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

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.

Multicentre retrospective analysis on pulmonary metastasectomy: an European perspective

OBJECTIVES

To assess the current practice of pulmonary metastasectomy at 15 European Centres. Short- and long-term outcomes were analysed.

METHODS

Retrospective analysis on patients ≥18 years who underwent curative-intent pulmonary metastasectomy (January 2010 to December 2018). Data were collected on a purpose-built database (REDCap). Exclusion criteria were: previous lung/extrapulmonary metastasectomy, pneumonectomy, non-curative intent and evidence of extrapulmonary recurrence at the time of lung surgery.

RESULTS

A total of 1647 patients [mean age 59.5 (standard deviation; SD = 13.1) years; 56.8% males] were included. The most common primary tumour was colorectal adenocarcinoma. The mean disease-free interval was 3.4 (SD = 3.9) years. Relevant comorbidities were observed in 53.8% patients, with a higher prevalence of metabolic disorders (32.3%). Video-assisted thoracic surgery was the chosen approach in 54.9% cases. Wedge resections were the most common operation (67.1%). Lymph node dissection was carried out in 41.4% cases. The median number of resected lesions was 1 (interquartile range 25-75% = 1-2), ranging from 1 to 57. The mean size of the metastases was 18.2 (SD = 14.1) mm, with a mean negative resection margin of 8.9 (SD = 9.4) mm. A R0 resection of all lung metastases was achieved in 95.7% cases. Thirty-day postoperative morbidity was 14.5%, with the most frequent complication being respiratory failure (5.6%). Thirty-day mortality was 0.4%. Five-year overall survival and recurrence-free survival were 62.0% and 29.6%, respectively.

CONCLUSIONS

Pulmonary metastasectomy is a low-risk procedure that provides satisfactory oncological outcomes and patient survival. Further research should aim at clarifying the many controversial aspects of its daily clinical practice.

High Yield of Chest X-ray in the Follow-Up of Colorectal Cancer

Purpose: Worldwide, colorectal carcinoma (CRC) has a high incidence and a substantial cancer-related mortality. The recurrence risk is 30–50% and lung metastases are common. Treatment of lung metastases with stereotactic ablative radiotherapy (SABR) or metastasectomy may increase survival. The best modality for thoracic screening in the follow-up, however, remains controversial. In this study, we aimed to unravel the additional value of routine chest X-ray (CXR) for detecting lung metastases during the follow-up of CRC patients treated with curative surgery. Methods: Between 2013 and 2017, 668 CRC patients were treated with curative intent, of whom 633 patients were included in follow-up, which consisted of CXR, serum Carcino-Embryonic Antigen (CEA) and ultrasound of the liver. Patients who developed lung metastases, diagnosed with CXR and characterised by a normal concomitant serum CEA level, were identified. Number, size and treatment of lung metastases were described. Results: Thirty-four (5.4%) patients developed lung metastases. Seventeen (50%) were detected by CXR without pathological CEA levels. Eleven (65%) of these patients were treated with curative intent, whereas 21% of patients with lung metastases and elevated CEA levels were treated with curative intent (p = 0.049). Higher numbers of lung metastases were associated with a lower chance of curative treatment. Conclusions: More than 50% of patients with lung metastases on CXR in the follow-up would not have been detected with CEA-triggered imaging only. In addition, patients with colorectal lung metastases without elevated CEA levels were often suitable for curative treatment and, therefore, CXR seems to have additional value within the follow-up of CRC.

Outcomes and Prognostic Factors of Patients with Metastatic Colorectal Cancer Who Underwent Pulmonary Metastasectomy with Curative Intent: A Brazilian Experience

BACKGROUND

We aimed to identify clinicopathological and molecular features associated with progression-free survival (PFS) and overall survival (OS) after pulmonary metastasectomy for metastatic colorectal cancer in a retrospective cohort in Brazil.

MATERIALS AND METHODS

We did a retrospective review of thoracic surgeries performed in a single large academic hospital in Brazil from January 1985 to September 2019. Demographics, previously described prognostic factors, and clinicopathological and molecular characteristics were abstracted. Univariate Cox regression was performed for each variable, and, when significant, data were dichotomized to provide clinically meaningful thresholds.

RESULTS

Records from 698 patients were reviewed. Fifty-eight patients underwent pulmonary metastasectomy with curative intent. Of those, 53.4% had a single metastatic lesion. The median size of the largest lesion was 1.5 cm. Results of RAS, RAF, and mismatch repair testing and of cytokeratin 20 (CK20) and CDX2 testing were available for 13.8% and 58.6% of the sample, respectively. Median PFS was 14 months, median OS was 58 months, and 5-year survival was 49.8%. Unfavorable prognostic factors for OS included disease-free interval (DFI) <24 months, synchronous presentation, size of the largest lesion ≥2 cm, and loss of CK20 expression. Presenting with more than one lesion was prognostic for PFS but not for OS.

CONCLUSION

In this Brazilian cohort, our findings corroborate existing data supporting DFI, synchronous presentation, and number and size of lesions as prognostic factors. Furthermore, we found that loss of CK20 expression may be associated with more aggressive disease and shorter OS. Additional molecular prognostic factors after pulmonary metastasectomy for colorectal cancer should be further explored.

IMPLICATIONS FOR PRACTICE

This study consolidates disease-free interval, synchronous presentation, and number and size of lesions as clinically relevant data that may help guide therapy for patients with colorectal cancer and lung metastases who are candidates for curative-intent metastasectomy. Additionally, in this sample, lack of cytokeratin 20 expression in metastases was associated with shorter progression-free survival and overall survival, suggesting that biomarkers also may have a role in guiding therapy in this setting and that additional biomarkers should be further explored.

The Validity of a New Edition of Classification for Ovarian Metastasis from Colorectal Cancer

OBJECTIVES

In the 9th edition of the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma (JCCRC), ovarian metastasis is classified as distant metastasis. We assessed the significance of resection of ovarian metastases and the validity of this 9th edition of JCCRC for ovarian metastases from colorectal cancer (CRC).

METHODS

We retrospectively analyzed the clinicopathological factors and overall survival of 17 patients with ovarian metastases from CRC who underwent resection and 110 female CRC patients with Stage IV (M1a) disease.

RESULTS

The patients with only ovarian metastases who underwent resection had a longer median survival time than patients with both ovarian and peritoneal metastases who underwent resection (45.4 months vs. 9.3 months, P = 0.029). The 5-year overall survival of the patients with only ovarian metastases who underwent R0 resection was as long as that of the female Stage IV (M1a) CRC patients after R0 resection (50% vs. 48%, P = 0.334).

CONCLUSIONS

We found that, after resection, patients with only ovarian metastases had significantly better prognoses than patients with ovarian and peritoneal metastases. R0 resection of ovarian metastasis indicated as good prognosis as R0 resection of metastasis to one distant organ without ovaries. So the 9th edition of JCCRC, which classifies ovarian metastasis from CRC as distant metastasis, is appropriate.

Clinical significance of RBM3 expression in surgically treated colorectal lung metastases and paired primary tumors

BACKGROUND

The lungs are the second most common site of metastases in colorectal cancer (CRC). The aim of this study was to investigate prognostic factors, including RNA-binding motif protein 3 (RBM3) expression, in patients with CRC treated with pulmonary metastasectomy (PM).

METHODS

The cohort included all patients treated with PM at Skåne University Hospital, Lund, Sweden, from 2000 to 2014. Clinicopathological, treatment, and survival data were collected. Immunohistochemical staining of RBM3 was evaluated on tissue microarrays with samples from all lung metastases and a subset of paired primary tumors. Kaplan-Meier analysis and Cox proportional hazards modeling were applied to examine the associations of investigative factors with overall survival (OS) and recurrence-free survival.

RESULTS

In total, 216 patients with a primary tumor in the rectum (57%), left colon (34%), or right colon (9%) underwent PM. The 5-year OS rate was 56%. Age > 60 years, more than one metastasis, size of metastasis > 3 cm, disease-free interval < 24 months, low RBM3 score in the lung metastasis, and no adjuvant chemotherapy following PM were prognostic factors for shorter OS.

CONCLUSIONS

Several prognostic factors, including RBM3 expression, may be of aid in selecting CRC patients with lung metastases for PM as well as adjuvant therapy.

Pulmonary metastasectomy for esophageal basaloid squamous cell carcinoma component at 66 months after esophagectomy

Background

Solitary pulmonary metastasis from esophageal basaloid squamous cell carcinoma (BSCC) components is an extremely rare recurrence of esophageal squamous cell carcinoma (SCC).

Case presentation

A 68-year-old Japanese woman was found to have a suspected malignant mass, approximately 2 cm in diameter, in her left lower pulmonary lobe, at 66 months after undergoing a curative esophagectomy with three-field lymph node dissection for esophageal SCC with a focal basaloid component. After a CT-guided biopsy, pathological examination indicated a metastasis from esophageal BSCC components. She underwent a thoracoscopic partial resection of the left lower pulmonary lobe for the solitary pulmonary metastasis. The pathohistology of the resected specimen led to diagnosis of metastatic esophageal BSCC, which showed immunohistochemical findings similar to those of the primary esophageal carcinoma. The patient received two courses of adjuvant chemotherapy (5-fluorouracil, docetaxel plus nedaplatin) and recovered to resume a normal life with maintenance therapy. However, multiple lung and brain metastases were diagnosed at 2 years after the pulmonary metastasectomy. She survived 5 years and 6 months after the pulmonary metastasectomy, but died at 10 years and 6 months after her initial esophagectomy.

Conclusion

This was a rare surgical resected case of solitary pulmonary metastasis from esophageal BSCC components.

Pulmonary laser-assisted metastasectomy is associated with prolonged survival in patients with colorectal cancer

Background

Pulmonary metastases develop in 10-15% of patients with colorectal cancer. Surgical metastasectomy currently provides the only hope for a cure for these patients. The aim of this study was to analyze the expanding role of pulmonary metastasectomy in the context of laser-assisted surgery (LAS) vs. non-laser-assisted surgery (NLAS).

Methods

We performed a single-center retrospective analysis of 204 patients who underwent curative pulmonary metastasectomy for colorectal cancer between 01/2005 and 12/2016. The main endpoint was survival. The Kaplan-Meier method was applied for statistical analysis and survival rates were compared with the log rank test.

Results

Median follow-up was 53 months. A total of 267 metastases were resected in 154 operations in the NLAS group (median: 1) vs. 438 metastases in 122 operations in the LAS group (median: 5; P<0.0001). The interval between treatment of the primary tumor and the first pulmonary metastasectomy was significantly shorter in the LAS group (19 vs. 32 months; P=0.008). Anatomical resections were significantly reduced using LAS, 8% vs. 23% respectively. Despite more negative predictors in the LAS group, there was no statistically significant difference in overall disease-specific 5-year survival (70% LAS vs. 58% NLAS; P=0.18).

Conclusions

Survival after pulmonary metastasectomy has previously been shown to correlate with a low number of metastases and a longer disease-free interval. However, with the tissue-saving LAS technique complete resectability can be achieved in patients with more metastases and long-term survival is possible for selected patients.

Harnessing the innate immune system and local immunological microenvironment to treat colorectal cancer

Significant progress in the development of new immunotherapies has led to successful clinical trials for malignant melanoma and non-small cell lung cancer; however, for the majority of solid tumours of the gastrointestinal tract, little or no progress has been seen. The efficacy of immunotherapies is limited by the complexities of a diverse set of immune cells, and interactions between the tumour cells and all other cells in the local microenvironment of solid tumours. A large fraction of immune cells present in and around solid tumours derive from the innate arm of the immune system and using these cells against tumours offers an alternative immunotherapeutic option, especially as current strategies largely harness the adaptive arm of the immune system. This option is currently being investigated and attempts at using the innate immune system for gastrointestinal cancers are showing initial results. Several important factors, including cytokines, chemotherapeutics and the microbiome, influence the plasticity and functionality of innate (myeloid) cells in the microenvironment, and this complexity of regulation has limited translation into successful trials so far. In this review, current concepts of the immunobiology of the innate arm in the tumour microenvironment are presented in the context of clinical translation.

Surgical resection of pulmonary metastases from colorectal cancer: 11 years of experiences

Objective

To analyze the benefits and prognostic factors after surgical resection of pulmonary metastases from colorectal cancer (CRC).

Methods

From Jan. 2004 to Jan. 2015, continuous 88 cases diagnosed with pulmonary metastases from CRC, including 15 cases of synchronous metastases and 73 metachronous metastases, were analyzed in the retrospective study.

Results

All of these 88 cases underwent curative pulmonary resection including 8 cases of simultaneous surgery. The one-year, three-year and five-year survival of the 88 cases were 93.4%, 60.2% and 35.7%, respectively. 63 patients just have one metastasis, and 25 patients have more than one metastasis. Additionally, the one-year, three-year and five-year survival was 98.1%, 70.2% and 40.3% respectively in one metastasis group, while 80.1%, 37.9% and 22.5% respectively in more than one metastasis group (p = 0.003). DFS of 37 metachronous metastases were equal or greater than 18 months, and DFS of 36 metachronous metastases were less than 18 months. The one-year, three-year and five-year survival was 97.8%, 77.9% and 41.4% respectively in the DFS≥18 month group, while 88.2%, 44.6% and 28.1% respectively in the DFS<18 month group (p = 0.01).

Conclusion

Surgical resection of pulmonary metastases from colorectal cancer can improve survival rate in selected patients. It seems that the number of metastases is an independence prognostic factor in surgical treatment. Furthermore, longer DFI implies longer survival for resectable CRC pulmonary metastases.