Do Repeated Operations for Recurrent Colorectal Lung Metastases Result in Improved Survival?

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.

Comparison of the Long-term Survival Outcome of Surgery versus Stereotactic Body Radiation Therapy as Initial Local Treatment for Pulmonary Oligometastases from Colorectal Cancer: A Propensity Score Analysis

PURPOSE

Optimal local treatment for pulmonary oligometastases from colorectal cancer (CRC) remains unclear. We aimed to compare the long-term survival outcomes between surgery and stereotactic body radiation therapy (SBRT) as the initial local treatment for CRC pulmonary oligometastases.

MATERIALS AND METHODS

We retrospectively reviewed 335 consecutive patients who initially underwent surgery or SBRT for CRC pulmonary metastases from 2011 to 2022, and 251 patients (173 surgery and 78 SBRT) were ultimately included. Freedom from intrathoracic progression (FFIP), progression-free survival (PFS), and overall survival (OS) were compared using stabilized inverse probability of treatment weighting (sIPTW) analysis. In addition, patterns of intrathoracic progression and subsequent treatment were analyzed.

RESULTS

Median follow-up was 61.6 months for surgery and 54.4 months for SBRT. After sIPTW adjustment, significant differences emerged in both FFIP and PFS between surgery and SBRT (FFIP: hazard ratio [HR] = 0.50, 95% confidence interval [CI], 0.31-0.79; PFS: HR = 0.56, 95% CI, 0.36-0.87). The 3- and 5-year FFIP rates were 58.6% and 54.8%, respectively, after surgery, and 34.6% and 31.3%, respectively, after SBRT (P = .006). The 3- and 5-year PFS rates were 49.4% and 45.2%, respectively, after surgery, and 28.8% and 26.1%, respectively, after SBRT (P = .010). However, OS was not significantly affected by treatment approach (HR = 0.93, 95% CI, 0.49-1.76). The 3- and 5-year OS rates were 85.9% and 73.1%, respectively, after surgery, and 78.9% and 68.7%, respectively, after SBRT (P = .849). Recurrence at the treated site was more prevalent after SBRT than after surgery (33.3% vs 16.9%), whereas new intrathoracic tumors occurred more frequently after surgery than after SBRT (71.8% vs 43.1%). Both groups chose radiation therapy as the primary local salvage treatment.

CONCLUSIONS

Notwithstanding the significant differences in FFIP and PFS between surgery and SBRT, the long-term survival of patients with CRC pulmonary oligometastases did not depend on the initial choice of the local treatment approach.

Effect of perioperative chemotherapy on resection of isolated pulmonary metastases from colorectal cancer: A single center experience

BACKGROUND

Numerous studies have assessed surgical resection as a standard treatment option for patients with colorectal cancer (CRC) and resectable pulmonary metastases (PM). However, the role of perioperative chemotherapy after complete resection of isolated PM from patients with CRC patients remains controversial. We hypothesize that perioperative chemotherapy does not provide significant survival benefits for patients undergoing resection of PM from CRC.

AIM

To determine whether perioperative chemotherapy affects survival after radical resection of isolated PM from CRC.

METHODS

We retrospectively collected demographic, clinical, and pathologic data on patients who underwent radical surgery for isolated PM from CRC. Cancer-specific survival (CSS) and disease-free survival were calculated using Kaplan-Meier analysis. Inter-group differences were compared using the log-rank test. For multivariate analysis, Cox regression was utilized when indicated.

RESULTS

This study included 120 patients with a median age of 61.6 years. The 5-year CSS rate was 78.2%, with 36.7% experiencing recurrence. Surgical resection for isolated PM resulted in a 5-year CSS rate of 50.0% for second metastases. Perioperative chemotherapy (P = 0.079) did not enhance survival post-resection. Factors associated with improved survival included fewer metastatic lesions [hazard ratio (HR): 2.51, P = 0.045], longer disease-free intervals (HR: 0.35, P = 0.016), and wedge lung resections (HR: 0.42, P = 0.035). Multiple PM predicted higher recurrence risk (HR: 2.22, P = 0.022). The log-rank test showed no significant difference in CSS between single and repeated metastasectomy (P = 0.92).

CONCLUSION

Perioperative chemotherapy shows no survival benefit post-PM resection in CRC. Disease-free intervals and fewer metastatic lesions predict better survival. Repeated metastasectomy is warranted for eligible patients.

Factors associated with receipt of pulmonary metastasectomy in patients with lung-limited metastatic colorectal cancer: Disparities in care and impact on overall survival

OBJECTIVES

Pulmonary metastasectomy (PM) for colorectal cancer may provide respite from systemic therapy and prolonged disease-free intervals. We sought to identify factors associated with PM and to characterize the differential impact on overall survival for those offered lung resection.

METHODS

The National Cancer Database was queried for stage IV colorectal cancer patients with lung-limited metastatic disease between 2010 and 2016. Among patients who underwent primary tumor resection, those who underwent PM were compared with those who did not. Penalized regression with the least absolute selection and shrinkage operator was used to determine factors associated with receiving metastasectomy as well as overall survival.

RESULTS

In total, 867 (15.1%) patients underwent resection of both primary tumor and pulmonary metastases whereas 4864 (84.8%) had primary tumor resection alone. In unadjusted analyses, metastasectomy patents were younger, more often privately insured, more educated, and traveled farther to receive care (all P < .001). In multivariable analyses, younger age, traveling >25 miles, and care at high-volume hospitals were associated with PM (P < .01). In addition, primary site surgery without PM was associated with worse overall survival (hazard ratio, 1.35; confidence interval, 1.23-1.49), even after adjusting for patient, tumor, and hospital-related factors.

CONCLUSIONS

Patients who were older, who received care closer to home, and who were treated at low-volume hospitals were less likely to receive metastasectomy for lung-limited colorectal cancer after definitive resection of their primary tumor. Failure to receive PM resulted in worse overall survival, emphasizing the strong need for efforts to provide uniform, equitable care to all patients.

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.

Repeated Pulmonary Metastasectomy: Third Operations and Beyond

BACKGROUND

For extrathoracic malignant neoplasms that have metastasized to the lungs, previous investigations have demonstrated both oncologic and survival benefits after pulmonary and repeated metastasectomy. Little is known about the feasibility of incrementally increasing numbers of subsequent metastasectomy procedures.

METHODS

We conducted a retrospective review of patients who underwent ≥3 pulmonary resection procedures for recurrent, metachronous metastatic disease of nonlung primary malignant neoplasms at a single institution between 1992 and 2020. Primary outcomes collected pertained to safety and feasibility, including estimated blood loss (EBL), hospital length of stay, and details of postoperative complications.

RESULTS

There were 117 patients who met inclusion criteria, having undergone at least 3 metastasectomy operations, with 55 (47.1%) undergoing a fourth operation and 20 (17.1%) undergoing a fifth operation. EBL did not differ between first and second operations (106.6 mL vs 102.5 mL; P = .76). It was, however, significantly greater at third operations (102.5 mL vs 238.7 mL; P = .000016). We noted an increase in wound complications between the second and third operations (0.9% vs 6.8%; P = .02) and incremental increases in likelihood of prolonged air leak with each subsequent operation. The need for reoperation was low for all and similar between operations. Importantly, hospital length of stay was similar for all procedures, as were the frequencies of hospital readmission.

CONCLUSIONS

Third-time redo pulmonary metastasectomy can be performed safely and feasibly in select patients. Further repeated resection should remain a therapeutic option for patients, although risks for potentially longer operating time, greater EBL, and prolonged air leaks may be anticipated.

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.

Chemical and physical features of biological fluids in treatment of hydatid disease

The aim of this paper is to better understand the dynamics of crystallogenic and starting activity in biological fluids of patients throughout surgery and the late postoperative phase in alveococcosis. Samples of saliva from 22 individuals with alveococcosis were included in the research. Biological fluid samples were taken at the time of admission and before the patient was discharged. Following that, slides were made utilizing the teziocrystalloscopy method, which incorporates the investigation of the crystal forming activity of mixed saliva with its starting characteristics using a 0.9 percent sodium chloride solution as the foundation ingredient. Using our own set of criteria, we evaluated the outcomes of crystalloscopic and tezigraphic experiments. Specrophotometric examination of tezigraphic and crystalloscopic facies was done using a PowerWave XS microplate spectrophotometer at wavelengths of 400, 350, and 300 nm to augment the results from ocular morphometry of dried saliva micro slides. Surgical therapy results in a partial normalization of physical and chemical parameters, as well as the composition of the patient's biological fluids after the patient is discharged from the hospital.

Management of single pulmonary metastases from colorectal cancer: State of the art

Colorectal cancer (CRC) is one of the most common causes of death from cancer. Lung seeding occurs in approximately 10% of patients surgically treated for primary CRC with radical intent: the lung is the most common site of metastases after the liver. While surgical treatment of liver metastases is widely accepted to affect long-term outcomes, more controversial and not standardized is the therapy for CRC patients developing lung metastases. Experience suggests the potential curative role of pulmonary metastasectomy, especially in oligometastatic disease. However, the optimal strategy of care and the definition of prognostic factors after treatment still need to be defined. This review focused on the uncommon scenario of single pulmonary metastases from CRC. We explored pertinent literature and provide an overview of the epidemiology, clinical characteristics and imaging of single pulmonary metastases from CRC. Additionally, we identified the best available evidence for overall management. In particular, we analyzed the role and results of locoregional approaches (surgery, radiotherapy or ablative procedures) and their integration with systemic therapy.

Anatomical Resection Improves Disease-Free Survival After Lung Metastasectomy of Colorectal Cancer

Purpose

This study aimed to evaluate the role of anatomical resection (AR) in lung metastasectomy (LM) of colorectal cancer (CRC) and to investigate clinically relevant prognostic factors.

Patients and Methods

The medical records of 350 consecutive patients who underwent LM of CRC from 2011 to 2019 were reviewed. The patients were designated into AR group (lobectomy and segmentectomy), and non-anatomical resection (NAR) group (wedge resection), respectively. Kaplan–Meier method was used to analyze disease-free survival (DFS), pulmonary-specific disease-free survival (PDFS) and overall survival (OS). Cox proportional hazards regression model was performed to analyze the factors associated with DFS, PDFS and OS.

Results

A total of 92 (31.2%) patients were enrolled in AR group and 203 (68.8%) in non-anatomical resection (NAR) group. AR significantly improved the 3-year DFS (64.1% vs 46.8%, HR 0.587, 95% CI 0.397–0.867, P = 0.007) and PDFS (75.0% vs 60.1%, HR 0.565, 95% CI 0.356–0.899, P = 0.016) compared with NAR. However, the extent of resection did not significantly impact the 3-year OS (AR 92.4% vs NAR 85.7%, HR 0.511, 95% CI 0.224–1.165, P = 0.110). In multivariate analysis, AR was identified as a protective factor for DFS (HR 0.576, 95% CI 0.356–0.934, P = 0.025) and PDFS (HR 0.631, 95% CI 0.409–0.973, P = 0.037). Preoperative abnormal CA19-9 was identified as the only prognostic factor for OS.

Conclusion

AR was superior to NAR for DFS and PDFS after LM from CRC.

Survival prognostic and recurrence risk factors after single pulmonary metastasectomy

Background

Identification of the prognostic factors of recurrence and survival after single pulmonary metastasectomy (PM).

Methods

Retrospective analysis of all consecutive patients who underwent PM for a single lung metastasis between 2003 and 2018.

Results

A total of 162 patients with a median age of 64 years underwent single PM. Video-Assisted Thoracic Surgery (VATS) was performed in 83.9% of cases. Surgical resection was achieved by wedge in 73.5%, segmentectomy in 7.4%, lobectomy in 17.9% and pneumonectomy in 1.2% of cases. The median durations of hospital stay and of drainage were 4 days (IQR 3–7) and 1 day (IQR 1–2), respectively. During the follow-up (median 31 months; IQR 15–58), 93 patients (57.4%) presented recurrences and repeated PM could be realized in 35 patients (21.6%) achieved by VATS in 77.1%. Non-colorectal tumour (HR 1.84), age < 70 years (HR 1.77) and previous extra-thoracic metastases (HR 1.61) were identified as prognostic factors of recurrence. Overall survival at 5-year was estimated at 67%. Non-colorectal tumour (HR 2.40) and mediastinal lymph nodes involvement (HR 3.42) were significantly associated with an increased risk of death.

Conclusions

Despite high recurrence rates after PM, surgical resection shows low morbidity rate and acceptable long-term survival, thus should remain the standard treatment for single pulmonary metastases.

Trial registration: The Local Ethics Committee approved the study (No. 2019–02,474) and individual consent was waived.

Role of surgical resection and its alternative local therapy for pulmonary metastasis of colorectal cancer

We reviewed surgical and alternative treatments for pulmonary metastasis of colorectal cancer, focusing on recent reports. The standard treatment for pulmonary metastasis of colorectal cancer is pulmonary resection, if resectable, despite the fact that the metastasis is hematogenous to distant organs. Guidelines in several countries, including Japan, have described pulmonary resection as a useful option because of the favorable long-term prognosis reported in various studies pertaining to pulmonary resection. The indications for pulmonary resection have been reviewed in several studies; additionally, the number of metastases, pretreatment carcinoembryonic antigen value, and disease-free interval from the primary resection to pulmonary recurrence have been proposed. However, no consensus has been reached to date. Contrastingly, recent advances in chemotherapy have remarkably improved the outcome of distant metastases, indicating that it is time to reconsider the significance of local treatment, including pulmonary resection. In addition to surgical resection, minimally invasive therapies, such as stereotactic body radiation therapy and radiofrequency ablation have been developed as local treatments for pulmonary metastases, and their long-term results have been reported. Prospective controlled trials and large-scale data analyses are needed to determine the best local treatment for pulmonary metastases and to find the appropriate indication for each treatment.

Efficacy of adjuvant chemotherapy after complete resection of pulmonary metastasis from colorectal cancer

The most effective treatment for pulmonary metastasis from colorectal cancer (CRC) is complete resection. However, as the recurrence rate after resection of the pulmonary metastases from CRC is high, postoperative adjuvant chemotherapy is often performed in clinical practice. The purpose of the present study was to evaluate the efficacy and safety of single-agent adjuvant chemotherapy after resection of pulmonary metastasis from CRC. The medical records of 16 patients who underwent the first complete resection of pulmonary metastasis from CRC were retrospectively reviewed. A total of eight patients were treated with single-agent adjuvant chemotherapy after resection of pulmonary metastasis, and oral fluoropyrimidines were selected in all regimens. As a result, the relapse-free survival rate after resection of pulmonary metastasis in the group that received postoperative adjuvant chemotherapy was significantly improved in comparison with the group treated with surgery alone. In the subgroup analysis, patients who benefited from postoperative adjuvant chemotherapy in some high-risk groups were selected, including patients with a high tumor stage or poor immunological status. In conclusion, single-agent adjuvant chemotherapy after resection of pulmonary metastasis from CRC was effective for reducing the risk of recurrence and was safe to administer. In addition, certain risk factors may identify patients who would receive more benefit from postoperative adjuvant chemotherapy after resection of pulmonary metastasis from CRC.

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.

Histological growth patterns and molecular analysis of resected colorectal lung metastases

Lung is the site of metastasis in about 15-25 % of colorectal cancer (CRC) patients. Lung metastasectomy of CRC represents a standard therapy in patients with resectable metastases. In this study we investigated both histological patterns of metastases and mutations in MAPkinase pathway genes and their relationship to prognosis. The study included 74 patients that underwent metastasectomy of colorectal lung metastasis (CLM). In patients that underwent surgical resection of more than one metastasis in the same operation the largest was chosen. In patients that had undergone multiple lung metastasectomy only the sample from the first metastasectomy was included. Histologically metastases were scored according to amount and distribution of necrosis and fibrosis and three patterns were identified: "pattern A", metastasis with extensive, confluent central necrosis surrounded by a rim of neoplastic glands; "pattern B", metastasis characterized by a proliferation of neoplastic glands in a dense stroma with focal necrosis mainly intraglandular; "pattern C", metastasis with a mixed A and B morphology. In all samples direct sequencing of exon 2 of KRAS and NRAS genes and exon 15 of BRAF genes was carried out.Histological patterns weren't related to metastasis size or other clinical features however pattern C metastases showed a significant worst disease free survival (DFS). KRAS mutations were observed in 39 % of patients. Mutations in KRAS codon 13 resulted significantly associated with synchronous metastasis and poor prognosis. No mutations were identified in exon 2 NRAS gene whilst 1.4 % harboured a mutation in BRAF. To our knowledge this is the first study that investigates in a large series of CLM histological growth patterns, molecular alterations and their relationship to prognosis. Our data suggest a prognostic role in CLM of KRAS specific mutations and histopathological patterns.

Prognostic value of KRAS mutation in patients undergoing pulmonary metastasectomy for colorectal cancer: A systematic review and meta-analysis

BACKGROUND

The purpose of the study was to evaluate whether KRAS mutation could be an independent prognostic biomarker in patients undergoing pulmonary metastasectomy (PM) for colorectal cancer (CRC).

METHODS

A systemic review was performed by searching online databases to identify studies reporting overall survival (OS) and recurrence free survival (RFS) of CRC patients undergoing PM. Pooled HRs were calculated for OS and RFS.

RESULTS

A total of 15233 patients from 60 studies were included. Pooled analysis showed that KRAS mutation was associated with worse OS (HR: 1.86, 95 % Cl: 1.35-2.57) and RFS (HR: 1.68, 95 % Cl: 1.38-2.04). A significant effect on OS and/or RFS was also shown by other 18 factors.

CONCLUSIONS

This meta-analysis found that KRAS mutation is an important prognostic predictor for OS and RFS in CRC patients undergoing PM, supporting a comprehensive model including clinicopathological and biological factors for optimal patients selection and prognosis for surgical treatment.

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.

Past, present, and future perspectives of pulmonary metastasectomy for patients with advanced colorectal cancer

Over a half-century has passed since Thomford et al. proposed the selection criteria for pulmonary metastasectomy, and several prognostic factors have been identified. Although screening modalities and operations have changed dramatically, the important concepts of the selection criteria remain unchanged. Recent improvements in the survival outcomes of colorectal cancer patients undergoing pulmonary metastasectomy may be the result of strict adherence to the selection criteria for oligometastatic lung tumors, which can mimic local disease. Pulmonary metastasectomy has become an important option for selected patients with oligometastasis, based mainly on a large amount of retrospective data, but its effect on survival remains unclear. Curable pulmonary metastasis might be regarded as a "semi-local disease" under the spontaneous control of an acquired alteration in host immune status. The current practice of pulmonary metastasectomy for colorectal cancer focuses on selecting the most appropriate operation for selected patients. However, in the rapidly evolving era of immunotherapy, treatment-naïve patients for whom surgery is not suitable might be pre-conditioned by immunotherapy so that they may be considered for salvage surgery.

Lung metastasectomy after colorectal cancer: prognostic impact of resection margin on long term survival, a retrospective cohort study

BACKGROUND

Pulmonary metastasectomy is considered a potentially curative treatment for selected patients with metastatic colorectal cancer (CRC). Several prognostic factors have been analysed, but to date, it is still not well defined which is the optimal resection margin during lung metastasectomy (LM). This study analyses the long-term results and prognostic factors after LM in CRC patients with particular attention to the resection margins. Primary endpoint of this study is to assess the correlation between resection margins and long-term outcomes.

METHODS

Observational cohort study on all proven cases of CRC lung metastases (2000-2016) resected with curative intent in a single centre.

RESULTS

The series included 210 consecutive patients (M/F 133/77) with a mean age of 65.4 (± 9.96) years, 75% (159/210) of them with a solitary metastasis. Mean size of metastasis was 2.57 cm (± 1.45). One hundred sixty-eight patients underwent wedge resections (80%) and lymphadenectomy was carried out in 90 cases (42.9%). With a mean follow-up of 56 months (range 5-192), we observed a 1-, 3- and 5-year overall survival (OS) of 95%, 74% and 54%, respectively. The patients were divided into three groups according to the resection margin distance from the tumour: (a) ≥ 2 cm (145 cases); (b) < 2, ≥ 1 cm (37 cases); and (c) < 1 cm (12 cases). The OS was significantly different between the three groups (p = 0,020); univariate and multivariate analyses showed that a narrow resection margin was an independent prognostic factor of worse survival (p = 0.006 and HR 3.4 p = 0.009).

CONCLUSIONS

Long-term survival of patients after LM is strongly associated with a greater distance between the lesion and the resection margin.

Does adjuvant chemotherapy improve the prognosis of patients after resection of pulmonary metastasis from colorectal cancer? A systematic review and meta-analysis

BACKGROUND

It remains controversial whether patients benefit from adjuvant chemotherapy (ACT) after resection of pulmonary metastasis (PM) from colorectal cancer (CRC). This meta-analysis was intended to evaluate the efficacy of ACT in patients after resection of PM from CRC.

METHODS

We systematically retrieved articles from PMC, PubMed, Cochrane Library, and Embase (up to March 5, 2019). Survival data, including overall survival (OS) and disease-free survival (DFS), were tested by hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

We included 18 cohort studies with a total of 3885 patients. The meta-analysis showed that ACT had no significant effect on OS (HR = 0.78; 95% CI = 0.60-1.03; P = 0.077) and DFS (HR = 0.91; 95% CI = 0.74-1.11; P = 0.339) in patients after resection of PM from CRC. There was no significant difference in OS (HR = 0.79; 95% CI = 0.42-1.50; P = 0.474) in patients after resection of PM from CRC treated with bevacizumab (BV). Subgroup analysis showed that ACT did not improve OS (HR = 0.86; 95% CI = 0.57-1.29; P = 0.461) in patients who had undergone previous resection of extra PM. ACT did not improve OS in patients who had positive hilar/mediastinal lymph node metastasis (HR = 0.80; 95% CI = 0.57-1.14; P = 0.22).

CONCLUSION

In conclusion, ACT does not provide survival benefits for patients after resection of PM from CRC. ACT and targeted agents (BV) are not suggested for these patients.

Surgical management of colorectal lung metastases

Pulmonary metastasectomy for colorectal cancer is an established means of treatment for select patients. This article will highlight the recent evidence published in the literature related to current practices for the surgical management of colorectal lung metastases and propose a diagnostic algorithm for use in clinical practice. It will also discuss controversies related to pulmonary metastasectomy, including the optimal timing of surgery, the extent of lymph node sampling/dissection, and the extent of surgical resection.