PULMONARY

METASTECTOMY

THORACIC SERVICES
HISTORICAL ASPECT
• Resection for pulmonary metastases was first
performed in late 1882 by Weinlechner for metastatic
rib sarcoma

• In 1939, Barney and Churchill in US reported, Long term

survivor for 23 years after resection of pulmonary
metastasis in Renal cell carcinoma with lung metastasis
HISTORICAL ASPECT
• In 1947 Alexander and Haight, had 1st large series for 25
patients
• Specified criteria for resection of lung metastasis;
• Metastasis limited to the lung
• Primary is controlled
• Patient must be capable of tolerating complete
resection of all metastases
INCIDENCE
• Lung is the second most common site for of metastasis
• In 20% of autopsied patients, the lung was the sole site
of metastasis in 50 - 80% of osteogenic sarcomas & in 30
- 50% of soft tissue sarcomas - Weiss & Gilbert
 IMAGING
• CXR: non-specific
• CT Scan: most important pre-op investigation
sensitivity > 10mm 100%
6-10mm 66%
< 6mm 48%
• Standard CT scan has an approximate 20 to 26% rate of
differing from the findings at operation by way of either
false-positive or false-negative findings - Cerfolio RJ

• Cerfolio RJ, Bryant AS, McCarty TP, Minnich DJ. A prospective study to determine the incidence of non-imaged malignant pulmonary
nodules in patients who undergo metastasectomy by thoracotomy with lung palpation. Ann Thorac Surg. 2011 Jun; 91(6):1696-700;
discussion 1700-1.
• RCT between HRCT and Conventional CT found with
sensitivity of 82% versus 75% - Margaritora S et al
• Parson’s compared the no of nodules identified on the
pre-op CT of 53 patients to HPR, and found CT detected
approximately 55% of the nodules
• Spiral CT scan (1mm & 3 mm cuts), found 67 of 69
metastatic nodules detected by bi-manual palpation
intraoperatively in non-osteosarcoma patients – Kang J

• Margaritora S et al. Pulmonary metastases: can accurate radiological evaluation avoid thoracotomic approach? Eur J Cardiothorac Surg
2002;21:1111—4.
WORK-UP
For improving patient selection sometimes,
• PFT
• PET CT (unsuspected extrapulmonary disease)
• Bone Scan
• FOB
NEED OF SURGERY
5-year survival rates are
RCC 35 - 47%
colorectal cancer 39-67%
soft-tissue sarcoma 29-52%
osteosarcoma 38-49%
NSGCT 79-94%

• Favorable prognostic factors include a long DFI, the

absence of thoracic LN metastases, and a small number
of pulmonary metastases – Pfannschmidt J

• Surgical intervention for pulmonary metastases. Dtsch Arztebl Int.2012 Oct;109(40):645-51. doi: 10.3238/arztebl.2012.0645. Epub 2012
Oct 5.
PROGNOSTIC FACTORS
TUMOUR HISTOLOGY
• The likelihood that a new pulmonary nodule is a
metastasis as opposed to a second primary is directly
related to the original type of malignancy
• Sarcoma or melanoma, more likely to be a metastasis
• Genito-urinary or colorectal cancer, about a 50% chance
to be a metastasis

• McCormack P. Surgical resection of pulmonary metastases. Semin Surg Oncol 1990; 6:297-302
SOLITARY VS MULTIPLE
• R0 resection, the number of metastatic nodules (one or
two) and the length of DFI are significant favourable
factors in osteogenic and soft tissue sarcoma – Mizuno
• Single metastasis have a better outcome, compared
with multiple metastases, but the impact on long-term
survival could not be proven by the majority of studies –
Pfannschmidt J

• Mizuno T. Pulmonary metastasectomy for osteogenic and soft tissue sarcoma: who really benefits from surgical treatment? Eur J
Cardiothorac Surg.2012 Jul 24. [Epub ahead of print]
• Joachim Pfannschmidt. Surgical Resection of Pulmonary Metastases From Colorectal Cancer: A Systematic Review of Published Series.
Ann Thorac Surg 2007;84:324-338
DFI
• Resection of pulmonary metastases in absence of other
modalities, can give long-lasting DFI
• The 5-year DFI-related survival rates for post pulmonary
metastectomy of colorectal primary, were 22.6%(0-11
months), 38.6% (12-35 months), and 55% (>35 months)
– Pfannschmidt
• Improved survival associated with Ro, single met and
DFI > 18 months in Osteosarcoma and STS – KAIFI J

• Joachim Pfannschmidt. Surgical Resection of Pulmonary Metastases From Colorectal Cancer: A Systematic Review of Published Series. Ann Thorac
Surg 2007;84:324-338
• JUSSUF T. KAIFI . Indications and Approach to Surgical Resection of Lung Metastases Journal of Surgical Oncology 2010;102:187–195
SURGICAL PRINCIPLES
• Obtain clear margins with removal of as little normal lung
tissue as possible
• Inadequacy of margins mandates re-excision to reduce
the possibility of local recurrence
SELECTION CRITERIA
• The primary is treated and being controlled
• No evidence of distant extra pulmonary metastases
• Complete resection achievable
• The patient is a good surgical candidate, with adequate
postoperative pulmonary function

• Thomford NR, Woolner LB, Clagett OT. The surgical treament of metastatic tumors in the lungs. J Thorac Cardiovasc Surg 1965;49:357—63.
EXTENT OF SURGICAL RESECTION
• Peripherally located: Wedge resection
• Central disease: Anatomic resection

International Registry of Lung Metastases (1997)

Analysis of 5206 pts
Wedge resection 67%
Segmentectomy 9%
Lobectomy 21%
Pneumonectomy 3%

• Pastorino U, Buyse M, Friedel G, et al. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac
Cardiovasc Surg 1997;113:37– 49.
 Lateral Median
Clamshell VATS
Thoracotomy Sternotomy

Exposure to Exposure to Low morbidity;

Familiar,
hemithoraces, hemithoraces Exposure to lung
Advantages optimum
anterior and to entire surface and
exposure
mediastinum mediastinum pleural space

Higher Posterior lesion

Limited morbidity; difficult to
Two procedures
Disadvantages exposure to left longer operating locate, no
Bilateral disease
lower lobe time Malunion palpation of
of sternum lung
EXTENT OF SURGICAL RESECTION
• A systematic review of 20 studies focused on the
outcomes found that if feasible, wedge resection is as
effective as anatomic resection - Pfannschmidt et al
UNILATERAL VS BILATERAL
• Bilateral exploration by sternotomy provided no survival
benefit, compared with unilateral in colorectal primary -
Roth et al
• Younes et al, performed 179 unilateral and 88 bilateral
thoracotomies, found no significant difference in survival
in patients, contralateral recurrence
• Repeat throracotomy, improved survival in STS and
Osteosarcoma upto 25-28 months - Buddingh EP

• Roth JA, Pass HI, Wesley MN, White D, Putnam JB, Seipp C. Comparison of median sternotomy and thoracotomy for resection of pulmonary
metastases in patients with adult soft-tissue sarcomas. Ann Thorac Surg 1986;42:134—8.
• Younes RN, Gross JL, Deheinzelin D. Surgical resection of unilateral lung metastases: is bilateral thoracotomy necessary? World J Surg
2002;26:1112—6.
• Buddingh EP, Anninga JK, Versteegh MI, et al. Prognostic factors in pulmonary metastasized high-grade osteosarcoma. Pediatr Blood
Cancer 2010;54(2):216
VATS VS OPEN
• Reported a 5-year survival of 30.8% for in resected
colorectal pulmonary metastases via VATS – Landreneau
et al
• No significant difference in survival in patients who
underwent VATS compared VATS followed by
confirmatory thoracotomy – Mutsaerts et al,
• VATS has ability to perform repeat operations, fewer
pleural adhesions than thoracotomy, and does not
complicate a potential repeat operation by thoracotomy

• Landreneau RJ et al. Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases. Eur J Cardiothorac
Surg 2010;18:671—6.
• Mutsaerts EL et al. Long term survival of thoracoscopic metastasectomy vs metastasectomy by thoracotomy in patients with a solitary
pulmonary lesion. Eur J Surg Oncol 2008;28:864—8.
• After VATS metastasectomy, several nonimaged
unexpected, nodules are frequently found during
subsequent observer-blinded thoracotomy - J Eckardt
• Microscopic metastases that are initially unresected may
be resected once they become detectable on follow-up
CT scans, without affecting patient survival – KAIFI J

• Jens Eckardt. Thoracoscopic Versus Open Pulmonary Metastasectomy: A Prospective, Sequentially Controlled Study. CHEST 2012;
142(6):1598–1602
LYMPH NODE STATUS
• It’s unclear whether the removal of mediastinal lymph
nodes is associated with a survival benefit or merely
allows for a more accurate staging and planning of
treatment; still many prefers to do
• ACOSOG Z0030 Trial: complete mediastinal LN dissection
is associated with, longer median operative time of 15
min, but no difference in median hospitalization time
and little morbidity in this large series of major
pulmonary resections

Ercan S, Nichols III FC, Trastek VF, Deschamps C, Allen MS, Miller DL, Schleck CD, Pairolero PC. Prognostic significance of lymph
node metastasis found during pulmonary metastasectomy for extrapulmonary carcinoma. Ann Thorac Surg 2004;77:1786—91.
 J Thorac Cardiovasc Surg 2007;133:967-72

Overall 5-year survival was

46%: It was 60% for
subjects with no lymph
node metastasis and 17%
and 0% for those with N1
and N2 disease,
respectively
RECURRENCE AND RE-DO SX
• May confer a survival advantage
• In IRLM study, the recurrence rate was 53% in R0 cases;
5-year survival with repeat surgery was 44%
• Lesions undetected by preoperative imaging or during
surgery, but detected during follow-up, may not alter
survival as long as they are resected before they become
unresectable - Joachim Pfannschmidt

• Pastorino U et al. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg 1997; 113:
37-49.
• Joachim Pfannschmidt. Surgical Intervention for Pulmonary Metastases. Dtsch Arztebl Int. 2012 October; 109(40): 652–658.
SURVIVAL AFTER RE-SX

• Migliore, Marcello. Extending Surgery for Pulmonary Metastasectomy: What Are the Limits? Journal of Thoracic Oncology: 2010(5)6; S155-
S160.
RE-DO SX
• For various primary, median survival of 60 months who
undergo 1st metastasectomy, 45.6 months for 2nd, 34.7
months for 3rd or more.
• Patients in whom further surgery appeared impossible
had a median survival of 8 months - Jaklitsch et al

• Jaklitsch MT, Mery CM, Lukanich JM, Richards WG, Bueno R, Swanson SJ, Mentzer SJ, Davis BD, Allred EN, Sugarbaker DJ Sequential
thoracic metastasectomy prolongs survival by re-establishing local control within the chest. J Thorac Cardiovasc Surg. 2001 Apr;
121(4):657-67
 COLORECTAL CANCER
• Stage IV, a median survival of up to 24 months, after
metastasectomy a 5-year survival rate of up to 68%
• If synchronous liver metastases are present, a 5-year
survival rate of 42% is reported after sequential lung
and liver metastasectomy - Pfannschmidt J
• Meta-analysis of 25 studies, 2925 pts
A short DFI, elevated CEA, multiple LM and the presence
of mediastinal LN metastases are strong predictors of
poor survival - Vodicka J

• Pfannschmidt J, Hoffmann H, Dienemann H: Reported outcome factors for pulmonary resection in metastatic colorectal cancer. J
Thorac Oncol 2010; 5 (6 Suppl 2): S172–8.
• Pfannschmidt J. Surgical Intervention for Pulmonary Metastases. Dtsch Arztebl Int. 2012 October; 109(40): 652–658.
• Gonzalez M. Risk Factors for Survival after Lung Metastasectomy in Colorectal Cancer Patients: A Systematic Review andMeta-
Analysis. Ann Surg Oncol.2012 Oct 28. [Epub ahead of print]
• Preoperative PET and the absence of previous or
synchronous liver metastases were associated with a
non-significant trend toward increased survival
 SOFT-TISSUE SARCOMA
• 25-40% cases develop lung metastasis within 2yrs
• EORTC meta-analysis of 255 pts, reported survival rate
after R0 resection, of 54% at 3 yr & 38% at 5yr
• Thames Cancer Registry for 1985-2004, 5 yr survival rates
for all patients with metastatic sarcoma were 20-25% for
bone, & 13-15% for soft tissue sarcoma - Treasure T

• Treasure T Pulmonary metastasectomy for sarcoma: a systematic review of reported outcomes in the context of Thames Cancer
Registry data. MJ Open..2012 Oct 8;2(5). pii: e001736. doi: 10.1136/bmjopen-2012-001736. Print 2012.
OSTEOGENIC SARCOMA
• Strategy of Pulmonary metastasectomy follows, good
survival, rarely extrapulmonary metastatic, lesions are
easily identified, no effective systemic therapies

• The 3-year and 5-year event-free survival from the first

metastasectomy was 45% and 38%; and 33% and 32%,
respectively from the second one - Briccoli et al

• Briccoli A, Rocca M, Salone M, et al. Resection of recurrent pulmonary metastases in patients with osteosarcoma. Cancer 2005;104:1721–5.
RENAL CELL CANCER
• 20 % of RCC present with metastases at diagnosis

• Studied prognostic factors, R0 resection, the number and

size of metastases, having a effect on postoperative
survival

• 5-year survival of 45% in Ro resection, compared with

only 8-15% in R+ - Murthy et al, Pfannschmidt et al
RENAL CELL CANCER
• In multivariate analysis, predictive factors male gender, DFI
> 1 yr, single metastatic site and R0 resection - Ljungberg B
• 5 year overall survival of 29-31%
• 60 % underwent a subsequent resection for recurrence
with lung metastasis, compared with 25 % with recurrent
bone metastasis
• Median survival was 4.7 years and 21% remained free of
disease at last follow-up

• Ljungberg B The Role of Metastasectomy in Renal Cell Carcinoma in the Era of Targeted Therapy. Curr Urol Rep. 2012 Dec 5.
MELANOMA
Petersen et al,
analyzed 1,720 patients,
found that patients with
R0 resection had a
median survival of 19
months (vs 11months)
and a 5-year survival of
21% (vs 13%)

• Petersen R, Hanish S, Haney J, et al. Improved survival with pulmonary metastasectomy: an analysis of 1720 patients with
pulmonary metastatic melanoma. J Thorac Cardiovasc Surg 2007;133:104 –10.
THYROID
• The overall 5 year survival
was 60%
• Papillary histology:
• longer DFI (>3years)
• Younger age

• J.R. Porterfield et al./European Journal of Cardio-thoracic Surgery36(2009)155-158

BREAST CANCER
• Solitary lesions can be resected with good results, but
rare, < 1% of all metastatic pts
• Multiple metastases  metastasectomy is rare
• Palliative chemotherapy with lung metastases from
breast cancer

• Lanza LA, Natarajan G, Roth JA, Putnam JB. Long-term survival after resection of pulmonary metastases from carcinoma of the breast. Ann
Thorac Surg 1992;54:244–248.
HEAD AND NECK
• Radical resection of all metastases, a statistically
significant predictor of survival (43% in R0) - Finley et al
• Location and stage of the primary, determine the
prognosis in head and neck cancer - Leibel et al (Tongue
had the worst prognosis)
• Median survival and overall survival, 19.4 vs 5.4 months
of patients of pulmonary metastectomy is far better
than, not operated on
HEAD AND NECK

• Review of 83 patients, a 5-year survival of 50%

• Glandular tumors had 64% survival compared to 34%
survival at 5 years in SCC, Adenoid cystic carcinoma
patients had a 5-year survival of 84%
EFFECT ON PFT
• A 0.6% decrease in spirometry values and DLCO for every
additional wedge resection, and a decrease of
approximately 5% that may be attributed to
thoracotomy - Stefan Welter
• Functional loss after three or more non-anatomical
resections is comparable to that recorded after
lobectomy - Francesco Petrella
• Spirometric changes (FEV1 and FVC modification) after
pulmonary metastasectomy are affected by total
volume lung parenchyma resected (>11 cm, p < 0.05)
within the first 90 days; at 3 months got reversed
• Stefan Welter. Changes in Lung Function Parameters After Wedge Resections:A Prospective Evaluation of Patients Undergoing
Metastasectomy . CHEST. 2012;141(6):1482-1489
• Francesco Petrella. Which factors affect pulmonary function after lung metastasectomy? European Journal of Cardio-thoracic Surgery 35
(2009) 792—796
EFFECT ON QOL
• Prospective study of 35 patients
• Classic metastasectomy patients report more thoracic
pain, shoulder dysfunction, and dysphagia
• All QoL domains returned to baseline at 6 months after
a classic metastasectomy

• Balduyck, Bram et al. Quality of Life Evolution after Pulmonary Metastasectomy: A Prospective Study Comparing Isolated Lung
Perfusion with Standard Metastasectomy . Journal of Thoracic Oncology: October 2012 - Volume 7 - Issue 10 - p 1567–1673
SURVIVAL
• No randomised trials
• No comparable survival data presented but a blithe
assumption that any survivors beyond three or five years
can be attributed to the beneficial effects of surgical
extirpation of disease
• Survival after complete metastasectomy (R0) was 36 % at
5 years and 26% at 10 years vs 13% in R+
SURVIVAL
SURVIVAL
Thank You