A Plea for Consistency in the Reporting of Surgical Series Illustrated with an Analysis of 51 Follow-Up Reports of Pulmonary Metastasectomy in Colorectal Carcinoma

Results of redo pulmonary metastasectomy

Repeat surgical resection (redo) for pulmonary metastases is a questionable, albeit intriguing topic. We performed an extensive review of the literature, to specifically analyze results of redo pulmonary metastasectomies. We reviewed a total of 3,523 papers. Among these, 2,019 were excluded for redundancy and 1,105 because they were not completely retrievable. Out of 399 eligible papers, 183 had missing information or missing abstract, while 96 lacked data on survival. A total of 120 papers dated from 1991 onwards were finally included. Data regarding mortality, major morbidity, prognostic factors and long-term survivals of the first redo pulmonary metastasectomies were retrieved and analyzed. Homogeneity of data was affected by the lack of guidelines for redo pulmonary metastasectomy and the risks of bias when comparing different studies has to be considered. According to the histology sub-types, redo metastasectomies papers were grouped as: colorectal (n=42), sarcomas (n=36), others (n=20) and all histologies (n=22); the total number of patients was 3,015. Data about chemotherapy were reported in half of the papers, whereas targeted or immunotherapy in 9. None of these associated therapies, except chemotherapy in two records, did significantly modify outcomes. Disease-free interval before the redo procedure was the prevailing prognostic factor and nearly all papers showed a significant correlation between patients’ comorbidities and prognosis. No perioperative mortality was reported, while perioperative major morbidity was overall quite low. Where available, overall survival after the first redo metastasectomy ranged from 10 to 72 months, with a 5-years survival of approximately 50%. The site of first recurrence after the redo procedure was mainly lung. Despite the data retrievable from literature are heterogeneous and confounding, we can state that redo lung metastasectomy is worthwhile when the lesions are resectable and the perioperative risk is low. At present, there are no “non-surgical” therapeutic options to replace redo pulmonary metastasectomies.

Pulmonary Metastasectomy versus Continued Active Monitoring in Colorectal Cancer (PulMiCC): a multicentre randomised clinical trial

BACKGROUND

Lung metastasectomy in the treatment of advanced colorectal cancer has been widely adopted without good evidence of survival or palliative benefit. We aimed to test its effectiveness in a randomised controlled trial (RCT).

METHODS

Multidisciplinary teams in 13 hospitals recruited participants with potentially resectable lung metastases to a multicentre, two-arm RCT comparing active monitoring with or without metastasectomy. Other local or systemic treatments were decided by the local team. Randomisation was remote and stratified by site with minimisation for age, sex, primary cancer stage, interval since primary resection, prior liver involvement, the number of metastases, and carcinoembryonic antigen level. The central Trial Management Group were blind to patient allocation until completion of the analysis. Analysis was on intention to treat with a margin for non-inferiority of 10%.

RESULTS

Between December 2010 and December 2016, 65 participants were randomised. Characteristics were well-matched in the two arms and similar to those in reported studies: age 35 to 86 years (interquartile range (IQR) 60 to 74); primary resection IQR 16 to 35 months previously; stage at resection T1, 2 or 3 in 3, 8 and 46; N1 or N2 in 31 and 26; unknown in 8. Lung metastases 1 to 5 (median 2); 16/65 had previous liver metastases; carcinoembryonic antigen normal in 55/65. There were no other interventions in the first 6 months, no crossovers from control to treatment, and no treatment-related deaths or major adverse events. The Hazard ratio for death within 5 years, comparing metastasectomy with control, was 0.82 (95%CI 0.43, 1.56).

CONCLUSIONS

Because of poor and worsening recruitment, the study was stopped. The small number of participants in the trial (N = 65) precludes a conclusive answer to the research question given the large overlap in the confidence intervals in the proportions still alive at all time points. A widely held belief is that the 5-year absolute survival benefit with metastasectomy is about 35%: 40% after metastasectomy compared to < 5% in controls. The estimated survival in this study was 38% (23-62%) for metastasectomy patients and 29% (16-52%) in the well-matched controls. That is the new and important finding of this RCT.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT01106261. Registered on 19 April 2010.

Pulmonary metastasectomy: a call for better data collection, presentation and analysis

A systematic review of the literature for outcomes in pulmonary metastasectomy has revealed the variability in reporting and the paucity of data that would allow a clear understanding of the effectiveness of this operation. The authors, a surgeon and a mathematician, start from the experience of assessing the evidence on which the practice of pulmonary metastasectomy is based and give some simple examples on a more adequate approach to the collection and analysis of surgical data and the importance of its correct interpretation. Retrospective data analysis is constrained by the availability of data. While this can give insight on certain aspects, it is important to discern what data are necessary to give a complete understanding of the effectiveness of a practice. Typically well designed prospective studies and randomised controlled trials with a pre-specified data collection plan give more complete, consistent and reliable data than follow-up or retrospective studies. Pulmonary metastasectomy lends itself well as an example of practice based on uncertain evidence and biased reporting. All the available published studies are follow-up studies, there is no randomised controlled trial, so no control data to estimate its treatment effect on patient's survival. The pool of colorectal or sarcoma patients from which patients are selected to have a pulmonary metastasectomy is never reported on, thus it is hard to estimate the degree of selection and the influence of the surgeon's decision.

Pulmonary metastasectomy in colorectal cancer: a prospective study of demography and clinical characteristics of 543 patients in the Spanish colorectal metastasectomy registry (GECMP-CCR)

OBJECTIVES

To capture an accurate contemporary description of the practice of pulmonary metastasectomy for colorectal carcinoma in one national healthcare system.

DESIGN

A national registry set up in Spain by Grupo Español de Cirugía Metástasis Pulmonares de Carcinoma Colo-Rectal (GECMP-CCR).

SETTING

32 Spanish thoracic units.

PARTICIPANTS

All patients with one or more histologically proven lung metastasis removed by surgery between March 2008 and February 2010.

INTERVENTIONS

Pulmonary metastasectomy for one or more pulmonary nodules proven to be metastatic colorectal carcinoma.

PRIMARY AND SECONDARY OUTCOME MEASURES

The age and sex of the patients having this surgery were recorded with the number of metastases removed, the interval between the primary colorectal cancer operation and the pulmonary metastasectomy, and the carcinoembryonic antigen level. Also recorded were the practices with respect to mediastinal lymphadenopathy and coexisting liver metastases.

RESULTS

Data were available on 543 patients from 32 units (6-43/unit). They were aged 32-88 (mean 65) years, and 65% were men. In 55% of patients, there was a solitary metastasis. The median interval between the primary cancer resection and metastasectomy was 28 months and the serum carcinoembryonic antigen was low/normal in the majority. Liver metastatic disease was present in 29% of patients at some point prior to pulmonary metastasectomy. Mediastinal lymphadenectomy varied from 9% to 100% of patients.

CONCLUSIONS

The data represent a prospective comprehensive national data collection on pulmonary metastasectomy. The practice is more conservative than the impression gained when members of the European Society of Thoracic Surgeons were surveyed in 2006/2007 but is more inclusive than would be recommended on the basis of recent outcome analyses. Further analyses on the morbidity associated with this surgery and the correlation between imaging studies and pathological findings are being published separately by GECMP-CCR.

Routine preoperative chest computed tomography does not influence therapeutic strategy in patients with colorectal cancer

AIM

Patients with lung metastasis from colorectal cancer (CRC) may benefit from surgical resection. Chest computed tomography (CT) is often included in the preoperative staging. Interpretation of the nature of pulmonary lesions is not always easy and many question its clinical value.

METHOD

Clinical data for all patients treated at our institution for CRC have been collected prospectively in a dedicated database. Since August 2008 chest CT has been routinely performed for preoperative staging. The outcome of 147 patients operated on since then (Group A) was compared with a numerically equal group of patients (147) (Group B) treated before the introduction of preoperative routine chest CT.

RESULTS

Pulmonary lesions were identified in 45 (30%) patients in Group A and 10 (6.8%) in Group B. Ten and nine lesions, respectively, were interpreted as metastases. In 28 (19%) patients in Group A, the lesions were considered to be indeterminate and only four were confirmed as malignant. Overall metastases were present after 1 year of follow-up in 5 (50%) of 10 patients in Group A and 5 (55%) of 9 in Group B. The global incidence of synchronous and metachronous metastases was 6.8%, with no statistical difference between the two groups.

CONCLUSION

This study shows that chest CT reveals a higher number of pulmonary lesions, only a small proportion of which were malignant. The investigation does not add value to routine staging methods in patients with CRC.