Clinical outcomes of lung metastasectomy in patients with colorectal cancer

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.

Adjuvant systemic chemotherapy with or without bevacizumab in patients with resected pulmonary metastases from colorectal cancer

INTRODUCTION

We investigated the impact of modern chemotherapy regimens and bevacizumab following pulmonary metastasectomy (PM) from metastatic colorectal cancer (CRC).

METHODS

A total of 122 consecutive patients who were curatively resected for pulmonary metastases of CRC in twelve oncology centers were retrospectively analysed between January 2000 and April 2012.

RESULTS

Of 122 patients, 14 did not receive any treatment following PM. The remaining 108 patients received fluoropyrimidine-based (n = 12), irinotecan-based (n = 56) and oxaliplatin-based (n = 40) chemotherapy combinations. Among these, 52 patients received bevacizumab (BEV) while 56 did not (NoBEV). Median recurrence-free survival (RFS) was 17 months and median overall survival (OS) has not been reached at a median follow-up of 25 months after PM. Three and five-year OS rates were 66% and 53%, respectively. RFS and OS were similar, irrespective of the chemotherapy regimen or BEV use. Positive pulmonary margin, KRAS mutation status, and previous liver metastasectomy were negative independent prognostic factors for RFS, while pathologically confirmed thoracic lymph node involvement was the only negative independent prognostic for OS in multivariate analysis.

CONCLUSIONS

No significant RFS or OS difference was observed in respect to chemotherapy regimens with or without BEV in patients with pulmonary metastases of CRC following curative resection.

Pulmonary metastases of colorectal carcinoma: Clinical characteristics, metastatic features, therapeutic methods and prognosis

AIM: To explore the clinical characteristics, metastatic features, therapeutic methods and prognosis in patients with pulmonary metastases of colorectal carcinoma.

METHODS: The clinical data of 120 patients with pulmonary metastases of colorectal cancer were retrospectively analyzed. The clinical parameters of the patients, treatment methods and the factors affecting prognosis were analyzed.

RESULTS: In patients with pulmonary metastases of colorectal carcinoma, the 6-mo, 1-, 2-, 3-, and 5-year survival rates were 78%, 44%, 26%, 19% and 16%, respectively, with an overall median overall survival (OS) period of 18.0 mo. Pulmonary symptoms, sex, age, single or multiple pulmonary metastases, the presence or absence of liver metastases, mediastinal and/or hilar lymph node involvement were not significant prognostic factors of OS (P > 0.05). Univariate analysis showed that factors significantly predicting a poor prognosis included primary tumor site (P = 0.017), vessel invasion (P = 0.024) and high T stage (P = 0.008). However, none of these were prognostic factors on multivariate analysis. There was a trend of better survival in patients submitted to metastasectomy compared with those submitted to chemotherapy alone, although there was no statistical difference (median OS: 33.0 mo vs 18.0 mo, P = 0.128). Among 153 patients who underwent radical colorectal resection, 82 had pulmonary metastases in two years after surgery, with a median disease free interval (DFI) of 20.0 mo. The factors that affected DFI included primary tumor site, morphotype, differentiation degree, T stage and N stage (P < 0.05). T stage was an independent predictive factor of DFI (P = 0.019).

CONCLUSION: T stage is an independent predictor of DFI, showing that the tumor with strong ability of invasion tend to cause lung metastasis more commonly.

Carbon ion radiotherapy for oligo-recurrent lung metastases from colorectal cancer: a feasibility study

Background

The purpose of this study was to evaluate the efficacy and feasibility of carbon ion radiotherapy (CIRT) for oligo-recurrent lung tumors from colorectal cancer (CRC).

Methods

From May 1997 to October 2012, 34 consecutive patients with oligo-recurrent pulmonary metastases from CRC were treated with CIRT. The patients were not surgical candidates for medical reasons or patient refusal. Using a respiratory-gated technique, carbon ion therapy was delivered with curative intent using 4 coplanar beam angles. A median dose of 60 GyE (range, 44–64.8 GyE) was delivered to the planning target volume (PTV), with a median daily dose of 15 GyE (range, 3.6–44 GyE). Treatment outcome was analyzed in terms of local control rate (LCR), survival rate, and treatment-related complications.

Results

In total, 34 patients with 44 oligo-recurrent pulmonary lesions were treated with CIRT. Median follow-up period was 23.7 months. The 2- and 3-year actuarial LCRs of the treated patients were 85.4% ± 6.2% and 85.4% ± 6.2%, respectively. Overall survival was 65.1% ± 9.5% at 2 years, and 50.1% ± 10.5% at 3 years. Although survival rates were relatively worse in the subsets of patients aged < 63 years or with early metastasis (< 36 months after resection of primary site), these factors were not significantly correlated with overall survival (P = 0.13 and 0.19, respectively). All treatment-related complications were self-limited, without any grade 3–5 toxicity.

Conclusions

CIRT is one of the most effective nonsurgical treatments for colorectal lung metastases, which are relatively resistant to stereotactic body radiotherapy. CIRT is considered to be the least invasive approach even in patients who have undergone repeated prior thoracic metastasectomies.

Pulmonary metastasectomy for colorectal cancer: long-term survival and prognostic factors

BACKGROUND

Despite the development of novel chemotherapy and biological agents, surgery is still an important option for patients with pulmonary metastases. Predictors of survival usually include disease-free interval, histology of the primary tumor, number of metastases and complete resection. The aim of this study was to report the outcomes of patients with pulmonary metastases from colorectal carcinoma submitted to surgical resection, and to identify prognostic factors that significantly affect overall survival.

METHODS

We retrospectively analyzed 120 patients with previously treated colorectal carcinoma that had developed pulmonary metastases, admitted between 1990 and 2006. Overall survival was estimated using Kaplan-Meier analysis. The log-rank and Breslow tests were used to compare survival differences for each variable. Multivariate analyses to determine the independent prognostic factors for overall survival were performed using the Cox proportional hazard model as identified by the univariate analyses.

RESULTS

The median follow-up was 20.3 months (range: 3.27-134.2 months). The patients included in this study underwent a total of 165 thoracotomies (mean of 1.37 thoracotomies/patient). The median overall survival for all patients was 34.73 months, with an estimated 5-year survival rate of 24.39%. Multivariate analyses identified unilateral lesions, neoadjuvant chemotherapy at lung resection and complete resection as independent prognostic factors for overall survival.

CONCLUSIONS

These results indicate that prognostic factors identified in studies on pulmonary metastasectomy for all primary tumors should be interpreted carefully for patients with possibility of pulmonary metastasectomy from colorectal carcinoma.