Transxiphoid video-assisted pulmonary metastasectomy: relevance of helical computed tomography occult lesions

Uniportal non-intubated lung metastasectomy

BACKGROUND

More than 15 years ago, we started a program of uniportal video-assisted thoracoscopies (VATS) lung metastasectomy in non-intubated local anesthesia. Hereby we present the short and long-term results of this combined surgical-anesthesiological technique.

METHODS

Between 2005 and 2015, 71 patients (37 men and 34 women) with pulmonary oligometastases, at the first episode, underwent uniportal VATS metastasectomy under non-intubated anesthesia.

RESULTS

Four patients (5.6%) required intubation for intolerance. Mean number of lesions resected per patient was 1.51. There was no mortality. The study group demonstrated a significant reduction of operative time from the beginning of the experience (P=0.001), good level of consciousness at Richmond scale and quality of recovery after both 24 and 48 hours. Median hospital stay was 3 days and major morbidity rate was 5.5%. Both disease-free survival and overall survival were similar to those achieved with intubated surgery.

CONCLUSIONS

VATS lung metastasectomy in non-intubated local anesthesia was safely performed in selected patients with oligometastases with significant advantages in overall operative time, hospital stay and economical costs. Long-term results were similar.

Is manual palpation of the lung necessary in patients undergoing pulmonary metastasectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether manual palpation of the lung is necessary in patients undergoing pulmonary metastasectomy. In total, 56 articles were found using the described search strategy. After screening these articles and their references, 18 publications represented the best evidence to answer the clinical question. No randomized controlled trial addressing the three-part question was available. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers were tabulated. The studies reported on 1472 patients with different primary cancers. The patients underwent more than 1630 pulmonary metastasectomies between 1990 and 2014 after the treatment of primary cancer. Almost three quarters of patients underwent open procedures like thoracotomy or sternotomy. Most frequently, helical CT with a slice thickness ranging between 1 and 10 mm was used for preoperative imaging. The sensitivity in detecting pulmonary nodules ranged from 34 to 97%. The corresponding sensitivity rates for PET-CT were 66-67.5 and 75% for high-resolution CT. The positive predictive value for lesions detected by helical CT varied from 47 to 96%. Helical CT reached a specificity between 54 and 93% in detecting pulmonary nodules. The surgeons identified more nodules by meticulous palpation than helical CT. It is noteworthy that up to 48.5% of these palpated nodules were benign lesions (false-positive). Patients with smaller imaged nodules, multiple imaged nodules or primary mesenchymal tumour are more likely to have occult pulmonary nodules. We conclude that not all palpable pulmonary nodules can be imaged preoperatively. Thoracotomy allows the manual palpation of the ipsilateral hemithorax and might be superior to video-assisted thoracic surgery regarding radical resection. However, not all palpable nodules are malignant, and the impact of non-resected pulmonary metastases on patient survival is not clearly evaluated.

Multi-reoperations for lung metastases

In this study, we investigated role and results of multi-reoperations for lung metastases. From 1986 to 2010, 113 consecutive patients (61 men and 52 women; mean age: 53.2 ± 12.8 years) underwent repeated lung metastasectomy with curative intent in our institution. Two procedures were performed in 113 patients, three in 54, four in 31, five in eight and six in three. There was no perioperative mortality. Cumulative 5-year survival was 65% and this was significantly higher than the value recorded for patients undergoing only one metastasectomy (42%; p = 0.021). Size, number of resections and probability of recurrence increased by number of operation whereas disease free interval reduced. At any metastasectomy both short disease-free interval and multiple metastases resulted in the most significant negative prognosticators. In conclusion, redo metastasectomy is worthwhile for the initial procedures, afterwards both disease-free and overall survivals decrease and surgery lose its efficacy.

Video-assisted thoracoscopic surgery versus open thoracotomy for pulmonary metastasectomy: a systematic review

BACKGROUND

Pulmonary metastasectomy has become a popular procedure for patients with pulmonary metastases. It can be achieved via the traditional open thoracotomy or the more recently developed video-assisted thoracoscopic surgery (VATS). However, there has been much debate as to which approach is better in terms of detection of pulmonary metastases and, in turn, survival and recurrence outcomes. We aim to compare the two different approaches in terms of survival and recurrence outcomes.

METHODS

Medline and EMBASE databases were searched for relevant publications dated prior to May 2013. The bibliographies of the included articles were examined for additional relevant articles that were not included in the search. All publications reporting on overall survival and recurrence-free survival were included. The articles were carefully examined and data were extracted. STATA 12L and RevMan5.2 software were used to combine the data using the random effects model.

RESULTS

A total of 1960 studies were identified through the search. Thirty-two articles had extractable data regarding overall survival and recurrence-free survival. However, only eight articles were included in the end as the other 24 articles had incomplete data. From the included articles, we found that the VATS group had slightly higher odds of 1-, 3- and 5-year overall survival with odds ratios of 1.53, 1.69 and 1.41, respectively, and also higher odds of 1-, 3- and 5-year recurrence-free survival with odds ratios of 1.29, 1.54 and 1.54, respectively.

CONCLUSION

VATS offers a suitable alternative to open thoracotomy for the treatment of pulmonary metastases.

Hand-assisted thoracoscopic surgery for pulmonary metastasectomy through sternocostal triangle access: superiority in detection of non-imaged pulmonary nodules

Hand-Assisted Thoracoscopic Surgery for pulmonary metastasectomy through sternocostal triangle access allows manual palpation of both lungs, thus permitting effective treatment of lung metastases. In our research, 62 patients from November 2001 to January 2012 underwent our Hand-Assisted Thoracoscopic Surgery procedures for pulmonary metastasectomy. Clinical data, including the number of pulmonary metastases determined by Computed Tomography/Positron Emission Tomography-Computed Tomography, surgical findings and survival data of these patients were collected. We found that the median follow-up time was 23.7 months (range 2.4 to 85.6 months). 30 cases of them had post-operative recurrences and the median disease-free survival period was 27.4 months. For Computed Tomography scan, the overall sensitivity for proved metastases was 63% (115/182). 67 non-imaged malignant nodules were palpated and removed in 14 cases. For Positron Emission Tomography-Computed Tomography scan, the overall sensitivity was 66% (79/120). 41 non-imaged malignant nodules were palpated and removed in 12 cases. This study show that the Hand-Assisted Thoracoscopic Surgery provides an easier way for routine bilateral pleural exploration, and thus is critical and effective in detection of non-imaged malignant pulmonary metastases, which might contribute to long-term disease-free survival.

Evaluation of video-assisted thoracoscopic surgery for pulmonary metastases: a meta-analysis

Background

To evaluate the evidence comparing video-assisted thoracic surgery (VATS) and open thoracotomy in the treatment of metastatic lung cancer using meta-analytical techniques.

Methods

A literature search was undertaken until July 2013 to identify the comparative studies evaluating disease-free survival rates and survival rates. The pooled odds ratios (OR) and the 95% confidence intervals (95% CI) were calculated with the fixed or random effect models.

Results

Six retrospective studies were included in our meta-analysis. These studies included a total of 546 patients: 235 patients were treated with VATS, and 311 patients were treated with open thoracotomy. The VATS and the thoracotomy did not demonstrate a significant difference in the 1-,3-,5-year survival rates and the 1-year disease-free survival rate. There were significant statistical differences between the 3-year disease free survival rate (p = 0.04), which favored open thoracotomy.

Conclusions

The VATS approach is a safe and feasible treatment in terms of the survival rate for metastatic lung cancer compared with the thoracotomy. The 3-year disease-free survival rate in the VATS group is inferior to that of open thoracotomy. The VATS approach could not completely replace open thoracotomy.

Impact of image quality, radiologists, lung segments, and Gunnar eyewear on detectability of lung nodules in chest CT

BACKGROUND

Despite the increasingly higher spatial and contrast resolution of CT, nodular lesions are prone to be missed on chest CT. Tinted lenses increase visual acuity and contrast sensitivity by filtering short wavelength light of solar and artificial origin.

PURPOSE

To test the impact of Gunnar eyewear, image quality (standard versus low dose CT) and nodule location on detectability of lung nodules in CT and to compare their individual influence.

MATERIAL AND METHODS

A pre-existing database of CT images of patients with lung nodules >5 mm, scanned with standard does image quality (150 ref mAs/120 kVp) and lower dose/quality (40 ref mAs/120 kVp), was used. Five radiologists read 60 chest CTs twice: once with Gunnar glasses and once without glasses with a 1 month break between. At both read-outs the cases were shown at lower dose or standard dose level to quantify the influence of both variables (eyewear vs. image quality) on nodule sensitivity.

RESULTS

The sensitivity of CT for lung nodules increased significantly using Gunnar eyewear for two readers and insignificantly for two other readers. Over all, the mean sensitivity of all radiologist raised significantly from 50% to 53%, using the glasses (P value = 0.034). In contrast, sensitivity for lung nodules was not significantly affected by lowering the image quality from 150 to 40 ref mAs. The average sensitivity was 52% at low dose level, that was even 0.7% higher than at standard dose level (P value = 0.40). The strongest impact on sensitivity had the factors readers and nodule location (lung segments).

CONCLUSION

Sensitivity for lung nodules was significantly enhanced by Gunnar eyewear (+3%), while lower image quality (40 ref mAs) had no impact on nodule sensitivity. Not using the glasses had a bigger impact on sensitivity than lowering the image quality.

Imaging requirements in the practice of pulmonary metastasectomy

The primary imaging modality for the detection of pulmonary metastases is computed tomography (CT). Ideally, a helical CT scan with 3- to 5-mm reconstruction thickness or a volumetric thin section scanning should be performed within 4 weeks of pulmonary metastasectomy. A period of observation to see whether further metastases develop does not seem to allow better patient selection. If positron emission tomography is available, it may identify the extrathoracic metastatic sites in 10 to 15% of patients. Despite helical CT scan, palpation identifies the metastases not detected by imaging in 20 to 25% of patients and remains the standard. No data define the optimal interval for follow-up surveillance imaging.

Current status of pulmonary metastasectomy from primary epithelial tumors

The resection of pulmonary metastases can prolong the survival of selected patients and its therapeutic value is now accepted. The criteria for eligibility have also evolved. We reviewed the recent literature on pulmonary metastasectomy for various epithelial primary tumors and tried to establish better prognostic indicators for its surgical application. In addition to the welldefined requisites for pulmonary metastasectomy, other requirements include the absence of mediastinal lymph node involvement, a limited number of pulmonary metastatic lesions, a long disease-free interval, small metastasis, and no elevation of tumor markers, although the clinical importance of each factor varies among the primary tumors. On the other hand, with the development of video-assisted thoracoscopic surgery (VATS) and advances in thoracic imaging technology, VATS metastasectomy might become an accepted treatment for metastatic nodules located in the periphery of the lung, which can be easily removed by a wedge resection. Repeat surgery is also possible during follow-up after VATS.

Pulmonary metastasectomy for soft tissue sarcomas: is it justified?

Pulmonary metastases are common in patients following resection for soft tissue sarcoma. Pulmonary resection of metastatic soft tissue sarcomas is widely practiced in surgical oncology. No randomized phase III trials are available, and data for this review were retrieved only from retrospective studies. This article addresses the issues of patient selection, surgical technique, and adjuvant chemotherapy, and provides the surgical oncologist with a current review of pulmonary metastasectomy in metastatic soft tissue sarcoma. In summary, there is a substantial body of evidence demonstrating that resection of soft tissue pulmonary metastases can be performed safely and with a low mortality rate. For a subset of highly selected patients, the overall results of a 5-year actuarial survival rate ranged between 25% and 37.6%. These outcomes exceed those normally associated with metastatic soft tissue sarcoma and are well comparable with surgical resection for other malignancies.

Evaluation of video-assisted thoracoscopic surgery for pulmonary metastases: 11-years of experience

BACKGROUND

Although video-assisted thoracoscopic surgery (VATS) has been applied to pulmonary resection for pulmonary metastases, the clinical validity of this approach remains controversial. The purpose of this study was to evaluate the validity and problems of VATS for pulmonary metastasectomy.

METHODS

From January 1993 to December 2003, VATS for pulmonary metastasectomy was performed in 53 resections for 48 patients at our institution. The medical records of these patients were retrospectively reviewed.

RESULTS

The primary tumor was colorectal cancer in 23 patients, renal cell carcinoma in 6, breast cancer in 6, germ cell tumor in 5, head and neck cancer in 2, and others in 6. Thirty-six cases had a solitary lesion, 8 had unilateral multiple lesions, and 9 had bilateral multiple lesions. The following procedures were performed: 7 lobectomies, 5 segmentectomies, and 41 wedge resections. There was no major postoperative morbidity related to VATS. At a median follow-up period of 29.0 months, 13 patients were alive without recurrences. The 3-year overall survival rate and the 3-year intrathoracic disease-free survival rate were 59.8% and 33.4%, respectively. Five cases had recurrence at the surgical stump or at the port sites, but these recurrences have not been found in the recent period since June 1997. Intrathoracic recurrences within 3 months after VATS occurred in four.

CONCLUSION

VATS for pulmonary metastases is not superior to the conventional open thoracotomy and is not recommended as a standard procedure. Further studies with a larger number of cases performed by skilled surgeons familiar with VATS are needed.

A review of clinical and molecular prognostic factors in osteosarcoma

Traditional prognostic determinants in osteosarcoma have included demographics (age, sex), tumour size, site, stage, and the response to chemotherapy. Many of these are determined using varying techniques and units of measurement, which can make comparison between studies difficult. The absence of survival difference between limb sparing surgery and amputation has been repeatedly demonstrated in primary disease, and even in the setting of pathological fracture. On the other hand, there is still some controversy over the existence of increased local recurrence for limb-sparing surgery, and the implications of this. Commonly used prognostic determinants such as metastases, and response to chemotherapy enable a high degree of prognostic accuracy but usually at a late stage in the course of disease. Leading on from this, there is a need to uncover molecular pathways with specific influence over osteosarcoma progression to facilitate earlier treatment changes. Some important pathways are already being defined, for example the association of CXCR4 with metastases on presentation, the likelihood of doxorubicin resistance with positive P-glycoprotein, and the reduced survival prediction of over expressed survivin. It is anticipated that the future of osteosarcoma treatment will involve treatment tailored to the molecular profile of tumours at diagnosis, adjuvant therapy directed towards dysfunctional molecular pathways rather than the use of cytotoxics, and a more standardised approach to the measurement of clinical prognostic factors.

Surgical resection of pulmonary metastases from colorectal cancer: a systematic review of published series

The treatment of patients with pulmonary metastases from colorectal cancer continues to evolve. Recently the use of novel agents as a first-line treatment in metastatic colorectal disease has generated cautious optimism in the oncological community. However, pulmonary metastasectomy remains a mainstay in a multidisciplinary concept for a highly selected subset of patients. A selected group of patients with metastases limited to the lungs may benefit from pulmonary metastasectomy with a 5-year survival rate of up to more than 50%. This review evaluates the current status of surgical resection in pulmonary metastases from colorectal cancer, with special emphasis on prognostic factors that influence survival, as well as on surgical approach and lymph node dissection and its impact on the management of patients with metastatic colorectal disease.

Transxiphoid Hand-Assisted Videothoracoscopic Surgery

BACKGROUND

We have performed transxiphoid hand-assisted videothoracoscopy since 1995 to allow manual palpation in bilateral lung metastasectomy. This approach was extended to other thoracoscopic procedures requiring a handport. No extensive report about early and late results has yet been published.

METHODS

We retrospectively reviewed the first 100 consecutive patients undergoing transxiphoid hand-assisted videothoracoscopy. Acute and chronic postoperative pain, respiratory function, patient's satisfaction score (1 to 5), quality of life (Short Form-36), and survival rate were evaluated.

RESULTS

Seventy-four patients had lung metastases, 5 had primary lung cancers, 16 had benign nodules, and 5 had Morgani's hernia. Five patients needed conversion to thoracotomy, whereas 7 successfully underwent a second transxiphoid operation. Sixty-five metastatic patients were bilaterally explored, 44 were without radiologic evidence of contralateral lesions, discovering 23 occult metastases and 10 patients with occult contralateral disease. A total of 207 minimal resections and 11 lobectomies were performed. Mean operative time was 103 +/- 35 minutes. We had no intraoperative mortality or major complications. Thirty-day postoperative morbidity documented arrhythmia (n = 4) and acute pneumonia (n = 4). Visual Analogue Scale pain, C-reactive protein, fibrinogen, and serum interleukin-6, -8, and -10 normalized within 72 hours. Respiratory function and most of the Short Form-36 domains recovered within 3 months. Six-month mean patient satisfaction score was 4.0 +/- 0.8. Three- and 5-year survival rates for metastatic patients were 52% and 43%, respectively. Mean disease-free interval was 12 +/- 5.8 months.

CONCLUSIONS

Transxiphoid hand-assisted videothoracoscopy proved a good alternative to conventional approaches, and provided rapid recovery without affecting the survival rate in those patients with metastatic lesions. We recommend it whenever a handport during video-assisted procedure is required.

Awake pulmonary metastasectomy

OBJECTIVE

General anesthesia with single-lung ventilation and bimanual lung palpation is considered mandatory in pulmonary metastasectomy. We assessed the safety, feasibility, and early results of awake pulmonary metastasectomy under sole thoracic epidural anesthesia.

METHODS

Between December 2003 and December 2005, 14 patients with radiologic evidence of peripheral solitary lung metastases underwent awake thoracoscopic metastasectomy under sole thoracic epidural anesthesia at T4 to T5. To achieve bimanual-like full lung palpation, a modified digital-instrumental palpation method was used. Anesthesia time, operative time, global operating room time, patient satisfaction with the anesthesia, and technical feasibility scored into 4 grades (from 1 = poor to 4 = excellent) were assessed. Preoperative and postoperative data were compared with those of a historical cohort undergoing video-assisted transxiphoid lung metastasectomy through general anesthesia and 1-lung ventilation.

RESULTS

There was neither mortality nor major morbidity. Technical feasibility was excellent in 10 instances and good or satisfactory in 2 instances, whereas anesthesia satisfaction score was excellent to good in 12 patients. Of 18 resected nodules, 15 proved to be metastases. At awake and control group comparisons, significant differences included median operative time (25.5 minutes vs 48.5 minutes, P < .00001), global in-operating room time (62.5 minutes vs 147.5 minutes, P < .00001), and hospital stay (2.5 days vs 4.0 days, P = .02). There was no difference in lung recurrence (2 vs 3, P = .66) 3-year actuarial survivals (40% vs 78%, P = .29).

CONCLUSIONS

Awake pulmonary metastasectomy proved safe and feasible. Global operating room time and hospital stay were significantly shorter than those of the control group who underwent operation with general anesthesia, whereas oncologic results were comparable.

Management of osteosarcoma pulmonary metastases

Although there has been considerable improvement in survival among children with osteosarcoma over the past 30 years, patients with metastatic disease fare very poorly. The best-case scenario for metastatic patients is a survival rate of 30% assuming complete resection of lung metastases without other disease. To achieve this optimal outcome, an aggressive surgical approach is recommended in which all metastatic disease is resected. This includes metastatic foci that are detected by imaging as well as those only identified by palpation at thoracotomy. Investigation into the biology of the metastatic process of osteosarcoma as well as in identification of molecular features that correlate with prognosis is very active and will likely yield important findings that will impact therapy in the future. An area of investigation that remains needed is the prospective evaluation of the surgical management of these patients with the goal of critically evaluating the impact of the various surgical strategies on patient outcome measures, such as disease-recurrence and survival.

Accuracy of helical CT in the detection of pulmonary metastases: is intraoperative palpation still necessary?

BACKGROUND

Pulmonary metastasectomy is well accepted in patients with isolated metastases from an extrathoracic malignancy. The standard approach involves careful intraoperative palpation of the lungs because more metastases are frequently found than were seen by preoperative conventional computed tomography (CT). Helical CT detects more nodules than conventional CT, raising the question of whether palpation of the lungs is still necessary if helical CT is used.

METHODS

Retrospective review was done of medical records of patients undergoing metastasectomy with curative intent at the University of North Carolina (UNC) from 1999 to 2003. During this time at UNC, helical CT was routinely performed using a standardized technique, and all metastasectomy patients underwent manual lung palpation. The primary outcome measure of this study was whether malignant nodules (palpated, resected, and proven histologically) were reliably detected preoperatively by helical CT.

RESULTS

Thirty-four patients were identified who underwent 41 cases of pulmonary metastasectomy with lung palpation. Our analysis revealed that in 22% (9/41), more malignant nodules were found intraoperatively than were detected by helical CT. Of 88 malignant intraparenchymal nodules, 69 were detected by helical CT (sensitivity 78%). Subset analyses of tumor histology, disease-free interval, the presence of a single lesion versus multiple lesions, the interval between the CT and metastasectomy, and the size of the largest lesion were unable to identify a cohort in which lung palpation was no longer needed after preoperative helical CT.

CONCLUSIONS

Despite the advent of helical CT, palpation of the lung is necessary if the goal is to resect all detectable disease.

Pulmonary nodules on multi-detector row CT scans: performance comparison of radiologists and computer-aided detection

PURPOSE

To compare the performance of radiologists and of a computer-aided detection (CAD) algorithm for pulmonary nodule detection on thin-section thoracic computed tomographic (CT) scans.

MATERIALS AND METHODS

The study was approved by the institutional review board. The requirement of informed consent was waived. Twenty outpatients (age range, 15-91 years; mean, 64 years) were examined with chest CT (multi-detector row scanner, four detector rows, 1.25-mm section thickness, and 0.6-mm interval) for pulmonary nodules. Three radiologists independently analyzed CT scans, recorded the locus of each nodule candidate, and assigned each a confidence score. A CAD algorithm with parameters chosen by using cross validation was applied to the 20 scans. The reference standard was established by two experienced thoracic radiologists in consensus, with blind review of all nodule candidates and free search for additional nodules at a dedicated workstation for three-dimensional image analysis. True-positive (TP) and false-positive (FP) results and confidence levels were used to generate free-response receiver operating characteristic (ROC) plots. Double-reading performance was determined on the basis of TP detections by either reader.

RESULTS

The 20 scans showed 195 noncalcified nodules with a diameter of 3 mm or more (reference reading). Area under the alternative free-response ROC curve was 0.54, 0.48, 0.55, and 0.36 for CAD and readers 1-3, respectively. Differences between reader 3 and CAD and between readers 2 and 3 were significant (P < .05); those between CAD and readers 1 and 2 were not significant. Mean sensitivity for individual readings was 50% (range, 41%-60%); double reading resulted in increase to 63% (range, 56%-67%). With CAD used at a threshold allowing only three FP detections per CT scan, mean sensitivity was increased to 76% (range, 73%-78%). CAD complemented individual readers by detecting additional nodules more effectively than did a second reader; CAD-reader weighted kappa values were significantly lower than reader-reader weighted kappa values (Wilcoxon rank sum test, P < .05).

CONCLUSION

With CAD used at a level allowing only three FP detections per CT scan, sensitivity was substantially higher than with conventional double reading.

Optimizing the surgical management of lung nodules in children with osteosarcoma: thoracoscopy for biopsies, thoracotomy for resections

BACKGROUND

The goal of this study was to assess the role of thoracoscopy (TS) and thoracotomy (TT) in the management of lung nodules in children with osteosarcoma.

METHODS

Charts of 16 osteosarcoma patients undergoing surgery for lung nodules were retrospectively analyzed for a correlation between nodule localization at CT scan, findings at surgery, and pathology.

RESULTS

Fourteen TSs were performed in 10 children, eight of which were converted: two for technical problems, and six for inconsistency between CT scan and intraoperative findings. In three converted cases, TT allowed detection of more nodules than CT scan and/or TS. Eight TTs were performed as primary intention in seven children, in one as secondary surgery after a previous TS. In three cases, TT detected more nodules than CT scan. Overall, TT detected more nodules than CT scan in seven of 16 cases (sensitivity, 56.2%), six of whom had a predicted bilateral involvement. Neoplastic tissue was present in lung samples of all but three patients (86.4%).

CONCLUSIONS

Lung nodules in osteosarcoma patients are usually metastases. CT scan is unreliable in detecting all the nodules, especially in the case of predicted bilateral involvement. If excision of all metastases is considered the goal of surgery, a TT approach should be chosen in patients with more than one thoracic nodule.

Thoracoscopy using a substernal handport for palpation

BACKGROUND

A substernal handport allows palpation of the lung and thus circumvents one of the major limitations of thoracoscopy.

METHODS

This approach has been used in 24 consecutive patients, primarily during planned metastasectomy or when palpation was needed for deeper or smaller lesions that were difficult to find.

RESULTS

No long-term complications from this procedure were noted, and the 3 early complications were either minor or unrelated to the procedure. This approach allowed adequate resection to be accomplished by a less invasive approach in 67% of patients, although conversion to an open procedure was necessary in 33% of patients for anatomic and technical reasons. Among the 16 patients who underwent this procedure alone, the median length of stay in the hospital was 3 days. The rate of incomplete resection and of recurrence after metastasectomy was comparable to that for an open approach.

CONCLUSIONS

Our experience documents that a substernal handport is safe, does not compromise the ability to perform an adequate metastasectomy, and allows biopsy of lesions that are otherwise not amenable to a minimally invasive approach. This technique should be included in the standard armamentarium of approaches for thoracic surgery.

Complete port-accessed lobectomy by the muscle-sparing method

We report the case of a 53-year-old woman who underwent complete port-accessed middle lobectomy by a new technique that preserves all muscles, including the extracostal and intercostal muscles. The operation was performed by using only thoracovideoscopy, and the resected lobe was withdrawn in a pouch through a subxiphoid incision through the substernal route. This complete port-accessed lobectomy is a new technique and is thought to be less invasive than video-assisted lobectomy with minithoracotomy.

[Surgical treatment of pulmonary metastases from renal cancer]

Based on a large single-center follow-up database, we evaluated the long-term results after curative resection of pulmonary metastases from renal cancer. During a 20-year period, 105 patients underwent a total of 150 resections with curative intention. Hospital mortality was 0.95%, 5- and 10-year survival rates were 40% and 33%, respectively. Significant prognostic relevance was shown for complete pulmonary resection, lymph node involvement upon primary resection as well as size of the resected lung metastasis. Our findings of low perioperative morbidity and mortality rates lead us to propose that in patients without additional metastases curative resection of pulmonary lesions should be considered. Moreover, recurrent pulmonary metastases should also be considered for surgical treatment since resection for cure significantly improves survival in these patients.

Pulmonary metastasectomy for 165 patients with colorectal carcinoma: A prognostic assessment

OBJECTIVE

The purpose of this study was to analyze our entire experience with pulmonary resection for metastatic colorectal carcinoma to determine prognostic factors and critically evaluate the potential role of extended metastasectomy.

METHODS

We analyzed the postoperative survival of 165 patients who underwent curative pulmonary surgery at eight institutions in the Kansai region of western Japan (Kansai Clinical Oncology Group) from 1990 to 2000.

RESULTS

Overall survivals at 5 and 10 years were 39.6% and 37.2%, respectively. Cumulative survival of patients who underwent simultaneous bilateral metastasectomy was significantly lower than that of the patients who underwent unilateral metastasectomy or sequential bilateral metastasectomy (P =.048). Five-year survival was 53.6% for patients without hilar or mediastinal lymph node metastasis, versus 6.2% at 4 years for patients with metastases (P <.001). Five-year survival of patients with a prethoracotomy carcinoembryonic antigen level less than 10 ng/mL was 42.7%, versus 15.1% at 4 years for patients with a carcinoembryonic antigen level 10 ng/mL or greater (P <.0001). Twenty-one patients underwent a second or third thoracotomy for recurrent colorectal carcinoma. Overall 5-year survival from the date of the second thoracotomy was 52.1%. The 34.1% 10-year survival for the 26 patients with hepatic metastasis resected before thoracotomy did not differ significantly from that of patients without hepatic metastases (P =.38).

CONCLUSIONS

The status of the hilar or mediastinal lymph nodes and prethoracotomy carcinoembryonic antigen level were significant independent prognostic factors. Patients with pulmonary metastases potentially benefit from pulmonary metastasectomy even when there is a history of solitary liver metastasis. Careful follow-up is warranted, because patients with recurrent pulmonary metastases can undergo repeat thoracotomy with acceptable long-term survival. Simultaneous bilateral metastasectomy confers no survival benefit. Prospective studies may determine the significance of this type of pulmonary metastasectomy.

Long-term results after pulmonary resection of renal cell carcinoma metastases

BACKGROUND

Until now no conclusive data exist regarding the factors influencing long-term survival after pulmonary resection of renal cell carcinoma metastases. The aim of the present study, therefore, was to discover definitive prognostic factors for survival using a large and homogeneous single center patient cohort.

METHODS

Between 1980 and 2000, 105 patients, after curative resection of lung metastases from renal cell carcinoma, were followed in this long-term study. These patients underwent a total of 150 surgical procedures. Survival analysis was done using the Kaplan-Meier method and the log-rank test. Multivariate analysis of prognostic factors was performed using the Cox multivariate proportional hazard model.

RESULTS

Median survival after curative resection reached 43 months (range, 1 to 218 months). Survival at 3, 5, and 10 years was 54%, 40%, and 33%, respectively. Univariate analysis revealed that a complete resection, a less than 4-cm diameter of the metastases and tumor-free lymph nodes at the time of primary operation, were highly significant dependent prognostic factors (p < 0.001). These factors were also shown to be independent prognostic factors as suggested by multivariate analysis (p < 0.05).

CONCLUSIONS

The size of the metastatic nodule, the completeness of pulmonary resection, and the lymph node status at the time of nephrectomy are the most important prognostic factors that influence survival after resection of pulmonary metastases. Recurrence of resectable pulmonary metastases does not impair survival, thus favoring repeated resection in patients with recurrent disease.

Surgical techniques for pulmonary metastasectomy

The surgical approaches to pulmonary metastasectomy have evolved during the past 20 years. Important principles include the complete resection of all gross disease, the use of parenchyma-sparing resections, and the simultaneous resection of bilateral metastases wherever technically feasible. Video-assisted thoracic surgery resection has become popular, but is still not standard because it can lead to an incomplete resection. Stapled and precision electrocautery wedge resections remain the most common techniques for parenchymal resection.

The surgical management of pulmonary metastasis: current concepts

Lung metastases have been found in 25-30% of all patients with cancer at autopsy. Those patients satisfying criteria for surgical resection represent a much smaller subgroup. Given the potentially curative nature of pulmonary metastasectomy in the absence of disseminated disease, it has become widely accepted as an important treatment option for a variety of malignancies with metastasis to the lungs. A standardized approach remains unfounded however, given limited numbers of patients, various histologic subtypes and few published studies utilizing randomized prospective methodology.Ultimately, the development of metastasis represents a major determinant of survival for patients with cancer. Pulmonary metastasectomy is an important treatment modality for patients with metastatic pulmonary disease. The indications for pulmonary metastasectomy and the surgeon's role in pulmonary metastatic disease continue to evolve. Future prospective studies and the compilation of comparable data yielding prognostic factors for specific histologies will better define indications for resection.