Repeated Pulmonary Metastasectomy: Third Operations and Beyond

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.

Workup, Indications, and Guiding Principles of Selection for Pulmonary Metastasectomy

Pulmonary metastasectomy is a potentially curative intervention for many different and distinct primary malignancies. It is safe in a diverse patient population. A short disease-free interval, multiple metastases, large metastases, and incomplete resection are all poor prognostic indicators for survival. Patients should be approached as any lung resection patient would, including a full history and physical, and a thorough review of their imaging, labs, medications, previous surgeries, and pulmonary function tests. All patients should be discussed at a multidisciplinary tumor board, and a formal and united plan with input from all specialties should be developed before offering surgical intervention.

Six radical surgeries for metachronous multiple primary lung cancer: A case report

INTRODUCTION AND IMPORTANCE

Comprehensive reports on surgery for metachronous multiple primary lung cancers after the third or subsequent surgeries are lacking. Herein, we report a case in which six radical surgeries were performed for metachronous primary lung cancer.

CASE PRESENTATION

The patient was a 62-year-old man when he underwent his first surgery, a right lower lobectomy, and the pathological diagnosis was adenocarcinoma. Fifteen years after the first surgery, when the patient was 77 years, an 11-mm nodule was found in right segment 2a, and it had been growing for 3 years; thus, he underwent his sixth surgery. Surgery involved adhesion removal (duration, 90 min) and right upper wedge resection. A delayed pulmonary fistula developed on postoperative day (POD) 11, and adhesion therapy was performed six times, but no improvement was observed; therefore, fenestration was performed on POD 28. The patient progressed well, and he was discharged home on POD 58. However, his nutritional status gradually deteriorated, and he died of pneumonia 5 months after surgery.

CLINICAL DISCUSSION

Third or subsequent surgeries are expected to increase the risk of prolonged operation time, increased bleeding, and prolonged air leakage as surgical complications. In addition, strong adhesions, especially in the hilar area, make it very difficult to identify and fix existing structures, especially the pulmonary artery and vein, and increase the risk of injury.

CONCLUSION

When planning multiple metachronous lung cancer surgeries, it is important to consider bleeding and adhesions during the next surgery, plan thoracoscopic surgery, and minimize air leakage during surgery.

A modern approach to multiple pulmonary resections in children with recurrent metastatic pulmonary disease

Implications of repeated resections of pulmonary metastasis (PM) are not well documented in the modern era. Fifteen children underwent two (n = 8), three (n = 3), or four or more (n = 3) resections (total = 38 procedures), most commonly for osteosarcoma (71%). Operative approach included muscle-sparing thoracotomy (71%), non-muscle-sparing thoracotomy (18%), and video-assisted thoracoscopy (11%). Median resected nodules per procedure was four (range = 1-95). Prolonged air leaks were the most common postoperative complication (29%). Median hospital stay was 4 days, and no children were discharged with or have required oxygen. Event-free survival is 67% at median follow-up time of 54 months, with an overall survival rate of 64%. Repeat resection of PM appears to be well tolerated, without prolonged hospital stays or compromised pulmonary function.

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.

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.

Colorectal Cancer Pulmonary Metastasectomy: When, Why and How

Colorectal cancer is the third-most-diagnosed cancer in males and in females, representing 8% of estimated new cases, and the third cause of cancer-related death in both sexes, accounting for 9% of cancer deaths in men and 8% in women. About 20% of patients diagnosed with CRC present metastatic disease. Although lung metachronous or synchronous metastatic spread without other involved sites has been reported in only a small proportion of patients, considering that this tumor is frequently diagnosed, the clinical approach to CRC pulmonary metastases represents a major issue for thoracic surgeons and CRC oncologists. Among patients diagnosed with pulmonary metastases from CRC, about 9-12% are eligible for local treatments with radical intent, including surgical resection, SBRT (stereotactic body radiation therapy) and ablation therapy. Due to the lack of randomized controlled trials among different local strategies, there is no definitive evidence about the optimal approach, although surgical resection is considered the most effective therapeutic option in this clinical scenario. Oncological achievement of primary radical resection, the biology of primary tumor and metastatic sites, disease free interval and or progression free survival are independent prognostic factors which make it possible to define a cohort of patients which might significantly benefit from pulmonary metastasectomy.

Outcomes and prognostic factors of repeat pulmonary metastasectomy

OBJECTIVES

Information on prognostic factors after repeat pulmonary metastasectomy (PM) is limited, and outcomes after a third PM are not well documented.

METHODS

A single-institute retrospective study was conducted. Between 2000 and 2020, 68 patients underwent repeat PM for pulmonary metastases from various cancers. Outcomes and prognostic factors for the second PM and outcomes after the third PM were analysed.

RESULTS

This study included 39 men and 29 women. The mean age at second PM was 53.2 years old. The primary tumours were soft tissue sarcoma in 24 patients, colorectal cancer in 19 and osteosarcoma in 10. The interval between the first PM procedure and detection of pulmonary metastasis after the first PM (months) was ≤12 in 37 patients and >12 in 31 patients. At the second PM, 20 patients underwent lobectomy or bilobectomy, and 48 underwent sublobar resection. Complete resection was achieved in 60 patients, and 52 patients experienced recurrence after the second PM. The 5-year relapse-free survival and overall survival rates after the second PM were 27% and 48%, respectively. Multivariable analysis revealed that the interval between the first PM and the subsequent detection of pulmonary metastasis (≤12 months) was a poor prognostic factor for both relapse-free survival and overall survival after the second PM. Seventeen patients underwent a third PM, 3 of whom achieved a 3-year disease-free survival.

CONCLUSIONS

Patients with a period of >12 months between the first PM and the subsequent detection of pulmonary metastases showed favourable outcomes and are thus considered good candidates for second PM. A third PM may be beneficial for selected patients.

Lung surveillance following colorectal cancer pulmonary metastasectomy: Utilization of clinicopathologic risk factors to guide strategy

BACKGROUND

Appropriately selected patients clearly benefit from resection of colorectal cancer (CRC) pulmonary metastases (PMs). However, there remains equipoise surrounding optimal chest surveillance strategies following pulmonary metastasectomy. We aimed to identify risk factors that may inform chest surveillance in this population.

METHODS

Patients who underwent CRC pulmonary metastasectomy were identified from a single institution's prospectively maintained surgical database. Clinicopathologic and genomic characteristics were collected. Patients were stratified by diagnosis of subsequent PM within 6 months of the index lung resection. Multivariate modeling was used to evaluate risk factors.

RESULTS

A total of 197 patients met the study's inclusion criteria, of whom 52.3% (n = 103) developed subsequent PM, at a median of 9.51 months following the index metastasectomy. Patients with KRAS alterations (odds ratio [OR], 3.073; 95% confidence interval [CI], 1.363-6.926; P = .007), TP53 alterations (OR, 3.109; 95% CI, 1.318-7.341; P = .010) were found to be at risk of PM diagnosis within 6 months of the index metastasectomy, while those with an APC alteration (OR, .218; 95% CI, 0.080-0.598; P = .003) were protected. Moreover, patients who received systemic therapy within 3 months of the initial PM diagnosis also were more likely to develop early lung recurrence (OR, 2.105; 95% CI, 0.971-4.563; P = .059).

CONCLUSIONS

Patients with KRAS alterations, TP53 alterations, and no APC alterations developed early recurrence in the lung following pulmonary metastasectomy, as did those who received chemotherapy after their initial PM diagnosis. As such, these groups benefit from early lung imaging after metastasectomy, as chest surveillance protocols should be based on patient-centered clinicopathologic and genomic risk factors.