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

Repeat resection of pulmonary metastasis is beneficial for patients with colorectal carcinoma

BACKGROUND

The role for repeat pulmonary metastasectomy for colorectal carcinoma has not been well defined. To identify the class of patients who benefit from pulmonary resection of recurrent pulmonary metastases, we herein reviewed our institutional experience.

METHODS

Between 1990 and 2007, 84 patients with pulmonary metastases from colorectal carcinomas underwent complete pulmonary resection, and 22 of them (26%) later underwent complete resection for repeat pulmonary metastasis. Various perioperative variables were investigated retrospectively in these patients to confirm a role for repeat metastasectomy and analyze prognostic factors after repeat pulmonary metastasectomy.

RESULTS

Overall survival and disease-free survival after repeat pulmonary metastasectomy were, respectively, 61 and 32% at 5 years. On univariate analysis, male gender and less than 1 year of disease-free status after the first pulmonary metastasectomy demonstrated significantly adverse overall survival (p = 0.01 and p = 0.009, respectively). Elevated preoperative serum carcinoembryonic antigen (CEA) level and maximum tumor size larger than 3 cm were also significantly adverse prognostic factors for disease-free survival (p = 0.03 and p = 0.04, respectively). The overall survival curve after repeat pulmonary metastasectomy was almost identical with that after complete resection of the first pulmonary metastasis.

CONCLUSIONS

Patients with more than 1 year of disease-free status after the first pulmonary metastasectomy demonstrated a significantly better overall survival. Normal preoperative serum CEA level and maximum tumor size <3 cm were significantly adverse prognostic factors for disease-free survival. Our data imply that repeat pulmonary metastasectomy might be beneficial as it can salvage a subset of patients with colorectal carcinoma who retain favorable prognostic determinants.

Influence of modern systemic therapies as adjunct to cytoreduction and perioperative intraperitoneal chemotherapy for patients with colorectal peritoneal carcinomatosis: a multicenter study

BACKGROUND

To evaluate the role of modern systemic therapies and its role as palliative or curative therapy for patients with colorectal peritoneal carcinomatosis with an emphasis on patient selection with the colorectal Peritoneal Surface Disease Severity Score (PSDSS).

METHODS

From three specialized treatment centers, patients with colorectal peritoneal carcinomatosis were identified between December 1988 to December 2009 to receive best supportive care, standard, or modern systemic therapies. Intent was classified as palliative or curative (if treated by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy). Patients were stratified according to the PSDSS. Survival was estimated by the Kaplan-Meier method.

RESULTS

Palliative and curative treatment achieved a median survival of 9 (95% confidence interval [95% CI] 5.9-12.8) and 38 (95% CI 30.2-45.2) months, respectively (P < 0.001). The type of chemotherapy in the palliative and curative group influenced outcome (P < 0.001, P = 0.011, respectively). In the palliative group, PSDSS I/II had a median survival of 24 (95% CI 15.6-32.6) and PSDSS III/IV had a median survival of 6 (95% CI 4.9-8.0) months (P < 0.001). In the curative group, PSDSS I/II had a median survival of 49 (95% CI 40.0-58.3) and PSDSS III/IV had a median survival of 31 (95% CI 20.4-40.9) months (P = 0.002).

CONCLUSIONS

Modern systemic therapies were associated with improved outcome in patients with colorectal peritoneal carcinomatosis treated systemically alone or with cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. Preoperative evaluation with the PSDSS may improve patient selection and optimize outcomes.

[Oncosurgical strategies for metastatic liver cancer]

Patients with liver metastases from colorectal cancer (CRC) present a major public health challenge with approximately, 1,2 million cases of CRC occur yearly worldwide. Resection of colorectal liver metastases (CRLM) is the only treatment offering the possibility of cure and has been shown to provide clear survival benefits. However, only 10 to 20% of patients with CRLM are eligible for this procedure upfront. During the last decade, major advances in the management of CRLM have taken place involving three fields: oncology, interventional radiology, and surgery. These advances have increased the resectability rate to 20-30% of cases with a 5-year survival of 35-50%. Neoadjuvant treatment with chemotherapeutic agents such as irinotecan and oxaliplatin, and hepatic artery infusion combined with systemic therapy and biologic agents (bevacizumab, cetuximab) play an important role in increasing the number of patients eligible to secondary resection. However, with the progressive use of neoadjuvant chemotherapy further studies are necessary to answer questions such as the risk: benefit ratio in maximizing response rates versus vascular changes in the liver (current opinion still divided concerning their importance). These questions remain challenging and should not be underestimated. In this review, we have described the current oncosurgical strategies employed in patients with resectable and non resectable CRLM, their benefits, and future treatment strategies.

Evolution of neoadjuvant therapy for extended hepatic metastases--have we reached our (non-resectable) limit?

Surgical resection offers the best chance for cure in patients with colorectal liver metastases; however, only 15-25% of them can benefit from surgery. To increase resectability a number of strategies have been developed in different fields including chemotherapy, surgery, and radiology. Bringing them together into an integrated framework has expanded the number of patients that can be treated with curative intent. This review focuses on recent oncosurgical changes, their impact, and future directions.

Safety distance in the resection of colorectal lung metastases: a prospective evaluation of satellite tumor cells with immunohistochemistry

OBJECTIVE

After complete pulmonary metastasectomy of colorectal lung metastases, tumor recurrence at the site of former resection develops in some patients. Well-described risk factors for local recurrence in the lung include incomplete resection and aerogenous spread of floating cancer cell clusters. The aim of this study was to describe the distribution and frequency of satellite cancer cells or clusters in resected tissue to deduce recommendations for safety margins in the future.

METHODS

Seventeen colorectal metastases from 10 patients were processed. Evaluation for pattern of growth, satellite cancer cells, and inflammatory reaction at the surface of the metastases was performed on 102 sections with CDX2 and cytokeratin 20 stains. The distance between the surface of the nodule and the satellite cancer cell was measured for each satellite and statistically evaluated.

RESULTS

As a pattern of growth, interstitial spread, inflammatory reaction, and lymphangitic spread were observed in 41.2%, 35.3%, and 23.5%, respectively. A total of 205 satellite cancer cells were identified in 16 of 17 metastases with a mean distance to the nodule of 0.99 ± 0.85 mm (range, 0.06-6.43 mm). The percentages of satellite tumor cells that are likely to be found within 1.59 mm, 3.43 mm, and 7.4 mm around the nodule are 68.27%, 95.5%, and 99.73%, respectively.

CONCLUSIONS

Satellite tumor cells, a potential source for local recurrence, are found in a high number around colorectal lung metastases. As a standard of care, a safety distance of 3 mm for small metastases and 8 to 10 mm for larger metastases must be maintained around the lesion to prevent local recurrence.

Preoperative chest computerized tomography in patients with locally advanced mid or lower rectal cancer: its role in staging and impact on treatment strategy

OBJECTIVES

Pulmonary metastasis is frequent in rectal cancer. Some guidelines recommend chest computerized tomography (CT) for preoperative workup in rectal cancer patients, which have no solid evidence to support this recommendation. This study was designed to evaluate the role of chest CT on preoperative staging in rectal cancer patients and to assess the impact on treatment strategy.

METHODS

Data were prospectively collected from 103 clinically T3/T4 mid or lower rectal cancer patients who had chest X-ray (CXR) and CT to evaluate lung metastasis. The chest images were classified into four groups: metastasis, indeterminate, benign, and negative. Patients showing indeterminate lesions had follow-up CTs at 3- to 6-month intervals.

RESULTS

Nine patients (8.7%) had pulmonary metastases detected on CT. CXR did not reveal any pulmonary metastatic lesions in four of the nine patients. Of these four, treatment was changed in three patients because of these findings. Forty (38.8%) patients had indeterminate nodules on chest CT. Of these, 37 patients had follow-up CTs and four patients (10.8%) showed interval changes that were confirmed as pulmonary metastasis.

CONCLUSIONS

It seems reasonable to perform chest CT for preoperative staging in patients with T3/T4 mid or lower rectal cancer.

Current status of pulmonary metastasectomy

Malignant disease's ability to metastasize remains one of the major obstacles when treating patients with cancer. The change from loco-regional to systemic disease usually renders the patient beyond surgical treatment, as local treatment with surgery in a systemic disease is usually considered without benefit. However, numerous retrospective studies have demonstrated that resection of metastases limited to the lungs may be associated with prolonged survival. No prospective, randomized studies have been published, and most series compare highly selected patients with historical data for unresected patients. In this article, we discuss the current status on pulmonary metastasectomy. Preoperative assessment and selection of surgical candidates is covered. The different surgical strategies including surgical approach, unilateral versus bilateral exploration, lymph node dissection, and repeat surgery are discussed. Finally, we review some of the common tumors that metastasize to the lungs, the role of metastasectomy in their treatment and the prognostic factors with impact on survival.

Sequential surgical resection of hepatic and pulmonary metastases from colorectal cancer

BACKGROUND

Resection of isolated hepatic or pulmonary metastases from colorectal cancer is widely accepted and associated with a 5-year survival rate of 25-40%. The value of aggressive surgical management in patients with both hepatic and pulmonary metastases still remains a controversial area.

MATERIALS AND METHODS

A retrospective review of 1,497 patients with colorectal carcinoma (CRC) was analysed. Of 73 patients identified with resection of CRC and, at some point in time, both liver and lung metastases, 17 patients underwent metastasectomy (resection group). The remaining 56 patients comprised the non-resection group. Primary tumour, hepatic and pulmonary metastases of all patients were surgically treated in our department of surgery, and the results are that of a single institution.

RESULTS

The resection group had a 3-year survival of 77%, a 5-year survival of 55% and a 10-year survival of 18%; median survival was 98 months. The longest overall survival was 136 months; six patients are still alive. In the resection group, overall survival was significantly higher than in the non-resection group (p < 0.01). Independent from the chronology of metastasectomy, 5-year survival was 55% with respect to the primary resection, 28% with respect to the first metastasectomy and 14% with respect to the second metastasectomy. A disease-free interval (>18 months), stage III (UICC) and age (<70 years) were found to be significant prognostic factors for overall survival.

CONCLUSION

Our report strongly supports aggressive surgical therapy in patients with both hepatic and pulmonary metastases from CRC. Overall survival for surgically treated selected patients with both hepatic and pulmonary metastases from CRC is comparable to hepatic or pulmonary metastasectomy. Simultaneous metastases tend to have a poorer outcome than metachronous metastases.

Strict follow-up programme including CT and ¹⁸F-FDG-PET after curative surgery for colorectal cancer

AIM

The risk of local recurrence following curative surgery for colorectal cancer (CRC) is up to 50%. A rigorous follow-up program may increase survival. Guidelines on suitable methods for scheduled follow up examinations are needed. This study evaluates a strict follow-up program including carcinogenic embryonic antigen (CEA), chest X-ray, abdominal ultrasound (US), computed tomography (CT) and (18)F-FDG positron emission tomography (FDG-PET).

METHOD

A cohort of 132 patients, treated by surgery with curative intent for CRC, was included. Patients were followed prospectively with scheduled controls at 3, 6, 12 and 24 months after curative surgery. CEA, chest X-ray, US, CT and FDG-PET supplemented by clinical examination. The end-point was recurrence. Sensitivity and specificity was estimated 2 years after surgery.

RESULTS

Of the 132 patients included in the study, 25 experienced recurrence, detected at scheduled controls (n = 18) and at intervals between them (n = 7). The results of CT and FDG-PET were correlated with recurrence. CT combined with FDG-PET had the highest specificity and sensitivity.

CONCLUSION

A total of 72% of recurrences were detected at scheduled controls. The findings supported a strict follow-up program following curative surgery for colorectal cancer. FDG-PET combined with CT should be included in control programs.

Pulmonary metastasectomy in colorectal cancer: the PulMiCC trial

In March 2010, a randomized trial called Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) was launched and is open to recruitment. The evidence for pulmonary metastasectomy reviewed in this supplement includes no randomized trials. Claims for a survival benefit for patients undergoing this surgery rely on case series. Furthermore, there is little documentation of any symptoms attributable to pulmonary metastases that are alleviated or obviated by metastasectomy. The PulMiCC study aims are to examine whether or not surgical resection of pulmonary metastases from colorectal cancer lengthens survival and to record systematically the harms and benefits of such surgery and quality of life.

Pulmonary metastasis: rationale for local treatments and techniques

The indication for pulmonary metastasectomy has been postulated based on nonrandomized clinical experiences. The postoperative survival rate of selected patients with pulmonary metastasis is acceptable; nevertheless, pulmonary metastasectomy might cure patients if the neoplastic cells are located only in the lung parenchyma. Computed tomography has been the most reliable preoperative diagnostic methods for identifying pulmonary metastasis. However, it has the limitations that small nodules often cannot be detected, or they are overestimated. Through thoracoscopy, which has largely been applied for metastasectomy in Japan, bimanual palpation during surgery cannot be performed. Considering the fact that the survival rate of the patients undergoing thoracoscopy is not significantly different from that of the patients undergoing conventional thoracotomy, pulmonary metastasectomy is a suboptimal method for eradicating the disease. Less invasive local therapy may be promising for repeat local intervention.

Reported outcome factors for pulmonary resection in metastatic colorectal cancer

Pulmonary resection of metastatic colorectal cancer is widely practiced in surgical oncology. However, only a highly selected subset of patients is eligible for resection, and the average recurrence rate is still high. We reviewed the recent literature on pulmonary metastasectomy for colorectal cancer and tried to address the issue of patient selection based on prognostic parameters associated with long-term survival. No randomized phase III trials are available, and data for this review were retrieved only from retrospective studies. We excluded papers reporting on patients earlier than 1990. In summary, there is a substantial body of evidence demonstrating that resection of pulmonary metastases can be performed safely and with a low mortality rate. For a subset of highly selected patients, the overall results of a 5-year actuarial survival rate after complete resection ranged between 40 and 68%. These outcomes exceed those normally associated with metastatic colorectal cancer. It is this perception that has encouraged surgeons and caused the practice to grow.

Early intrapulmonary recurrence after pulmonary metastasectomy related to colorectal cancer

BACKGROUND

Early intrapulmonary recurrence is a major problem after pulmonary metastasectomy related to colorectal cancer. However, the risk factors for early intrapulmonary recurrence are not clear.

METHODS

Between August 2001 and December 2007, 125 patients underwent pulmonary metastasectomy after colorectal cancer. The prognostic factors for overall survival were evaluated, including early (within 6 months) intrapulmonary recurrence. The factors related to early intrapulmonary recurrence were also analyzed.

RESULTS

Thirteen patients (10.4%) had early intrapulmonary recurrence. The median follow-up was 46 months (range, 21 to 99). Early intrapulmonary recurrence (hazard ratio 2.716; 95% confidence interval: 1.027 to 7.182; p = 0.044), extrapulmonary metastasectomy, metastatic hilar or mediastinal lymph nodes, and high prethoracotomy carcinoembryonic antigen levels were independent prognostic factors on multivariate analysis. Extrapulmonary metastasectomy (odds ratio 4.840; 95% confidence interval: 1.314 to 17.821; p = 0.018) and bilateral pulmonary metastasis (odds ratio 6.228; 95% confidence interval: 1.689 to 22.960; p = 0.006) were independent risk factors for early intrapulmonary recurrence.

CONCLUSIONS

Early intrapulmonary recurrence after pulmonary metastasectomy related to colorectal cancer is a prognostic factor for poor overall survival. Extrapulmonary metastasectomy and bilateral pulmonary metastasis are risk factors for early intrapulmonary recurrence. Pulmonary metastasectomy in patients with these risk factors should be considered carefully.

Indications and approach to surgical resection of lung metastases

Pulmonary metastasectomy is a curative option for selected patients with cancer spread to the lungs. Complete surgical removal of pulmonary metastases can improve survival and is recommended under certain criteria. Specific issues that require consideration in a multidisciplinary setting when planning pulmonary metastasectomy include: adherence to established indications for resection, the surgical strategy including the use of minimally invasive techniques, pulmonary parenchyma preservation, and the role of lymphadenectomy.

Predicting survival after pulmonary metastasectomy for colorectal cancer: previous liver metastases matter

BACKGROUND

Few patients with lung metastases from colorectal cancer (CRC) are candidates for surgical therapy with a curative intent, and it is currently impossible to identify those who may benefit the most from thoracotomy. The aim of this study was to determine the impact of various parameters on survival after pulmonary metastasectomy for CRC.

METHODS

We performed a retrospective analysis of 40 consecutive patients (median age 63.5 [range 33-82] years) who underwent resection of pulmonary metastases from CRC in our institution from 1996 to 2009.

RESULTS

Median follow-up was 33 (range 4-139) months. Twenty-four (60%) patients did not have previous liver metastases before undergoing lung surgery. Median disease-free interval between primary colorectal tumor and development of lung metastases was 32.5 months. 3- and 5-year overall survival after thoracotomy was 70.1% and 43.4%, respectively. In multivariate analysis, the following parameters were correlated with tumor recurrence after thoracotomy; a history of previous liver metastases (HR = 3.8, 95%CI 1.4-9.8); and lung surgery other than wedge resection (HR = 3.0, 95%CI 1.1-7.8). Prior resection of liver metastases was also correlated with an increased risk of death (HR = 5.1, 95% CI 1.1-24.8, p = 0.04). Median survival after thoracotomy was 87 (range 34-139) months in the group of patients without liver metastases versus 40 (range 28-51) months in patients who had undergone prior hepatectomy (p = 0.09).

CONCLUSION

The main parameter associated with poor outcome after lung resection of CRC metastases is a history of liver metastases.

Long-term outcomes and quality of life after rectal carcinoma surgery

Background

A cohort study was undertaken to investigate the long-term oncological outcome, late adverse effects and quality of life (QOL) after treatment for rectal cancer.

Methods

This was an analysis of prospectively collected data from 268 consecutive patients with rectal carcinoma treated between 1995 and 1997 at the Department of Surgery, University Hospital Erlangen, Germany.

Results

Median follow-up was 8·8 years. The overall 10-year survival rate was 48·1 per cent. Of 219 patients who had a curative resection, 67 developed recurrent disease and 13 had second malignancies. Seventy patients had either a permanent stoma or a late adverse effect. Anorectal dysfunction and small bowel obstruction were significantly more common among patients who had multimodal treatment (P &lt; 0·001 and P = 0·049 respectively). Analysis of QOL in 97 long-term survivors showed that receiving chemoradiotherapy, a permanent stoma and lower-third rectal carcinoma were associated with significantly worse outcomes on several measures.

Conclusion

Late adverse effects and recurrences occurred in a significant number of patients during long-term follow-up. QOL varied according to tumour location and treatment type.

Radiofrequency ablation as an adjunct to systemic chemotherapy for colorectal pulmonary metastases

BACKGROUND

Radiofrequency ablation (RFA) is an alternative to local treatment for pulmonary metastases in patients who are nonsurgical candidates. Based on previously documented efficacy of this treatment, the authors retrospectively studied the prognostic factors for long-term survival.

METHODS

One hundred patients with unresectable colorectal pulmonary metastases underwent percutaneous RFA. Clinical and treatment variables were collected and evaluated using univariate and multivariate analyses with overall survival as the primary endpoint.

RESULTS

At a median follow-up period of 23 (range, 1 to 96) months from the time of RFA treatment, 49 patients have died. The median overall survival after RFA treatment was 36 months and 5-year overall survival rates of 30%. Univariate analyses demonstrated that histopathological grade (p < .001), time to RFA treatment (p = .017), response to treatment (p < .001), repeat RFA treatments (p = .001), presence of extrapulmonary metastases (p < .001), presence of mediastinal lymphadenopathy (p = .007), and adjunct systemic chemotherapy (p < .001) were associated with overall survival. Multivariate analyses demonstrated that response to RFA treatment (p < .001), repeat RFA treatment (p = .002), presence of extrapulmonary metastases (p = .008), and use of adjunct systemic chemotherapy (p = .05) were independent predictors for survival.

CONCLUSIONS

Radiofrequency ablation for colorectal pulmonary metastases represents a step forward towards a nonsurgical option of combining systemic and local treatment for metastatic disease and is a safe treatment with a low risk profile.

Lung metastasectomy in colorectal cancer: is this surgery effective in prolonging life?

The commonest context in which pulmonary metastasectomy is performed is for recurrent colorectal cancer. With a more active policy of surveillance among cancer teams, ready access to ever faster CT scans and a willingness to perform further surgery to control recurrent cancer, the practice of pulmonary metastasectomy is increasing. In this pro/con debate the issues are explored. It is recognized by both sides that there is no randomized trial evidence on which to base the practice. The difference of opinion is whether there is sufficient evidence from very many case series of both pulmonary and hepatic metastasectomy on which to base current practice. The surgeon's view is that the weight of evidence from many follow-up studies is in favour of continuing this practice. The mathematician's view is that case selection could account for nearly all the observed results.

Cost-effectiveness analysis of FDG PET-CT in the management of pulmonary metastases from malignant melanoma

OBJECTIVES

Most guidelines consider FDG PET-CT to detect occult extra-pulmonary disease prior to lung metastasectomy. A cost-effectiveness analysis, using a Markov model over a 10 year period, was performed to compare two different surveillance programs, either PET-CT or whole-body CT, in patients with suspected pulmonary metastasised melanoma.

METHODS

Data from published studies provided probabilities for the model. Complication and care costs were obtained from standardised administrative databases from 19 hospitals identified by DRG codes (reported in 2009 Euros). For the cost calculation of PET-CT we performed a microcosting analysis. All costs and benefits were yearly discounted at respectively 3% and 1.5%. Outcomes included life-months gained (LMG) and the number of futile surgeries avoided. Cost-effectiveness ratios were in Euros per LMG. Univariate and probabilistic sensitivity analyses addressed uncertainty in all model parameters.

RESULTS

The PET-CT strategy provided 86.29 LMG (95% CI: 81.50-90.88 LMG) at a discounted cost of euro3,974 (95% CI: euro1,339-12,303), while the conventional strategy provided 86.08 LMG (95% CI: 81.37-90.68 LMG) at a discounted cost of euro5,022 (95% CI: euro1,378-16,018). This PET-CT strategy resulted in a net saving of euro1,048 with a gain of 0.2 LMG. Based on PET-CT findings, 20% of futile surgeries could be avoided.

CONCLUSION

Integrating PET-CT in the management of patients with high risk MM appears to be less costly and more accurate by avoiding futile thoracotomies in one of five patients as well as by providing a small survival benefit at 10 years.

[Detection of lymph node involvement and surgical treatment of pulmonary neoplastic processes. Current state of diagnostic and therapeutic procedures]

An analysis is made of different publications associated with the surgical staging and treatment of primary and metastasic pulmonary neoplastic processes. A suitable treatment program is essential to determine lymph node involvement in patients with bronchogenic carcinoma. The indication and sequence of the procedure to use (CT-PET, transbronchial puncture, videomediastinoscopic ultrasound guided transbronchial needle aspiration) is evaluated in accordance to the sensitivity, specificity and positive and negative predictive value of the different methods. Another interesting challenge is to define the criteria for indicating a sublobar resection in certain tumours and patients. Different factors, age, lung function, tumour location and type of sublobar resection, are analysed. Levels of evidence and recommendations of the procedure are also considered. Surgical resection is an accepted therapeutic option in the treatment of colorectal cancer lung metastases. Its indication is based on acceptable survival rates and knowledge of the impact of various factors (interval free of disease, number of metastases, presence of liver metastasis, presence of lymph node involvement, or increased pre-operative levels of carcinoembryonic antigen), is analysed in detail.

Pulmonary metastasectomy in colorectal cancer: a systematic review and quantitative synthesis

OBJECTIVES

Surgical removal of pulmonary metastases from colorectal cancer is undertaken increasingly but the practice is variable. There have been no randomized trials of effectiveness. We needed evidence from a systematic review to plan a randomized controlled trial.

DESIGN

A formal search for all studies concerning the practice of pulmonary metastasectomy was undertaken including all published articles using pre-specified keywords. Abstracts were screened, reviewed and data extracted by at least two of the authors. Information across studies was collated in a quantitative synthesis.

RESULTS

Of 101 articles identified, 51 contained sufficient quantitative information to be included in the synthesis. The reports were published between 1971 and 2007, and reported on 3504 patients. There was little change over time in patient characteristics such as age, sex, the time elapsed since resection of the primary cancer, its site or stage. The proportion with multiple metastases or elevated carcinoma embryonic antigen (CEA) did not change over time but there was an apparent increase in the proportion of patients who also had hepatic metastasectomy. Differences in 5-year survival between groups defined by CEA or by single versus multiple metastases persisted over time. Few data were available concerning postoperative morbidity, postoperative lung function or change in symptoms.

CONCLUSION

The quality of evidence available concerning pulmonary metastasectomy in colorectal cancer is not sufficient to draw inferences concerning the effectiveness of this surgery. There is great variety in what was reported and its utility. Given the burdensome nature of the surgery involved, better evidence, ideally in the form of a randomized trial, is required for the continuance of this practice.

Pulmonary resection for metastases of colorectal adenocarcinoma

BACKGROUND

Surgery is a safe and effective treatment for patients with lung metastases from colorectal carcinoma. Combining chemotherapy and surgery seems to prolong survival time after metastasectomy. Our purpose was to review the effectiveness of surgery with time and evolving managements.

METHODS

The records of 127 patients were retrospectively analyzed. The characteristics of primary cancer, lung metastases, resections, and associated therapy were studied according to their incidence on survival.

RESULTS

There were 74 male and 53 female patients (mean age, 65 years); 223 operations were performed and 314 metastases were resected. Completeness of surgery (n = 117) was the main factor for prolonged survival (5- and 10-year survival, 41% and 27%, versus 0%). There was no factor of significantly better prognosis, but a tendency to higher survival rates was observed in cases of single metastasis, in patients undergoing several lung operations, and in patients in whom liver metastases were previously removed. Three of 7 patients with mediastinal lymph node involvement survived more than 5 years; 58 patients were operated on before January 2000, and 59 between January 2000 and December 2007. Five-year survival rates were 35.1% versus 63.5%, respectively (p = 0.0096), probably related to better selection with modern workup, more frequent use of chemotherapy, and repeated pulmonary resections.

CONCLUSIONS

Different treatment protocols were reported in the literature and in our series with time, resulting in better survival rates and a more aggressive surgical tendency. The beneficial role of such combined therapy justifies further research, including prospective trials.

Prognostic factors of pulmonary metastasectomy for colorectal carcinomas

BACKGROUND

Pulmonary metastasectomy for colorectal carcinoma is a well-accepted procedure; however, reports on indications and prognostic factors are inconsistent. This study was designed to clarify a role for resection of pulmonary metastases for such tumors and to define the patients who benefit from pulmonary metastasectomy.

METHODS

Between 1990 and 2007, 84 patients with pulmonary metastases from colorectal carcinomas underwent curative pulmonary resection. All patients had obtained or had obtainable locoregional control of their primary tumors. Various perioperative variables were investigated retrospectively to confirm a role for metastasectomy and to analyze prognostic factors for overall survival and disease-free survival after metastasectomy.

RESULTS

Overall survival rate after metastasectomy was 60.5% and 48.4% at 5 and 10 years, respectively. Disease-free survival rate was 34.4% and 30.6% at 5 and 10 years after pulmonary resection, respectively. On multivariate analysis, patients with unilateral pulmonary metastasis presented a significantly favorable overall survival (P = 0.045). In contrast, there was no significant prognostic factor for disease-free survival.

CONCLUSIONS

Current practice of pulmonary metastasectomy for colorectal carcinoma in our institution was well justified. Our study confirmed that unilateral pulmonary metastasis was significantly relevant to a better prognosis.

Surgical management of pulmonary metastases

Metastasectomy is the only curative option for some patients with secondary pulmonary malignancy. Many studies suggest a survival benefit in selected patients if complete resection of pulmonary metastases is accomplished. There are several operative approaches that may be used, with the goal of complete resection and with minimal parenchymal loss. Evaluation for resection must include ascertainment of control of the primary tumor and assessment of the ability to achieve complete resection. Minimally invasive approaches may offer advantages in quality of life outcomes, with equivalent oncologic outcomes.

Systematic review of randomized and nonrandomized trials of the clinical response and outcomes of neoadjuvant systemic chemotherapy for resectable colorectal liver metastases

BACKGROUND

Neoadjuvant chemotherapy prior to hepatectomy in patients with resectable colorectal liver metastases (CLM) may facilitate the resectability of the liver lesions and treat occult metastasis but may also lead to hepatic parenchyma damage. There is argument over the oncologic benefit of this practice in patients who would already be suitable for a curative hepatectomy.

METHODS

Extensive literature search of databases (MEDLINE and PubMed) to identify published studies of preoperative systemic chemotherapy for resectable CLM was undertaken with clinical response to treatment and survival outcomes as the endpoints.

RESULTS

Twenty-three studies were reviewed: 1 phase III randomized control trial, 3 phase II studies, and 19 observational studies, comprising 3,278 patients. Objective (complete/partial) radiological response was observed in 64% (range 44-100%) [complete 4% (range 0-38%), partial 52% (range 10-90%)] of patients after neoadjuvant chemotherapy. Pathologically, a median of 9% (range 2-24%) and 36% (range 20-60%) had complete and partial response, respectively. Of patients, 41% (range 0-65%) had stable or progressive disease whilst on neoadjuvant chemotherapy. Median disease-free survival (DFS) was 21 (range 11-40) months. Median overall survival (OS) was 46 (range 20-67) months.

CONCLUSION

Current evidence suggests that objective response to neoadjuvant chemotherapy may be achieved with improvement in DFS in patients with resectable CLM. A prospective randomized trial of neoadjuvant therapy versus adjuvant therapy after liver resection is required to determine the optimal perisurgical treatment regimen.

Outcome after resection of hepatic and pulmonary metastases of colorectal cancer

INTRODUCTION

Multimodal therapies (especially surgery of metastases and "aggressive" chemotherapy) in patients with metastases of colorectal cancers (CRC) are increasingly performed and may provide long-term survival in selected patients with more than one location of metastases. In the current literature, there are only few studies with relatively low patient numbers reporting on the outcome after resection of both hepatic and pulmonary metastases of CRC. We therefore evaluated survival of patients who underwent sequential resection of hepatic and pulmonary metastases under potentially curative intention.

MATERIAL AND METHODS

From 1987 until 2006, 44 patients (32% female; median age, 58 years) with hepatic and pulmonary CRC metastases underwent resections at both metastatic sites. The primary CRCs were in 50% rectal and in 50% colonic carcinomas (61% node positive, all with free resection margins). Metastases occurred synchronously (regarding primary CRC) in 32% of the patients. In 86%, liver resection was performed prior to pulmonary resection. The first resection of metastases was performed a median of 16 months after resection of the primary CRC; the median interval between the first and the second resection of metastases was 7 months. Forty-seven percent of the patients also underwent at least a third metastasectomy. During resection of the first and second site of metastases, free margins were achieved in 98% and 95%, respectively. Survival analysis was performed using Kaplan-Meier and Cox regression methods.

RESULTS

The 5-year survival rates (SV) were 64% after initial surgery of CRC, 42% after the first resection of metastases, and 27% after the last metastasectomy. Patients with synchronous metastases had a 5-year SV after first metastasectomy of 43% and in patients with metachronous metastases of 41% (n.s.). The location of the primary tumor (20% 5-year SV in rectal vs. 57% in colonic cancer; p < 0.02) and the lung as primary site of metastatic disease (5-year SV 0% vs. 60% in patients with primarily hepatic metastases only; p < 0.001) significantly influenced survival in univariate analysis. Patients with rectal cancer had a significantly higher frequency of the lung as first metastatic site (46%) compared to patients with colonic cancer (14%; p < 0.03). Multivariate survival analysis revealed the lung as first metastatic site and as the sole significant independent factor for the outcome (p < 0.001; relative risk vs. liver first metastases 4.7).

CONCLUSION

In selected patients with metastasized CRC resection of both hepatic and pulmonary metastases may improve survival rates or even provide long-term survival. Patients with lung as the first site of metastatic disease (either lung only or in combination with hepatic metastases) have a significantly worse outcome than patients with metastases primarily confined to the liver.

Factors influencing survival after complete resection of pulmonary metastases from colorectal cancer

BACKGROUND

The aim of this retrospective study was to determine the efficacy of complete (R0) resection for pulmonary metastases of colorectal carcinoma, and to clarify prognostic factors for survival that could be used to identify patients likely to benefit most from pulmonary resection.

METHODS

Data on 113 patients who underwent R0 resection of pulmonary metastases from colorectal cancer were reviewed. Overall median follow-up was 49 (range 1-140) months. Clinical and pathological factors were reviewed, and prognostic factors influencing survival were identified.

RESULTS

The overall 5-year survival rate was 67.8 per cent. Multivariable Cox hazard regression analysis revealed that the prethoracotomy serum carcinoembryonic antigen (CEA) level and lymphatic invasion by pulmonary tumour correlated significantly with survival. The 5- and 7-year survival rates of patients with a prethoracotomy CEA level below 5 ng/ml and no lymphatic invasion by pulmonary tumour were 94 and 79 per cent respectively. Pathological features of the primary colorectal cancer, previous hepatectomy for liver metastasis and repeated thoracotomy had no impact on survival.

CONCLUSION

Long-term survival can be expected after R0 resection of pulmonary metastases from colorectal cancer, particularly in patients with a prethoracotomy CEA level below 5 ng/ml and no lymphatic invasion by pulmonary tumour.

Peritoneal carcinomatosis and liver metastases from colorectal cancer treated with cytoreductive surgery perioperative intraperitoneal chemotherapy and liver resection

BACKGROUND

An aggressive therapy comprising of cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) and liver resection/ablation is generally not offered to patients with both colorectal peritoneal carcinomatosis (CRPC) and liver metastases (LM) as it no longer represents a loco-regional disease. We review the outcomes of patients who underwent an aggressive treatment with a curative intent for both CRPC and LM as a prelude towards determining the suitability of this treatment.

METHODS

Patients with CRPC were treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy in our institution. Patients with LM underwent additional treatment of liver resection/ablation. The characteristics and survival of patients with isolated CRPC and those with both CRPC and LM were compared.

RESULTS

Fifty-five patients underwent complete cytoreductive surgery for treatment of CRPC, amongst which 16 patients had LM. The overall median survival was 36 months. Fourteen of the 16 patients treated for CRPC and LM underwent synchronous treatment. When patients with CRPC alone or CRPC with LM were compared, patients with CRPC and LM had a lower PCI (p=0.03), received less HIPEC infusion (p<0.001), received less of both HIPEC and EPIC infusion (p=0.007), had a shorter procedural duration (p=0.001) and required less blood transfusion (p=0.02). There was no difference in survival between patients who had CRPC alone or CRPC with LM who underwent aggressive treatment (p=0.77).

CONCLUSIONS

A curative procedure may be offered to selected patients with CRPC and LM, especially in those with a low peritoneal cancer index.

Treatment in advanced colorectal cancer: what, when and how?

Treatment of advanced colorectal cancer (CRC) increasingly requires a multidisciplinary approach and multiple treatment options add to the complexity of clinical decision-making. Recently novel targeted therapy against angiogenesis and epidermal growth factor receptor completed a plethora of phase III studies. The addition of bevacizumab to chemotherapy improved the efficacy over chemotherapy alone in both first and second line settings, although the magnitude of benefit may not be as great when a more optimal chemotherapy platform is used. Studies performed thus far did not address conclusively whether bevacizumab should be continued in subsequent lines of treatment. Anti-angiogenesis tyrosine kinase inhibitors have not shown any additional benefit over chemotherapy alone so far. Although some benefits were seen with cetuximab in all settings of treating advanced CRC, K-ras mutation status provides an important determinant of who would not benefit from such a treatment. Caution should be exercised in combining anti-angiogenesis with anti-EGFR strategy until further randomised data become available. In this review, we have focused on the implications of these trial results on the everyday management decisions of treating advanced CRC.

[Survival analysis of resection of lung metastases from colorectal cancer]

INTRODUCTION

The publication of the International Registry of Lung Metastases (IRLM) in 1997 was a turning point in favor of surgical resection of lung metastases. Prognostic groups were defined according to resectability, number of metastases, and disease-free interval. The objective of this study was to determine survival in patients who underwent resection of lung metastases from colorectal carcinoma and to evaluate how applicable the prognostic factors established by the IRLM are in this specific patient group.

PATIENTS AND METHODS

Patients with lung metastases from colorectal carcinoma who underwent resection between January 1, 2000, and November 30, 2006, were retrospectively analyzed. Survival was calculated using the Kaplan-Meier method, with log-rank comparisons between groups.

RESULTS

Survivals at 1, 3, 5, and 6 years was 92%, 75%, 54%, and 43%, respectively. The main finding was that 3-year survival was better in patients who underwent atypical resection of the metastasis (75%) than those who required lobectomy (55%). There were no significant differences in survival in terms of number of lung metastases resected or disease-free interval.

CONCLUSIONS

Survival in patients requiring lobectomy for resection of lung metastases from colorectal carcinoma was worse than in those who underwent atypical resection. The number of metastases and disease-free interval may be questionable prognostic factors in the case of lung metastases from colorectal carcinoma.

Current status of pulmonary metastasectomy from primary epithelial tumors

The resection of pulmonary metastases can prolong the survival of selected patients and its therapeutic value is now accepted. The criteria for eligibility have also evolved. We reviewed the recent literature on pulmonary metastasectomy for various epithelial primary tumors and tried to establish better prognostic indicators for its surgical application. In addition to the welldefined requisites for pulmonary metastasectomy, other requirements include the absence of mediastinal lymph node involvement, a limited number of pulmonary metastatic lesions, a long disease-free interval, small metastasis, and no elevation of tumor markers, although the clinical importance of each factor varies among the primary tumors. On the other hand, with the development of video-assisted thoracoscopic surgery (VATS) and advances in thoracic imaging technology, VATS metastasectomy might become an accepted treatment for metastatic nodules located in the periphery of the lung, which can be easily removed by a wedge resection. Repeat surgery is also possible during follow-up after VATS.

Pulmonary resection for colorectal cancer metastases: duration between cancer onset and lung metastasis as an important prognostic factor

BACKGROUND

Pulmonary resection is the most effective treatment available for colorectal lung metastases. However, the characteristics of those patients most likely to benefit from surgical resection have not yet been adequately clarified. We have made a critical analysis for the potential prognostic factors and their clinical significance in lung metastasis from colorectal cancer.

METHODS

We analyzed 63 consecutive patients who underwent curative pulmonary resection for colorectal lung metastases at National Taiwan University Hospital from January 1997 to December 2006. Median follow-up was 37.3 (range 12-122) months. Disease-free and overall survival rates were evaluated by Kaplan-Meier analysis, and multivariate analyses of various prognostic characteristics were performed.

RESULTS

Overall 5-year survival and disease-free survival rates were 43.9% and 19.5%, respectively. Multivariate analysis showed that the interval for development of lung metastases from primary colorectal cancer and the mode of operation were the only two independent prognostic factors for survival. With regard to disease-free survival, the interval between initial resection of colorectal cancer and following lung metastases was the only significant independent prognostic factor. Besides, subset analysis showed that the 5-year survival rate in repeated resection group for recurrence of colorectal metastasis in residual lung was 85.7%.

CONCLUSION

Pulmonary resection, initial or even repeated resection for metastatic tumor from colorectal cancer should be encouraged for selected patients as it can significantly improve survival. Patients who have lung metastases within 1 year after primary tumor resection and those who do not undergo anatomical resection for metastatic lung tumor should be followed more carefully due to poor prognosis.

Pulmonary metastasectomy in colorectal cancer: time for a trial

Pulmonary metastasectomy is undertaken for a range of cancers. The questions we raise here are specifically related to colorectal cancer, the commonest tumour for which pulmonary metastasectomy is undertaken. The primary objective of metastasectomy is to increase survival. There are no randomised trials in support of this practice nor are there any other forms of controlled studies. We present a critical look at the assumption of efficacy for this surgery and propose that a trial is needed and suggest a trial design.

Adrenalectomy for clinically isolated metastasis from colorectal carcinoma: report of eight cases

PURPOSE

Metastasis to the adrenal glands is a relatively frequent finding at autopsy. Adrenal metastasis of colorectal carcinoma is rare (14 percent). Isolated adrenal metastasis is even rarer, and presents a therapeutic dilemma.

METHODS

Between 1997 and 2006, eight patients (5 men; mean age, 62 years) underwent adrenalectomy for metastasis of colorectal carcinoma. The tumors were Stage D in four cases, Stage B in two cases, and Stage C in the remaining two. Adjuvant chemotherapy was instituted.

RESULTS

All patients were asymptomatic, and adrenal metastasis was suspected from an elevated serum level of carcinoembryogenic antigen or discovered by computed tomography. Adrenal metastases were metachronous in seven patients, with median disease-free interval of 3.75 years. At the time of follow-up, one patient remained alive and free of disease 12 months after adrenalectomy, one patient was lost to follow-up after 22 months, and 6 patients have died from malignancy. The mean survival for the patients who died was 32 months.

CONCLUSIONS

The rarity of isolated adrenal metastasis of colorectal carcinoma makes a randomized, prospective trial comparing surgery vs. nonsurgical management highly unlikely. Our results provide further support for surgical resection of solitary adrenal metastasis, which may translate into survival benefit.

[Metastases of colorectal carcinoma]

Metastases of colorectal cancer represent an interdisciplinary therapeutic challenge. Evidence-based guidelines are supportive of treatment decisions in specific situations with the objective to improve the therapeutic outcome for patients. Interventional tumor therapies are increasingly applied therapeutic options in the treatment of colorectal metastases. The current literature indicates that thermoablation of colorectal liver metastasis can lead to an improved survival in selected patients. However, recommendation of thermoablation as a part of guidelines for the therapy of colorectal metastases is restricted due to a shortcoming of randomized controlled trials. Therefore, interventional tumor therapies have to be evaluated in comparison with standard therapies, particularly with regard to surgical resection and chemotherapy. Moreover, the interdisciplinary combination of tumor ablation, surgical resection, and chemotherapy is a promising approach for the optimization of oncological therapy strategies in the treatment of colorectal metastases.