostic factors, trying to define "the right patient" for the local treatment.

BACKGROUND

"Oligometastatic disease" is defined as a state in which metastases are limited in number and site and characterized by unusual cancer biology and behavior. In this setting local therapy could have a potential curative role. Recently, technological advances in Radiation Oncology permitted the introduction of Stereotactic Body Radiation Therapy (SBRT), a novel treatment modality that delivers ablative dose of radiation to the extra-cranial sites with high precision using single or a small number of fractions.

MATERIALS AND METHODS

We performed a literature search using Medical Subject Heading terms "stereotactic body radiation therapy" and "lung metastases", considering a period of 10 years.

RESULTS

Many non-randomized studies have shown that SBRT for lung oligometastases is safe and effective, with local control rates of about 80%. To date SBRT represents an alternative and competitive option in patients with lung oligometastatic disease who refuse surgical treatment or unsuitable for surgery. Based on published studies, SBRT might have major benefit for a patient with breast histology, disease-free interval ≥12 months, control of the primary tumor, small lesions, limited number of lesions and higher radiation dose delivered.

CONCLUSIONS

Well-designed collaborative trials are necessary to draw final conclusions. To date, the discussion within a multidisciplinary team becomes crucial to perform a careful patients' selection in the setting of oligometastatic disease.

Unexpected lymph node disease in resections for pulmonary metastases

BACKGROUND

Pulmonary metastasectomy is widely accepted for different malignant diseases. The role of mediastinal lymph node (LN) dissection in these procedures is discussed controversially. We evaluated our results of LN removal at the time of pulmonary metastasectomy with respect to the frequency of unexpected LN disease.

METHODS

This was a retrospective analysis of 313 resections performed in 209 patients. Operations were performed in curative intention. Patients with known thoracic LN involvement and those without lymphadenectomy (n = 43) were excluded. Patients were analyzed according the type of LN dissection. Subgroups of different primary cancers were evaluated separately.

RESULTS

Sublobar resections were performed in 256 procedures with lymphadenectomy, and 14 patients underwent lobectomy. Patients underwent radical lymphadenectomy (n = 158) or LN sampling (n = 112). The overall incidence of unexpected tumor in LN was 17% (radical lymphadenectomy, 15.8%; sampling, 18.8%). Unexpected LN involvement was found in 17 patients (35.5%) with breast cancer, in 120 (9.2%) with colorectal cancer, and in 53 (20.8%) with renal cell carcinoma. The 5-year survival was 30.2% if LN were tumor negative and 25% if positive (p = 0.19). LN sampling vs radical removal had no significant effect on 5-year survival (23.6% vs 30.9%; p = 0.29).

CONCLUSIONS

Dissection of mediastinal LN in resection of lung metastases will reveal unexpected LN involvement in a relevant proportion of patients, in particular in breast and renal cancer. Routine LN dissection appears necessary and may become important for further therapeutic decisions. On the basis of our data, LN sampling seems to be sufficient.

History and present status of pulmonary metastasectomy in colorectal cancer

Clinical practice with respect to metastatic colorectal cancer differs from the other two most common cancers, breast and lung, in that routine surveillance is recommended with the specific intent of detecting liver and lung metastases and undertaking liver and lung resections for their removal. We trace the history of this approach to colorectal cancer by reviewing evidence for effectiveness from the 1950s to the present day. Our sources included published citation network analyses, the documented proposal for randomised trials, large systematic reviews, and meta-analysis of observational studies. The present consensus position has been adopted on the basis of a large number of observational studies but the randomised trials proposed in the 1980s and 1990s were either not done, or having been done, were not reported. Clinical opinion is the mainstay of current practice but in the absence of randomised trials there remains a possibility of selection bias. Randomised controlled trials (RCTs) are now routine before adoption of a new practice but RCTs are harder to run in evaluation of already established practice. One such trial is recruiting and shows that controlled trial are possible.

Integrating systemic and surgical approaches to treating metastatic colorectal cancer

Multiple new treatment options for metastatic colorectal cancer have been developed over the past 2 decades, including conventional chemotherapy and agents directed against vascular endothelial growth factor and epidermal growth factor receptor. Combination regimens, integrated with surgical approaches, have led to an increase in median survival, and a minority of patients with resectable disease can survive for years. Clinical decision-making therefore requires a strategic, biomarker-based multidisciplinary approach to maximize life expectancy and quality of life. This review describes systemic approaches to the treatment of patients with metastatic colorectal cancer, including integration with liver resection, other liver-directed therapies, and primary resection.

Current readings: Percutaneous ablation for pulmonary metastatic disease

Percutaneous image-guided ablation is a technique for maintaining local control of metastatic lung lesions that may, in selected patients, confer a survival benefit over no treatment or systemic therapy alone. Although the currently accepted treatment for oligometastatic pulmonary disease is surgical resection, the existing body of literature, including the recent investigations reviewed within this article, supports a role for percutaneous ablation as an important and relatively safe therapeutic option for nonsurgical and in carefully selected surgical patients, conferring survival benefits competitive with surgical metastasectomy. Continued clinical investigations are needed to further understand the nuances of thermal technologies and applications to treat lung primary and secondary pulmonary malignancy, directly compare available therapeutic options and further define the role of percutaneous image-guided ablation in the treatment of pulmonary metastatic disease.

Stereotactic Ablative Radiotherapy (SABR) in inoperable oligometastatic disease from colorectal cancer: a safe and effective approach

Background

To assess the safety and efficacy of Stereotactic Ablative Radiotherapy (SABR) in oligometastatic patients from colorectal cancer.

Methods

82 patients with 1–3 inoperable metastases confined to one organ (liver or lung), were treated with SABR for a total of 112 lesions in an observational study. Prescription dose ranged between 48 and 75Gy in 3 or 4 consecutive fractions. Primary end-points were local control (LC), overall survival (OS) and progression-free survival (PFS). Secondary end-point was toxicity.

Results

Median follow-up was 24 months (range 3–47). One, two and three years LC rate was 90%,80% and 75% (85%,75% and 70% for lung and 95%, 90% and 85% for liver metastases; no statistically significance was found). The difference in LC between the subgroup of lesions treated with ≥60 Gy (n = 58) and those irradiated with <60 Gy (n = 52) was statistically significant, with a 1, 2 and 3 yrs LC of 97%,92% and 83% for the higher dose, compared to 85%,70% and 70% for the lower dose (p < 0.04). Median OS was 32 months. Actuarial OS rate at 1, 2 and 3 yrs was 85%,65% and 43%. Univariate analysis showed a correlation only between OS and cumulative GTV > 3 cm (p < 0.02). Median PFS was 14 months, with a PFS rate of 56% at 1 yr and 40% at 2-3 yrs, without correlation with the site and prescription dose (p < 0.48 and p < 0.56). No patients experienced radiation-induced liver disease or grade >3 toxicity.

Conclusions

SABR is a safe and feasible alternative treatment of oligometastatic colorectal liver and lung metastases in patients not amenable to surgery or other ablative treatments.

Adjuvant systemic chemotherapy with or without bevacizumab in patients with resected pulmonary metastases from colorectal cancer

INTRODUCTION

We investigated the impact of modern chemotherapy regimens and bevacizumab following pulmonary metastasectomy (PM) from metastatic colorectal cancer (CRC).

METHODS

A total of 122 consecutive patients who were curatively resected for pulmonary metastases of CRC in twelve oncology centers were retrospectively analysed between January 2000 and April 2012.

RESULTS

Of 122 patients, 14 did not receive any treatment following PM. The remaining 108 patients received fluoropyrimidine-based (n = 12), irinotecan-based (n = 56) and oxaliplatin-based (n = 40) chemotherapy combinations. Among these, 52 patients received bevacizumab (BEV) while 56 did not (NoBEV). Median recurrence-free survival (RFS) was 17 months and median overall survival (OS) has not been reached at a median follow-up of 25 months after PM. Three and five-year OS rates were 66% and 53%, respectively. RFS and OS were similar, irrespective of the chemotherapy regimen or BEV use. Positive pulmonary margin, KRAS mutation status, and previous liver metastasectomy were negative independent prognostic factors for RFS, while pathologically confirmed thoracic lymph node involvement was the only negative independent prognostic for OS in multivariate analysis.

CONCLUSIONS

No significant RFS or OS difference was observed in respect to chemotherapy regimens with or without BEV in patients with pulmonary metastases of CRC following curative resection.

Clinical significance of surgical resection for the recurrence of esophageal cancer after radical esophagectomy

BACKGROUND

This study aimed to clarify the clinical significance of surgical resection for recurrent lesions after esophagectomy for esophageal cancer.

METHODS

Recurrence was detected in 113 of 365 consecutive patients who underwent surgical resection for esophageal cancer, and some treatment was performed for recurrence in 100 of the 113 patients. The treatments were classified into two groups: chemotherapy and/or radiation with surgery (surgery group, n = 14) and chemotherapy and/or radiation without surgery (no surgery group, n = 86). The outcomes were retrospectively analyzed.

RESULTS

Of the 14 patients in the surgery group, 3 underwent repeated resection. Thus, a total of 22 resections were performed for these patients. The resected organs were the lymph nodes in nine patients, the lungs in six patients, local recurrence in two patients, subcutaneous recurrence in two patients, the liver in one patient, the brain in one patient, and the parotid gland in one patient. Among the 22 recurrent cases, 20 involved solitary lesions or multiple lesions located in a small resectable region. When the two groups were compared, the surgery group showed a more favorable prognosis in terms of both survival after esophagectomy (median survival time, 103.3 vs 23.1 months; p = 0.0060) and survival after initial recurrence (92.1 vs 12.2 months; p = 0.0057).

CONCLUSIONS

Multimodal treatment provides a significant benefit for patients with recurrence after esophagectomy for esophageal cancer. Surgical intervention should be aggressively included in the treatment strategy when the recurrent lesion is solitary or localized.

Comparing respiratory gated with delayed scans in the detection of colorectal carcinoma hepatic and pulmonary metastases with 18F-FDG PET-CT

PURPOSE

In patients experiencing colorectal carcinoma, exhaustive analysis of indicates extent of hepatic and pulmonary surgery that prolongs survival of patients.

PATIENTS AND METHODS

To localize metastasis, we compared 2 F-FDG PET-CT imaging protocols, early respiratory gated scan, and delayed scan, to standard PET imaging procedure. SUVmax and lesion-to-healthy tissue ratio were measured in 60 pulmonary and 21 hepatic lesions by each of the 2 imaging protocols.

RESULTS

In the liver, metastatic lesion-to-healthy tissue ratios significantly increased on delayed scans as compared with early scans (P < 0.001). Better ratios could not be obtained when using respiratory gated scans, whereas more lesions were detected on delayed scans. In the lungs, metastatic lesion- to-healthy tissue ratio increased significantly on delayed scans for largest lesions (P < 0.001). Ratios were not better when exploring smallest metastatic lesions or when using respiratory gated scans. Factors interfering with F-FDG PET-CT sensitivity are discussed, such as respiratory motion and high FDG physiological uptake in healthy liver parenchyma.

CONCLUSIONS

Our studies indicate that routine acquisitions should use delayed hepatic scans for all patients referred for evaluation, recurrence check, or monitoring of colorectal adenocarcinoma. Delayed pulmonary scans are useful for the largest metastatic lesions and should be used in addition to early scan. In our experience, respiratory gated scans seem to be less convenient because of a low sensitivity in detection, as compared with the delayed technique; in addition, this technique is currently complicated by some technical issues, although these might be overcome with new gated protocols.

The oligometastatic state - separating truth from wishful thinking

The oligometastatic paradigm implies that patients who develop a small number of metastatic lesions might achieve long-term survival if all these lesions are ablated with surgery or stereotactic radiotherapy. Clinical data indicate that the number of patients with oligometastatic disease receiving aggressive treatment is increasing rapidly. We examine the key evidence supporting or refuting the existence of an oligometastatic state. Numerous single-arm studies suggest that long-term survival is 'better-than-expected' after ablative treatment. However, the few studies with adequate controls raise the possibility that this long-term survival might not be due to the treatments themselves, but rather to the selection of patients based on favourable inclusion criteria. Furthermore, ablative treatments carry a risk of harming healthy tissue, yet the risk-benefit ratio cannot be quantified if the benefits are unmeasured. If the strategy of treating oligometastases is to gain widespread acceptance as routine clinical practice, there should be stronger evidence supporting its efficacy.

Thoracoscopic or open surgery for pulmonary metastasectomy: an observer blinded study

BACKGROUND

Video-assisted thoracic surgery (VATS) resection of pulmonary metastases has long been questioned because radiologically undetected parenchymal lesions may be missed when bimanual palpation is restricted to the portholes. Technology, however, has improved and advanced VATS resections are now performed routinely worldwide. This prompted us to conduct a prospective observer-blinded study on pulmonary metastasectomy.

METHODS

Eligible patients with oligometastatic pulmonary disease on computed tomography (CT) underwent high-definition VATS, with digital palpation by 1 surgical team and subsequent immediate thoracotomy during the same anesthesia by a different surgical team, with bimanual palpation and resection of all palpable nodules. Preoperative CT evaluations and surgical results were blinded. Primary endpoints were number and histopathology of detected nodules.

RESULTS

During a 3-year period 89 consecutive patients, with newly developed nodules suspicious of lung metastases from previous cancers in colon-rectum (n=59), kidney (n=15), and other malignancies (n=15) were included, with a total of 140 suspicious nodules visible on CT. During VATS, 122 nodules were palpable (87%). All nodules were identified during thoracotomy, where 67 additional and unexpected nodules were also identified; 22 were metastases (33%), 43 (64%) were benign lesions, and 2 (3%) were primary lung cancers.

CONCLUSIONS

In patients operated for nodules suspicious of lung metastases, a substantial number of additional nodules were detected during thoracotomy despite advancements in CT imaging and VATS technology. Many of these nodules were malignant and would have been missed if VATS was used exclusively. Consequently, we considered VATS inadequate if the intention is to resect all pulmonary metastases during surgery.

Pulmonary metastasectomy for colorectal cancer: How many nodules, how many times?

Colorectal cancer (CRC) is one of the most common cancers worldwide, with 5%-15% of CRC patients eventually developing lung metastasis (LM). Despite doubts about the role of locoregional therapy in the management of systemic disease, many surgeons have performed pulmonary metastasectomy (PM) for CRC in properly selected patients. However, the use of pulmonary metastasectomy remains controversial due to the lack of randomized controlled studies. This article reviews the results of surgical treatment of pulmonary metastases for CRC, focusing on (1) current treatment guidelines and surgical techniques of PM in patients with LM from CRC; (2) outcomes of PM and its prognostic factors; and (3) controversial issues in PM, focusing on repeated metastasectomy, bilateral multiple metastases, and combined liver and lung metastasectomy.

Role of stereotactic body radiotherapy for oligometastasis from colorectal cancer

Systemic chemotherapy has enabled prolongation of survival in patients with stage IV colorectal cancer. This has subsequently increased the relative significance of local therapy for patients with oligometastases because they can be cured by removal of oligometastatic lesions. One of the most frequently reported tumor histologies for oligometastases is colorectal cancer. Resection is the standard therapy in most settings of oligometastases. Recently, studies have shown that stereotactic body radiotherapy (SBRT) may become a treatment option that provides high local control with minimal morbidity. Two-year local control rates following SBRT for hepatic and pulmonary oligometastases are almost over 80% and are even higher for patients treated with high-dose regimens. The indications of SBRT for other metastatic sites or conditions include isolated lymph nodes, spinal and adrenal metastasis, and post-surgical pelvic recurrence. Many retrospective studies have indicated that SBRT for various lesions results in good outcomes with low morbidity, both in the curative and palliative setting. However, few reports with a high level of evidence have indicated the efficacy of SBRT compared to standard therapy. Hereafter, the optimal indication of SBRT needs to be prospectively investigated to obtain convincing evidence.

Improved long-term survival after resection of colorectal liver metastases following staging with FDG positron emission tomography

BACKGROUND AND OBJECTIVES

Actual long-term survival of patients with colorectal liver metastases staged by PET CT has not been reported. Objectives were to investigate whether PET CT staging results in actual improved long-term survival, to examine outcome in patients with 'equivocal' PET CT scans, and those excluded from hepatectomy by PET CT.

METHODS

A retrospective analysis of patients undergoing hepatectomy for colorectal liver metastases between March 1998 and September 2008.

RESULTS

Overall 5- and 10-year survival was 44.8% and 23.9%. PET CT staging resulted in management changes in 23% of patients. PET CT staged patients showed significantly better survival than those staged by CT alone at 3 years (79.8% vs. 54.1%) and at 5 years (54.1% vs. 37.3%) with median survivals of 6.4 years versus 3.9 years (log rank P = 0.018). Patients with equivocal PET CT scans showed worse median survival than those with favourable PET CT (log rank P = 0.002), but may include a subpopulation whose prognosis trends towards a more favourable outcome than those excluded from liver resection by PET CT, whose median survival remains limited to 21 months.

CONCLUSIONS

Staging of patients with colorectal liver metastases by PET CT is associated with significantly improved actual long-term survival, and provides valuable prognostic information which guides surgical and oncological treatments.

A simulation model of colorectal cancer surveillance and recurrence

Background

Approximately one-third of those treated curatively for colorectal cancer (CRC) will experience recurrence. No evidence-based consensus exists on how best to follow patients after initial treatment to detect asymptomatic recurrence. Here, a new approach for simulating surveillance and recurrence among CRC survivors is outlined, and development and calibration of a simple model applying this approach is described. The model’s ability to predict outcomes for a group of patients under a specified surveillance strategy is validated.

Methods

We developed an individual-based simulation model consisting of two interacting submodels: a continuous-time disease-progression submodel overlain by a discrete-time Markov submodel of surveillance and re-treatment. In the former, some patients develops recurrent disease which probabilistically progresses from detectability to unresectability, and which may produce early symptoms leading to detection independent of surveillance testing. In the latter submodel, patients undergo user-specified surveillance testing regimens. Parameters describing disease progression were preliminarily estimated through calibration to match five-year disease-free survival, overall survival at years 1–5, and proportion of recurring patients undergoing curative salvage surgery from one arm of a published randomized trial. The calibrated model was validated by examining its ability to predict these same outcomes for patients in a different arm of the same trial undergoing less aggressive surveillance.

Results

Calibrated parameter values were consistent with generally observed recurrence patterns. Sensitivity analysis suggested probability of curative salvage surgery was most influenced by sensitivity of carcinoembryonic antigen assay and of clinical interview/examination (i.e. scheduled provider visits). In validation, the model accurately predicted overall survival (59% predicted, 58% observed) and five-year disease-free survival (55% predicted, 53% observed), but was less accurate in predicting curative salvage surgery (10% predicted; 6% observed).

Conclusions

Initial validation suggests the feasibility of this approach to modeling alternative surveillance regimens among CRC survivors. Further calibration to individual-level patient data could yield a model useful for predicting outcomes of specific surveillance strategies for risk-based subgroups or for individuals. This approach could be applied toward developing novel, tailored strategies for further clinical study. It has the potential to produce insights which will promote more effective surveillance—leading to higher cure rates for recurrent CRC.

Risk factors for lymph node metastases and prognosticators of survival in patients undergoing pulmonary metastasectomy for colorectal cancer

BACKGROUND

Systematic lymph node dissection is not routinely performed in patients undergoing pulmonary metastasectomy (PM) of colorectal cancer. The aim of the study was to identify risk factors for lymph node metastases (LNM) and to determine prognosticators for survival in colorectal cancer patients with pulmonary metastases.

METHODS

We retrospectively reviewed our prospective database of 165 patients with colorectal cancer undergoing PM and systematic lymph node dissection with curative intent from 1999 to 2009. The χ(2) test, regression analyses, Kaplan-Meier analyses, log rank tests, and Cox regression analyses were used to determine prognosticators for LNM and survival.

RESULTS

The prevalence of LNM was 22.4%. Lymph node metastases were more often detected in case of rectal cancer and if anatomic resections in term of segmentectomy or lobectomy had to be performed for PM. The number of pulmonary metastases showed a nonlinear association with the risk of positive postoperative LNM. For 1 to 10 pulmonary metastases, each additional pulmonary metastasis conferred a 16% increase in risk for LNM. Rectal cancer, M-status of the primary tumor, number of pulmonary metastases, and disease progression during pre-PM chemotherapy were independent prognosticators for survival. Lymph node metastases were not an independent prognosticator.

CONCLUSIONS

Rectal cancer, required anatomic resections, and multiple metastases were risk factors for LNM. Rectal cancer, M-status of the primary tumor, number of pulmonary metastasis, and disease progression during pre-PM chemotherapy were independent negative predictors of survival, stratifying patients with poor prognosis who may benefit from chemotherapy before or after PM.

Should preoperative chest CT be recommended to all colon cancer patients?

OBJECTIVE

The aim of this study was to evaluate the efficacy of preoperative chest computed tomography (CT) and the risk factors for lung metastasis in colon cancer patients without liver metastasis who had negative findings on initial chest X-ray (CXR).

BACKGROUND

Preoperative staging with chest CT is recommended in colon cancer patients. However, there have been only scant data on the clinical efficacy.

METHODS

Three hundred nineteen consecutive colon cancer patients without liver metastasis were retrospectively reviewed and analyzed. The patients had negative findings on preoperative CXR, and they underwent surgery for colon cancer during the period of January 2008 to April 2010.

RESULTS

Lung nodule on chest CT was found in 136 patients (42.6%). Twenty of those were definitely diagnosed with lung metastasis (6.3%) by follow-up chest CT or pathologic confirmation. There was no case of delay in surgery due to findings of lung nodule. Comparing the group with lung metastases to that without lung metastases, postoperative pathologic findings reported more advanced T and N status (P = 0.004, P < 0.001, respectively), and lymphatic invasion was more frequent (P = 0.003) in the group with lung metastasis. By multivariate analysis, CT-predicted lymph node metastases and pathologic lymph node metastases were risk factors for lung metastases.

CONCLUSIONS

Preoperative staging chest CT is not beneficial to colon cancer patients without liver metastasis and lymph node metastasis suggested on abdominal and pelvic CT who had negative finding on initial CXR.

Stereotactic body radiotherapy for oligo-recurrence within the nodal area from colorectal cancer

Recurrence of colorectal cancer (CRC) often presents as solitary metastases, oligometastases or oligo-recurrence. Surgical resection became the preferred treatment for patients with CRC lung and hepatic metastases. However, surgical treatment for oligo-recurrence within nodal area is not a widely accepted treatment due to due to their relative rarity and high postoperative morbidity. Stereotactic body radiotherapy (SBRT) is one of the emerging radiation treatment techniques in which a high radiation dose can be delivered to the tumor. High-dose SBRT can ablate the tumor with an efficacy similar to that achieved with surgery, especially for small tumors. However, there have been very few studies on SBRT for oligo-recurrence within nodal area, although several studies have evaluated the role of SBRT in the treatment of liver and lung metastases from CRC. This article reviews the current clinical status of and treatment methods for oligo-recurrence within nodal area from CRC, with particular emphasis on SBRT.

Radiofrequency ablation for pulmonary metastases from gastrointestinal cancers

The lung is one of the most common targets of metastases from gastrointestinal (GI) cancers. Surgical treatment (i.e., metastasectomy) is an accepted therapeutic option for pulmonary metastases from GI cancers. However, surgery may be contraindicated in advanced stages of cancer, compromised lung function, and/or comorbidities. This issue has prompted the search for innovative and less invasive ways of treating pulmonary metastases. Image-guided radiofrequency ablation (RFA) has attracted great interest as a minimally invasive approach against intrathoracic malignancies. In this technique, radiofrequency energy is applied via a needle electrode inserted into the target tissue. As the cells are agitated by the applied energy, they release heat, causing denaturation and cell death. Recently, this technique has been used on patients with pulmonary metastatic disease arising from GI cancers such as colorectal cancer, esophageal cancer, and hepatocellular carcinoma, as well as on patients with primary lung cancer. The present review updates the clinical outcomes and advances in RFA therapy of lung metastases from GI cancers.

Recurrence pattern depends on the location of colon cancer in the patients with synchronous colorectal liver metastasis

BACKGROUND

The veins from the lower rectum drain into the systemic venous system, while those from other parts of the colon drain into the portal venous system. The aim of this study was to investigate recurrence pattern and survival according to the anatomical differences in patients with colorectal liver metastases (CRLM).

METHODS

From October 1994 to December 2009, synchronous CRLM patients who underwent surgery were identified from our prospectively collected database. The patients were excluded if there had been extrahepatic metastases. The patients were divided into two groups according to the location of the primary colorectal cancer: lower rectal cancer (group 1) and upper rectal or colon cancer (group 2). The recurrence patterns and survival were investigated.

RESULTS

A total of 316 patients were included: 53 patients in group 1 and 263 patients in group 2. After a median follow-up of 37 months, the extrahepatic recurrence curve of group 1 was superior to that of group 2 (P < 0.001), although there was no difference between the hepatic recurrence curves (P = 0.93). The disease-free and overall survival curves of group 1 were inferior to those of group 2 (P = 0.004) (P < 0.001). Lower rectal cancer was a significant risk factor for extrahepatic recurrence in Cox proportional hazard model analysis (hazard ratio = 1.7, P = 0.04).

CONCLUSIONS

The extrahepatic recurrence rate is high in lower rectal cancer patients after surgical treatment for synchronous CRLM.

The Presence of Mutations in the K-RAS Gene Does Not Affect Survival after Resection of Pulmonary Metastases from Colorectal Cancer

Introduction. Our objective was to identify mutations in the K-RAS gene in cases of pulmonary metastases from colorectal cancer (CRC) and determine whether their presence was a prognostic factor for survival. Methods. We included all patients with pulmonary metastases from CRC operated on between 1998 and 2010. K-RAS mutations were investigated by direct sequencing of DNA. Differences in survival were explored with the Kaplan-Meier method log-rank tests and multivariate Cox regression analysis. Results. 110 surgical interventions were performed on 90 patients. Factors significantly associated with survival were disease-free interval (P = 0.002), age (P = 0.007), number of metastases (P = 0.001), lymph node involvement (P = 0.007), size of the metastases (P = 0.013), and previous liver metastasis (P = 0.003). Searching in 79 patients, K-RAS mutations were found in 30 cases. We did not find statistically significant differences in survival (P = 0.913) comparing native and mutated K-RAS. We found a higher rate of lung recurrence (P = 0.040) and shorter time to recurrence (P = 0.015) in patients with K-RAS mutations. Gly12Asp mutation was associated with higher recurrence (P = 0.022) and lower survival (P = 0.389). Conclusions. The presence of K-RAS mutations in pulmonary metastases does not affect overall survival but is associated with higher rates of pulmonary recurrence.

Strengths and weaknesses of a stepped wedge cluster randomized design: its application in a colorectal cancer follow-up study

OBJECTIVES

To determine the advantages and disadvantages of a stepped wedge design for a specific clinical application.

STUDY DESIGN AND SETTING

The clinical application was a pragmatic cluster randomized surgical trial intending to find an increased percentage of curable recurrences in patients in follow-up after colorectal cancer. Advantages and disadvantages of the stepped wedge design were evaluated, and for this application, new advantages and disadvantages were presented.

RESULTS

A main advantage of the stepped wedge design was that the intervention rolls out to all participants, motivating patients and doctors, and a large number of patients who were included in this study. The stepped wedge design increased the complexity of the data analysis, and there were concerns regarding the informed consent procedure. The repeated measurements may bring burden to patients in terms of quality of life, satisfaction, and costs.

CONCLUSION

The stepped wedge design is a strong alternative for pragmatic cluster randomized trials. The known advantages hold, whereas most of the disadvantages were not applicable to this application. The main advantage was that we were able to include a large number of patients. Main disadvantages were that the informed consent procedure can be problematic and that the analysis of the data can be complex.

Descriptive analysis of and overall survival after surgical treatment of lung metastases

OBJECTIVE:

To describe demographic characteristics, surgical results, postoperative complications, and overall survival rates in surgically treated patients with lung metastases.

METHODS:

This was a retrospective analysis of 119 patients who underwent a total of 154 lung metastasis resections between 1997 and 2011.

RESULTS:

Among the 119 patients, 68 (57.1%) were male and 108 (90.8%) were White. The median age was 52 years (range, 15-75 years). In this sample, 63 patients (52.9%) presented with comorbidities, the most common being systemic arterial hypertension (69.8%) and diabetes (19.0%). Primary colorectal tumors (47.9%) and musculoskeletal tumors (21.8%) were the main sites of origin of the metastases. Approximately 24% of the patients underwent more than one resection of the lesions, and 71% had adjuvant treatment prior to metastasectomy. The rate of lung metastasis recurrence was 19.3%, and the median disease-free interval was 23 months. The main surgical access used was thoracotomy (78%), and the most common approach was wedge resection with segmentectomy (51%). The rate of postoperative complications was 22%, and perioperative mortality was 1.9%. The overall survival rates at 12, 36, 60, and 120 months were 96%, 77%, 56%, and 39%, respectively. A Cox analysis confirmed that complications within the first 30 postoperative days were associated with poor prognosis (hazard ratio = 1.81; 95% CI: 1.09-3.06; p = 0.02).

CONCLUSIONS:

Surgical treatment of lung metastases is safe and effective, with good overall survival, especially in patients with fewer metastases.

Radiofrequency ablation as treatment for pulmonary metastasis of colorectal cancer

Radiofrequency ablation (RFA) causes focal coagulation necrosis in tissue. Its first clinical application was reported in 2000, and RFA has since been commonly used in both primary and metastatic lung cancer. The procedure is typically performed using computed tomography guidance, and the techniques for introducing the electrode to the tumor are simple and resemble those used in percutaneous lung biopsy. The most common complication is pneumothorax, which occurs in up to 50% of procedures; chest tube placement for pneumothorax is required in up to 25% of procedures. Other severe complications, such as pleural effusion requiring chest tube placement, infection, and nerve injury, are rare. The local efficacy depends on tumor size, and local progression after RFA is not rare, occurring in 10% or more of patients. The local progression rate is particularly high for tumors > 3 cm. Repeat RFA may be used to treat local progression. Short- to mid-term survival after RFA appears promising and is approximately 85%-95% at 1 year and 45%-55% at 3 years. Long-term survival data are sparse. Better survival may be expected for patients with small metastasis, low carcinoembryonic antigen levels, and/or no extrapulmonary metastasis. The notable advantages of RFA are that it is simple and minimally invasive; preserves pulmonary function; can be repeated; and is applicable regardless of previous treatments. Its most substantial limitation is limited local efficacy. Although surgery is still the method of choice for treatment with curative intent, the ultimate application of RFA may be to replace metastasectomy for small metastases. Randomized trials comparing RFA with surgery are needed.

Pulmonary metastasectomy for malignant melanoma: prognostic factors for long-term survival

More than 80% of patients with metastatic melanoma initially show only one distant organ site involvement, most commonly the lungs. Several studies on patients with pulmonary metastatic diseases have determined prognostic factors for survival; however, these studies included patients with a variety of primary tumor types and failed to discriminate melanoma-specific prognostic factors. Surgical therapy has been shown in several studies to be associated with a 5-year survival rate as high as 39%. We retrospectively analyzed 48 patients with previously treated melanoma who developed pulmonary metastases and were admitted between 1990 and 2006. The overall survival was estimated using Kaplan-Meier analysis. Log-rank and Breslow's tests were used to compare survival differences for each variable. Multivariate analyses to determine the independent prognostic factors for overall survival were performed using the Cox proportional hazard model, as identified by the univariate analyses. The median overall survival for all patients was 32 months, with an estimated 5-year survival rate of 36%. Multivariate analyses identified the type of resection and the number of malignant nodules resected as independent prognostic factors for overall survival. We observed a significant survival benefit from pulmonary metastasectomy for a subset of patients with metastatic pulmonary melanoma.

Pulmonary metastasectomy: what is the practice and where is the evidence for effectiveness?

Pulmonary metastasectomy is a commonly performed operation and is tending to increase as part of a concept of personalised treatment for advanced cancer. There have been no randomised trials; belief in effectiveness of metastasectomy is based on registry data and surgical follow-up studies. These retrospective series are comprised predominately of solitary or few metastases with primary resection to metastasectomy intervals longer than 2-3 years. Five-year survival rates of 30-50% are recorded, but as case selection is based on favourable prognostic features, an apparent association between metastasectomy and survival cannot be interpreted as causation. Cancers for which lung metastasectomy is used are considered in four pathological groups. In non-seminomatous germ cell tumour, for which chemotherapy is highly effective, excision of residual pulmonary disease guides future treatment and in particular allows an informed decisions as to further chemotherapy. Sarcoma metastasises predominately to lung and pulmonary metastasectomy for both bone and soft tissues sarcoma is routinely considered as a treatment option but without randomised data. The commonest circumstance for lung and liver metastasectomy is colorectal cancer. Repeated resections and ablations are commonplace but without evidence of effectiveness for either. For melanoma, results are particularly poor, but lung metastases are resected when no other treatment options are available. In this review, the available evidence is considered and the conclusion reached is that in the absence of randomised trials there is uncertainty about effectiveness. A randomised controlled trial, Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC), is in progress and randomised trials in sarcoma seem warranted.

Size of metastatic deposits affects prognosis in patients undergoing pulmonary metastectomy for colorectal cancer

INTRODUCTION

Pulmonary metastectomy for colorectal cancer (CRC) is a well accepted procedure although data regarding indications and prognostic outcomes are inconsistent. This study aimed to analyse our experience with resection of pulmonary CRC metastases to evaluate clinically relevant prognostic factors affecting survival.

METHODS

A retrospective analysis was undertaken of the records of all patients with pulmonary metastases from CRC who underwent a thoracotomy between 2004 and 2010 at a single surgical centre.

RESULTS

Sixty-six patients with pulmonary metastases from the colon (n=34) and the rectum (n=32) were identified. The 30-day hospital mortality rate was 0%, with 63 patients undergoing a R0 resection and 3 having a R1 resection. The median survival was 45 months and the cumulative 3-year survival rate was 61%. Size of pulmonary metastasis and ASA (American Society of Anesthesiologists) grade were statistically significant prognostic factors (p=0.047 and p=0.009 respectively) with lesions over 20mm associated with a worse prognosis. Sex, age, site, disease free interval (cut-off 36 months), primary tumour stage, hepatic metastases, number of metastases (solitary vs multiple), type of operation (wedge vs lobe resection), hilar lymph node involvement and administration of adjuvant chemotherapy were not found to be statistically significant prognostic factors.

CONCLUSIONS

Pulmonary metastectomy has a potential survival benefit for patients with metastatic CRC. Improved survival even in the presence of hepatic metastases or multiple pulmonary lesions justifies aggressive surgical management in carefully selected patients. In our cohort, size of metastatic deposit was a statistically significant poor prognostic factor.