Incidence of Ipsilateral Side Recurrence After Open or Video-Assisted Thoracic Surgery Resection of Colorectal Lung Metastases

Transcontinental Differences in Management of Pulmonary Metastatic Disease: Europe

Several international registries, including 4 from Europe-Italy, Spain, the Netherlands, and the European Society of Thoracic Surgeons-are dedicated to addressing deficiencies in pulmonary metastasectomy research. The randomized PulMiCC and SABR-COMET trials provide contradictory outcomes and new randomized trials have been initiated. Europe's metastasectomy approach transitioned from open thoracotomy to video-assisted thoracoscopic surgery, with 72% of surgeons favoring minimally invasive methods by 2023. European Society for Medical Oncology guidelines recommend surgery for completely resectable lesions and propose ablative approaches as supplementary or alternative treatments for inoperable cases due to frailty or unfavorable anatomy.

Low Rates of Intrapulmonary Local Recurrence After Laser Metastasectomy: A Single-Center Retrospective Cohort Study of Colorectal Cancer Metastases

Objective: Colorectal pulmonary metastasis is the most common resected metastatic disease of the lung. Pulmonary metastasectomy (PM) for colorectal oligometastases is a well-established intervention with curative intent. Local recurrence at the resection site in the lung is a problem, with an impact on survival. The use of a 1320 nm neodymium:yttrium aluminum garnet (Nd:YAG) laser causes the vaporization and coagulation at the resection line and thereby increases safety margins around the nodule. We aimed to evaluate the local recurrence rate after laser-assisted pulmonary metastasectomy (LPM) for colorectal metastases. Methods: We conducted a retrospective analysis of 49 patients treated with laser-assisted pulmonary metastasectomy for 139 metastatic nodules from colorectal cancer from 2010 to 2018. All nodules were resected using Nd:YAG 1320 nm laser, aiming for a safety margin of five mm. The minimum follow-up time after PM was 24 months. Results: Local intrapulmonary recurrence developed at 7 of the 139 (5.0%) resection sites in 5 of the 49 patients (10.2%). Microscopically incomplete resection was a significant risk factor for recurrence (p = 0.023). Larger nodule size (>12 mm) negatively impacted local recurrence (p = 0.024). Nodules larger or equal to 12 mm in size also lowered the patients' probability of survival by 67.29% (HR: 0.3271, 95% CI: 0.1265-0.846, p = 0.018). Conclusions: The rate of local recurrence at the resection site after LPM for colorectal metastases is low. Complete resection is a positive predictor of survival without local recurrence. Microscopic complete resection with the addition of vaporization and coagulation at the resection margin seems to be sufficient to prevent local recurrence. However, larger nodules may require larger safety margins.

Video-assisted thoracoscopic surgery versus open thoracotomy for resection of lung metastasis-A meta-analysis of reconstructed time-to-event data

This study aimed to conduct a systematic review and meta-analysis comparing video-assisted thoracoscopic surgery (VATS) and open thoracotomy (OT) in the context of pulmonary metastasectomy. Three databases were assessed. The primary outcome was overall survival. The secondary outcomes were recurrence-free survival, ipsilateral recurrence, and hospital length of stay (LOS). Hazard ratios (HRs), odds ratios (ORs), and mean difference (MD) with 95% confidence intervals (CIs) were calculated. Reconstruction of time-to-event data and sensitivity analyses were performed for the primary endpoint. After screening, 11 studies were included encompassing 2159 patients undergoing lung metastasectomy (VATS: 827; OT: 1332). Compared to OT, patients who underwent VATS had higher overall survival rates (HR 0.75; 95% CI 0.67-0.85; p < 0.01), no significant difference in recurrence-free survival (HR 1.07; 95% CI 0.88-1.29; p = 0.48), shorter hospital LOS (MD -1.99 days; 95% CI -2.59 to -1.39; p < 0.01), and no significant difference in ipsilateral recurrence rates (OR 0.86; 95% CI 0.52-1.42; p = 0.56). For patients undergoing pulmonary metastasectomy, VATS strategy is associated with higher survival rates and reduced hospital LOS when compared with OT. Moreover, metastasis recurrence does not seem to be associated with long-term mortality in this population.

Lung Metastasectomy: Where Do We Stand? Results from an Italian Multicentric Prospective Database

Background/Objectives: The surgical resection of pulmonary metastases is considered a therapeutic option in selected cases. In light of this, we present the results from a national multicenter prospective registry of lung metastasectomy. Methods: This retrospective analysis involves data collected prospectively and consecutively in a national multicentric Italian database, including patients who underwent lung metastasectomy. The primary endpoints were the analysis of morbidity and overall survival (OS), with secondary endpoints focusing on the analysis of potential risk factors affecting both morbidity and OS. Results: A total 470 lung procedures were performed (4 pneumonectomies, 46 lobectomies/bilobectomies, 13 segmentectomies and 407 wedge resections) on 461 patients (258 men and 203 women, mean age of 63.1 years). The majority of patients had metastases from colorectal cancer (45.8%). In most cases (63.6%), patients had only one lung metastasis. A minimally invasive approach was chosen in 143 cases (30.4%). The mean operative time was 118 min, with no reported deaths. Morbidity most frequently consisted of prolonged air leaking and bleeding, but no re-intervention was required. Statistical analysis revealed that morbidity was significantly affected by operative time and pulmonary comorbidities, while OS was significantly affected by disease-free interval (DFI) > 24 months (p = 0.005), epithelial histology (p = 0.001) and colorectal histology (p = 0.004) during univariate analysis. No significant correlation was found between OS and age, gender, surgical approach, surgical extent, surgical device, the number of resected metastases, lesion diameter, the site of lesions and nodal involvement. Multivariate analysis of OS confirmed that only epithelial histology and DFI were risk-factors, with p-values of 0.041 and 0.031, respectively. Conclusions: Lung metastasectomy appears to be a safe procedure, with acceptable morbidity, even with a minimally invasive approach. However, it remains a local treatment of a systemic disease. Therefore, careful attention should be paid to selecting patients who could truly benefit from surgical intervention.

Long-Term Follow-Up after Laser-Assisted Pulmonary Metastasectomy Shows Complete Lung Function Recovery

Preserving maximum lung function is a fundamental goal of parenchymal-sparing pulmonary laser surgery. Long-term studies for follow-up of lung function after pulmonary laser metastasectomy are lacking. However, a sufficient postoperative lung function is essential for quality of life and reduces potential postoperative complications. In this study, we investigate the extent of loss in lung function following pulmonary laser resection after three, six, and twelve months. We conducted a retrospective analysis using a prospective database of 4595 patients, focusing on 126 patients who underwent unilateral pulmonary laser resection for lung metastases from 1996 to 2022 using a 1318 nm Nd:YAG laser or a high-power pure diode laser. Results show that from these patients, a median of three pulmonary nodules were removed, with 75% presenting central lung lesions and 25% peripheral lesions. The median preoperative FEV1 was 98% of the predicted value, decreasing to 71% postoperatively but improving to 90% after three months, 93% after six months, and 96% after twelve months. Statistical analysis using the Friedman test indicated no significant difference in FEV1 between preoperative levels and those at six and twelve months post-surgery. The findings confirm that pulmonary laser surgery effectively preserves lung function over time, with patients generally regaining their preoperative lung function within a year, regardless of the metastases' location.

Surgical and Interventional Management of Lung Metastasis: Surgical Assessment, Resection, Ablation, Percutaneous Interventions

The lungs are the second most common site of metastases for colorectal cancer after the liver. Pulmonary metastases can be identified at the time of diagnosis of the primary tumor, or metachronously. About 20% of patients with colorectal cancer will develop pulmonary metastases. The best options for treatment include a multidisciplinary treatment approach consisting of surgical resection whenever possible, and chemotherapy. Surgical options most often include minimally invasive segmentectomy or wedge resection, while patients unable to have surgery may benefit from radio frequency ablation or radiation treatment. Prognosis is dependent on preoperative carcinoembryonic antigen level, number, and location of metastatic lesions, and resectability of primary tumor. Overall, pulmonary metastases are best treated by complete resection whenever possible.

Experience of Simultaneous Bilateral Open Surgery and VATS for Pulmonary Metastasectomy

BACKGROUND

Resection is the current treatment of choice for resectable bilateral pulmonary metastases. This study aimed to compare the differences in outcomes between simultaneous bilateral open and video-assisted thoracic surgery (VATS) for pulmonary metastasectomy.

METHODS

Forty-three patients underwent pulmonary metastasectomy through one-stage bilateral open thoracotomy (n = 16) and VATS (n = 27) between 2011 and 2020. Perioperative and oncological data were analyzed.

RESULTS

The predominant primary tumor histology in both groups was colorectal cancer. The operative time, blood loss, and pain score on postoperative day 1 (POD1) were higher in the open group (p < 0.001, 0.009, and 0.03, respectively). No significant differences in pain score on POD2 and POD3, postoperative length of stay, or complications were found. Notably, numbers of the resected metastatic lung nodules were significantly greater in the open group (median number: 9.5 vs. 3, p < 0.001). Recurrence-free survival (RFS) and overall survival (OS) were comparable. The median RFS was 15 months (interquartile range [IQR], 6-22) in the open group and 18 months (IQR, 8-47) in the VATS group. The median OS was 28 months (IQR, 14-44) and 29 months (IQR, 15-54) in the open group and VATS group, respectively.

CONCLUSION

One-stage bilateral pulmonary metastasectomy is safe and reduces medical expenditures in selected patients regardless of surgical approach. Although the open group harbored a greater number of metastatic foci, perioperative and oncological outcomes were similar to that of the VATS group.

Pulmonary metastasectomy in colorectal carcinoma

Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths worldwide. It is estimated that 50% of all patients with CRC develop metastases, most commonly in the liver and the lung. Lung metastases are seen in approximately 10–15% of all patients with CRC. A large number of these patients with metastatic CRC can only receive palliative treatment due to invasion of other organs and disseminated disease. However, a subset of these patients present with potentially resectable metastases. Pulmonary metastasectomy is considered to be a potentially curative treatment for selected patients with resectable metastatic CRC. Current data suggest that patients that undergo pulmonary metastasectomy have 5-year survival rates of approximately 40%. However, the majority of data published regarding lung metastasectomy is based on small, retrospective case series. Due to this lack of prospective data, it is still unclear which subset of patients will benefit most from curative-intent surgery. Furthermore, there is also controversy regarding which prognostic and genetic factors are related to survival outcomes and whether there is a difference between open and thoracoscopic approaches in terms of overall and disease-free survival. In this review, we aim to summarize the latest data on prognostic factors and survival outcomes after pulmonary metastasectomy in patients with metastatic CRC.