Surgery of colorectal cancer lung metastases: analysis of survival, recurrence and re-surgery

Incidence, treatment, and survival of patients with isolated colorectal lung metastases: A registry-based retrospective cohort study

BACKGROUND

The benefit of surgical resection for colorectal cancer (CRC) lung metastases is unclear. The aim was to investigate the incidence, treatment strategy, and 5-year overall survival (OS) in CRC patients with isolated lung metastases.

METHODS

This registry-based retrospective cohort study included patients treated with curative resection of CRC within the county of Skåne during the period 2010-2016, who had synchrone or metachrone isolated lung metastases. Exclusion criteria were previous or concurrent metastases at other organ sites. Patients were identified in the Swedish Colorectal Cancer Registry (SCRCR) and data were retrieved from SCRCR and medical charts. Patients were divided into groups based on whether they had synchronous or metachronous lung metastases and curative or palliative treatment intent. The primary endpoint was 5-year OS. Multivariable Cox-regression and Kaplan-Meier survival analysis were performed.

RESULTS

Of 8457 curatively resected CRC patients, 93 (1.1%) had isolated lung metastases (53 synchronous/40 metachronous). Of these, 53 were treated with curative intent, 51 (96%) of whom were managed surgically. The remaining 40 patients were treated palliatively and either with chemotherapy or with best supportive care. Five-year OS was 42% (39/93), median 50 months (IQR: 24-60) for the entire cohort, and 68% (36/53), median 60 months (IQR 55-60) and 7.5% (3/40), median 22 months (IQR: 12-33) for curative and palliative patients, respectively. In multivariable analysis, age (hazard ratio (HR): 1.04, confidence interval (CI): 1.01-1.07), multiple lung metastases (HR: 1.64, CI: 1.08-2.47), and unilateral distribution (HR: 0.41, CI: 0.20-0.84) were predictors of OS.

CONCLUSIONS

Isolated CRC lung metastases are rare. Curative treatment was associated with considerably better 5-year OS than palliative treatment (68% vs 8%). Age, solitary metastases, and unilateral distribution were predictors of survival.

Updated insights into the impact of adjuvant chemotherapy on recurrence and survival after curative resection of liver or lung metastases in colorectal cancer: a rapid review and meta-analysis

BACKGROUND

Colorectal cancer (CRC) frequently metastasizes to the liver and lungs, leading to poor prognosis. Advances in chemotherapy, minimally invasive surgery, and perioperative care have expanded adjuvant chemotherapy (AC) regimens and eligibility for AC. However, the impact of AC after curative resection of distant metastases on recurrence and prognosis remains uncertain. This study evaluated the role of AC in CRC liver and lung metastases, focusing on cases with curative resection based on the latest studies published in the past five years.

METHODS

This systematic review followed PRISMA guidelines. Literature searches of Medline and Cochrane Library (2019-2023) identified studies on AC or observation after curative resection of CRC metastases, reporting outcomes such as overall survival (OS) and disease-free survival (DFS). Data analysis was performed using Review Manager and R software, with results expressed as hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Seven studies met the eligibility criteria, including one randomized controlled trial and six retrospective studies, encompassing 1580 patients who underwent curative resection (R0) for CRC metastases. This meta-analysis showed a positive trend in OS for the AC group compared to that for the surgery-alone group (HR 0.86, 95% CI: 0.73-1.01; p = 0.06), but the difference was insignificant. AC significantly improved DFS (HR 0.81, 95% CI: 0.66-0.99; p = 0.04). Subgroup analysis indicated that AC significantly improved DFS and tended to improve OS for liver metastasis. In contrast, AC did not improve OS in cases of lung metastasis.

CONCLUSIONS

This meta-analysis suggests that AC demonstrated significant positive effects on DFS. Moreover, AC could contribute to improvements in OS. These findings, supported by the latest research, reinforce the recommendation of AC as a valuable strategy for improving both recurrence and survival outcomes in patients with curatively resected distant CRC metastases.

A Retrospective Analysis of Real-Life Management of Colorectal Cancer Lung-Limited Metastases Treated with Surgery: Outcomes and Prognostic Factors

Background: Unlike liver metastases, the role of surgery in colorectal cancer lung-limited metastases (CCLLM) is not yet established, and data are still poor. We performed a retrospective analysis to evaluate the impact of surgery on the management of CCLLM. Material and Method: We retrospectively analyzed patients who received surgery for CCLLM at our Institution from January 2010 to June 2019. The aim of the study was to evaluate the impact of clinical and pathological features on the survival (OS and DFS) of patients treated with surgery for CCLLM. Results: One hundred and fifty patients were included in the analysis. Seventy-six patients received preoperative chemotherapy (pCT) and 56 an adjuvant treatment (aCT), while 18 underwent up-front surgery without CT. In the whole population, median OS (mOS) and median DFS (mDFS) were 54.1 months (95%CI 44.0-82.1) and 24.0 months (95%CI 20.0-31.2), respectively. In multivariate analysis, number of metastases was the only factor correlated to DFS (p = 0.0006) and OS (p = 0.0018). Conclusion: Our study, although retrospective and of small size, shows that tumor burden (number of metastases) is the main prognostic factor in patients undergoing lung surgery for CCLLM. Moreover, our results suggest that surgery for lung metastases might prolong survival. These data strengthen the role of multidisciplinary management to allow patients with CCLLM to pursue local treatment whenever possible, even regardless of previous liver surgery or RAS mutated status.

Effect of perioperative chemotherapy on resection of isolated pulmonary metastases from colorectal cancer: A single center experience

BACKGROUND

Numerous studies have assessed surgical resection as a standard treatment option for patients with colorectal cancer (CRC) and resectable pulmonary metastases (PM). However, the role of perioperative chemotherapy after complete resection of isolated PM from patients with CRC patients remains controversial. We hypothesize that perioperative chemotherapy does not provide significant survival benefits for patients undergoing resection of PM from CRC.

AIM

To determine whether perioperative chemotherapy affects survival after radical resection of isolated PM from CRC.

METHODS

We retrospectively collected demographic, clinical, and pathologic data on patients who underwent radical surgery for isolated PM from CRC. Cancer-specific survival (CSS) and disease-free survival were calculated using Kaplan-Meier analysis. Inter-group differences were compared using the log-rank test. For multivariate analysis, Cox regression was utilized when indicated.

RESULTS

This study included 120 patients with a median age of 61.6 years. The 5-year CSS rate was 78.2%, with 36.7% experiencing recurrence. Surgical resection for isolated PM resulted in a 5-year CSS rate of 50.0% for second metastases. Perioperative chemotherapy (P = 0.079) did not enhance survival post-resection. Factors associated with improved survival included fewer metastatic lesions [hazard ratio (HR): 2.51, P = 0.045], longer disease-free intervals (HR: 0.35, P = 0.016), and wedge lung resections (HR: 0.42, P = 0.035). Multiple PM predicted higher recurrence risk (HR: 2.22, P = 0.022). The log-rank test showed no significant difference in CSS between single and repeated metastasectomy (P = 0.92).

CONCLUSION

Perioperative chemotherapy shows no survival benefit post-PM resection in CRC. Disease-free intervals and fewer metastatic lesions predict better survival. Repeated metastasectomy is warranted for eligible patients.

Colorectal Cancer Pulmonary Metastasectomy: When, Why and How

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treatment and survival of patients with metachronous colorectal lung metastases

INTRODUCTION

The lungs are the second most common site for metachronous metastases in colorectal cancer. No treatment algorithm is established, and the role of adjuvant chemotherapy is unclear. This study aimed to map pulmonary recurrences in a modern multimodal treated population, and to evaluate survival depending on management.

METHODS

Retrospective study based on the COLOFOL-trial population of 2442 patients, radically resected for colorectal cancer stage II-III. All recurrences within 5 years were identified and medical records were scrutinized.

RESULTS

Of 165 (6.8%) patients developing lung metastases as first recurrence, 89 (54%) were confined to the lungs. Potentially curative treatment was possible in 62 (37%) cases, of which 33 with surgery only and 29 with surgery and chemotherapy combined. The 5-year overall survival (5-year OS) for all lung recurrences was 28%. In patients treated with chemotherapy only the 5-year OS was 7.5%, compared with 55% in patients treated with surgery, and 72% when surgery was combined with chemotherapy. Hazard ratio for mortality was 2.9 (95% confidence interval 1.40-6.10) for chemotherapy only compared to surgery.

CONCLUSION

A high proportion of metachronous lung metastases after colorectal surgery were possible to resect, yielding good survival. The combination of surgery and chemotherapy might be advantageous for survival.

The efficacy and safety of thermal ablation for patients with lung malignancy: a meta-analysis of 12 studies in China

BACKGROUND

Thermal ablation has been increasingly used in the treatment of lung cancer in recent years. This meta-analysis aims to investigate the therapeutic effect and safety of thermal ablation plus chemotherapy as compared with chemotherapy alone in treating patients with lung malignancy in China based on current evidence.

METHODS

Databases including PubMed, Web of Science, Embase and the Cochrane Library were searched for clinical reports. Additional literature search was also performed by searching the reference list of included studies and latest reviews. Raw data including objective response rate, disease control rate, progression-free survival, overall survival and the incidence of major complication were extracted and pooled.

RESULTS

A total of 12 studies in China including 1282 patients with lung malignancy were included in this meta-analysis. The number of studies that reported data of objective response rate, disease control rate, progression-free survival, overall survival and major complication was 8, 7, 7, 6 and 7, respectively. The combination therapy of thermal ablation plus chemotherapy showed a significantly better efficacy in improving objective response rate (odds ratio = 2.73; P < 0.001) and disease control rate (odds ratio = 2.43; P < 0.001) as compared with chemotherapy alone. Thermal ablation was also a significant protective factor for progression-free survival (hazard ratio = 0.43; P < 0.001) and overall survival (hazard ratio = 0.49; P < 0.001). Besides, thermal ablation did not increase the risk of major complication (odds ratio = 0.75; P = 0.252).

CONCLUSION

The present meta-analysis based on these studies in China suggested that thermal ablation is a promising technique to provide better disease response and survival outcomes for patients with lung malignancy. Thermal ablation is worth further promotion in treating lung malignancy and application in clinical practice.

Time to Incurable Recurrence for Patients Treated With Pulmonary Metastasectomy for Colorectal Cancer

BACKGROUND

Probability of cure is important for patients with lung metastasis who must decide whether to undergo metastasectomy. Although progression-free survival (PFS) is thought to reflect this, it does not include curative effects by repeat metastasectomy. Thus, the authors developed a new indicator, time to incurable recurrence (TTIR), in which only incurable recurrence was set as an event that included death, with incurable recurrence defined as recurrence not treated by definitive local therapy (DLT), recurrence treated by DLT but with PFS maintained less than 2 years, or recurrence followed by re-recurrence.

METHODS

This multi-institutional study included 339 patients who underwent lung metastasectomy for colorectal cancer between 1990 and 2008.

RESULTS

Among the 339 patients, 191 experienced recurrence, 77 received DLT for recurrence, 38 had a PFS of 2 years or longer after the treatment, and 33 had maintained a PFS at the last follow-up date. The patients had PFS ranging from 39 to 212 months (median, 101 months). The 5-year OS, PFS, and TTIR rates were respectively 63.4%, 42.2%, and 51.9%. The TTIR curve was similar to the OS curve 7 years after the initial metastasectomy. The difference between TTIR and PFS at 7 years was 9.7%, indicating probability of cure by repeat DLT. Multivariable analysis showed different prognostic factors among OS, PFS, and TTIR.

CONCLUSION

At the initial metastasectomy, TTIR may reflect probability of a cure, including cure by repeat DLT, and can be used to analyze prognostic factors associated with cure.

Survival and prognostic factors of isolated pulmonary metastases originating from colorectal cancer: An 8-year single-center experience

Background

Isolated pulmonary metastasis (IPM) is a rare entity that accounts for 10% of pulmonary metastases seen in colorectal cancer (CRC). This study aims to evaluate the overall 5-year survival of IPM originating from CRC and identify potential prognostic factors affecting the overall survival (OS).

Methods

A retrospective cohort study conducted in a tertiary care center. The study included all patients diagnosed with CRC aged 18–75 years who underwent primary tumor resection with curative intent between 2008 and 2015, and developed IPM. Patients with no follow-up and those with extra-pulmonary metastases were excluded.

Results

The prevalence of IPM in the overall CRC cases was 4.18% (20/478 patients). The mean age of patients with IPM was 52.7 ± 12.9 years. Ten patients had synchronous IPM (50%), thirteen had unilateral (65%), and eleven underwent metastasectomy (55%). The 5-year OS was 40%, and the mean OS was 3.12 ± 1.85 years. Several factors were found to be associated with a favorable outcome, which include unilateral IPM (3.69 vs. 2.07 years; P = 0.024), metachronous (4.25 vs. 2.14 years; P = 0.017), metastasectomy (4.81 vs. 1.83 years; P = 0.005). In addition, mortality was likely to be decreased by more than 90% after metastasectomy (unadjusted odds ratio = 0.071; 95% confidence interval [CI] = 0.01–0.8; P = 0.032).

Conclusions

Forty percent of the included patients survived the 5-year follow-up. Better survival was associated with the metastases being unilateral, metachronous, and metastasectomy. Mortality was lower in patients with pulmonary recurrence after metastasectomy.

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IPM showed an incidence of 4% among resectable CRC patients.

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IPM demonstrated 40% 5-year overall survival.

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Survival was not influenced by age, comorbidities, KRAS mutation, nor the number of pulmonary lesions.

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Unilateral lesions, metachronous metastases, and metastasectomy were associated with a favorable outcome.

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The mortality was likely to be decreased by >90% after metastasectomy.

Management of single pulmonary metastases from colorectal cancer: State of the art

Colorectal cancer (CRC) is one of the most common causes of death from cancer. Lung seeding occurs in approximately 10% of patients surgically treated for primary CRC with radical intent: the lung is the most common site of metastases after the liver. While surgical treatment of liver metastases is widely accepted to affect long-term outcomes, more controversial and not standardized is the therapy for CRC patients developing lung metastases. Experience suggests the potential curative role of pulmonary metastasectomy, especially in oligometastatic disease. However, the optimal strategy of care and the definition of prognostic factors after treatment still need to be defined. This review focused on the uncommon scenario of single pulmonary metastases from CRC. We explored pertinent literature and provide an overview of the epidemiology, clinical characteristics and imaging of single pulmonary metastases from CRC. Additionally, we identified the best available evidence for overall management. In particular, we analyzed the role and results of locoregional approaches (surgery, radiotherapy or ablative procedures) and their integration with systemic therapy.

Imaging Characteristics and Prognostic Value of Isolated Pulmonary Metastasis from Colorectal Cancer Demonstrated with18F-FDG PET/CT

Objective. Solitary pulmonary lesions (SPNs) in patients with a history of colorectal cancer (CRC) may be attributed to metastatic lung tumors, primary lung cancer, or benign nodules. We aimed to analyze the imaging characteristics of SPNs in CRC patients to differentiate these pulmonary nodules and evaluate the prognostic value of isolated pulmonary metastasis from CRC using 18F-FDG PET/CT. Methods. From January 2013 to January 2021, 62 CRC patients with SPNs demonstrated with 18F-FDG PET/CT were retrospectively enrolled in the present study. We compared the radiological and clinical characteristics of these patients. In addition, survival time and prognostic factors were statistically analyzed using the Kaplan-Meier method and multivariable Cox proportional hazards models. Results. There were 33 cases of isolated lung metastasis, 20 cases of second primary lung cancer (SPLC), and nine cases of benign nodules. The proportion of nodules with a maximal diameter greater than the median value was lower in the isolated lung metastasis group compared with the SPLC group ( $p<0.05$ ), showing polygonal shape, ill-defined margin, pleural indentation, air bronchogram, speculation, and ground-glass opacity. Patients with isolated lung metastasis had a significantly higher maximal diameter of lung lesion, SUVmax of lung lesion, and 18F-FDG uptake compared with the benign nodule group ( $p<0.05$ ). Multivariate analysis revealed that the following two factors were significant independent predictors of PLC: air bronchogram (hazard ratio [HR] =22.327; 95% confidence interval [CI]: 1.910-261.061; $p=0.013$ ) and spiculation (HR =6.148; 95% CI 1.469-25.725; $p=0.013$ ). Initial TNM stage IV (HR =19.831, 95% CI 1.061-370.782; $p=0.046$ ) was extremely associated with a decreased lifespan of CRC patients with isolated lung metastasis. Conclusions. The result showed that CT features, including air bronchogram and spiculated margins, could be used to differentiate SPLC from single isolated lung metastasis in CRC patients. In patients with isolated lung metastasis, primary CRC TNM stage IV was associated with a poorer prognosis, and patients with such conditions might need more care.

Correlation between preoperative CT scan and lung metastases according to surgical approach in patients with colorectal cancer

INTRODUCTION

The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study.

METHODS

Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan-Meier method.

RESULTS

93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was ≤1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p=0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT>1), with no differences between approaches (8.6% vs 10%, p=0.874). 51 patients with M1/CT>1, showed a lower median DSS (35.4 months vs 55.8; p=0.002) and DFS (14.2 months vs 29.3; p=0.025) compared to 470 with M1/CT≤1. No differences were observed in DSS and DFS according to VATS or thoracotomy.

CONCLUSIONS

Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively.

Role of surgical resection and its alternative local therapy for pulmonary metastasis of colorectal cancer

We reviewed surgical and alternative treatments for pulmonary metastasis of colorectal cancer, focusing on recent reports. The standard treatment for pulmonary metastasis of colorectal cancer is pulmonary resection, if resectable, despite the fact that the metastasis is hematogenous to distant organs. Guidelines in several countries, including Japan, have described pulmonary resection as a useful option because of the favorable long-term prognosis reported in various studies pertaining to pulmonary resection. The indications for pulmonary resection have been reviewed in several studies; additionally, the number of metastases, pretreatment carcinoembryonic antigen value, and disease-free interval from the primary resection to pulmonary recurrence have been proposed. However, no consensus has been reached to date. Contrastingly, recent advances in chemotherapy have remarkably improved the outcome of distant metastases, indicating that it is time to reconsider the significance of local treatment, including pulmonary resection. In addition to surgical resection, minimally invasive therapies, such as stereotactic body radiation therapy and radiofrequency ablation have been developed as local treatments for pulmonary metastases, and their long-term results have been reported. Prospective controlled trials and large-scale data analyses are needed to determine the best local treatment for pulmonary metastases and to find the appropriate indication for each treatment.

Outcomes of Combined Peritoneal and Local Treatment for Patients with Peritoneal and Limited Liver Metastases of Colorectal Origin: A Systematic Review and Meta-Analysis

Background

Almost half of all colorectal cancer (CRC) patients will experience metastases at some point, and in the majority of cases, multiple organs will be involved. If the peritoneum is involved in addition to the liver, the current guideline-driven treatment options are limited. The reported overall survival ranges from 6 to 13 months for the current standard of care (systemic treatment). This study aimed to evaluate morbidity and clinical long-term outcomes from a combined local treatment of hepatic metastases with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) used to treat peritoneal metastases.

Methods

A systematic search was performed in PubMed, Embase.com, Web of Science, and Cochrane. Studies evaluating the clinicopathologic data of patients who had both peritoneal and hepatic metastases treated with CRS-HIPEC were included provided sufficient data on the primary outcomes (overall and disease-free survival) were presented. The quality of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS).

Results

Patients treated for peritoneal and liver metastases (PMLM group) had a pooled mean survival of 26.4 months (95% confidence interval [CI] 22.4–30.4 months), with a 3-year survival rate of 34% (95% CI 26.7–42.0%) and a 5-year survival rate of 25% (95% CI 17.3–33.8%). Surgical complications occurred more frequently for these patients than for those with peritoneal metastasis only (40% vs 22%; p = 0.0014), but the mortality and reoperation rates did not differ significantly.

Conclusion

This systematic review showed that CRS and HIPEC combined with local treatment of limited liver metastasis for selected patients is feasible, although with increased morbidity and an association with a long-term survival rate of 25%, which is unlikely to be achievable with systemic treatment only.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10925-y.

Pulmonary resection for tissue harvest in adoptive tumor-infiltrating lymphocyte therapy: Safety and feasibility

BACKGROUND AND OBJECTIVES

Adoptive T-cell therapies (ACTs) using expansion of tumor-infiltrating lymphocyte (TIL) populations are of great interest for advanced malignancies, with promising response rates in trial settings. However, postoperative outcomes following pulmonary TIL harvest have not been widely documented, and surgeons may be hesitant to operate in the setting of widespread disease.

METHODS

Patients who underwent pulmonary TIL harvest were identified, and postoperative outcomes were studied, including pulmonary, cardiovascular, infectious, and wound complications.

RESULTS

83 patients met inclusion criteria. Pulmonary TIL harvest was undertaken primarily via a thoracoscopy with a median operative blood loss and duration of 30 ml and 65 min, respectively. The median length of stay was 2 days. Postoperative events were rare, occurring in only five (6%) patients, including two discharged with a chest tube, one discharged with oxygen, one episode of urinary retention, and one blood transfusion. No reoperations occurred. The median time from TIL harvest to ACT infusion was 37 days.

CONCLUSIONS

Pulmonary TIL harvest is safe and feasible, without major postoperative events in our cohort. All patients were able to receive intended ACT infusion without delays. Therefore, thoracic surgeons should actively participate in ongoing ACT trials and aggressively seek to enroll patients on these protocols.

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.

Prognostic value of KRAS mutation in patients undergoing pulmonary metastasectomy for colorectal cancer: A systematic review and meta-analysis

BACKGROUND

The purpose of the study was to evaluate whether KRAS mutation could be an independent prognostic biomarker in patients undergoing pulmonary metastasectomy (PM) for colorectal cancer (CRC).

METHODS

A systemic review was performed by searching online databases to identify studies reporting overall survival (OS) and recurrence free survival (RFS) of CRC patients undergoing PM. Pooled HRs were calculated for OS and RFS.

RESULTS

A total of 15233 patients from 60 studies were included. Pooled analysis showed that KRAS mutation was associated with worse OS (HR: 1.86, 95 % Cl: 1.35-2.57) and RFS (HR: 1.68, 95 % Cl: 1.38-2.04). A significant effect on OS and/or RFS was also shown by other 18 factors.

CONCLUSIONS

This meta-analysis found that KRAS mutation is an important prognostic predictor for OS and RFS in CRC patients undergoing PM, supporting a comprehensive model including clinicopathological and biological factors for optimal patients selection and prognosis for surgical treatment.

Taiwan Society of Colon and Rectal Surgeons (TSCRS) Consensus for Cytoreduction Selection in Metastatic Colorectal Cancer

BACKGROUND

Taiwan has witnessed a surge in the incidence of colorectal cancer (CRC), of which 40-60% metastasize. Continuous updating of cytoreductive strategies in metastatic CRC (mCRC) has contributed to median overall survival reaching 40 months. In this changing scenario, to standardize the approaches across Taiwan, a group of experts from the Taiwan Society of Colon and Rectal Surgeons (TSCRS) convened to establish evidence- and opinion-based recommendations for defining the criteria of "resectability" in mCRC.

METHODS

Over the course of one-on-one consultations, lasting 30-40 min each, with 30 medical specialists (19 colorectal surgeons, 4 general surgeons, and 7 medical oncologists) from 16 hospitals in Taiwan followed by a 2-h meeting with 8 physician experts (3 general surgeons, 4 colorectal surgeons, and 1 thoracic surgeon), 12 key questions on cytoreduction were addressed. This was further contextualized based on published literature.

RESULTS

The final consensus includes eight recommendations regarding the criteria for metastasis resection, role of local control treatment in liver potentially resectable patients, management of synchronous liver metastases, approach for peritoneal metastasis, place for resection in multiple-organ metastasis, and general criteria for resectability.

CONCLUSIONS

mCRC patients undergoing R0 resection have the greatest survival advantage following surgery. Our role as a multidisciplinary team (MDT) should be to treat potentially resectable mCRC patients as rapidly and safely as possible, and achieve R0 resection as far as possible and for as long as possible (continuum of care). This TSCRS consensus statement aims to help build clinical capacity within the MDTs, while making better use of existing healthcare resources.

Correlation between preoperative CT scan and lung metastases according to surgical approach in patients with colorectal cancer

INTRODUCTION

The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study.

METHODS

Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan-Meier method.

RESULTS

93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was ≤1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p=0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT>1), with no differences between approaches (8.6% vs 10%, p=0.874). 51 patients with M1/CT>1, showed a lower median DSS (35.4 months vs 55.8; p=0.002) and DFS (14.2 months vs 29.3; p=0.025) compared to 470 with M1/CT≤1. No differences were observed in DSS and DFS according to VATS or thoracotomy.

CONCLUSIONS

Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively.

Circulating tumor DNA as a marker of minimal residual disease following local treatment of metastases from colorectal cancer

BACKGROUND

Local treatment of liver and/or lung metastases from colorectal cancer (CRC) is increasingly used in daily practice and comprises resection, radiofrequency ablation (RFA) and stereotactic radiotherapy (SBRT). The need for prognostic markers for patients undergoing such treatment is currently unmet. We investigated post-treatment circulating tumor-specific DNA (ctDNA) analysis and address a possible prognostic value in a pilot study.

MATERIALS

From July 2015 to September 2017, patients undergoing standard of care local treatment of liver and/or lung metastases were included in a prospective translational study. Blood samples were drawn 2 weeks after local treatment and during follow-up. CtDNA was detected by ddPCR and a mass spectrometry-based platform MassARRAY^®.

RESULTS

Post treatment blood samples were available for 35 patients including five with detectable ctDNA (KRAS mutation, n = 2; NRAS mutation, n = 2; BRAF mutation, n = 1) by ddPCR. 17 out of 35 patients (49%) developed recurrence within a median of 273 days (95%CI 95-NA) among patients positive for ctDNA, while the median time to recurrence was not reached for the group of patients negative for ctDNA (p = .03).

CONCLUSION

The presence of ctDNA following local treatment of metastatic CRC is associated with an increased risk of recurrence and a short time to failure.

Analyses of local control and survival after stereotactic body radiotherapy for pulmonary oligometastases from colorectal adenocarcinoma

This study is a subset analysis of a retrospective multicenter study performed in Japan and its purpose was to investigate the effectiveness of stereotactic body radiotherapy (SBRT) for pulmonary oligometastases from colorectal cancer. Local control (LC), freedom from further metastases, relapse-free survival and overall survival (OS) after SBRT were retrospectively analyzed. The Kaplan-Meier method was used to estimate lifetime data and the log-rank test was performed as univariate analyses. The Cox proportional hazards model was applied in multivariate analyses. Data for 330 patients with 371 tumors were used for analyses. The median follow-up period was 25.0 months. The 3-year LC, freedom from further metastases, relapse-free survival and OS rates were 64.9, 34.9, 24.9 and 63.4%, respectively. The results of multivariate analyses showed that a higher LC rate was associated with no history of local therapy for oligometastases (P = 0.01), SBRT without concurrent chemotherapy (P < 0.01), type B calculation algorithm (P < 0.01) and higher biological effective radiation doses (≥115 Gy, P = 0.04). A longer OS was associated with no history of local therapy for oligometastases (P = 0.04), a more recent period of SBRT (2010-15, P = 0.02), tumor located in the upper or middle lobe (P < 0.01) and higher biological effective radiation doses (≥115 Gy, P = 0.01). In conclusion, OS after SBRT was good, but LC rate was relatively low. The use of high biological effective radiation doses can improve both LC and OS outcomes.

Proctor-guided virtual reality-enhanced three-dimensional video-assisted thoracic surgery: an excellent tutoring model for lung segmentectomy

OBJECTIVE

Lung segmentectomy using video-assisted thoracoscopic surgery (VATS) is an effective strategy to treat early-stage lung cancer. The objective of this case report is to show the efficacy of Hyper Accuracy 3D™ (HA3D) reconstruction as a tool for trainee surgeons and expert surgeons to perform complex procedures.

METHODS

An 84-year-old man was treated for colon-rectal cancer. During follow-up, a pulmonary nodule on the right anterior upper lobe suspected for intestinal metastasis was revealed by a computed tomography scan. According to functional tests and radiology, a right anterior upper lobe segmentectomy was planned. HA3D lung reconstruction was used during surgery.

RESULTS

Using the HA3D virtual model, the procedure was performed with healthy tissue sparing, ensuring safe resection margins. No postoperative morbidities were noted. The patient referred good pain control. The hospital stay was 6 days.

CONCLUSIONS

VATS segmentectomy is a technically demanding procedure. HA3D lung reconstruction can help surgeons effectively perform the resection, aiding at individuating intersegmental planes, bronchi, and vessels, guaranteeing oncologic radicality and safe surgical margins, and preserving respiratory function.

Is video-assisted thoracoscopic surgery sufficient for lymph node dissection in pulmonary metastasectomy?

AIM

We evaluated the results of patients undergoing pulmonary metastasectomy with video-assisted thoracoscopic surgery (VATS) and aimed to investigate postoperative lymph node positivity after lymph node dissection (PM-LND).

MATERIAL AND METHODS

Patients who underwent pulmonary metastasectomy and mediastinal lymph node dissection with VATS between March 2015 and March 2020 in our clinic were included in the study.

RESULTS

The mean age of 58 patients who underwent pulmonary metastasectomy and mediastinal lymph node dissection with VATS was 56.5. Thirty-four of the patients were female and 24 were male. A total of 61 surgical procedures, 3 of which were bilateral, were performed in 58 patients. The mean number of resected pulmonary metastases was 1.72. The total number of dissected lymph nodes was 191, with an average of 3.1 per surgical procedure. Colon carcinoma (20 patients) and breast carcinoma (16 patients) were the most common primary tumor origin. Others were thyroid, sarcoma, renal cell carcinoma and melanoma. Unexpected lymph node positivity was present in 9 of 58 patients.

CONCLUSIONS

Video-assisted thoracoscopic surgery is a technique that can be applied in pulmonary metastasectomy with its advantages such as a low complication rate and rapid recovery. In these patients, lymph node dissection, which is one of the determining factors of prognosis, can be performed effectively with VATS. Mediastinal and hilar lymph node dissection combined with pulmonary metastasectomy is effective in detecting unexpected lymph node positivity.

Surgery versus stereotactic radiotherapy for treatment of pulmonary metastases. A systematic review of literature

It is not clear as to which is the best treatment among surgery and stereotactic radiotherapy (SBRT) for lung oligometastases. A systematic review of literature with a priori selection criteria was conducted on articles on the treatment of pulmonary metastases with surgery or SBRT. Only original articles with a population of patients of more than 50 were selected. After final selection, 61 articles on surgical treatment and 18 on SBRT were included. No difference was encountered in short-term survival between pulmonary metastasectomy and SBRT. In the long-term surgery seems to guarantee better survival rates. Mortality and morbidity after treatment are 0–4.7% and 0–23% for surgery, and 0–2% and 4–31% for SBRT. Surgical metastasectomy remains the treatment of choice for pulmonary oligometastases.

Patients with metastatic cancer with a limited number of deposits may benefit from surgical removal or irradiation of tumor nodules in addiction to chemotherapy. Surgical resection has been demonstrated to improve survival and, in some cases, can be curative. Stereotactic radiotherapy is emerging as a less invasive alternative to surgery, but settings and implications of the two treatments are profoundly different. The two techniques show similar results in the short-term, with lower complications rates for radiotherapy, while in the long-term surgery seems to guarantee higher survival rates.

Peri-operative chemotherapy for resectable colorectal lung metastasis: a systematic review and meta-analysis

Purpose

Several studies have evaluated surgical resection of pulmonary metastases as a standard treatment option for colorectal cancer (CRC) patients with resectable pulmonary metastases. However, the role of peri-operative chemotherapy after complete resection of pulmonary metastases from CRC patients is still controversial. This systematic review and meta-analysis is aimed to investigate the clinical efficacy of peri-operative chemotherapy after resection of CRC pulmonary metastases.

Methods

PubMed, the Cochrane Library databases, and Embase were searched for studies evaluating the effect of peri-operative chemotherapy on the survival of patients with CRC after pulmonary metastasectomy. The hazard ratio (HR) was used for analyzing overall survival (OS) and progression-free survival (PFS)/recurrence-free survival (RFS)/disease-free survival (DFS).

Results

Eight studies were included in the final analysis. The outcome showed that peri-operative chemotherapy had a significant favourable effect on OS (HR 0.83, 95% CI 0.75–0.92, p < 0.05) and PFS/RFS/DFS (HR 0.67, 95% CI 0.53–0.86, p < 0.05) in patients who received pulmonary metastasectomy. Multivariate analysis also validated this result (OS: HR 0.56, 95% CI 0.36–0.86, p < 0.05; PFS/RFS/DFS: HR 0.64, 95% CI 0.46–0.87, p < 0.05). There was a significant benefit in peri-operative group on OS and PFS/RFS/DFS in studies with R0 resection of pulmonary metastases (OS: HR 0.72, 95% CI 0.53–0.97, p < 0.05; PFS/RFS/DFS: HR 0.72, 95% CI 0.54–0.95, p < 0.05) and metachronous pulmonary metastases (OS: HR 0.40, 95% CI 0.22–0.75, p < 0.05; PFS/RFS/DFS: HR 0.67, 95% CI 0.49–0.92, p < 0.05).

Conclusion

Our meta-analysis demonstrated a significant difference in favor of peri-operative chemotherapy in CRC patients who underwent resection of pulmonary metastases. More clinical data and studies are needed to validate the findings of our study.

Electronic supplementary material

The online version of this article (10.1007/s00432-020-03142-9) contains supplementary material, which is available to authorized users.

Optimal timing for the resection of pulmonary metastases in patients with colorectal cancer

This study aims to clarify the surgical treatment time of pulmonary metastasis in patients with colorectal cancer.Early relapse after resection of pulmonary metastasis is often encountered when the interval from the detection of pulmonary metastasis to pulmonary metastasectomy was short.In this retrospective analysis, data of patients with colorectal cancer who underwent surgical treatment of pulmonary metastasis at the Gunma Prefectural Cancer Center, Gunma, from April 2001 through September 2018 were evaluated. The patients were divided into 2 groups. We examined the interval period from the diagnosis of pulmonary metastasis to pulmonary metastasectomy. This period was divided into every 3 months, and the prognosis of each group was compared with clarify the appropriate timing of pulmonary metastasectomy.The primary endpoints were 5-year overall survival and recurrence-free survival rates.The most significant difference was observed when the cutoff value was 9 months (5-year recurrence-free survival 45.8% vs 85.6%, P < .01). No significant difference was found in any background factors between the 2 groups. Twenty-five patients (34.7%) experienced recurrence after pulmonary metastasectomy. The most common site of recurrence was the lung (48%). Among the 12 cases of recurrence of pulmonary metastasis, 11 cases belonged to the <9 months group. A multivariable survival analysis found that the interval period of <9 months was a significant predictor of recurrence.Our study suggests that clinical follow-up for 9 months prior pulmonary metastasectomy in colorectal patients would improve the prognosis.

Lung metastasectomy after colorectal cancer: prognostic impact of resection margin on long term survival, a retrospective cohort study

BACKGROUND

Pulmonary metastasectomy is considered a potentially curative treatment for selected patients with metastatic colorectal cancer (CRC). Several prognostic factors have been analysed, but to date, it is still not well defined which is the optimal resection margin during lung metastasectomy (LM). This study analyses the long-term results and prognostic factors after LM in CRC patients with particular attention to the resection margins. Primary endpoint of this study is to assess the correlation between resection margins and long-term outcomes.

METHODS

Observational cohort study on all proven cases of CRC lung metastases (2000-2016) resected with curative intent in a single centre.

RESULTS

The series included 210 consecutive patients (M/F 133/77) with a mean age of 65.4 (± 9.96) years, 75% (159/210) of them with a solitary metastasis. Mean size of metastasis was 2.57 cm (± 1.45). One hundred sixty-eight patients underwent wedge resections (80%) and lymphadenectomy was carried out in 90 cases (42.9%). With a mean follow-up of 56 months (range 5-192), we observed a 1-, 3- and 5-year overall survival (OS) of 95%, 74% and 54%, respectively. The patients were divided into three groups according to the resection margin distance from the tumour: (a) ≥ 2 cm (145 cases); (b) < 2, ≥ 1 cm (37 cases); and (c) < 1 cm (12 cases). The OS was significantly different between the three groups (p = 0,020); univariate and multivariate analyses showed that a narrow resection margin was an independent prognostic factor of worse survival (p = 0.006 and HR 3.4 p = 0.009).

CONCLUSIONS

Long-term survival of patients after LM is strongly associated with a greater distance between the lesion and the resection margin.

Does adjuvant chemotherapy improve the prognosis of patients after resection of pulmonary metastasis from colorectal cancer? A systematic review and meta-analysis

BACKGROUND

It remains controversial whether patients benefit from adjuvant chemotherapy (ACT) after resection of pulmonary metastasis (PM) from colorectal cancer (CRC). This meta-analysis was intended to evaluate the efficacy of ACT in patients after resection of PM from CRC.

METHODS

We systematically retrieved articles from PMC, PubMed, Cochrane Library, and Embase (up to March 5, 2019). Survival data, including overall survival (OS) and disease-free survival (DFS), were tested by hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

We included 18 cohort studies with a total of 3885 patients. The meta-analysis showed that ACT had no significant effect on OS (HR = 0.78; 95% CI = 0.60-1.03; P = 0.077) and DFS (HR = 0.91; 95% CI = 0.74-1.11; P = 0.339) in patients after resection of PM from CRC. There was no significant difference in OS (HR = 0.79; 95% CI = 0.42-1.50; P = 0.474) in patients after resection of PM from CRC treated with bevacizumab (BV). Subgroup analysis showed that ACT did not improve OS (HR = 0.86; 95% CI = 0.57-1.29; P = 0.461) in patients who had undergone previous resection of extra PM. ACT did not improve OS in patients who had positive hilar/mediastinal lymph node metastasis (HR = 0.80; 95% CI = 0.57-1.14; P = 0.22).

CONCLUSION

In conclusion, ACT does not provide survival benefits for patients after resection of PM from CRC. ACT and targeted agents (BV) are not suggested for these patients.

An overview on clinical, pathological and molecular features of lung metastases from colorectal cancer

Introduction: Lung metastases occur in 10-20% of patients with colorectal cancer (CRC). Most of them are treated with palliative intent and have a poor prognosis. Pulmonary metastasectomy may be a curative option for carefully selected patients with 5-year survival rates ranging from 25% to 60%. However, up to 70% of patients develop recurrence after pulmonary metastasectomy. Therefore, the identification of prognostic factors is essential in CRC patients with resectable lung metastases. Areas covered: This review aims at summarizing the actual body of knowledge available on lung metastases from CRC focusing on their clinical, pathological and molecular profile. Moreover, we provide an update on experts' attitudes towards lung metastasectomy, adjuvant or perioperative chemotherapy. Expert opinion: Traditional clinical prognosticators such as the total number of pulmonary metastases, carcinoembryonic antigen (CEA) serum levels before surgery, and presence of lymph node metastases cannot provide reliable criteria to predict survival after lung metastasectomy. Indeed, research efforts have been directed in recent years toward studying the biological characteristics of lung lesions to better define prognosis and response to treatment, and ultimately shed new light on their proper local and systemic management.

Surgical margins and risk of local recurrence after wedge resection of colorectal pulmonary metastases

OBJECTIVE

During resection of pulmonary metastases, the need to spare lung parenchyma is often weighed against the increased risk of local recurrence if an inadequate surgical margin is obtained. We sought to identify risk factors for local recurrence after wedge resection of pulmonary metastases of a colorectal origin.

METHODS

A retrospective study of patients who underwent a wedge resection for colorectal pulmonary metastases from 2006 to 2016 was performed. Cox regression with robust variance was used to estimate the risk of local recurrence per nodule treated.

RESULTS

We identified 335 patients who underwent 679 wedge resections. The 2-year local recurrence risk for each nodule was 11.8% (95% confidence interval, 8.9%-14.6%), and the 5-year risk was 20.6% (95% confidence interval, 16.2%-24.8%). Longer margin length decreased the risk of local recurrence (hazard ratio, 0.434 per additional cm of length; P = .015), whereas larger tumor size increased this risk (hazard ratio, 1.520 per additional cm of size; P = .012). However, other factors tested, including tumor grade, KRAS mutation status, and response to induction chemotherapy, did not affect recurrence risk. A pathologic margin length of at least half the tumor size was estimated to result in a local recurrence rate <11%.

CONCLUSIONS

Among surgically resected colorectal pulmonary metastases, technical factors related to margin length and tumor size were associated with the risk of local recurrence, whereas tumor grade and KRAS status were not. However, the increased risk of local recurrence with larger tumors was diminished with a sufficient margin length.

Metastasis directed therapy for liver and lung metastases from colorectal cancer-A population-based study

About 10-20% of patients with metastatic colorectal cancer (mCRC) are candidates for metastasis directed therapies such as surgical resection, ablation and stereotactic radiotherapy. We examined the temporal changes in use of metastasis directed therapies and established prognostic factors for survival in a nationwide cohort study. The Danish nationwide medical registries were used to retrieve data on treatment for liver and/or lung metastasis in patients with metastatic colorectal cancer in the period 2000-2013. Overall survival through 2014 was calculated from the time of treatment of metastases by Kaplan-Meier method and mortality between groups was assessed using Cox regression. We report 2,912 patients undergoing a total of 3,602 procedures with an increased use of all modalities during 14 calendar years. Median survival was 3.7 years (interquartile range (IQR) 2.0-9.7 years). In the multivariate analysis, the nodal stage of the primary tumor had the most pronounced association with survival with a hazard ratio for mortality of 1.56 (95% CI: 1.33-1.83) for N2 stage with reference to N0. Furthermore, female gender, age, comorbidity, surgical treatment, administration of chemotherapy, and left-sided primary tumors were associated with improved prognosis in the multivariate analysis.

Integration of stereotactic radiotherapy in the treatment of metastatic colorectal cancer patients: a real practice study with long-term outcome and prognostic factors

Background

There are very few clinical or prognostic studies on the role of SRT (Stereotactic Radiation Therapy) in the continuum of care of metastatic colorectal cancer (mCRC) patients.

Patients and methods

Patients affected by oligo-mCRC were treated with SRT before or after front-line standard treatments. SRT was delivered according to a risk-adapted protocol. Total body CT (Computed Tomography) scan was done before therapy and every three months thereafter. The radiologic responses to therapy were evaluated by RECIST (Response Evaluation Criteria In Solid Tumors). FDG-PET (FluoroDeoxyGlucose - Positron Emission Tomography) was done before and after SRT; metabolic responses were evaluated by using the EORTC (European Organization for Research and Treatment of Cancer) criteria. The Kaplan-Meier product limit method was applied to graph Overall Survival (OS) and Progression-Free Survival (PFS).

Results

Forty-seven patients were included. Twenty-one patients had disease limited to lungs, 9 to lung and liver, 7 only to liver, 10 to multiple sites. The median prescription SRT dose was 60 Gy per organ in 3 fractions (median biological effective dose of 180 Gy). The reduction of delta SUVmax (maximum Standardized Uptake Value) correlated with the local control (p<0.001) and two-years survival (p=0.003). At univariate analysis, localization of primary tumor, site of metastases, KRAS (Kirsten RAt Sarcoma) oncogene mutational status, response to first-line chemotherapy, response to SRT and number of treated lesions predicted both PFS and OS.

Discussion

This real practice experience suggests that further studies are needed to analyze the promising role of SRT in the multidisciplinary management of mCRC.

Differential expression profiles of long noncoding RNA and mRNA in colorectal cancer tissues from patients with lung metastasis

Lungs are the most common extra-abdominal site of metastasis of colorectal cancer (CRC), in which long noncoding RNA (lncRNA) may serve a role. In the present study, a high-throughput microarray assay was performed to detect lncRNA expression and identify novel targets for further study of lung metastasis in CRC. In the CRC tissues from patients with lung metastasis, 7,632 lncRNA (3,574 upregulated and 4,058 downregulated) and 6,185 mRNA (3,394 upregulated and 2,791 downregulated) were detected to be differentially expressed with a fold change ≥2 and P<0.05 compared with the CRC tissues without metastasis. A total of six differentially regulated lncRNA were confirmed by reverse transcription-quantitative polymerase chain reaction in 20 pairs of CRC samples. Furthermore, gene ontology and pathway analysis were conducted to predict the possible roles of the identified mRNA. The upregulated mRNA were associated with cell division (biological processes), protein kinase B binding (molecular functions) and cellular components. The downregulated mRNA were associated with cell adhesion, platelet-derived growth factor binding and membrane components. Pathway analysis determined that the upregulated mRNA were associated with the Wnt signaling pathway in the CRC tissues from patients with lung metastasis, while the downregulated mRNA were associated with the phosphoinositide 3-kinase/Akt signaling pathway. The results of the present study suggested that differentially expressed lncRNA may be associated with lung metastasis and may provide insights into the biology and prevention of lung metastasis.

Pulmonary metastasectomy for colorectal cancer: analysis of prognostic factors affecting survival

BACKGROUND

Pulmonary metastasectomy is considered a standard procedure in the treatment of metastatic colorectal cancer (CRC). Different prognostic factors including multiple metastatic nodules, the presence of extra-pulmonary metastases and BRAF mutation status have been associated with poor survival. The aim of this study was to evaluate which factors influenced survival in CRC patients undergoing pulmonary metastasectomy by studying primary tumors and pulmonary metastases.

METHODS

All patients treated for primary CRC who presented pulmonary metastases in a 10-year period were considered (group A). A control group treated for primary CRC who did not develop any pulmonary or extra-pulmonary metastases was taken for comparison (group B). Different prognostic factors including gender, age, tumor location, histological type, inflammatory infiltrate, BRAF, CDX2 and extra-pulmonary metastases were analyzed. Overall survival (OS) and patients' survival after pulmonary metastasectomy were also considered.

RESULTS

Fifty-four patients were evaluated in group A and twenty-three in group B. In group A, BRAF immunohistochemistry did not significantly differ between primary tumors and pulmonary metastases; no difference of BRAF expression was found between group A and B. Even the expression of CDX2 was not significantly different in primary tumors and metastases. Similarly, in group B CDX2 did not significantly differ from primary CRC of group A. The most significant prognostic factor was the presence of extra-pulmonary metastases. Patients with extra-pulmonary metastases experienced a significant shorter survival compared to patients with pulmonary metastases alone (P=0.001 with log-rank test vs. P=0.003 with univariate Cox regression). Interestingly, patients with right pulmonary metastases presented a significant longer survival than those with left pulmonary metastases (P=0.027 with log-rank test vs. 0.04 with univariate Cox regression).

CONCLUSIONS

The main prognostic factor associated with poor survival after lung resection of CRC metastases is a history of extra-pulmonary metastases. BRAF and CDX2 did not have a significant role in this small series of patients.

Pulmonary Manifestations of Solid Non-Pulmonary Malignancies

The lungs are a common site of metastatic disease. Pulmonary metastases develop due to local blood flow and cellular or biochemical properties of tumor cells. Metastases develop from any type of malignancy and may occur via hematogenous, lymphatic, aerogenous, and/or direct spread. Metastatic disease may present with symptoms indistinguishable from primary lung cancer, including dyspnea, hemoptysis, and chest pain. Radiographically, these may present as parenchymal lung disease, mediastinal lymphadenopathy, airway obstruction, or pleural and vascular disease. No part of the thorax is spared from metastatic potential. This review highlights complications of non-pulmonary solid malignancies based on sites of anatomic metastases.

The Role of Minimally Invasive Surgery in the Treatment of Lung Metastases

INTRODUCTION

The ideal surgical approach for pulmonary metastasectomy remains controversial. Thoracoscopic surgery may offer advantages in quality of life outcomes, with equivalent oncologic long-term results. This study aimed to demonstrate the validity of video-assisted thoracoscopic surgery (VATS) in the treatment of lung metastases.

METHODS

In all 224 patients who underwent 300 VATS metastasectomies from January 2000 to December 2013 were retrospectively reviewed. Sixty-nine patients underwent major resection (68 thoracoscopic lobectomies and one pneumonectomy) and 155 patients underwent a wedge resection/segmentectomy. Complete curative pulmonary resections were performed in 219 (97%) cases. The Kaplan-Meier method was used to estimate survival curves. Univariate and subsequent multivariate Cox model regression were performed to identify independent factors of overall survival.

RESULTS

One hundred eighty-six patients developed lung metastases from epithelial tumors, 28 from sarcomas, seven from melanomas, and three from germ cell tumors. The final pathological examination revealed no cases of R1 disease. After a mean follow-up of 40 months, 118 patients (53%) had died. According to a multivariate analysis, a better prognosis was not observed for patients with a particular histological type; in addition, disease-free interval time, age, number of metastases, and type of surgery did not have any statistical influence on long-term survival.

CONCLUSIONS

Thoracoscopic surgery is a safe and efficacious procedure, with a five-year overall survival that is equivalent to open surgery.