Results of a pulmonary metastasectomy in patients with colorectal cancer

Thoracoscopic pulmonary metastasectomy in metastatic colorectal cancer: Surgical outcomes and prognostic factors

BACKGROUND

This study aimed to confirm the effectiveness of thoracoscopic metastasectomy for colorectal cancer (CRC) and determine its prognostic factors.

METHODS

Of the 181 patients who underwent video-assisted thoracoscopic surgery (VATS) for pulmonary metastases from CRC between 2011 and 2017, 173 were retrospectively reviewed. Surgical outcomes, long-term survival, and the factors affecting the prognosis were analyzed.

RESULTS

The patients in the study were predominantly male (n = 104, 60.1%), and the median age was 65 years (range, 25-83 years). The median follow-up time was 46 months (range, 0-114 months). The surgical procedures were 156 wedge resections, five segmentectomies, and 12 lobectomies. Conversion to thoracotomy was required in nine patients. The postoperative complication rate was 2.9%, and the in-hospital mortality rate was 1.2%. The overall 1-, 3-, and 5-year survival rates were 94.8%, 70.6%, and 51.8%, respectively. Univariate analysis showed that the prognostic factors for survival were age (p = 0.027), pathological stage of CRC (p = 0.019), prior extrathoracic metastasis (p = 0.005), preoperative carcinoembryonic antigen level (p = 0.020), number of pulmonary metastases (p = 0.011), and disease-free interval (p = 0.026). In the multivariate analysis, two factors were related to prognosis: age (hazard ratio [HR], 1.881; 95% confidence interval [CI]; 1.189-2.976; p = 0.007) and prior extrathoracic metastasis (HR, 2.170; 95% CI; 1.269-3.711; p = 0.005).

CONCLUSIONS

VATS for pulmonary metastasectomy for CRC can be performed relatively safely, and our results regarding long-term survival are comparable with those of other studies. In this study, older age (≥70 years) and prior extrathoracic metastasis were independent prognostic factors of poor prognosis.

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.

Incidence and prognosis of pulmonary metastasis in colorectal cancer: a population-based study

PURPOSE

It is unclear how primary tumor location affects the pulmonary metastasis in colorectal cancer patients with different primary tumor locations. We aim to explore the relationship between primary tumor location and the incidence and prognosis of colorectal cancer patients with pulmonary metastasis at diagnosis.

METHODS

From Surveillance, Epidemiology, and End Results (SEER) database, 9920 out of 192,969 CRC patients were identified with pulmonary metastasis at diagnosis between 2010 and 2015. Patients were classified into three subsets according to primary tumor location. The incidence of pulmonary metastasis and median survival were calculated. Multivariable logistic and Cox regression were performed to identify the risk factors of pulmonary metastasis and prognosis.

RESULTS

The incidence of pulmonary metastasis was 5.14% in the entire colorectal cancer cohort and 25.66% in metastatic colorectal cancer patients. The median survival of those patients was 10 months. Rectal cancer patients exhibited the highest incidence of pulmonary metastasis, while they had the longest median survival (15 months). The right-sided colon cancer patients had the lowest incidence of pulmonary metastasis, but the shortest median survival (8 months). 61 to 80 years old, over 80, black, two or three extrapulmonary metastatic sites and CEA-positive had a negative influence both on the incidence and prognosis.

CONCLUSIONS

The importance of primary tumor location in affecting the incidence of pulmonary metastasis and prognosis of colorectal cancer patients was highlighted in this study. Primary tumor location should be considered in clinical interference and personalized treatment for colorectal cancer patients with pulmonary metastasis.

Curative-intent radiotherapy in patients with oligometastatic lesions from colorectal cancer: A single-center study

The purpose of the present study was to investigate the efficacy and safety of radiotherapy for patients with oligometastases from colorectal cancer (CRC).This was a retrospective cross-sectional study. Patients with liver and/or lung oligometastatic lesions from CRC treated with curative-intent radiotherapy in West China Hospital, Sichuan University, between 2009 and 2013 were included. Radiotherapy modality included 3-dimensional conformal radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), and stereotactic body radiation therapy (SBRT); simultaneous chemotherapies along with radiotherapy of metastasis were allowed. Overall survival (OS) and progression-free survival (PFS) were calculated using the Kaplan-Meier method. Local control (LC) rates, toxicities, and factors of prognostic significance were also assessed.A total of 40 CRC patients with 57 liver and/or lung oligometastatic lesions were included. Most of the patients (95%) had received at least 1 line of previous systemic chemotherapy. Among them, 19 patients with 26 lesions received 3D-CRT with a median dose of 51.5 Gy in 16.1 fractions, 7 patients with 11 lesions received IMRT with a median dose of 49.3 Gy in 10.4 fractions, and 14 patients with 20 lesions received SBRT with a median dose of 56.4 Gy in 6.7 fractions, respectively. The median follow-up time was 34 months (range, 9-86 months). Median OS and PFS for patients were 30.0 months [95% confidence interval (95% CI), 21.3-38.7] and 11.0 months (95% CI, 9-13), respectively. One, 3, and 5 years' LC rates for metastasis were 63.2%, 24.6%, and 16.9%, respectively. In subgroup analysis, patients with metachronous metastases had longer OS (median, 41.0 months; 95% CI, 33.3-48.7) than patients with synchronous lesions (median, 17.0 months; 95% CI, 7.4-26.6, P = .001). All patients tolerated the radiation treatment well, and there was no treatment-related death. Multivariate analysis showed that number of metastasis lesions and simultaneous liver and lung metastases were potential survival predictors.The study demonstrated that curative radiotherapy might be a tolerable and potential alternative for the treatment of patients with liver and/or lung oligometastases from CRC, and patients with metachronous lesions might have better survival than those with synchronous lesions when treated with curative-intent radiotherapy.

The clinical value of circulating tumour cells (CTCs) in patients undergoing pulmonary metastasectomy for metastatic colorectal cancer

Background

Circulating tumour cells (CTCs) are a potential surrogate for distant metastasis and are considered a useful clinical prognostic marker for metastatic colorectal cancer (mCRC). This prospective study evaluated the preoperative CTC count as a prognostic factor for pulmonary metastasectomy in mCRC patients.

Methods

Seventy-nine mCRC patients who underwent curative-intent pulmonary metastasectomy were included. Preoperatively, 7.5 mL of peripheral blood from each patient was quantitatively evaluated for CTCs with the CellSearch^® system. The clinical significance of CTC count was evaluated according to Kaplan-Meier analyses and log-rank test. Multivariate analyses of the perioperative variables were performed.

Results

The distribution of CTC counts were as follows; 0 in 66 patients (83.5%), 1 in eight patients (10.1%), 2 in three patients (3.8%), and 3 and 6 in one patient (1.3%). The patients with multiple CTCs (CTC count ≥2) had significant shorter disease-free survival (DFS) (P=0.005, median DFS; 19.8 vs. 8.6 months) and overall survival (OS) (P=0.035, median DFS; not reached vs. 37.8 months), respectively. Multivariate analysis showed the patients with multiple CTCs had elevated risk of recurrence [hazard ratio (HR), 3.28; 95% confidence interval (CI), 1.24-8.67; P=0.017].

Conclusions

The detected rate of CTCs was quite low in mCRC patients who underwent pulmonary metastasectomy. The patient with multiple CTCs had shorter DFS in this study. The larger prospective clinical study is needed to establish the meaning of CTC in mCRC candidate for pulmonary metastasectomy.

Prognostic Analysis of Surgical Resection for Pulmonary Metastasis from Hepatocellular Carcinoma

INTRODUCTION

Pulmonary metastases are the most common among extrahepatic recurrences from hepatocellular carcinoma (HCC). It causes high risk of HCC-related death, despite recent progress in therapeutic options. However, a role of pulmonary metastasectomy as well as prognostic factors after metastasectomy has not been well established. We aimed to investigate survival outcomes and prognostic factors after pulmonary resection for metastases from HCC.

METHODS

A series of 93 patients who underwent pulmonary resections for metastases from HCC between June 1990 and July 2013 from multi-institutional database were retrospectively evaluated. Perioperative clinicopathological data and their association with prognosis were investigated.

RESULTS

Of 93 patients, 77 had one pulmonary metastasis, and 16 had two or more. Recurrence after pulmonary resection was noted in 60 patients (64.5 %). The estimated 5-year overall survival rate was 41.4 % with median survival time after pulmonary metastatectomy of 39.0 months. Univariate prognostic analysis showed that disease-free interval of ≥12 months was significantly associated with favorable outcomes in both overall survival (5-year rate, 59.3 vs. 28.7 %, p = 0.026) and disease-specific survival (5-year rate, 62.5 vs. 36.2 %; p = 0.038) after pulmonary metastatectomy. A multivariate analysis revealed that disease-free interval was an independent prognostic factor (HR = 2.020, 95 % CI, 1.069-3.816, p = 0.030).

CONCLUSION

We have shown that a disease-free interval was an independent prognostic factor in patients who underwent pulmonary resection for metastasis from HCC. Also, pulmonary metastasectomy can be one of the therapeutic choices for select patients.

Survival after pulmonary metastasectomy in colorectal cancer patients: does a history of resected liver metastases worsen the prognosis? A literature review

Objective

: To assess the impact of past liver metastases on the survival duration of patients who are undergoing surgery for lung metastases.

Methods

: We conducted a review of literature published from 2007 to 2014. The studies were identified by searching PubMed, MEDLINE, and Embase and were supplemented by a manual search of the references listed by the retrieved studies. The following search terms were used: lung metastasectomy, pulmonary metastasectomy, lung metastases, and lung metastasis. We selected retrospective and prospective studies published from 2007 to 2014 on patients with lung metastases from colorectal cancer and were undergoing surgery with curative intent. We excluded reviews, studies that focused on surgical techniques, patients who were treated non-surgically, analyses of specific subgroups of patients, and those that did not report follow-up of the patients undergoing surgery.

Results

: We identified 28 papers that assessed survival after lung metastases, 21 of which were mostly retrospective studies that identified previous liver metastases to explore their impact on patient survival. In more than half of the papers analyzed (63.2%), patients with a history of resected liver metastases had a lower survival rate than those who did not have such a history, and the difference was statistically significant in eight of these studies. However, data were presented differently, and authors reported mean survival time, survival rates, or hazard ratios.

Conclusions

: A history of liver metastases seems to be a negative prognostic factor, but the individual data need to undergo a meta-analysis.

[Liver and lung metastases of colorectal cancer. Long-term survival and prognostic factors]

INTRODUCTION

The resection of liver and lung metastases from colorectal cancer has not yet been completely investigated. The aim of this study was to investigate the overall survival and prognostic factors for patients with liver and lung metastases from colorectal cancer.

METHODS

A retrospective review of a prospective database of 52 patients with liver and lung metastases from colorectal cancer, undergoing metastasectomy with curative intent from 1999-2009 at a single institution was carried out.

RESULTS

The mean overall survival (OS) was 64 months. For synchronous liver and lung metastases the mean overall survival was 63 months (5-year survival 54 %) and for metachronous liver and lung metastases 74 months (5-year survival 58 %, p = 0.451). A poor prognostic outcome was observed in cases of localization of the primary tumor in the rectum (OS 81 vs. 38 months, p = 0.004), with multiple lung metastases (≥ 2 metastases, OS 74 vs. 59 months, p = 0.032) and with disease progression after premetastasectomy chemotherapy (OS 74 vs. 63 vs. 15 months, p < 0.001). No influence on overall survival was detected for bilateral lung metastases, thoracic lymph node metastases, disease recurrence and disease-free interval < 36 months.

CONCLUSION

Metastasectomy for liver and lung metastases of colorectal cancer is associated with a good overall survival in selected cases. Patients with liver and lung metastases should not be routinely excluded from metastasectomy and patients with thoracic lymph node metastases should also not be routinely excluded. Negative prognostic factors for survival are localization of the tumor in the rectum, multiple metastases and disease progression after premetastasectomy chemotherapy. Patients with disease progression after premetastasectomy chemotherapy should be excluded from metastasectomy.

Effect of early enteral nutrition with Bifico on levels of inflammatory mediators in plasma of patients with severe acute pancreatitis

AIM: To explore the effect of early enteral nutrition combined with probiotic treatment (Bifico) on the levels of inflammatory mediators in plasma of patients with severe acute pancreatitis (SAP).

METHODS: Eighty patients diagnosed with SAP between January 2006 and October 2013 at our hospital were included. They were given parenteral nutrition (PN group), enteral nutrition (EN group) or EN and probiotics (P + EN group). Plasma levels of interleukin-8 (IL-8), tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP) and lactate dehydrogenase (LDH), white blood cell count, serum amylase, and plasma lipase were measured 1 d before and 7 d and 14 d after treatment. Hospitalization time and gastrointestinal function score were also recorded and compared.

RESULTS: After treatment, white blood cell count, serum amylase, plasma lipase and IL-8, CRP and LDH, and gastrointestinal function score were decreased in all the three groups (P < 0.05), while TNF-α in the PN group had no significant change between before and after treatment (F = 0.793, 0.745; P = 0.854, 0.772). White blood cell count, amylase and lipase levels after treatment in the P + EN group were significantly lower than those in the PN group and EN group (4.9 × 10⁹/L ± 2.4 × 10⁹/L vs 9.6 × 10⁹/L ± 3.0 × 10⁹/L vs 5.3 × 10⁹/L ± 2.7 × 10⁹/L; 197 U/L ± 50 U/L vs 297 U/L ± 77 U/L vs 253 U/L ± 63 U/L; 297 U/L ± 72 U/L vs 724 U/L ± 103 U/L vs 323 U/L ± 74 U/L; F = 5.346, 5.753; P = 0.023, 6.556, 0.022, 0.029). IL-8 and TNF-α levels were also significantly lower than those in the PN group and EN group (27.0 pg/mL ± 7.9 pg/mL vs 47.6 pg/mL ± 8.4 pg/mL vs 31.0 pg/mL ± 8.0 pg/mL; 43.5 pg/mL ± 22.7 pg/mL vs 132.5 pg/mL ± 32.6 pg/mL vs 67.5 pg/mL ± 21.4 pg/mL; F = 8.375, 7.278; P = 0.017, 0.012). Plasma CRP and LDH levels were significantly lower in the P + EN group after treatment than in the PN group and EN group (39.4 mg/L ± 19.7 mg/L vs 102.5 mg/L ± 41.9 mg/L vs 68.3 mg/L ± 32.9 mg/L; 20.3 U/L ± 12.3 U/L vs 79.3 U/L ± 34.4 U/L vs 35.3 U/L ± 10.4 U/L; F = 8.353, 10.354; P = 0.032, 0.013). Gastrointestinal function scores in the PN group, EN group and P + EN group on 14 d were significantly decreased, and the decrease was more significant in the P + EN group than in the PN group and EN group (0.25 ± 0.02 vs 0.71 ± 0.08 vs 0.40 ± 0.04; F = 12.456; P = 0.000). The mortality and incidence of complications were significantly lower and duration of hospitalization was significantly shorter in the combination group than in the EN group (χ² = 4.428, 28.986; P = 0.019, 0.000).

CONCLUSION: Early application of EN combined with Bifico can reduce the levels of enzymes and mediators of inflammation, pancreatic secretion, complications, hospitalization time, and mortality in SAP patients.

Surgical resection of pulmonary metastases from colorectal cancer: Efficacy and prognostic factors

AIM: To assess the efficacy and prognostic factors for surgical resection of pulmonary metastases from colorectal cancer.

METHODS: Forty patients underwent surgical resection of pulmonary metastases from colorectal cancer at our hospital between May 1996 and March 2012. Data of follow-up till June 30, 2013 were obtained. The disease-free interval, progression-free survival and overall survival were used for survival analysis. Records of general information, operation mode and history were analyzed.

RESULTS: The median overall survival time was 36.5 (4.0-159.0) mo, and the 5-year survival rate was 37%. Location of primary tumor, chemotherapy, preoperative CEA level and tumor TNM stage were significantly related with the survival of patients after resection of pulmonary metastases (P = 0.012, 0.033, 0.007, 0.008). Multi-factor Cox regression model analysis showed that location of primary tumor and preoperative CEA level were independent risk factors for death (OR = 5.023, 4.332; P = 0.002, 0.017).

CONCLUSION: Pulmonary metastasectomy can significantly improve the survival of patients with pulmonary metastases of colorectal carcinoma, and the prognosis is related with location of primary tumor, chemotherapy, preoperative CEA level and tumor TNM stage, with location of primary tumor and preoperative CEA level being independent risk factors for mortality of patients.

Oligometastasis and oligo-recurrence: more than a mirage

The standard treatment choice for cancer metastasis has been systemic management, including cytotoxic chemotherapy, hormonal manipulation, and targeted therapy. Emerging evidence has shown an oligometastatic state, an intermediate state between limited primary cancer and polymetastatic cancer, in which local therapy for metastatic lesions results in satisfactory survival comparable to non-metastatic disease. We provide a comprehensive introduction of evidence from experimental and clinical studies in favor of the oligometastatic phenotype, we review the efficacy and safety of surgery and stereotactic body radiotherapy in the treatment of oligometastases, and finally, we discuss the way to differentiate the oligometastatic state from polymetastasis.

Pulmonary metastasectomy in colorectal cancer patients with previously resected liver metastasis: pooled analysis

BACKGROUND

Data addressing the outcomes and patterns of recurrence after pulmonary metastasectomy (PM) in patients with colorectal cancer (CRC) and previously resected liver metastasis are limited.

METHODS

We searched the PubMed database for studies assessing PM in CRC and gathered individual data for patients who had PM and a previous curative liver resection. The influence of potential factors on overall survival (OS) was analyzed through univariate and multivariate analysis.

RESULTS

Between 1983 and 2009, 146 patients from five studies underwent PM and had previous liver resection. The median interval from resection of liver metastasis until detection of lung metastasis and the median follow-up from PM were 23 and 48 months, respectively. Five-year OS and recurrence-free survival rates calculated from the date of PM were 54.4 and 29.3 %, respectively. Factors predicting inferior OS in univariate analysis included thoracic lymph node (LN) involvement and size of largest lung nodule ≥2 cm. Adjuvant chemotherapy and whether lung metastasis was detected synchronous or metachronous to liver metastasis had no influence on survival. In multivariate analysis, thoracic LN involvement emerged as the only independent factor (hazard ratio 4.86, 95 % confidence interval 1.56-15.14, p = 0.006).

CONCLUSIONS

PM offers a chance for long-term survival in selected patients with CRC and previously resected liver metastasis. Thoracic LN involvement predicted poor prognosis; therefore, significant efforts should be undertaken for adequate staging of the mediastinum before PM. In addition, adequate intraoperative LN sampling allows proper prognostic stratification and enrollment in novel adjuvant therapy trials.

The prognosis of pulmonary metastasectomy depends on the location of the primary colorectal cancer

BACKGROUND

Rectal cancer has a higher risk of developing lung metastasis compared with colon cancer. It is unclear whether the prognosis after pulmonary metastasectomy for these distinct tumors is different.

METHODS

Patients who underwent pulmonary metastasectomy for colorectal carcinoma were analyzed for survival and patterns of recurrence depending on the location of the primary colorectal cancer. Multivariate regression analysis was performed to identify clinical variables predictive of survival after pulmonary metastasectomy.

RESULTS

Between 1985 and 2012, 698 patients underwent pulmonary metastasectomy for metastatic colorectal cancer. Complete information was available in 626 patients. These patients were divided into groups based on whether the primary tumor was colon or rectal in origin. Median follow-up was 45.5 months (range, 23 to 287 months). There were no statistical differences between the two groups in terms of number of lung metastases, tumor size, or lymph node involvement. There was no difference in overall survival (p = 0.545). Five-year disease-free survival for colon cancer patients was 67.2% compared with 60.1% for rectal cancer (p = 0.004). The most common sites of recurrence after pulmonary metastasectomy were liver in colon cancer and lung in rectal cancer. Multivariate Cox proportional hazards analysis indicated that rectal cancer (hazard ratio, 1.39; 95% confidence interval, 1.07 to 1.83; p = 0.015) and multiple metastases (>3; hazard ratio, 1.41; 95% confidence interval, 1.04 to 1.89; p = 0.027) were independent adverse risk factors affecting disease-free survival after pulmonary metastasectomy.

CONCLUSIONS

Disease-free survival and site of recurrence after pulmonary metastasectomy for colorectal carcinoma are dependent on the site of the primary tumor. Lung metastases from rectal cancer have a worse disease-free survival compared with colon cancer. This may influence treatment and follow-up strategies.

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.

[Assessment of resectability of colorectal liver metastases and extended resection]

Most patients with colorectal liver metastases are treated within a multimodal therapy regime whereby liver resection is a key point in the curative treatment concept. The achievement of an R0 situation is of vital importance for long-term survival. Besides general operability and the assessment of comorbidities, resection depends on the quality of liver parenchyma (functional resectability) and the anatomical position of the tumor (oncological resectability). The improvement of operation techniques and perioperative medicine nowadays allow complex surgical procedures for metastasis surgery. This article presents the methods for the assessment of resectability and modern strategies of preoperative conditioning as well as approaches for extended liver resection.

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.

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

BACKGROUND

Resection of lung metastases (LM) from colorectal cancer (CRC) is increasingly performed with a curative intent. It is currently not possible to identify those CRC patients who may benefit the most from this surgical strategy. The aim of this study was to perform a systematic review of risk factors for survival after lung metastasectomy for CRC.

METHODS

We performed a meta-analysis of series published between 2000 and 2011, which focused on surgical management of LM from CRC and included more than 40 patients each. Pooled hazard ratios (HR) were calculated by using random effects model for parameters considered as potential prognostic factors.

RESULTS

Twenty-five studies including a total of 2925 patients were considered in this analysis. Four parameters were associated with poor survival: (1) a short disease-free interval between primary tumor resection and development of LM (HR 1.59, 95 % confidence interval [CI] 1.27-1.98); (2) multiple LM (HR 2.04, 95 % CI 1.72-2.41); (3) positive hilar and/or mediastinal lymph nodes (HR 1.65, 95 % CI 1.35-2.02); and (4) elevated prethoracotomy carcinoembryonic antigen (HR 1.91, 95 % CI 1.57-2.32). By comparison, a history of resected liver metastases (HR 1.22, 95 % CI 0.91-1.64) did not achieve statistical significance.

CONCLUSIONS

Clinical variables associated with prolonged survival after surgery for LM in CRC patients include prolonged disease-free interval between primary tumor and metastatic spread, normal prethoracotomy carcinoembryonic antigen, absence of thoracic node involvement, and a single pulmonary lesion.

Incidence and predictive factors for pulmonary metastases after curative resection of colon cancer

PURPOSE

To assess the actuarial incidence of pulmonary metastases as the first site of metastasis after R0 resection of colon cancer and to clarify predictive factors for pulmonary metastases as the first site of metastasis.

METHODS

Data for 746 patients who underwent R0 resection for colon cancer from 2000 to 2006 were reviewed. The mean duration of follow-up was 56.9 months.

RESULTS

Pulmonary metastases developed in 35 patients. Mean duration from colon surgery to identification of pulmonary metastases was 20.0 months. The overall occurrence rates of 5-year pulmonary metastasis according to Union for International Cancer Control (UICC) stage were 0.6 % (stage I), 2.2 % (stage II), 9.8 % (stage III), and 24.6 % (stage IV), respectively. Surgery for pulmonary metastases was performed first 18 patients (51.4 %), and 16 (88.9 %) of these 18 patients achieved R0 surgery. Multivariate analysis revealed that presence of regional lymph node involvement and preoperative serum carcinoembryonic antigen level (≥5 ng/ml) were significant independent risk factors for pulmonary metastases. Five-year actuarial incidence of pulmonary metastases increased significantly with increased number of risk factors (0 factors, 2.2 %; 1 factor, 6.6 %; 2 factors, 18.4 %).

CONCLUSIONS

The present study clearly demonstrated predictive factors for pulmonary metastases after R0 resection of colon cancer. Actuarial incidence of pulmonary metastases was significantly related to the number of risk factors present. The data should facilitate the establishment of novel algorithms for predicting pulmonary metastases after resection of colon cancer, which may lead to the appropriate surveillance strategies after colon surgery.

Pulmonary metastasectomy for gastric cancer: a 13-year single-institution experience

PURPOSE

Pulmonary metastases from gastric cancer are rare, and the role of surgery is unclear. The purpose of this study was to determine which patients with metachronous metastatic gastric cancer (MGC) might benefit from pulmonary resection.

METHODS

Between 1998 and 2011, 12 patients underwent 14 pulmonary resections for MGC. We reviewed their clinical courses and evaluated their radiological findings.

RESULTS

Solitary pulmonary lesions were identified for 11 metastases, and the remaining three showed multiple pulmonary lesions. Six patients received treatment for the metastases before pulmonary resection. Lobectomy was performed for five lesions and wedge resection was performed for the remaining nine lesions. At the median follow-up time of 23.0 months, four patients were alive without disease, and the median DFS following pulmonary resection was 6.6 months. The overall 5-year survival rate following pulmonary resection was 58.4 %. In a univariate analysis, the number of lesions and the tumor doubling time (TDT) were significant predictors of the DFS, although prior treatment was not a significant predictor of the DFS.

CONCLUSION

Pulmonary resection for MGC might be an effective therapeutic option when there is a solitary metastatic lesion that has a long TDT, even if the patient has been previously treated for metastases.

Prognostic factors in patients undergoing complete resection of pulmonary metastases of colorectal cancer: a multi-institutional cumulative follow-up study

PURPOSE

The aim of this retrospective study was to establish the prognostic factors for overall survival after pulmonary resection for lung metastases of colorectal carcinoma (CRC).

METHODS

The baseline characteristics and outcomes of 266 CRC patients undergoing complete pulmonary resection were collected from 19 institutions by the Japanese Society for Cancer of the Colon and Rectum (JSCCR) Study Group. We used the Cox proportional hazard regression to identify independent prognostic factors for OS.

RESULTS

The 5-year overall survival rate of patients undergoing complete resection of isolated pulmonary metastases was 56.5 %. The independent unfavorable prognostic factors after pulmonary resection included stage T4 (p = 0.0004) and N2 (p = 0.0082) as primary cancer-related factors, and more than three metastases (p = 0.0342), bilateral distribution (p = 0.0450), metastatic disease-free interval (DFI) of less than 2 years (p = 0.0257), and a preoperative carcinoembryonic antigen (CEA) level greater than 5.0 ng/mL (p = 0.0209) as pulmonary metastases-related factors.

CONCLUSIONS

This retrospective analysis suggested that the indications for pulmonary resection of CRC metastases should be decided not only by the status of lung metastases, but also by pulmonary-related factors such as the T and N stage of the primary lesion, preoperative CEA level, and the DFI.

Differences in the expression of epithelial-mesenchymal transition related molecules between primary tumors and pulmonary metastatic tumors in colorectal cancer

PURPOSE

Epithelial-mesenchymal transition (EMT) is a key event in cancer metastasis. This study immunohistochemically examined the expression of EMT-related molecules in both primary colorectal cancer and pulmonary metastases, and analyzed the expression pattern.

METHODS

Ten patients with colorectal cancer that underwent surgical resections for both the primary tumor and metastatic pulmonary tumors were included. The expression status of EMT-related molecules was examined using immunohistochemical staining.

RESULTS

Nine of the 10 cases maintained the expression of both E-cadherin and β-catenin in the primary site. The expression of E-cadherin and β-catenin in the pulmonary metastatic site was preserved in 10 and 12 out of 15 metastatic lesions, respectively. The EMT-related transcription factor, Twist, was positively expressed in all 10 cases, Smad interacting protein 1 (Sip1) in 9, Snail in 4 and Slug in 3 of the primary sites. On the other hand, staining for Twist, Sip1 and Snail at the metastatic pulmonary site, was negative in all 10 cases.

CONCLUSION

The expression of EMT-related transcription factors in metastatic pulmonary tumors from colorectal cancer decreased in comparison to the primary tumors. These findings suggested that the expression status of EMT-related transcription factors might play an important role in the implantation of metastatic foci.

The role of hepatic metastases and pulmonary tumor burden in predicting survival after complete pulmonary resection for colorectal cancer

OBJECTIVE

Our objective was to investigate the role of clinicopathologic factors as predictors of outcome after complete pulmonary resection for metastatic colorectal cancer.

METHODS

Consecutive patients undergoing radical pulmonary resection for colorectal cancer at our institution were included in the study. Clinicopathologic variables including sex, age, site and stage of the primary tumor, disease-free interval, prior hepatic resection, timing of pulmonary metastases, preoperative chemotherapy, type of pulmonary resection, number, size, and location of pulmonary metastases, and thoracic lymph node involvement were retrospectively collected and investigated for prognostic significance. Survival curves were generated by the Kaplan-Meier technique and difference between factors were evaluated by the log-rank test.

RESULTS

A total of 127 patients undergoing pulmonary resection between 1997 and 2009 were included in the study. The median follow-up was 67.1 months. The median overall survival from the time of pulmonary resection was 48.9 months. The 5-year overall survival was 45.4%. Among all investigated prognostic variables, the number of pulmonary metastases (1 vs >1) was the most important factor affecting the outcome after pulmonary resection (5-year overall survival 55.4% vs 32.2%; hazard rate, 1.92; P = .006).

CONCLUSIONS

In this study, the presence of a single pulmonary metastasis was a favorable predictor of survival after complete pulmonary resection for metastatic colorectal cancer. All the other prognostic variables did not seem to affect survival and should not contraindicate such surgery in clinical practice. However, the study sample size does not allow us to draw any definitive conclusion, and further investigation of the role of these prognostic factors in larger series is warranted.

Colorectal cancer and thoracic surgeons: close encounters of the third kind

Resection of lung metastases from colorectal cancer (CRC) is increasingly performed with a curative intent. This strategy was made possible in the 1990s by the development of new chemotherapeutic approaches, improved surgical techniques and better imaging modalities. However, evidence-based data showing clinical benefits of lung metastasectomy in this setting are nonexistent, and there are no prospective randomized trials to support the routine performance of these procedures for stage IV CRC. Current evidence suggests that resection of pulmonary metastases in combination with new cytotoxic agents, such as oxaliplatin, irinotecan and bevacizumab, may result in prolonged survival for many, and cure for a small minority of CRC patients who experienced tumor spread beyond the limits of the abdomen. This review focuses on the results of surgical management of CRC patients with lung metastases: we report the outcome of published series according to the presence or the absence of liver metastasis (and hepatic resection) prior to lung resection.

Pulmonary Oligometastases

Introduction. Pulmonary oligometastases are resected both for diagnostic and therapeutic reasons. The histological features may be nonspecific, resulting in diagnostic difficulties. Design. The authors retrospectively studied the clinical and pathological features of 73 open resections of lung metastases from 64 patients to determine the frequency and types of problems in establishing site of origin. Results. There were 18 primary organ sites, the most frequent being colon (n = 10), head and neck (9 squamous and 6 salivary gland), kidney (n = 7), and soft tissue (n = 7). Unusual histological features included detached alveolar tumor clusters at the periphery (83% of adenocarcinomas), lepidic spread (2 metastatic pancreatic tumors), and entrapped pneumocyte-lined cysts (6 tumors). A majority of squamous carcinomas from the head and neck presented difficulties in regard to excluding a second primary, especially 4 with basaloid features that mimicked primary basaloid lung carcinoma. Other tumors mimicking lung primaries included pancreatic, endometrial, and breast metastases. Germ-cell tumors, sarcomas, melanomas, and sarcomatoid carcinomas presented diagnostic difficulties. Overall, comparison with the primary tumor with or without immunohistochemical studies was performed in 38 of 73 cases (52%). Conclusions. Pulmonary oligometastases comprise a wide range of histological types and often require careful pathological evaluation to determine primary site of origin.

Colorectal cancer pulmonary oligometastases: pooled analysis and construction of a clinical lung metastasectomy prognostic model

BACKGROUND

Although resecting colorectal cancer (CRC) pulmonary metastasis is associated with long-term survival, identification of prognostic groups is needed for future randomized trials, and construction of a lung metastasectomy prognostic model (LMPM) is warranted.

PATIENTS AND METHODS

We searched the PubMed database for retrospective studies evaluating prognostic factors following resecting CRC lung metastasis. Individual patient data were analyzed. Independent prognostic factors were used to construct an LMPM.

RESULTS

Between 1983 and 2008, 1112 metastasectomies were carried out on 927 patients included in eight studies. Five-year survival rate was 54.3% following the first lung resection. Multivariate analysis identified three independently poor prognostic factors: pre-thoracotomy carcinoembryonic antigen ≥5 ng/ml, disease-free interval <36 months, and more than one metastatic lesion. Patients with good-, intermediate-, and high-risk groups according to the LMPM had a 5-year survival of 68.2%, 46.4%, and 26.1%, respectively (P < 0.001). Perioperative chemotherapy and previously resected liver metastasis had no influence on survival.

CONCLUSIONS

The low- and intermediate-risk groups have a good chance of long-term survival following metastasectomy. However, more studies are needed to investigate whether surgery offers any advantage over systemic therapy for the poor-risk group.