Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases

Treatment strategies for malignant pulmonary nodule: beyond lobectomy. Point-counterpoint

PURPOSE OF REVIEW

Technological advancement in low-dose computed tomography resulted in an increased incidental discovery of early-stage lung cancer and multifocal ground glass opacity. The demand for parenchyma-preserving treatment strategies is greater now than ever. Pulmonary ablative therapy is a groundbreaking technique to offer local ablative treatment in a lung-sparing manner. It has become a promising technique in lung cancer management with its diverse applicability. In this article, we will review the current development of ablative therapy in lung and look into the future of this innovative technique.

RECENT FINDINGS

Current literature suggests that ablative therapy offers comparable local disease control to other local therapies and stereotactic body radiation therapy (SBRT), with a low risk of complications. In particular, bronchoscopic microwave ablation (BMWA) has considerably fewer pleural-based complications due to the avoidance of pleural puncture. BMWA can be considered in the multidisciplinary treatment pathway as it allows re-ablation and allows SBRT after BMWA.

SUMMARY

With the benefits which ablative therapy offers and its ability to incorporate into the multidisciplinary management pathway, we foresee ablative therapy, especially BMWA gaining significance in lung cancer treatment. Future directions on developing novel automated navigation platforms and the latest form of ablative energy would further enhance clinical outcomes for our patients.

Primary and Metastatic Lung Cancer: Rationale, Indications, and Outcomes of Thermal Ablation

The widespread use of imaging as well as the efforts conducted through screening campaigns has dramatically increased the early detection rate of lung cancer. Historically, the management of lung cancer has heavily relied on surgery. However, the increased proportion of patients with comorbidities has given significance to less invasive therapeutic options like minimally invasive surgery and image-guided thermal ablation, which could precisely target the tumor without requiring general anesthesia or a thoracotomy. Thermal ablation is considered low-risk for lung tumors smaller than 3 cm that are located in peripheral lung and do not involve major blood vessels or airways. The rationale for ablative therapies relies on the fact that focused delivery of energy induces cell death and pathologic necrosis. Image-guided percutaneous thermal ablation therapies are established techniques in the local treatment of hepatic, renal, bone, thyroid and uterine lesions. In the lung, and specifically in the setting of metastatic disease, the 3 main indications for lung ablation are to serve as (1) curative intent, (2) as a strategy to achieve a chemo-holiday in oligometastatic disease, and (3) in oligoprogressive disease. Following these premises, the current paper aims to review the rationale, indications, and outcomes of thermal ablation as a form of local therapy in the treatment of primary and metastatic lung disease.

Thermal ablation in the management of oligometastatic colorectal cancer

PURPOSE

To review available evidence on thermal ablation of oligometastatic colorectal cancer.

METHODS

Technical and cancer specific considerations for percutaneous image-guided thermal ablation of oligometastatic colorectal metastases in the liver and lung were reviewed. Ablation outcomes are compared to surgical and radiation therapy literature.

RESULTS

The application of thermal ablation varies widely based on tumor burden, technical expertise, and local cancer triage algorithms. Ablation can be performed in combination or in lieu of other cancer treatments. For surgically non-resectable liver metastases, a randomized trial has demonstrated the superiority of thermal ablation combined with chemotherapy compared to systemic chemotherapy alone in term of progression-free survival and overall survival (OS), with 5-, and 8-year OS of 43.1% and 35.9% in the combined arm vs. 30.3% and 8.9% in the chemotherapy alone arm. As ablation techniques and technology improve, the role of percutaneous thermal ablation may expand even into surgically resectable disease. Many of the prognostic factors for better OS after local treatment of lung metastases are the same for surgery and thermal ablation, including size and number of metastases, disease-free interval, complete resection/ablation, negative carcinoembryonic antigen, neoadjuvant chemotherapy, and controlled extra-pulmonary metastases. When matched for these factors, thermal ablation for lung and liver metastases appears to provide equivalent overall survival as surgery, in the range of 50% at 5 years. Thermal ablation has limitations that should be respected to optimize patient outcomes and minimize complications including targets that are well-visualized by image guidance, measure <3cm in diameter, and be located at least 3mm distance from prominent vasculature or major bronchi.

CONCLUSIONS

The routine incorporation of image-guided thermal ablation into the therapeutic armamentarium for the treatment of oligometastatic colorectal cancer can provide long survival and even cure.

Radiomics complements clinical, radiological, and technical features to assess local control of colorectal cancer lung metastases treated with radiofrequency ablation

OBJECTIVES

Radiofrequency ablation (RFA) of lung metastases of colorectal origin can improve patient survival and quality of life. Our aim was to identify pre- and per-RFA features predicting local control of lung metastases following RFA.

METHODS

This case-control single-center retrospective study included 119 lung metastases treated with RFA in 48 patients (median age: 60 years). Clinical, technical, and radiological data before and on early CT scan (at 48 h) were retrieved. After CT scan preprocessing, 64 radiomics features were extracted from pre-RFA and early control CT scans. Log-rank tests were used to detect categorical variables correlating with post-RFA local tumor progression-free survival (LTPFS). Radiomics prognostic scores (RPS) were developed on reproducible radiomics features using Monte-Carlo cross-validated LASSO Cox regressions.

RESULTS

Twenty-six of 119 (21.8%) nodules demonstrated local progression (median delay: 11.2 months). In univariate analysis, four non-radiomics variables correlated with post-RFA-LTPFS: nodule size (> 15 mm, p < 0.001), chosen electrode (with difference between covered array and nodule diameter < 20 mm or non-expandable electrode, p = 0.03), per-RFA intra-alveolar hemorrhage (IAH, p = 0.002), and nodule location into the ablation zone (not seen or in contact with borders, p = 0.005). The highest prognostic performance was reached with the multivariate model including a RPS built on 4 radiomics features from pre-RFA and early revaluation CT scans (cross-validated concordance index= 0.74) in which this RPS remained an independent predictor (cross-validated HR = 3.49, 95% confidence interval = [1.76 - 6.96]).

CONCLUSIONS

Technical, radiological, and radiomics features of the lung metastases before RFA and of the ablation zone at 48 h can help discriminate nodules at risk of local progression that could benefit from complementary local procedure.

KEY POINTS

• The highest prognostic performance to predict post-RFA LTPFS was reached with a parsimonious model including a radiomics score built with 4 radiomics features. • Nodule size, difference between electrode diameter, use of non-expandable electrode, per-RFA hemorrhage, and a tumor not seen or in contact with the ablation zone borders at 48-h CT were correlated with post-RFA LTPFS.

Effectiveness of intraoperative bimanual palpation in metastatic tumors of lung

Background

In this study, we aimed to compare effectiveness of thoracic computed tomography versus intraoperative bimanual palpation in the detection of number of nodules in patients undergoing thoracotomy.

Methods

Between January 2011 and January 2019, a total of 157 patients (63 males, 94 females; mean age: 46.6±11.2 years; range, 13 to 77 years) who underwent pulmonary metastasectomy in our institution were retrospectively analyzed. Metastatic nodules evaluated using thoracic computed tomography were compared with nodules detected by intraoperative palpation.

Results

A total of 226 muscle-sparing thoracotomy was performed in 157 patients. The time between the preoperative thoracic computed tomography and operation ranged from 3 to 24 days. Metastasectomy with muscle-sparing thoracotomy was performed in 41 (26%) patients two times, in eight (5%) patients three times, and in four (2.5%) patients four times due to bilateral lung metastasis or re-metastasectomy. The thoracic computed tomography could detect 476 metastatic nodules, while 1,218 nodules were palpated and resected intraoperatively. Of these nodules, 920 were pathologically evaluated as metastatic.

Conclusion

Our study results showed that the number of nodules reported as pathologically malignant after resection was 1.9 times higher than those reported by thoracic computed tomography. This finding indicates that intraoperative bimanual examination significantly increases the possibility of complete resection. This situation raises the need for more caution for the thoracoscopic metastasectomy procedure in which there is no possibility of intraoperative bimanual palpation.

Leptin Overexpression as a Poor Prognostic Factor for Colorectal Cancer

Leptin acts as an adipocytokine functions via the leptin receptor, which stimulates growth, migration, and invasion of cancer cells. This study is aimed at identifying leptin as a prognostic factor in colorectal cancer (CRC). The differentially expressed genes with prognostic value in CRC tissues either with or without liver metastasis were assessed based on The Cancer Genomic Atlas (TCGA). Leptin was considered a candidate gene for further analysis. Its expression features of 206 CRC patients without liver metastasis and 201 patients with metastasis on tissue microarrays were assessed by immunochemical staining, and the effect of leptin on survival was assessed by Kaplan-Meier analyses. Overexpressed leptin indicated a poorer prognosis for CRC patients in overall survival (p < 0.05, log-rank test) based on the TCGA database. The leptin expression significantly correlated with metastasis stage (p < .010) and lymph node involvement (p < .010). Multivariate analysis also indicated that strong leptin expression was an independent adverse prognosticator in CRC (p = .017). Leptin may be valued as a prognostic marker could contribute to predicting a clinical outcome for patients with CRC.

Leptin Overexpression as a Poor Prognostic Factor for Colorectal Cancer

Leptin acts as an adipocytokine functions via the leptin receptor, which stimulates growth, migration, and invasion of cancer cells. This study is aimed at identifying leptin as a prognostic factor in colorectal cancer (CRC). The differentially expressed genes with prognostic value in CRC tissues either with or without liver metastasis were assessed based on The Cancer Genomic Atlas (TCGA). Leptin was considered a candidate gene for further analysis. Its expression features of 206 CRC patients without liver metastasis and 201 patients with metastasis on tissue microarrays were assessed by immunochemical staining, and the effect of leptin on survival was assessed by Kaplan-Meier analyses. Overexpressed leptin indicated a poorer prognosis for CRC patients in overall survival (p < 0.05, log-rank test) based on the TCGA database. The leptin expression significantly correlated with metastasis stage (p < .010) and lymph node involvement (p < .010). Multivariate analysis also indicated that strong leptin expression was an independent adverse prognosticator in CRC (p = .017). Leptin may be valued as a prognostic marker could contribute to predicting a clinical outcome for patients with CRC.

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

BACKGROUND

There is still controversy whether full lung palpation is required for patients undergoing pulmonary metastasectomy. We aimed to compare pulmonary ipsilateral recurrence (IR) after video-assisted thoracic surgery (VATS) or open surgery.

METHODS

A retrospective study of all patients who underwent surgery for colorectal cancer lung metastases between 2003 and 2012 was performed. IR rate was compared between the 2 groups after adjusting for a propensity score matching based on age, sex, disease-free interval, number of metastases, type of resection, presence of a cardiovascular risk factor, presence of a respiratory risk factor, as well as the interaction between the number of metastases and the disease-free interval. The propensity score was used for matched and weighted comparisons of VATS and open patients.

RESULTS

A total of 211 patients underwent surgery for colorectal cancer lung metastases. Of these, 75 (35.5%) were performed via VATS and 136 (64.5%) via open surgery. Before matching, 118 (55.9%) were male and the median age at the time of metastases diagnosis was 61 (range, 49.8-72.2) years. Median disease free-interval was 20 (19.7 ± 28.3) months; 22 (21.6 ± 28.5) months in VATS and 19 (19.0 ± 28.3) months in open surgery. In total, 19 (25.3%) developed IR in VATS, and 39 (28.7%) in open surgery. Five-year overall survival was 53.1% (61.9% VATS; 49.2% open). In the matched sample, IR was 23.6% in VATS vs 26.2% in open surgery (95% confidence interval for risk reduction with VATS: -22.6% to 17.5%; P = .80).

CONCLUSIONS

No significant difference was observed in IR rates between VATS and open surgery in the treatment of colorectal cancer lung metastases.

Prognostic factors for local control and survival for inoperable pulmonary colorectal oligometastases treated with stereotactic body radiotherapy

PURPOSE

The study aimed to evaluate overall survival and local control, and to identify factors independently associated with overall survival (OS) and local control (LC).

MATERIALS AND METHODS

This retrospective study examined 118 patients with primary colorectal cancer, in whom 202 inoperable pulmonary oligometastases were treated with stereotactic body radiotherapy between 2005 and 2015. Primary endpoint was to evaluate OS and identify prognostic factors associated with OS. Secondary aim was to evaluate LC and identify prognostic factors associated with LC.

RESULTS

Median follow-up was 31 months (range 3-88 months). Median OS was 39.2 months (95% CI 34.8-43.6 months). Two-, three-, and five-year OS was 69%, 55% and 36%, respectively. LC at 2-, 3-, and 5-year was 83%, 81% and 77% respectively. Factors independently associated with OS in the multivariable analysis included BED₁₀ ≥ 100 Gy (HR 0.52), male gender (HR 0.52), age < 70 years (HR 0.52) and presence of single metastasis (HR 0.37). BED₁₀ < 100 Gy (HR 3.67) and pre-SBRT chemotherapy (HR 2.66) were independently associated with poor LC in a multivariable analysis.

CONCLUSIONS

SBRT was associated with 2- year OS of 69% and 2-year LC of 83%. SBRT dose ≥ 100 Gy BED₁₀ was independently associated with both better overall survival and local control.

The Past, Present and Future of Pulmonary Metastasectomy: A Review Article

Pulmonary metastases are a sign of advanced malignancy and an omen of poor prognosis. Once primary tumors metastasize, they become notoriously difficult to treat and interdisciplinary management often involves a combination of chemotherapy, radiotherapy, and surgery. Over the last 25 years, the emerging body of evidence has recognized the curative potential of pulmonary metastasectomy. Surgical resection of pulmonary metastases is now commonly considered for patients with controlled primary disease, absence of widely disseminated extrapulmonary disease, completely resectable lung metastases, sufficient cardiopulmonary reserve, and lack of a better alternative systemic therapy. Since the development of these selection criteria, other prognostic factors have been proposed to better predict survival and optimize the selection of surgical candidates. Disease-free interval (DFI), completeness of resection, surgical approach, number and laterality of lung metastases, and lymph node metastases all play a dynamic role in determining patient outcomes. There is a definite need to continue reviewing these prognosticators to identify patients who will benefit most from pulmonary metastasectomy and those who should avoid unnecessary loss of lung parenchyma. This literature review aims to explore and synthesize the last 25 years of evidence on the long-term survival, prognostic factors, and patient selection process for pulmonary metastasectomy.

Pulmonary metastasectomy: a cross sectional survey

Background

No prospective randomised studies or international guidelines exist for conduct of pulmonary metastasectomy. The aim of this study was to generate general recommendations for the practice of pulmonary metastasectomy through a cross sectional survey of thoracic surgeons.

Methods

A panel of international experts who participated in a consensus statement formation on video-assisted thoracoscopic surgery (VATS) lobectomy were approached to participate in the survey. The Delphi methodology consisting of two rounds of voting was used to establish recommendations. Clinical practice was deemed 'recommended' if 50-74% of the experts reached agreement and 'highly recommended' if 75% or more of the experts reached agreement following the second round of voting.

Results

Twenty-two experts from 8 countries completed both rounds of standardised questionnaires. Recommendations were reached on all of the 18 questions concerning the role, indications, contraindications, preoperative evaluation, operative strategy, follow-up and alternative treatment strategies for pulmonary metastasectomy.

Conclusions

The results of this survey represent a collective agreement among international thoracic surgery experts and establishes general recommendations for the practice of pulmonary metastasectomy.

Repeat pulmonary resection for recurrent lung metastases from colorectal cancer: an analysis of prognostic factors

OBJECTIVES

The purpose of this study was to investigate the prognostic factors for repeat lung metastasectomy in patients with colorectal cancer, which may be clinically helpful in defining a subset of patients who are most likely to benefit from repeat lung metastasectomy.

METHODS

In total, 138 patients underwent complete lung resection for the first time due to metastases of colorectal cancer between January 2004 and December 2013 at Fujita Health University School of Medicine. Among them, 33 underwent repeat pulmonary metastasectomy for lung tumour recurrence. Kaplan-Meier survival curves and log-rank tests were used to analyse the survival rates.

RESULTS

No patient died as a direct result of surgery, and all patients were discharged after the repeat pulmonary metastasectomy. The 5-year survival rate after the initial pulmonary resection of the 33 patients who underwent repeat lung resection was 64%, which was not significantly different from that of the 105 patients who did not undergo repeat lung resection (5-year survival rate, 61%; P = 0.779). Univariate analysis identified only one significant prognostic factor: preoperative serum carcinoembryonic antigen (CEA) level (P = 0.002). The 5-year survival rates of patients with high preoperative CEA levels and normal CEA levels after repeat metastasectomy were significantly different at 47 and 90%, respectively.

CONCLUSIONS

Prethoracotomy serum CEA levels affect survival rates after repeat pulmonary resection. The preoperative assessment of serum CEA levels before repeat metastasectomy is important when considering repeat pulmonary resection, and prethoracotomy CEA levels should be taken into account when selecting patients for repeat lung resection.

Prognostic Factors for Survival after Resection of Pulmonary Metastases from Colorectal Carcinoma

PURPOSE

As chemotherapy has improved, the survival of patients with metastatic colorectal carcinoma has reached up to 2.5 years. Many of these patients experience pulmonary metastases; however, the prognosis after pulmonary metastasectomy is not satisfying. In this study, we analyzed the prognostic factors for survival in patients who underwent pulmonary metastasectomy.

METHODS

Eighty-seven patients with colorectal carcinoma received pulmonary metastasectomy. The pathological status of the primary tumor, outcome of the pulmonary metastasectomy, disease-free interval, perioperative carcinoembryonic antigen (CEA) level and history of liver metastases were assessed.

RESULTS

The five-year survival was 42.5% after pulmonary metastasectomy. A univariate analyses revealed that the CEA level (p = 0.043) and the number of pulmonary metastases (p = 0.047) were prognostic factors for survival. The CEA level was an independent prognostic factor in a multivariate analysis (relative risk = 2.01, p = 0.037). Among cases with elevated preoperative CEA levels, those whose CEA level normalized after metastasectomy had a better prognosis compared with those whose CEA level decreased but was still high, or whose level increased after metastasectomy (median survival time of 41.8 months compared with 28.1 or 15.7 months, respectively p = 0.021).

CONCLUSION

The CEA level can be a predictive marker for the prognosis in patients with pulmonary metastases from colorectal carcinoma.

Radiofrequency ablation is a valid treatment option for lung metastases: experience in 566 patients with 1037 metastases

Radiofrequency of lung metastases below 4 cm, demonstrated an overall survival of 62 months, associated with a 4-year local efficacy of 89%. Repeatability of the technique allows a 4-year lung disease control rate of 44.1%, with patient retreated safely up to four times. Radiofrequency is an option for treatment of small size lung metastases, namely the ones below 2 to 3 cm in diameter.

Background

Minimal invasive methods are needed as an alternative to surgery for treatment of lung metastases.

Patients and methods

The prospective database of two cancer centers including all consecutive patients treated with radiofrequency ablation (RFA) for lung metastasis over 8 years was reviewed. RFA was carried out under general anesthesia, with computed tomography guidance using a 15-gauge multitined expandable electrodes RF needle.

Results

Five hundred sixty-six patients including 290 men (51%), 62.7 ± 13.2 years old with primary tumor to the colon (34%), rectum (18%), kidney (12%), soft tissue (9%) and miscellaneous (27%) received 642 RFA for 1037 lung metastases. Fifty-three percent of patients had 1 metastasis, 25% had 2, 14% had 3, 5% had 4 and 4% had 5–8. Metastases were unilateral (75%), or bilateral (25%). The median diameter [extremes] of metastases was 15 mm (4–70). Twenty-two percent of patients had extrapulmonary disease amenable to local therapy including 49 liver, 16 bone and 60 miscellaneous metastases.

Median follow-up was 35.5 months. Median overall survival (OS) was 62 months. Four-year local efficacy was 89%. Four-year lung disease control rate was 44.1%, with patient retreated safely up to four times. Primary origin, disease-free interval, size and number of metastases were associated with OS in multivariate analysis. Progression at RFA site was associated with poor OS [P = 0.011, hazard ratio (HR): 1.69 (95% confidence interval 1.13–2.54)]. In the 293 colorectal cancer metastases, size >2 cm (HR = 2.10, P = 0.0027) and a number of metastases ≥3 (HR = 1.86, P = 0.011) remained significantly associated with OS. A prognostic score made of three groups based on the four above-mentioned prognostic factors demonstrated 3-year OS rates of respectively 82.2%, 69.5% and 53.6% (log-rank test, P ≤ 0.0001) among the three groups in the overall population, and of 81.3%, 72.8% and 57.9% (log-rank test, P = 0.005) in the colorectal cancer patients.

Conclusion

Radiofrequency is an option for treatment of small size lung metastases, namely the ones below 2–3 cm.

Long-term survival following percutaneous radiofrequency ablation of colorectal lung metastases

PURPOSE

To retrospectively evaluate long-term survival outcomes of radiofrequency (RF) ablation of colorectal lung metastases and evaluate factors associated with improved survival.

MATERIALS AND METHODS

Eighty-four patients (46 male and 38 female; median age, 65 y) with 172 colorectal lung metastases (median size, 1.2 cm) underwent 113 RF ablation sessions. Thirteen patients had viable extrapulmonary recurrences at the time of RF ablation. The primary endpoint was patient survival. Prognostic factors associated with survival were determined by univariate and multivariate analyses. Secondary endpoints were local tumor progression and adverse events (per National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0).

RESULTS

During follow-up (median duration, 37.5 mo), 36 patients (42.9%) died. The estimated overall survival (OS) rates were 95.2%, 65.0%, and 51.6% at 1, 3, and 5 years, respectively (median OS time, 67.0 mo). Multivariate analysis revealed that a carcinoembryonic antigen (CEA) level of at least 5 ng/mL before RF ablation (P = .03) and the presence of viable extrapulmonary recurrences at the time of RF ablation (P = .001) were independent negative prognostic factors. The local tumor progression rate was 14.0% (24 of 172 tumors). Grade 3 adverse events were observed after two sessions (1.8%), and grade 4/5 adverse events were not observed.

CONCLUSIONS

RF ablation of colorectal lung metastases provided favorable long-term survival with a low incidence of severe adverse events. Independent prognostic factors were a high CEA level before RF ablation and the presence of viable extrapulmonary recurrences at the time of RF ablation.

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.

Case report: Successful treatment of recurrent chordoma and bilateral pulmonary metastases following an 11-year disease-free period

INTRODUCTION

Chordomas are rare but aggressive tumors due to local recurrence and distant metastases. They originate commonly in the sphenooccipital and sacrococcygeal regions, and metastasize to the lungs, bone, skin, liver, and lymph nodes. They occur more frequently in men and people over the age of 40.

PRESENTATION OF CASE

A 28 year-old female presented with sacrococcygeal chordoma for which she received wide local excision and adjuvant radiation therapy. She enjoyed an unusual disease-free survival for 11 years until a routine surveillance scan of the pelvis identified local recurrence. Further work up revealed bilateral pulmonary metastases. She underwent local excision of the recurrent tumor and video-assisted thoracoscopic (VATS) wedge resection of pulmonary metastases. She also received adjuvant radiation therapy to the recurrent resection bed. Two years later, she remains free of disease and symptoms.

DISCUSSION

Chordomas are commonly insensitive to chemotherapy and radiation, making surgery the most successful therapeutic modality. However, there are few guidelines on the surveillance and treatment of recurrent chordoma. We report success with aggressive surgical resection of recurrence and metastasis as well as adjuvant radiation therapy.

CONCLUSION

The prolonged survival of our patient underscores the importance of (1) aggressive surgical resection of chordoma, whether primary, recurrent, or metastatic, with adjuvant radiation therapy, (2) minimization of surgical seeding of tumor, and (3) diligent cancer surveillance.

Pulmonary metastasectomy for colorectal cancer: How many nodules, how many times?

Colorectal cancer (CRC) is one of the most common cancers worldwide, with 5%-15% of CRC patients eventually developing lung metastasis (LM). Despite doubts about the role of locoregional therapy in the management of systemic disease, many surgeons have performed pulmonary metastasectomy (PM) for CRC in properly selected patients. However, the use of pulmonary metastasectomy remains controversial due to the lack of randomized controlled studies. This article reviews the results of surgical treatment of pulmonary metastases for CRC, focusing on (1) current treatment guidelines and surgical techniques of PM in patients with LM from CRC; (2) outcomes of PM and its prognostic factors; and (3) controversial issues in PM, focusing on repeated metastasectomy, bilateral multiple metastases, and combined liver and lung metastasectomy.

Stereotactic body radiotherapy for pulmonary metastases. Prognostic factors and adverse respiratory events

PURPOSE

The aim of this retrospective study was to evaluate the feasibility, safety, and effectiveness of stereotactic body radiotherapy (SBRT) for pulmonary metastases.

PATIENTS AND METHODS

Between April 2007 and March 2011, 87 patients underwent SBRT for pulmonary metastases using the in-house Air-Bag System(TM) to obtain the four-dimensional image for treatment planning and to reduce intrafractional intrathoracic organ motion with abdominal compression to reduce the risk of radiation pneumonitis. Survival and respiratory adverse events were analyzed.

RESULTS

The 2- and 3-year overall survival (OS) rates were 47 and 32 %, and the corresponding cause-specific survivals were 52 and 36 %. The 2- and 3-year OS rates were 57 and 49 % for patients in group 1, respectively, while the corresponding OS rates were 48 and 21 %, and 40 and 32 % for patients in groups 2 and 3, respectively. The 2- and 3-year local control (LC) rates were 80 and 80 %, respectively. The corresponding intrathoracic progression-free survival rates were 40 and 32 %, respectively. Concerning adverse respiratory events after SBRT for pulmonary metastases, 14 % were grade 0 (G0), 66 % G1, 13 % G2, 6 % G3, and 1 % G4. Concerning the adverse respiratory events (NCI-CTC) by grade scale, 1- and 2-year cumulative probabilities of radiation pneumonitis were 12 and 20 % for G2 and 4 and 10 % for G3/4, respectively. The mean values for cumulative V20 were 11.6 ± 8.5 %, 29.8 ± 18.6 %, and 25.7 ± 12.8 % in G0/1, G2, and G3/4, respectively. The number of pulmonary metastases that could be safely treated with SBRT was 6 PTVs (or seven gross tumor volumes) within a cumulative V20 of 30 % under the restricted intrafractional respiratory tumor motion using the Air-Bag System(TM).

CONCLUSION

We propose that the number of pulmonary metastases that can be safely treated with SBRT is 6 PTVs with a cumulative V20 of 30 % under the restricted respiratory tumor motion using the Air-Bag System(TM). SBRT for pulmonary metastases offers locally effective treatment for recurrent or residual lesions after first line chemotherapy.

Surgical management of colorectal lung metastasis

Colon cancer is a systemic disease in 19% of patients and metastasizes most frequently to the liver and the lung. Survival is enhanced with complete surgical resection of pulmonary metastases. Comprehensive restaging and verification of preoperative fitness must precede resection. The operative approach is dictated by the anatomic location of the metastases, whereas the extent of resection remains a balance between complete removal of metastatic deposits while preserving as much lung parenchyma as possible. The presence of metastatic involvement of hilar and mediastinal lymph nodes is ominous. Multidisciplinary care is highly recommended. An evidence-based algorithm for the identification assessment and treatment of patients with pulmonary metastases is proposed.

Current status of pulmonary metastasectomy

Malignant disease's ability to metastasize remains one of the major obstacles when treating patients with cancer. The change from loco-regional to systemic disease usually renders the patient beyond surgical treatment, as local treatment with surgery in a systemic disease is usually considered without benefit. However, numerous retrospective studies have demonstrated that resection of metastases limited to the lungs may be associated with prolonged survival. No prospective, randomized studies have been published, and most series compare highly selected patients with historical data for unresected patients. In this article, we discuss the current status on pulmonary metastasectomy. Preoperative assessment and selection of surgical candidates is covered. The different surgical strategies including surgical approach, unilateral versus bilateral exploration, lymph node dissection, and repeat surgery are discussed. Finally, we review some of the common tumors that metastasize to the lungs, the role of metastasectomy in their treatment and the prognostic factors with impact on survival.

Indications and approach to surgical resection of lung metastases

Pulmonary metastasectomy is a curative option for selected patients with cancer spread to the lungs. Complete surgical removal of pulmonary metastases can improve survival and is recommended under certain criteria. Specific issues that require consideration in a multidisciplinary setting when planning pulmonary metastasectomy include: adherence to established indications for resection, the surgical strategy including the use of minimally invasive techniques, pulmonary parenchyma preservation, and the role of lymphadenectomy.

Pulmonary resection for metastases from colorectal carcinoma

A pulmonary resection of metastatic colorectal carcinoma is an accepted method of treatment. The purpose of this study was to confirm the role of resections for pulmonary metastases from colorectal carcinoma, and to determine the clinical course, outcome, and prognostic factors after surgery. A retrospective analysis was conducted of the records of all patients with pulmonary metastases from colorectal carcinoma who underwent a surgical resection between 1995 and 2008, at a single surgical center. The overall 5-year survival rate was 74%. Multivariate Cox analysis demonstrated that the number of pulmonary metastases (HR: 9.40, 95% confidence interval (CI): 1.08-82.2, P=0.0428) and prethoracotomy carcinoembryonic antigen (CEA) level (HR: 9.79, 95% CI: 1.11-86.8, P=0.0404) were statistically significant predictors of survival after the first pulmonary metastasectomy. In addition, a second resection for recurrent metastases was performed in eight patients, and a third resection was done in one patient. There were no major postoperative complications among the patients who underwent second or third resections. Pulmonary resections are considered to be a safe and effective treatment in selective patients.

[Survival analysis of resection of lung metastases from colorectal cancer]

INTRODUCTION

The publication of the International Registry of Lung Metastases (IRLM) in 1997 was a turning point in favor of surgical resection of lung metastases. Prognostic groups were defined according to resectability, number of metastases, and disease-free interval. The objective of this study was to determine survival in patients who underwent resection of lung metastases from colorectal carcinoma and to evaluate how applicable the prognostic factors established by the IRLM are in this specific patient group.

PATIENTS AND METHODS

Patients with lung metastases from colorectal carcinoma who underwent resection between January 1, 2000, and November 30, 2006, were retrospectively analyzed. Survival was calculated using the Kaplan-Meier method, with log-rank comparisons between groups.

RESULTS

Survivals at 1, 3, 5, and 6 years was 92%, 75%, 54%, and 43%, respectively. The main finding was that 3-year survival was better in patients who underwent atypical resection of the metastasis (75%) than those who required lobectomy (55%). There were no significant differences in survival in terms of number of lung metastases resected or disease-free interval.

CONCLUSIONS

Survival in patients requiring lobectomy for resection of lung metastases from colorectal carcinoma was worse than in those who underwent atypical resection. The number of metastases and disease-free interval may be questionable prognostic factors in the case of lung metastases from colorectal carcinoma.

Laser ablation of metastatic lesions of the lung: long-term outcome

OBJECTIVE

Pulmonary metastatic lesions are present in 20-54% of all patients who die of cancer. Surgical studies have shown that local management of distant tumor metastasis as part of multimodal cancer therapy improves survival. Minimally invasive procedures such as thermal ablation are still to prove their clinical relevance. The aim of this study was to monitor therapeutic outcome and long-term results after percutaneous laser-induced thermal ablation.

SUBJECTS AND METHODS

Sixty-four patients with metastasis to the lung underwent laser-induced thermal ablation in an ongoing prospective study. A total of 129 percutaneous procedures were performed to manage a total of 108 lung lesions. The median tumor size was 2.0 cm (range, 0.4-8.5 cm). Adequate management of all known individual tumor correlates was critical for definitive patient therapy. The Kaplan-Meier method was used to calculate survival and recurrence rates.

RESULTS

Definitive management of initial pulmonary disease was achieved in 31 of 64 patients. The 1-, 2-, 3-, 4-, and 5-year survival rates after ablative therapy were 81%, 59%, 44%, 44%, and 27%. The median progression-free interval was 7.4 months. There were no therapy-related deaths. Pneumothorax occurred in 38% of the patients, necessitating periprocedural drainage in 5% of all cases. Parenchymal bleeding (13% of cases) always was self-limited.

CONCLUSION

Laser ablative therapy for pulmonary metastasis is a promising option in multimodal cancer therapy. The procedure is safe and effective. The initial clinical outcome data strongly suggest that this technique has the potential to improve survival among selected patients.

Repeat pulmonary resection for metachronous colorectal carcinoma is beneficial

BACKGROUND

Initial pulmonary metastatectomy for limited colorectal carcinoma metastases is associated with improved survival. The role of repeat thoracic interventions is less well defined. The purpose of this study is to clarify the role of repeat pulmonary resection for metastatic colorectal carcinoma.

METHODS

A retrospective study was performed using patients who underwent pulmonary metastatectomy for colorectal carcinoma at a single academic institution between January 1, 1985, and December 31, 2007. Sex, age at colorectal operation, colorectal TNM stage, and operative procedures for pulmonary metastases were recorded. Intervals between the original colorectal operation and thoracic operation and between the first pulmonary metastatectomy and repeat thoracic interventions were calculated. Log-rank comparison of Kaplan-Meier survival curves and covariate analysis were performed.

RESULTS

A total of 69 patients were identified as having undergone at least 1 pulmonary metastatectomy. There were 32 female and 37 male patients with a mean age of 57 +/- 11 years. The median disease-free interval from original colorectal operation to first pulmonary metastatectomy for all the patients was 27 months. A total of 125 pulmonary resections were performed: 64 wedge resections, 27 segmentectomies, 30 lobectomies, and 4 pneumonectomies. Of the 69 patients, 41 underwent a single thoracic metastatectomy, whereas 28 underwent at least 1 second thoracic metastatectomy (2nd, 17 patients; 3rd, 6; 4th, 4; 5th, 1). There were no perioperative mortalities. From the original colorectal resection, the 5-year survival was 59% (median, 52 months). From the initial pulmonary metastatectomy, the 5-year survival for all patients was 25% (median, 36 months). The 5-year survival for patients undergoing only 1 thoracic resection was 23% (median, 24 months), which was not significantly different compared to patients undergoing repeat thoracic resections, 29% (median: 42 months). In the covariate analysis, no parameters significantly impacted survival.

CONCLUSIONS

Patients undergoing multiple pulmonary resections have the same survival as patients undergoing a single pulmonary resection for metachronous colorectal carcinoma. These findings indicate pulmonary metastases may be favorably treated with repeat thoracic interventions.

Surgical treatment of metastatic disease to the lung

The presence of distant metastases usually implies disease not amenable to cure through surgical resection. In such cases, chemotherapy is the mainstay of treatment, with surgery or radiation reserved for palliative measures. However, metastases limited to the lung may be resected with resultant prolonged patient survival compared to unresectable, widely disseminated metastases. Isolated pulmonary metastases should therefore not be considered untreatable. In this review, we discuss the pathophysiology of pulmonary metastases. We outline prognostic factors associated with metastases, and propose criteria to help select patients for metastasectomy. Surgical approaches, including various open techniques and video-assisted thoracoscopy, are covered. Surgical issues, including the need for unilateral versus bilateral exploration, the extent of resection to achieve cure, the need for lymph node dissection, and the benefit of repeat operations, are discussed. Finally, we review some of the more common tumors that metastasize to the lungs, and the role of metastasectomy in their treatment. Resection of pulmonary metastases confers a survival benefit to a select group of patients so long as the primary tumor is controlled, metastases are limited to the lungs, the patient can tolerate the operation from a cardiopulmonary standpoint, and the metastases are completely resected.

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.

Prognostic factors and analysis of microsatellite instability in resected pulmonary metastases from colorectal carcinoma

BACKGROUND

In this study, we analyze our experience with pulmonary resection for metastases from colorectal carcinoma. The aims were to search for factors influencing prognosis and to investigate the presence of microsatellite instability in the primary tumors and the corresponding lung metastases.

METHODS

We identified 81 patients who underwent surgical resection between 1991 and 2004. The microsatellite instability was determined by immunohistochemical evaluation of MSH2 and MLH1 in 117 lesions (41 primary tumors and 76 lung metastases).

RESULTS

Overall 3-, 5-, and 10-year survival rates were 50%, 42%, and 30%, respectively. Univariate analysis showed that stage of the primary tumor (p = 0.037), radicalness of the resection (p = 0.019), and stratification into groups according to the International Registry of Lung Metastases classification (p = 0.039) were prognostic factors. Multivariate analysis showed that stage of the primary tumor (p = 0.030) and the radicalness of the resection (p = 0.014) were independent prognostic factors. All tumors displayed preserved expression of MSH2 and MLH1 and were considered microsatellite stable lesions.

CONCLUSIONS

Pulmonary resection of metastases from colorectal carcinoma results in long-term survival in selected patients. Complete resection, stage of the primary tumor and stratification into groups according to the International Registry of Lung Metastases classification were prognostic factors. All the metastases and the corresponding primary tumors were microsatellite stable lesions. This finding seems to demonstrate that pulmonary metastases are infrequent in colorectal carcinomas with microsatellite instability.

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.

The role of minimal access surgery for metastasectomy and cytoreduction

This article summarizes findings about the applicability of minimal-access techniques for thoracic and upper gastrointestinal cancers, including those affecting the lung, liver, stomach, and adrenal gland. If metastasectomy and cytoreductive surgery are rapidly evolving, minimal-access surgery in this setting is in its introductory stages. Nevertheless, minimal-access metastasectomy and cytoreductive surgery harbor great potential for selected patients, but further clinical studies are needed.

Surgical and Nonsurgical Therapy for Lung Metastasis: Indications and Outcomes

The management of pulmonary metastasis is a broad and multifaceted topic. Because of the filtration function and the favorable microenvironment of the lung, most malignancies cause pulmonary metastases. This article focuses on recent experience with secondary lung malignancies and their newer treatment options, indications, and technical aspects.

Lung cancer and radiofrequency ablation

Radiofrequency (RF) ablation is a recently developed technique for image-guided local destruction of selected tumors. Because the lung is a common site for cancer and usually has substantial functional reserve, RF ablation of lung cancers is an attractive option for minimally invasive treatment. The primary goal of the present review is to describe the natural history, staging systems, and conventional therapies for primary and secondary treatment of lung cancer, as well as the results of RF ablation in animal models and in humans for pulmonary applications, to clarify the appropriate role and limitations of this technology. The secondary goals are to review the principles of how RF works and to describe RF ablation techniques to familiarize interventionalists who may consider incorporating this technology into their practice and inform diagnostic radiologists of expected imaging findings and clinicians of their patients' anticipated courses and outcomes.