Pulmonary metastasectomy and repeat metastasectomy for colorectal pulmonary metastases: outcomes from the Dutch Lung Cancer Audit for Surgery

Metastasectomy and Stereotactic Body Radiotherapy for Colorectal Cancer With Liver and Lung Oligometastases: A Case Report of Complete Remission in a 96-Year-Old Patient

We report a rare case of an extremely old colorectal cancer (CRC) patient who had complete remission after liver metastasectomy and stereotactic body radiotherapy (SBRT) to lung oligometastases (OM), with good quality of life and no evidence of recurrence 12 years after the initial diagnosis. An 83-year-old male patient had a right hemicolectomy for stage pT3 pN0 adenocarcinoma of the colon. Soon he was found to have liver metastasis treated with radiofrequency ablation and then liver metastasectomy with clear margins, followed by chemotherapy in the form of FOLFIRI for six months. Six years later, positron emission tomography (PET) showed 1.6 cm OM in the left upper lobe lung. He was not considered a good candidate for surgery. We offered him SBRT 48 Gy in four fractions every other day. The lesion disappeared with no recurrence in the same location on PET and serial computed tomography (CT) scans. Three years later, PET-CT found a new OM in the left lingular lung measuring 1.2 cm. A CT-guided lung biopsy confirmed invasive adenocarcinoma favoring OM from the CRC. SBRT planning failed due to its proximity to the heart. He accepted the longer course of conventional volumetric modulated arc therapy at 60 Gy in 15 fractions with daily cone-beam CT guidance. Again, he tolerated treatment very well with no significant side effects, despite his age. He did not require any chemotherapy or other systemic treatment in the last 11 years, so he did not experience any toxicities related to such treatment. This case is important to show that old age alone should not be considered a contraindication for metastasectomy and SBRT for CRC with liver and lung OM.

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.

Optimizing Treatment Strategy for Oligometastases/Oligo-Recurrence of Colorectal Cancer

Colorectal cancer (CRC) is the third most common cancer, and nearly half of CRC patients experience metastases. Oligometastatic CRC represents a distinct clinical state characterized by limited metastatic involvement, demonstrating a less aggressive nature and potentially improved survival with multidisciplinary treatment. However, the varied clinical scenarios giving rise to oligometastases necessitate a precise definition, considering primary tumor status and oncological factors, to optimize treatment strategies. This review delineates the concepts of oligometastatic CRC, encompassing oligo-recurrence, where the primary tumor is under control, resulting in a more favorable prognosis. A comprehensive examination of multidisciplinary treatment with local treatments and systemic therapy is provided. The overarching objective in managing oligometastatic CRC is the complete eradication of metastases, offering prospects of a cure. Essential to this management approach are local treatments, with surgical resection serving as the standard of care. Percutaneous ablation and stereotactic body radiotherapy present less invasive alternatives for lesions unsuitable for surgery, demonstrating efficacy in select cases. Perioperative systemic therapy, aiming to control micrometastatic disease and enhance local treatment effectiveness, has shown improvements in progression-free survival through clinical trials. However, the extension of overall survival remains variable. The review emphasizes the need for further prospective trials to establish a cohesive definition and an optimized treatment strategy for oligometastatic CRC.