Repeat resection for recurrent pulmonary metastasis of colorectal cancer

Reoperative Pulmonary Metastasectomy: Outcomes and Indications

Recurrent pulmonary metastasis after initial pulmonary metastasectomy is common and poses a clinical dilemma. Reoperative pulmonary metastasectomy is an option that in select patients has been shown to be safe and technically feasible resulting in encouraging survival results from non-randomized retrospective studies. As with metastasectomy in general, there is ongoing debate if observed benefit of repeat pulmonary resection is a result of surgery or a reflection of selection bias. This review summarizes available evidence regarding reoperative pulmonary metastasectomy, discusses selection bias, and outlines future directions in the context of our evolving understanding of the oligometastatic state.

Updated insights into the impact of adjuvant chemotherapy on recurrence and survival after curative resection of liver or lung metastases in colorectal cancer: a rapid review and meta-analysis

BACKGROUND

Colorectal cancer (CRC) frequently metastasizes to the liver and lungs, leading to poor prognosis. Advances in chemotherapy, minimally invasive surgery, and perioperative care have expanded adjuvant chemotherapy (AC) regimens and eligibility for AC. However, the impact of AC after curative resection of distant metastases on recurrence and prognosis remains uncertain. This study evaluated the role of AC in CRC liver and lung metastases, focusing on cases with curative resection based on the latest studies published in the past five years.

METHODS

This systematic review followed PRISMA guidelines. Literature searches of Medline and Cochrane Library (2019-2023) identified studies on AC or observation after curative resection of CRC metastases, reporting outcomes such as overall survival (OS) and disease-free survival (DFS). Data analysis was performed using Review Manager and R software, with results expressed as hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Seven studies met the eligibility criteria, including one randomized controlled trial and six retrospective studies, encompassing 1580 patients who underwent curative resection (R0) for CRC metastases. This meta-analysis showed a positive trend in OS for the AC group compared to that for the surgery-alone group (HR 0.86, 95% CI: 0.73-1.01; p = 0.06), but the difference was insignificant. AC significantly improved DFS (HR 0.81, 95% CI: 0.66-0.99; p = 0.04). Subgroup analysis indicated that AC significantly improved DFS and tended to improve OS for liver metastasis. In contrast, AC did not improve OS in cases of lung metastasis.

CONCLUSIONS

This meta-analysis suggests that AC demonstrated significant positive effects on DFS. Moreover, AC could contribute to improvements in OS. These findings, supported by the latest research, reinforce the recommendation of AC as a valuable strategy for improving both recurrence and survival outcomes in patients with curatively resected distant CRC metastases.

Long-term clinical outcomes after the second metastasectomy in patients with resected metastatic colorectal cancer

PURPOSE

Primary tumor resection and metastasectomy are curative for metastatic colorectal cancer. However, there is still a paucity of data regarding the clinical outcomes and risk factors after disease recurrence and second metastasectomy.

MATERIALS AND METHODS

We retrospectively evaluated the clinical outcomes of patients who underwent the second metastasectomy. In addition, risk factors for the outcomes were analyzed.

RESULTS

A total of 94 patients (39 females and 55 males) received a second metastasectomy after the recurrence. Recurrent sites included the lung (47 patients), liver (36 patients), both lung and liver (four patients), and non-lung/non-liver (seven patients). Among them, 89 (94.7 %) patients achieved R0 resection, while three (3.2 %) and two (2.1 %) patients achieved R1 and R2 resections, respectively. The 5-year disease-free survival (DFS) and overall survival (OS) were 42.8±5.3 % and 67.2±4.9 %, respectively. Multivariable analysis for DFS identified that primary rectal cancer (hazard ratio [HR] 0.45, P=0.033) and disease-free interval after the first metastasectomy of ≥12 months (HR 0.39, P=0.002) were good predictive factors; in contrast, non-lung/non-liver metastasis (HR 3.32, P=0.020) was a poor predictive factor. Multivariable analysis for OS showed that age ≥70 years (HR 3.27, P=0.011), non-lung/non-liver metastasis (HR 4.04, P=0.024), and lesion number ≥2 (HR 2.25, P=0.023) were poor prognostic factors.

CONCLUSION

Patients who underwent a second metastasectomy had a long-term disease-free state and good OS. Our data suggest that a second metastasectomy should be considered if a patient has a limited number of metastases confined to the liver and/or lung and long DFS after the first metastasectomy.

A Retrospective Analysis of Real-Life Management of Colorectal Cancer Lung-Limited Metastases Treated with Surgery: Outcomes and Prognostic Factors

Background: Unlike liver metastases, the role of surgery in colorectal cancer lung-limited metastases (CCLLM) is not yet established, and data are still poor. We performed a retrospective analysis to evaluate the impact of surgery on the management of CCLLM. Material and Method: We retrospectively analyzed patients who received surgery for CCLLM at our Institution from January 2010 to June 2019. The aim of the study was to evaluate the impact of clinical and pathological features on the survival (OS and DFS) of patients treated with surgery for CCLLM. Results: One hundred and fifty patients were included in the analysis. Seventy-six patients received preoperative chemotherapy (pCT) and 56 an adjuvant treatment (aCT), while 18 underwent up-front surgery without CT. In the whole population, median OS (mOS) and median DFS (mDFS) were 54.1 months (95%CI 44.0-82.1) and 24.0 months (95%CI 20.0-31.2), respectively. In multivariate analysis, number of metastases was the only factor correlated to DFS (p = 0.0006) and OS (p = 0.0018). Conclusion: Our study, although retrospective and of small size, shows that tumor burden (number of metastases) is the main prognostic factor in patients undergoing lung surgery for CCLLM. Moreover, our results suggest that surgery for lung metastases might prolong survival. These data strengthen the role of multidisciplinary management to allow patients with CCLLM to pursue local treatment whenever possible, even regardless of previous liver surgery or RAS mutated status.

The Case for Pulmonary Metastasectomy-Clinical Practice Narrative Review and Commentary

Pulmonary metastasectomy has become a well-established procedure for patients with certain types of solid tumors. Patients are usually scheduled for staged lung metastasectomy in case of primary tumor control, the absence of distant non-lung metastases, and when complete resection is achievable. Nodules are removed with precision resection in order to ensure radical resection with minimal margins; this technique permits good oncological results, preserving the surrounding pulmonary parenchyma and causing minimal distortion compared to staplers. When possible, anatomical resections should be avoided since they are not justified by real oncological advantages and, in the majority of cases, sacrifice too much healthy tissue, possibly leading to inoperability in the case of metachronous relapses. Thus, preserving the maximum amount of pulmonary parenchyma is crucial because repeated metastasectomies are possible and frequent, with no theoretical limits to the number of reinterventions. In our multidisciplinary board team, we support the role of pulmonary metastasectomy as a useful curative therapy, with acceptable morbidity and mortality, with indications to be discussed case-by-case.

Pulmonary metastasectomy and repeat metastasectomy for colorectal pulmonary metastases: outcomes from the Dutch Lung Cancer Audit for Surgery

BACKGROUND

Surgical resection of recurrent pulmonary metastases in patients with colorectal cancer is an established treatment option; however, the evidence for repeat resection is limited. The aim of this study was to analyse long-term outcomes from the Dutch Lung Cancer Audit for Surgery.

METHODS

Data from the mandatory Dutch Lung Cancer Audit for Surgery were used to analyse all patients after metastasectomy or repeat metastasectomy for colorectal pulmonary metastases from January 2012 to December 2019 in the Netherlands. Kaplan-Meier survival analysis was performed to determine the difference in survival. Multivariable Cox regression analyses were performed to identify predictors of survival.

RESULTS

A total of 1237 patients met the inclusion criteria, of which 127 patients underwent repeat metastasectomy. Five-year overall survival was 53 per cent after pulmonary metastasectomy for colorectal pulmonary metastases and 52 per cent after repeat metastasectomy (P = 0.852). The median follow-up was 42 (range 0-285) months. More patients experienced postoperative complications after repeat metastasectomy compared with the first metastasectomy (18.1 per cent versus 11.6 per cent respectively; P = 0.033). Eastern Cooperative Oncology Group performance status greater than or equal to 1 (HR 1.33, 95 per cent c.i. 1.08 to 1.65; P = 0.008), multiple metastases (HR 1.30, 95 per cent c.i. 1.01 to 1.67; P = 0.038), and bilateral metastases (HR 1.50, 95 per cent c.i. 1.01 to 2.22; P = 0.045) were prognostic factors on multivariable analysis for pulmonary metastasectomy. Diffusing capacity of the lungs for carbon monoxide less than 80 per cent (HR 1.04, 95 per cent c.i. 1.01 to 1.06; P = 0.004) was the only prognostic factor on multivariable analysis for repeat metastasectomy.

CONCLUSION

This study demonstrates that patients with colorectal pulmonary metastases have comparable median and 5-year overall survival rates after primary or recurrent pulmonary metastasectomy. However, repeat metastasectomy has a higher risk of postoperative complications.

Outcome of Repeated Resection of Pulmonary Metastases for Renal Cell Cancer

BACKGROUND

To date, many studies investigated results and prognostic factors of pulmonary metastasectomy (PM) in renal cell cancer (RCC). However, reports concerning repeated resection for patients with recurrent pulmonary metastases (RPM) are limited. In this study, we analyzed safety, efficacy, and prognostic factors for survival after PM focusing on RPM for RCC.

PATIENTS AND METHODS

Clinical, operative, and follow-up data of patients who underwent PM or RPM for RCC in our institution were retrospectively collected and correlated with each other from January 2005 to December 2019.

RESULTS

Altogether 154 oncological pulmonary resections in curative intention as PM or RPM were performed in 82 and 26 patients. Postoperative complications were similar in both groups (n = 22 [26.8%] vs. 4 [15.4%], p = 0.2). Zero mortality was documented up to the 30th postoperative day. RPM was not associated with decreased 5-year-survival compared with PM (66.2 vs. 57,9%, p = 0.5). Patients who underwent RPM for recurrent lung metastases had a better overall survival in comparison with the other treatments including chemotherapy, radiotherapy, immunotherapy, and best supportive care (p = 0.04). In the multivariate analysis, disease-free survival was identified as an independent prognostic factor for survival (hazard ratio: 0.969, 0.941-0.999, p = 0.04).

CONCLUSION

RPM is a safe and feasible procedure. The resection of recurrent lung metastases shows to prolong survival in comparison with the other therapeutic options for selected patients with RCC.

Survival by Number and Sites of Resections of Recurrence after First Curative Resection of Colorectal Liver Metastases

BACKGROUND

Recurrence after curative hepatectomy for colorectal liver metastases (CRLM) is common. We sought to determine if number and sites of resections of recurrence after hepatectomy for CRLM impact survival.

METHODS

The study included patients who underwent resection of recurrence following complete curative-intent resection of CRLM during 1998-2016 at two academic medical centers in Houston, USA, and Rome, Italy. The survival impacts of number and sites of resections of recurrence were evaluated. Patients with synchronous extrahepatic disease at curative CRLM resection were excluded.

RESULTS

Among 2163 patients who underwent curative hepatectomy, 1456 (67.3%) developed a recurrence. Four hundred seventy-eight patients underwent one (322/478; 67.4%) or two or more (156/478; 32.6%) resections of recurrence. The 5-year overall survival (OS) rate was higher in patients with resected than unresected recurrence (70.2% vs. 24.0%; p < 0.001). In patients who underwent only one resection of recurrence, the 5-year OS rate differed by location (lung, 81.6%; liver, 64.3%; other, 54.1%). In patients who underwent two or more resections of recurrence, the 5-year OS rate was similar for liver-only resection (87.5%) and resection of liver and other sites (66.1%) (p = 0.223) and for liver-only resection and other-sites-only resection (80.7%) (p = 0.258); 5-year OS rate by site of first resection of recurrence did not differ between liver (78.5%) and lung (81.8%) (p = 0.502) but was worse for other sites (61.1%) than for lung (p = 0.045).

CONCLUSION

When recurrence after initial CRLM resection is resectable, the ability to undergo resection was associated with improved survival and can be considered as an option regardless of the number of recurrence and resection. Sites of resection of recurrence impact survival and should be considered.

Survival and prognostic factors of isolated pulmonary metastases originating from colorectal cancer: An 8-year single-center experience

Background

Isolated pulmonary metastasis (IPM) is a rare entity that accounts for 10% of pulmonary metastases seen in colorectal cancer (CRC). This study aims to evaluate the overall 5-year survival of IPM originating from CRC and identify potential prognostic factors affecting the overall survival (OS).

Methods

A retrospective cohort study conducted in a tertiary care center. The study included all patients diagnosed with CRC aged 18–75 years who underwent primary tumor resection with curative intent between 2008 and 2015, and developed IPM. Patients with no follow-up and those with extra-pulmonary metastases were excluded.

Results

The prevalence of IPM in the overall CRC cases was 4.18% (20/478 patients). The mean age of patients with IPM was 52.7 ± 12.9 years. Ten patients had synchronous IPM (50%), thirteen had unilateral (65%), and eleven underwent metastasectomy (55%). The 5-year OS was 40%, and the mean OS was 3.12 ± 1.85 years. Several factors were found to be associated with a favorable outcome, which include unilateral IPM (3.69 vs. 2.07 years; P = 0.024), metachronous (4.25 vs. 2.14 years; P = 0.017), metastasectomy (4.81 vs. 1.83 years; P = 0.005). In addition, mortality was likely to be decreased by more than 90% after metastasectomy (unadjusted odds ratio = 0.071; 95% confidence interval [CI] = 0.01–0.8; P = 0.032).

Conclusions

Forty percent of the included patients survived the 5-year follow-up. Better survival was associated with the metastases being unilateral, metachronous, and metastasectomy. Mortality was lower in patients with pulmonary recurrence after metastasectomy.

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IPM showed an incidence of 4% among resectable CRC patients.

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IPM demonstrated 40% 5-year overall survival.

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Survival was not influenced by age, comorbidities, KRAS mutation, nor the number of pulmonary lesions.

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Unilateral lesions, metachronous metastases, and metastasectomy were associated with a favorable outcome.

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The mortality was likely to be decreased by >90% after metastasectomy.

Role of MicroRNA-223 and MicroRNA-182 as Novel Biomarkers in Early Detection of Colorectal Cancer

Background

Colorectal cancer is a common and lethal disease. It is estimated that approximately 145,600 new cases of large bowel cancer are diagnosed annually in the USA. MiRNA-223 and miRNA-182 have been reported in various cancers, such as lung, gastric, breast and colorectal cancer and proposed to be valid and reliable for diagnosis as well as prognosis.

Aim

This study aimed to determine the role of miR-223 and miR-182 as novel biomarkers for early detection and prognosis of CRC.

Patient and Methods

This case–control study was conducted at the department of Internal Medicine, Aswan University Hospital, in the period from the 1st of February 2020 to the 20th of April 2021. Thirty-five cases and thirty age- and sex-matched controls were included in the study. All patients were subject to complete clinical evaluation, routine investigations, occult blood in stool, serum levels of CEA and CA 19–9, serum levels of miR-223 and miR-182 by quantitative PCR.

Results

Significant difference between the two studied groups regarding biomarker changes was found. ROC curve analysis showed that the new markers had excellent diagnostic as well as prognostic criteria. Micro-RNA-223 diagnostic accuracy, sensitivity, specificity, PPV, NPV, FDR and FOR were 97%, 97.1%, 96.7%, 97%, 97%, 3.3% and 2.9%, respectively. Also, micro-RNA-182 diagnostic accuracy, sensitivity, specificity, PPV, NPV, FDR and FOR were 97%, 98%, 96%, 96%, 98%, 3.9% and 2%, respectively.

Conclusion

MiR-223 and miR-182 have been discovered to be relevant and reliable biomarkers for the early identification and prognosis of CRC. Increased levels of miR-223 and miR-182 were associated with increased risk of disease progression, and the more accurate the value of miR-223 and miR-182, the earlier the diagnosis of colorectal cancer.

[Results of redo liver resections for metastatic colorectal cancer]

OBJECTIVE

To analyze patients undergoing redo liver resections for metastatic colorectal cancer.

MATERIAL AND METHODS

The study included 14 patients with colorectal cancer who underwent several redo liver resections for metastatic lesions between September 2011 and June 2021. Mean age of patients was 63.5 years. Left-sided colonic G2 adenocarcinoma T4N1-2 prevailed (wild-type KRAS).

RESULTS

Fourteen patients (100%) underwent two liver resections, 7 (50%) - three resections, 1 (7.1%) - four resections. Mean period between the first and the second liver resections was 16.2 months, between the second and the third resections - 9.9 months, between the third and the fourth resections - 5 months. Maximum follow-up period after primary surgery was 9 years and 9 months. Seventy-five percent of patients were alive after 34.2 months, 50% - after 58.9 months. N+ status of colorectal tumor decreased survival while KRAS mutation and synchronous metastatic liver lesions increased survival.

CONCLUSION

Redo liver resections for metastatic colorectal cancer are safe and ensure favorable long-term survival in certain patients.

Systematic Review of Treatments for Colorectal Metastases in Elderly Patients to Guide Surveillance Cessation Following Hepatic Resection for Colorectal Liver Metastases

BACKGROUND

Although included in surveillance programmes for colorectal cancer (CRC) metastases, elderly patients are susceptible to declines in health and quality of life that may render them unsuitable for further surveillance. Deciding when to cease surveillance is challenging.

METHODS

There are no publications focused on surveillance of elderly patients for CRC metastases. A systematic review of studies reporting treatment outcomes for CRC metastases in elderly patients was performed to assess the risk-benefit balance of the key objectives of surveillance; detecting and treating CRC metastases.

RESULTS

Sixty-eight eligible studies reported outcomes for surgery and chemotherapy in the elderly. Liver resections and use of chemotherapy, including biologics, are more conservative and have poorer outcomes in the elderly compared with younger patients. Selected studies demonstrated poorer quality-of-life (QoL) following surgery and chemotherapy. Studies of ablation in elderly patients are limited.

DISCUSSION

The survival benefit of treating CRC metastases with surgery or chemotherapy decreases with advancing age and QoL may decline in the elderly. The relatively lower efficacy and detrimental QoL impact of multimodal therapy options for detected CRC metastases in the elderly questions the benefit of surveillance in some elderly patients. Care of elderly patients should thus be customized based on their preference, formal geriatric assessment, natural life-expectancy, and the perceived risk-benefit balance of treating recurrent CRC metastases. Clinicians may consider surveillance cessation in patients aged 75 years and above if geriatric assessment is unsatisfactory, patients decline surveillance, or patient fitness deteriorates catastrophically.

Outcome of Repeat Pulmonary Metastasectomy

Pulmonary metastasectomy is a well-established contribution to the cure of oligometastatic cancers, but its exact effectiveness is poorly understood. Here we report the outcomes of repeat pulmonary metastasectomy from a multicenter trial. This retrospective study included patients who underwent re-do metastasectomies between January 2010 and December 2014. The exclusion criterion was metastasectomy without curative intent. We reviewed medical files of 621 consecutive patients who underwent initial pulmonary metastasectomy. Of those, 64 patients underwent repeat metastasectomies, and these patients were included in the analysis. All the 64 patients underwent a second metastasectomy, later 35 of them underwent a third metastasectomy, 12 underwent a fourth metastasectomy, and 6 underwent a fifth metastasectomy. The total number of re-do metastasectomies was 181. The median overall survival among the patients undergoing re-do metastasectomy was 66.0 ± 3.8 months. Three and 5-year survival rates were 82.3% and 63.3%, respectively. The 5-year survival rates were 63.3% after the first, 50.9% after the second, 74.4% after the third, 83.3% after the fourth, and 60.0% after the fifth metastasectomy. We conclude that at the current stage of knowledge, there is an indication for repeat re-do metastasectomy with curative intent.

Results of redo pulmonary metastasectomy

Repeat surgical resection (redo) for pulmonary metastases is a questionable, albeit intriguing topic. We performed an extensive review of the literature, to specifically analyze results of redo pulmonary metastasectomies. We reviewed a total of 3,523 papers. Among these, 2,019 were excluded for redundancy and 1,105 because they were not completely retrievable. Out of 399 eligible papers, 183 had missing information or missing abstract, while 96 lacked data on survival. A total of 120 papers dated from 1991 onwards were finally included. Data regarding mortality, major morbidity, prognostic factors and long-term survivals of the first redo pulmonary metastasectomies were retrieved and analyzed. Homogeneity of data was affected by the lack of guidelines for redo pulmonary metastasectomy and the risks of bias when comparing different studies has to be considered. According to the histology sub-types, redo metastasectomies papers were grouped as: colorectal (n=42), sarcomas (n=36), others (n=20) and all histologies (n=22); the total number of patients was 3,015. Data about chemotherapy were reported in half of the papers, whereas targeted or immunotherapy in 9. None of these associated therapies, except chemotherapy in two records, did significantly modify outcomes. Disease-free interval before the redo procedure was the prevailing prognostic factor and nearly all papers showed a significant correlation between patients’ comorbidities and prognosis. No perioperative mortality was reported, while perioperative major morbidity was overall quite low. Where available, overall survival after the first redo metastasectomy ranged from 10 to 72 months, with a 5-years survival of approximately 50%. The site of first recurrence after the redo procedure was mainly lung. Despite the data retrievable from literature are heterogeneous and confounding, we can state that redo lung metastasectomy is worthwhile when the lesions are resectable and the perioperative risk is low. At present, there are no “non-surgical” therapeutic options to replace redo pulmonary metastasectomies.

Is repeated pulmonary metastasectomy justified?

Recurrence after pulmonary metastasectomy (PM) is frequent, but it is unclear to whom repeated pulmonary metastasectomy (RPM) offers highest benefits. Retrospective analysis of oncological and post-operative outcomes of consecutive patients who underwent PM from 2003 to 2018. Overall survival (OS) and disease-free interval (DFI) were calculated. Cox regression was used to identify variables influencing OS and DFI. In total, 264 patients (female/male: 114/150; median age: 62 years) underwent PM for colorectal cancer (32%), sarcoma (19%), melanoma (16%) and other primary tumors (33%). Pulmonary metastasectomy was approached by video-assisted thoracic surgery (VATS) in 73% and pulmonary resection was realized by non-anatomical resection in 76% of cases. The overall median follow-up time was 33 months (IQR 16–56 months) and overall 5-year survival rate was 62%. Local or distant recurrences were observed in 172 patients (65%) and RPM could be performed in 66 patients (25%) for a total of 116 procedures. RPM was realized by VATS in 49% and pulmonary resection by wedge in 77% of cases. In RPM patients, the 5-year survival rate after first PM was 79%. Post-operative cardio-pulmonary complication rate (13% vs. 12%; p = 0.8) and median length of stay (4 vs. 5 days; p = 0.2) were not statistically different between first PM and RPM. Colorectal cancer (HR 0.56), metachronous metastasis (HR 0.48) and RPM (HR 0.5) were associated with better survival. In conclusion, our results suggest that RPM offers favorable survival rates without increasing post-operative morbidity.

Development and clinical application of bispecific antibody in the treatment of colorectal cancer

INTRODUCTION

Treatment of colorectal cancer as one of the most commonly diagnosed and a frequent cause of cancer-related deaths is of great challenges in health-related issues.

AREAS COVERED

Immunotherapy is the fourth pillar of cancer treatment which provides more novel therapeutic options with expanding investigational potentials. One of the modalities in immunotherapy is the use of bispecific antibodies. Despite demonstrating many promising roles, it still needs more advanced studies to identify the actual pros and cons. In this review, the application of bispecific antibody in the treatment of colorectal cancer has been explained, based on preclinical and clinical studies. The literature search was conducted mainly through PubMed in June and September 2019.

EXPERT OPINION

Bispecific antibody is in its early stages in colorectal cancer treatment, requiring modern technologies in manufacturing, better biomarkers and more specific target antigens, more studies on individual genetic variations, and conducting later phase clinical trials and systematic reviews to achieve better survival benefits.

Benefits of repeated resections for liver and lung metastases from colorectal cancer

OBJECTIVE

We aimed to evaluate oncological outcomes after repeat metastasectomies in patients having undergone previous resections for colorectal cancer metastases.

METHODS

We examined 248 patients who underwent metastasectomies for lung and/or liver metastases at our center during a 7-year period, from January 2005 to December 2011. Recurrence-free survival 1 (RFS1) after the metastasectomy for the initial recurrence, recurrence-free survival 2 (RFS2) after the second, and recurrence-free survival 3 (RFS3) after the third repeated resections for recurrence were assessed. The overall survival (OS) rate after the first metastasectomy for the first recurrence (OS) was also assessed.

RESULTS

Sites of recurrence of the first metastasectomy were the liver, lung, and liver and lung in 115, 117, and 16 cases, respectively, and 133 patients had a second recurrence (133/248, 53.6%). Twenty-seven patients had a third recurrence (27/52, 51.9%), of whom 14 underwent a third metastasectomy. The 5-year and 10-year OS rates were 74.8% and 57.9%, respectively. The 1-year RFS1, RFS2, and RFS3 rates were 76%, 75%, and 39%, respectively. The hazard ratios for RFS were 1.142 and 2.590 for the first and second repeat surgeries, when compared to the first metastasectomy. The third metastasectomy showed significantly lower RFS than did the second metastasectomy.

CONCLUSION

A second metastasectomy should be considered the optimal treatment for a second recurrence. However, careful considerations should be made before performing a third metastasectomy.

[Rationale of thoracic lymph node dissection in pulmonary metastasectomy]

The goal of metastasectomy is a R0 resection. Depending of the tumor entity the prevalence of lymph node metastases in pulmonary metastasectomy can be up to 45%; however, systematic lymph node dissection is not yet established as a fixed component of metastasectomy. Although there is a high prevalence of lymph node metastases and the increase in the prevalence with a higher number of lung metastases, it remains unclear if a systematic lymph node dissection should be part of pulmonary metastasectomy. For this reason, the goal of this review was to evaluate the rationale of systematic lymph node dissection in pulmonary metastasectomy based on the currently available literature. Furthermore, it was investigated whether patients with additional thoracic lymph node metastases should be excluded per se from pulmonary metastasectomy, even though positive lymph node metastases might be associated with a lower but nevertheless good long-term survival after resection.

Long-term outcome after sequential liver and lung metastasectomy is comparable to outcome of isolated liver or lung metastasectomy in colorectal carcinoma

BACKGROUND AND AIMS

Previously, colorectal cancer (CRC) metastasis of both liver and lungs was considered disseminated disease, which contraindicated surgical metastasectomies. Increasing evidence from studies on patient series have indicated that survival improved after resecting both liver and lung metastases. However, those results and long-term outcomes remain controversial. We aimed to compare surgical outcomes between patients treated for both liver and lung metastases to the patients who had only isolated liver or lung metastases.

MATERIAL AND METHODS

All patients (n = 105) underwent surgery for CRC metastases between July 2002 and September 2015. Three groups were compared: the sequentially operated group (n = 33 patients) underwent sequential liver and lung resections; the liver group (n = 38 patients) underwent liver resections; and the lung group (n = 34 patients) underwent lung resections. The main endpoints were long-term survival rates.

RESULTS

The groups were not different in disease-free survival (P = 0.727) or overall survival (P = 0.218). Five-year survival rates were 69.7% in the sequentially operated group, 65.1% in the liver group, and 50.0% in the lung group.

CONCLUSION

Long-term outcomes after sequential liver and lung resections of CRC metastases were comparable to outcomes after isolated liver or lung metastasectomies. Therefore, aggressive surgical interventions should be considered for patients with both liver and lung metastases of CRC.

Progressive Oncological Surgery Is Associated with Increased Curative Resection Rates and Improved Survival in Metastatic Colorectal Cancer

Background: Secondary resection rates in first-line chemotherapy trials for metastatic colorectal cancer (mCRC) remain below 15%, representing a clear contrast to reports by specialised surgical centres, where progressive liver, peritoneal-surface, and pulmonary surgery increased access to curative-intent treatment. We present a long-term evaluation of oncosurgical management in a single-centre, analysing the aggregate effect of gradual implementation of surgical subspecialties and systemic treatments on mCRC patients’ resection rates and prognosis. Methods: Patients with newly diagnosed mCRC from 2003 to 2014 were retrospectively categorised into palliative treatment (PAT) and curative intent surgery (CIS) and three time periods were analysed for treatment changes and factors associated with survival. Results: Four hundred-twenty patients were treated (PAT:250/CIS:170). Over time periods, the number of presenting patients remained consistent, whereas curative resection rates increased from 29% to 55%, facilitated by an increment of patients undergoing hepatectomy (21 to 35%), pulmonary surgery (6 to 17%), and peritonectomy/intraoperative chemotherapy (0 to 8%). Also, recently, significantly more multi-line systemic treatments were applied. The median survival markedly improved from 21.9 months (2003–2006; 95% confidence interval (CI) 17.3–26.5) to 36.5 months (2011–2014; 95% CI 26.6–46.4; p = 0.018). PAT was a significant factor of poor survival and diagnosis of mCRC in the latest time period was independently associated with a distinctly lower risk for palliative treatment (odds ratio 0.15). Conclusions: In modern eras of medical oncology, achieving appropriate resection rates through utilization of state-of-the-art oncological surgery by dedicated experts represents a cornerstone for long-term survival in mCRC.

Repeating of local therapy of distant metastases increases overall survival in patients with synchronous metastasized rectal cancer-a monocentric analysis

PURPOSE

The aim was to evaluate the outcome of treatment-naive patients with synchronous metastatic rectal cancer after chemotherapy with FOLFOXIRI followed by local therapeutic procedures of all tumor lesions as complete as possible.

METHODS

We reviewed data of 30 patients with synchronous distant metastatic rectal cancer who underwent chemotherapy with FOLFOXIRI and subsequent local therapy in our institution.

RESULTS

Median follow-up was 28 months (range: 8; 74). Cumulative overall survival (OS) and progression-free survival (PFS) was 93.3, 76.9, 55.6% and 46.2, 29.7, 29.7% after 1, 2, 4 years. Non-response to chemotherapy with FOLFOXIRI was associated with a highly significant decreased OS (p < 0.0001). The consistent use of local ablative procedures led to a statistically significant increase in OS (p < 0.0001), but not in PFS (p = 0.635). Patients with ≤ 4 distant metastases showed a better OS (p = 0.033).

CONCLUSIONS

Response to intensified first-line chemotherapy with FOLFOXIRI, treatment of the primary rectal tumor, and repeated thorough local ablative procedures in patients with synchronous metastasized rectal cancer may lead to long-term survival, even in a subset of patients with unresectable disease at initial diagnosis.

Morbidity, mortality, and survival in elderly patients undergoing pulmonary metastasectomy for colorectal cancer

PURPOSE

The number of elderly patients with colorectal cancer is increasing. Nevertheless, they are undertreated compared to younger patients. This study compares postoperative morbidity, mortality, survival, and morbidity risk factors of elderly and younger patients undergoing pulmonary metastasectomy (PM).

METHODS

We retrospectively analyzed our prospective database of 224 patients operated for colorectal lung metastases between 1999 and 2014. Two groups were defined to evaluate the influence of the patients' age (A: < 70 years; B: ≥ 70 years). Morbidity, mortality, and risk factors for morbidity were analyzed using χ²-test and Fisher's exact test. The Kaplan-Meier method, log-rank test, and multivariate Cox regression were used to assess survival and prognosticators.

RESULTS

Altogether, minor morbidity, major morbidity, and mortality were 17%, 5.8%, and 0%, respectively. Between groups A (n = 170) and B (n = 54), there was no difference in minor and major morbidity (p = 0.100) or mortality (0%). Heart arrhythmia was a risk factor for increased morbidity in group B (p = 0.007). The 5-, 10-, and 15-year survival rates were 43%, 30%, and 27%, respectively, in group A and 55%, 36 and 19%, respectively, in group B (p = 0.316). Disease-free interval ≥ 36 months (p = 0.023; OR 2.88) and anatomic resections (p = 0.022; OR 3.05) were associated with prolonged survival in elderly patients.

CONCLUSIONS

Morbidity, mortality, and overall survival after PM with lymphadenectomy for elderly patients were comparable to younger patients. A disease-free interval > 36 months and anatomic lung resections might be associated with prolonged survival. However, elderly patients should also be evaluated for a curative treatment.