
Pulmonary metastases may appear simultaneously with the diagnosis, or up to 10 or more years later. Surgical Resection of Pulmonary Metastases is the treatment of choice. Resection of pulmonary metastases of leiomyosarcoma offers a possibility of cure, and a larger possibility of long term survival, if all tumorous tissue is removed. 
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Re-resection of recurrent pulmonary metastases is also possible. "Re-exploration for recurrent sarcomatous pulmonary metastases appears beneficial for patients who can be completely re-resected. Outcomes are described by factors that may be determined preoperatively, including metastasis size, metastasis number, and primary tumor histologic grade. Patients who cannot be completely re-resected or those with numerous, large metastasis and high-grade primary tumor pathology have poor outcomes and should be considered for investigational therapy." 
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Surgery can be done by thoracotomy, wide opening up of the chest, or by VATS [Video Assisted Thoracoscopic Surgery] which is like laparoscopic surgery, but in the chest.  VATS surgery cannot deal with large tumors; the tumors must be small enough to be retrieved through the operative incision [approximately 3cm, but you should discuss this with the surgeon].  

Where appropriate, ablative methods are now coming into use:  Radio Frequency Ablation [RFA] is a low morbidity, seemingly effective method of dealing with lung metastases if they are not near large blood vessels or vital structures.  See the web page on RFA on this site.  Lasers have also been used.  Cryosurgical techniques can be used if the tumor is tracheobronchial and can be reached. This technique is indicated in patients who cannot be given surgical or radiation treatment and in cases of asphyxial syndrome requiring faster relief of obstruction than is obtainable with radiation treatment. 

<b>For patients for whom the metastases are unresectable, or for whom there is additional and unresectable tumor mass elsewhere, chemotherapy is an option.  However, "unresectable" is a relative word.  What is "unresectable" in one surgeon's hands, might be resectable in another's.  If your lung tumor/s are "unresectable" by the local doctors, send your scans to Top Notch Oncological Thoracic  or CardioThoracic Surgeons, as well as Interventional Radiologists.  EIther the Thoracic Surgeons will have more experience with difficult cases and be able to give you a different opinion, or the Interventional Radiologists will be able to use chemoembolization, RFA, or cryosurgery or other means to shrink or deal with the tumors.    Another aspect of this is to conserve lung tissue.  IF you have a lung metastases that is small and toward the edge, do not have the entire lobe removed.  Often a wedge resection or RFA will conserve much more tissue.  Removing the entire lobe will certainly give you clear margins, but you don't need to lose that much lung tissue.  The probability is that more lung mets will return, and you want to conserve lung tissue as much as possible.  </b>

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<b>Surgical Resection of Pulmonary Metastases 
Selected Medical Journal Annotated References</b>

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Ann Surg 1999 May;229(5):602-10; discussion 610-2 
<b>Pulmonary metastases from soft tissue sarcoma: analysis of patterns of diseases and postmetastasis survival. </b>
Billingsley KG, Burt ME, Jara E, Ginsberg RJ, Woodruff JM, Leung DH, Brennan MF. 
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA. 

... "For patients with soft tissue sarcoma, the lungs are the most common site of metastatic disease. Although pulmonary metastases most commonly arise from primary tumors in the extremities, they may arise from almost any primary site or histology. To date, resection of disease has been the only effective therapy for metastatic sarcoma. ..., 719 patients either developed or presented with lung metastases. Patients were treated with resection of metastatic disease whenever possible. Disease-specific survival was the endpoint of the study. .. ... The overall median survival from diagnosis of pulmonary metastasis for all patients was 15 months. The 3-year actuarial survival rate was 25%. <b>The ability to resect all metastatic disease completely was the most important prognostic factor for survival.</b>" 

<b>Patients treated with complete resection had a median survival of 33 months and a 3-year actuarial survival rate of 46%. For patients treated with nonoperative therapy, the median survival was 11 months.</b> A disease-free interval of more than 12 months before the development of metastases was also a favorable prognostic factor. Unfavorable factors included ... patient age older than 50 years at the time of treatment of metastasis. ... <b>Resection of metastatic disease is the single most important factor that determines outcome in these patients. Long-term survival is possible in selected patients, particularly when recurrent pulmonary disease is resected. Surgical excision should remain the treatment of choice for metastases of soft tissue sarcoma to the lung.</b> 
&&url PMID: 10235518 


J Surg Oncol 2001 Jan;76(1):47-52 
<b>Pulmonary metastasectomy: might the type of resection affect survival? </b>
Mineo TC, Ambrogi V, Tonini G, Nofroni I. Thoracic Surgery Tor Vergata University, Rome, Italy. mineo@med.uniroma2.it 

<b> Metastasectomy proved to be the choice treatment in the case of pulmonary metastasis. In this study we assessed the impact on survival of three types of resection: minimal by laser or conventional device and lobectomy.</b> ...We considered 85 patients who underwent lung metastasectomy for tumors that originated from various sites. Fifty-two minimal resections were accomplished in 34 patients by conventional (diathermy dissection or stapler suture line) device, 59 resections in 29 by Nd:YAG laser. Lobectomies were 22. Minimum follow up required was 2 years. ... The 3-year Kaplan-Meier survival rate was 63%, 44%, 53% for laser, conventional resections and lobectomy. The 5-year survival was 40%, 28%, 26% respectively. Among the groups there was no significant difference (P = 0.15). Laser patients showed shorter periods of air leakage and hospital stay. ... The type of resection did not disclose statistically significant differences on survival. <b>Minimal surgery, especially by laser device, is recommended for less morbidity.</b> 
&&url PMID: 11223824 


Virchows Arch 2000 Sep;437(3):284-92 
<b>Benign metastasizing leiomyoma of the uterus: documentation of clinical, immunohistochemical and lectin-histochemical data of ten cases.</b> 
Kayser K, Zink S, Schneider T, Dienemann H, Andre S, Kaltner H, Schuring MP, Zick Y, Gabius HJ. Department of Pathology, Thoraxklinik, Heidelberg, Germany. klkayser@lung.de 

The clinical histories of 10 women suffering from benign metastasizing leiomyoma (BML) after hysterectomy and information on lung lesions detected in these women are presented, together with corresponding data for 2 women with metastasizing leiomyosarcoma of the uterus for comparison: gross appearance, survival, and light microscopical, immunohistochemical and lectin-histochemical findings are reported. All patients with BML had undergone hysterectomy for uterus leiomyomatosus without any detection of sarcomatous lesions in the uterus wall. After a median period of 14.9 years intrapulmonary masses were detected by imaging techniques. On average, six nodules with a mean diameter of 1.8 cm were seen. Resection of the lesions was performed in all cases. ... The lesions were characterized by low proliferation activity of 2.9% (measured with Ki-67), frequent hormone receptor expression (8 of the 10 cases presented hormone-specific receptors), low to moderate vascularization compared with metastases from the two uterine sarcomas, remarkable p53 overexpression ... The median survival of the BML patients was 94 months after excision of the intrapulmonary lesions, and the maximum survival of the two sarcoma patients was 22 months. The results recorded in this patient sample with the methodology applied suggest that benign metastasizing leiomyomas are a slow-growing variant of leiomyosarcoma of the uterus, which becomes clinically apparent at a young age and progresses with low velocity.  
&&url PMID: 11037349 


Am J Surg 2000 Feb;179(2):122-5 
<b>Importance of the control of lung recurrence soon after surgery of pulmonary metastases. </b>
Maniwa Y, Kanki M, Okita Y. Department of Surgery, Division II, Kobe University School of Medicine, Kobe, Japan. 

...In this study, we investigated factors that determined prognosis in patients who underwent surgery for metastatic lung tumors, focusing on early relapse of metastatic lung lesions after surgery, and considered countermeasures for improving long-term results based on this study. ...This study was performed in patients with metastatic lung tumors who underwent surgery during the 22 years after November 1975 in this department. ... The 1-year, 3-year, and 5-year survival rates in all patients were 70%, 42%, and 37%, respectively. On comparison among the groups, there were no significant differences by gender, age, organ with the primary lesion, disease-free interval, number of metastases, or surgical procedure. However, prognosis was significantly poorer in patients with recurrent metastatic lung lesions. Prognosis was especially poor in patients with recurrence within 6 months after pneumonectomy, and this was an important factor that worsened the surgical results. ... As the mechanism of early recurrence of lung metastasis after surgery for metastatic lung tumor, multiple micrometastases (dormancy) that cannot be detected during surgery for metastatic lung tumor may be present in the lung. Establishment of a method of controlling an increase in dormant metastasis may lead to improvement of surgical results of metastatic lung tumors. 
&&url PMID: 10773147 


J Surg Oncol 1999 Dec;72(4):193-8 
<b>Surgical treatment of lung metastases: prognostic factors for long-term survival.</b> 
Abecasis N, Cortez F, Bettencourt A, Costa CS, Orvalho F, de Almeida JM. Department of Surgery, Instituto Portugues de Oncologia Francisco Gentil-Centro de Lisboa, Lisboa, Portugal. nop479762@mail.telepac.pt 

"...Surgical resection of lung metastases is an established therapy for a large number of primary tumors, but there is some controversy about prognostic factors for long-term survival. ... From 1968 to 1996, we performed a retrospective review of a series of 85 patients (100 operations) that have been operated for resection of lung metastases. ... The operative mortality was 4% and the morbidity 18%. The mean follow-up after lung resection was 22.13 months (1-146). The actuarial 5-year survival rate was 29.2%. By univariate analysis, the following factors were associated with survival after resection: location and histology of the primary tumor, greatest dimension of the largest metastasis, radicality of the resection, involvement of the resection margins, and use of adjuvant therapy (P < 0.05).  <b>After multivariate analysis, only the dimension of the metastases and involvement of surgical margins have been found to be independently associated with survival. ... Surgical excision is a safe and effective therapy for lung metastases from a large number of primary tumors, provided a complete resection is feasible.</b>" Copyright 1999 Wiley-Liss, Inc. 
&&url PMID: 10589033

 
Ann Thorac Surg 1999 Jul;68(1):227-31 
<b>Prognostic factors and results after surgical treatment of primary sarcomas of the lung.</b> 
Regnard JF, Icard P, Guibert L, de Montpreville VT, Magdeleinat P, Levasseur P. Department of Thoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France. 

...Primary sarcoma of the lung is a rare tumor. Our purpose was to study survival after resection and prognostic factors, which have been rarely reported. ...In a 24-year period, we performed 20 complete resections and three exploratory thoracotomies only for primary lung sarcomas. One patient declined operation. Mean diameter of resected tumors was 9 cm (range, 4 to 18 cm). There were eight stage IB, eight stage IIB, one stage IIIA, and three stage IIIB. Sixty percent of patients with resected tumors received adjuvant therapy. Age, sex, resectability, tumor size, histologic cell type, stage, and adjuvant therapy were analyzed as predictors of survival. ... No postoperative deaths occurred. All 4 patients who had no resection died within 15 months. The 5- and 10-year actuarial survival after complete resection was 48%. The 5- and 10-year actuarial survival in stage IB was 83%, whereas the 4-year actuarial survival in stage IIB was 30% (p < 0.05). Complete resection and stage of disease were the sole significant prognostic factors. ... Complete resection of primary sarcoma of the lung, when feasible, can achieve prolonged survival, although almost half of the patients died of metastasis within 2 years of operation. Adjuvant therapy needs to be investigated. 
&&url PMID: 10421146 


Eur J Cardiothorac Surg 1999 Apr;15(4):456-60 
<b>Surgical treatment of primary pulmonary sarcomas. </b>
Bacha EA, Wright CD, Grillo HC, Wain JC, Moncure A, Keel SB, Donahue DM, Mathisen DJ. 
Thoracic Surgical Unit, Massachusetts General Hospital, Boston 02114, USA. 

...We sought to identify the long-term prognosis after surgical treatment for primary pulmonary sarcoma. METHODS: Twenty-three patients were retrospectively identified as having been treated surgically for primary pulmonary sarcoma between 1981 and 1996. The records of all patients were reviewed, and the histopathology reexamined by a pathologist. ...: Fifteen patients were male and eight female; their ages ranged from 20 to 78 (mean 51) years. Tumors measured between 0.9 and 12.0 (mean 5.2) cm across the greatest diameter. The histologic diagnoses were ... leiomyosarcoma (3), ... Three patients were found to be unresectable. All three underwent radiation and chemotherapy. Lobectomies or bilobectomies were performed in 13 patients including two sleeve resections, one carinal resection, and one chest wall resection. Four patients underwent radical pneumonectomies. Three patients with invasion of the pulmonary artery, pulmonary veins or atrial wall underwent extended resections with the use of cardiopulmonary bypass. In two, a homograft was used to reconstruct the right ventricular outflow tract. Of the resected patients, six had a positive resection margin, and four had at least one positive lymph node in the specimen. Three patients underwent repeat pulmonary resections for recurrences. Eleven patients received postoperative chemotherapy and eight had radiation therapy. Follow-up was available on 22 patients, and ranged from 2 to 183 (mean 48) months; 14 patients are disease free, six died of disease, one died of surgical complications (operative mortality 5%), and two are alive with disease. Actuarial 3- and 5-year survival of the resected patients was 69%. Size and grade were not found to be correlated with significantly increased survival, but completeness of resection was (P<0.05). ... Resection of primary pulmonary sarcomas can produce an acceptable survival rate if the resection is complete.<b> Cardiopulmonary bypass can be a useful adjunct when tumors involve a resectable area of the heart or great vessels.</b> 
&&url PMID: 10371121 


Eur J Surg 1998 Jul;164(7):507-12 
<b>Median sternotomy: the preferred incision for resection of lung metastases. </b>
van der Veen AH, van Geel AN, Hop WC, Wiggers T. Department of Surgical Oncology, University Hospital Rotterdam/Dr. Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands. 

...To describe our experience with median sternotomy for resection of lung metastases and to assess whether computer tomography (CT) accurately predicts the number and extent of lung metastases. ...Retrospective case record study. ... 78 patients with pulmonary metastases from various histological types of tumours who were operated on through a median sternotomy during the 10-year period January 1985-January 1995...Median sternotomy for resection of lung metastases with the intention to cure. Extension of the incision in case of extended disease. .... [whether there was] Presence of unilateral or bilateral metastases in relation to preoperative CT. 
...78 patients underwent a total of 82 sternotomies. <b>CT did not accurately diagnose the extent of disease in 38 patients (49%).</b> In 72 cases metastases were excised. In 58 patients (81%) histological examination showed tumour-free margins microscopically. 36 patients had bilateral metastases. CT showed unilateral disease in 49 patients. 14 (29%) had bilateral involvement. 4 patients required lobectomy and in two patients anterolateral extension of the sternotomy was necessary. Eleven patients (15%) developed minor complications. There was no operative mortality. ...<b> Bilateral staging and finding of occult metastases, complete surgical clearance in a one stage procedure, and lower morbidity are the reasons that we suggest that median sternotomy is the procedure of choice of resection of pulmonary metastases. For eligible patients the choice of surgical approach should not be made conditional on the results of CT alone.</b> 
&&url PMID: 9696972 


Nippon Geka Gakkai Zasshi 1998 Dec;99(12):855-60 
<b>[Surgical management of pulmonary metastases].[Article in Japanese]</b> 
Hara S, Otsuka H, Hirohata T, Nishi K, Yasutomi M. First Department of Surgery, Kinki University School of Medicine, Osakasayama, Japan. 

The results of surgical resection for pulmonary metastases from ..., soft tissue sarcoma, and osteosarcoma are reviewed. The number of pulmonary metastases, the presence of hilar or mediastinal involvement, and extrapulmonary foci are discussed in terms of surgical treatment. The size of pulmonary tumors or tumor doubling time has no significant effect on survival, while the number of metastatic foci does.... Higher relapse rates have been reported in patients with soft tissue sarcoma and osteosarcoma, although patients with these metastases can achieve long-term survival after a second metastasectomy. VATS is not be recommended for metastatic cancer surgery, because intraoperative identification of metastatic foci is often difficult.  
&&url PMID: 10063499 


Ann Thorac Surg 1998 Jul;66(1):231-3 
<b>Resection of pulmonary metastases in six patients with disease-free interval greater than 10 years. </b>
Kamiyoshihara M, Hirai T, Kawashima O, Morishita Y. 
Department of Surgery, National Sanatorium Nishi-Gunma Hospital, Shibukawa, Gunma, Japan. kamiyosi@sa2.so-net.ne.jp 

... The relationship between disease-free interval (DFI) and prognosis has been discussed; however, there is little information on long-term DFI. In this study, we surveyed the cases of pulmonary metastases with DFI greater than 10 years. ... Between January 1980 and December 1995, we saw 6 patients with DFI greater than 10 years. All the patients had a histopathologic diagnosis of pulmonary metastases based on surgical resection, and the patients' characteristics and clinical course were reviewed. 
...The median age was 63 years. Primary sites were breast in 2 patients, and one case each of skin, colon, thyroid, and bladder. The numbers of metastases were one in 4 patients and two in 2 patients. The median DFI was 134 months (range, 127 to 235 months). The median tumor-doubling time was 227 days (range, 80 to 815 days). All the patients underwent a lobectomy. Three patients with metastases from the bladder, colon, and breast died of recurrence. One patient with metastasis from the thyroid died of heart failure. Two patients with metastases from breast and skin cancer survived for more than 3 years. <b>CONCLUSIONS: Early death occurred regardless of the long DFI, suggesting that intensive follow-up is mandatory for patients with DFI greater than 10 years.</b> 
&&url PMID: 9692470 


Ann Thorac Surg 1998 Dec;66(6):1930-3 
<b>Pneumonectomy for lung metastases: indications, risks, and outcome. </b>
Spaggiari L, Grunenwald DH, Girard P, Solli P, Le Chevalier T. Department of Thoracic Surgery, Institut Mutualiste Montsouris, Paris, France. 

...Resection of pulmonary metastases (PM) by pneumonectomy [removal of a lung. Ed.] is infrequently performed and benefits are uncertain. ... From 1985 to 1995, 42 patients underwent pneumonectomy for PM. Twenty-nine patients had PM from sarcomas, .... The indications for pneumonectomy were pulmonary recurrences in 12 patients, PM centrally located in 26 patients, and high number of PM in 4 patients. There were 11 intrapericardial and 6 extended pneumonectomies. The average number of PM resected was 3. Twenty-two patients (52%) had lymph nodes involvement. ...: There were 2 postoperative deaths (4.8%) related to pneumonectomy and one death within 30 days for rapidly evolving disease; 4 patients (9.5%) had major postoperative complications that were medically treated. Five patients (12%) were operated on for recurrences on the residual lung. At the completion of the study, 12 patients were still alive, 8 without recurrences. The median survival was 6.5 months (range, 1 to 144 months); the 5-year survival was 16.8%. ... <b>Pneumonectomy should not be considered an absolute contraindication in patients with PM, but the poor outcome of our series suggests strict criteria of selection.</b> 
&&url PMID: 9930471 
 

Eur J Surg Oncol 1998 Oct;24(5):403-6 
<b>Thoracic cancer surgery in the elderly. </b>
Hasse J, Wertzel H, Kassa M, Burgard G. Department of Thoracic Surgery, University Hospital of Freiburg, Germany.
 
The risk of thoracic cancer surgery in patients of advanced age, i.e. 75 years or older, was analysed by reviewing 119 consecutive patients from August 1986 to May 1998 .... Repeated surgery ...gave a total of 124 operations. Of the patients, 22 were 80 years or older (21%) and 32% were female. The median age was 77 years (range 75-87 years). Six fatalities occurred within 30 days or during hospitalization. This corresponds to a 4.8% mortality for the whole series and 6.8% for the subgroup of bronchial carcinoma. The causes of death were surgical complications in two patients, one died from heart failure after simultaneous combined coronary artery bypass grafting and left lower lobectomy 2 hours after the operation from heart failure refractory to resuscitation. With this exception all these patients had stage II (n = 2) or stage III A (n = 3) bronchial carcinoma. <b>It is concluded that cancer surgery in the elderly is safe provided appropriate selection is observed. Indications should be very restrictive for advanced cancer and for pneumonectomy.</b> 
&&url PMID: 9800968 


Eur Respir J 1996 Sep;9(9):1826-30 
<b>Prognostic significance of thrombocytosis in patients with primary lung cancer.</b> 
Pedersen LM, Milman N. Dept of Pulmonary Medicine, Gentofte Hospital, University of Copenhagen, Denmark. 

In patients with malignancies, thrombocytosis has previously been related to disease stage, histological type, and survival. In the present study, the prevalence of thrombocytosis and the prognostic information provided by platelet counts were analysed in a large cohort of patients with primary lung cancer. At the time of diagnosis, pretreatment platelet counts were retrospectively recorded in 1,115 consecutive patients with histologically proven primary lung cancer. All patients were reviewed regarding histological type, tumour, node, metastasis (TNM) classification stage and survival. The prevalence of thrombocytosis in patients with lung cancer was compared with that in a series of 550 consecutive outpatients with benign lung disorders. In 269 surgically resected patients, postoperative platelet counts were recorded 1-3 months after resection of the tumour. In the follow-up period, thromboembolic episodes diagnosed either clinically or at autopsy were recorded. The overall prevalence of thrombocytosis (> 400 x 10(9) platelets.L-1) in the patients with lung cancer was 32%. The frequency of thrombocytosis was significantly higher compared with the control subjects (32 vs 6%; p < 0.0001). Platelet counts differed significantly among subgroups defined by the TNM classification, with the proportion of patients with > 400 x 10(9) platelets. L-1 greatest in the more advanced TNM stages (stage I and II 23% vs stage III and IV 37%; p < 0.0001). Patients with thrombocytosis had a significantly poorer survival than patients with normal platelet counts (p < 0.0001). In a multivariate survival analysis (Cox model), thrombocytosis continued to correlate strongly with poor survival even when adjusted for histological type, sex, age, and TNM stage (p < 0.001). In surgically resected patients, the frequency of preoperative and postoperative thrombocytosis differed significantly (23.0 vs 8.9%; p < 0.0001). Survival rate was significantly reduced in patients with preoperative thrombocytosis (p = 0.005). Thrombocytosis was not associated with an increased incidence of thromboembolism.<b> In conclusion, thrombocytosis is an independent prognostic factor of survival in patients with primary lung cancer. We suggest that platelet counts should be included in future multivariate analyses of survival in patients with lung cancer.</b> 
&&url PMID: 8880098 


Cancer 1996 Feb 15;77(4):675-82 
<b>Surgical treatment of lung metastases: The European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group study of 255 patients.</b>
van Geel AN, Pastorino U, Jauch KW, Judson IR, van Coevorden F, Buesa JM, Nielsen OS, Boudinet A, Tursz T, Schmitz PI. Dr. Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
 
... <b>Several reports have shown a prolonged survival after surgical treatment of pulmonary metastases from soft tissue sarcomas.</b> However, it is still unclear which prognostic factors predict a favorable outcome. Series are not comparable and the data are conflicting. Therefore, a multi-institutional study was undertaken to analyze prognostic factors in selecting patients for resection of pulmonary metastases from soft tissue sarcomas. ... This report is a retrospective study of the European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group. Two hundred fifty-five patients underwent complete resection of lung metastases from soft tissue sarcomas. Cases with chondrosarcoma and small round cell sarcomas like Ewing sarcoma were excluded. ...
The 3 year and 5 year overall postmetastasectomy survival rates were 54% and 38%, respectively. 
The disease free postmetastasectomy survival rates were 42% and 35%, respectively. 
* Analysis of prognostic factors for a more favorable outcome revealed 
* disease free intervals of 2.5 years or more, 
<b>* following a resection with microscopically free margins, </b>
* age less than 40 years, and 
* Grade I and II tumors. 
These prognostic factors have an independent influence on overall survival, using a multivariate Cox regression model. ... <b>Surgical excision of lung metastases from soft tissue sarcomas is well accepted and should be considered as a first line of treatment if preoperative evaluation indicates that complete clearance of the metastases is possible. Further investigation is needed before chemotherapy can be recommended as additional therapy.</b> Multicenter study 
&&url PMID: 8616759 


Am J Respir Crit Care Med 1994 Feb;149(2 Pt 1):469-76 
<b>Surgical resection of pulmonary metastases. Up to what number? </b>
Girard P, Baldeyrou P, Le Chevalier T, Lemoine G, Tremblay C, Spielmann M, Grunenwald D. Department of Thoracic Surgery, Centre Medico-Chirurgical de la Porte de Choisy, Paris, France. 

Specific results on the surgical resection of a large number of pulmonary metastases (PM) are currently unavailable, and the risk-benefit ratio of this aggressive approach may appear questionable. A systematic review of the records of 456 adult patients who underwent thoracic surgery for PM between 1979 and 1990 led to the identification of 44 patients<b> who underwent at least one resection of eight or more PM (range eight to 110), of whom 33 (75%) had PM from osteogenic or soft tissue sarcoma.</b> These 44 patients underwent a total of 77 operations, of which 47 (61%) were bilateral and nine (12%) incomplete resections. The 3- and 5-yr probabilities of survival after the first resection of eight or more PM were 36 and 28%, respectively, and were not significantly different from those of the 412 other patients who underwent surgery for PM over the same period.<b> In this small group of patients, only the quality of resection (complete or incomplete) was found to be a highly significant prognostic factor (p < 0.01).  A critical analysis of the reported data supports the view that, at least in patients with osteogenic or soft tissue sarcoma, the prognostic value of the number of PM seems to be more dependent on associated resectability than on the number per se and that, after careful preoperative patient selection, PM that can be resected should be resected, whatever their number.</b> 
&&url PMID: 8306048 


Pneumologie 1994 Jul;48(7):469-74 
<b>[Surgery of lung metastasis--indications, results and prognostic factors as an interdisciplinary concept]. [Article in German]</b> 
Schirren J, Wassenberg D, Krysa S, Branscheid D, di Rienzo G, Drings P, Vogt-Moykopf I. 
Thoraxklinik Heidelberg-Rohrbach. 

Surgical therapy of lung metastases nowadays is an established procedure. The operation's purpose is the radical and therefore potential curative resection. Beside there are diagnostic and palliative indications. ...Median sternotomy is the standard approach for revision of both lungs even in unilateral seeming disease. Preoperative staging is not reliable concerning number and extension of metastases. ... Surgery of lung metastases is part of an interdisciplinary oncological therapeutical concept and offers a prolonged survival to most of the patients and the possibility of cure to some. Even if prolongation of life is not feasible an improved quality and therefore a good palliation is obtained. 
&&url PMID: 7524062 


J Surg Oncol 1993 May;53(1):54-9 
<b>Selected benefits of thoracotomy and chemotherapy for sarcoma metastatic to the lung.</b> 
Mentzer SJ, Antman KH, Attinger C, Shemin R, Corson JM, Sugarbaker DJ. 
Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02115. 

To determine the benefit of aggressive surgical therapy, we studied 77 consecutive patients presenting to our sarcoma registry with pulmonary metastases. Detailed follow-up was available on all patients; the median follow-up of the 13 long-term survivors was 72 months from the date of diagnosis of the primary tumor. Survival of these 77 patients with metastatic disease was independent of the size, location, and histology of the primary tumor. 

<b>* Once metastases developed, survival of patients with pulmonary metastases was not influenced by the extent of surgical resection of the primary tumor or by the use of radiation therapy. 

* Pulmonary metastases were initially treated with thoracotomy and metastasectomy in 34 patients. 

* The median survival after thoracotomy was 26 months. Seven patients were alive more than 4 years after their diagnosis. 

* Pulmonary metastases were treated with chemotherapy alone in 43 patients. Although the survival was shorter (median survival 14 months) in patients treated with chemotherapy, an objective response to chemotherapy was obtained in 13 (30%) patients. Four of these patients were alive 4 years after their diagnosis. 

* These data demonstrate that both thoracotomy and chemotherapy are associated with long-term survival of patients with sarcoma metastatic to the lung.  

[These data also demonstrate that metastasectomy gives a longer median survival.  However, it is not mentioned here in the abstract whether those patients chosen for metastasectomy were in better condition, in terms of numbers of lung metastases, number of other metastases, sarcoma subtype, and/or additional medical conditions. Ed.]</b> 
&&url PMID: 8479198 


Gynecol Oncol 1992 May;45(2):202-5 
<b>Resection of pulmonary metastases from uterine sarcomas.</b> 
Levenback C, Rubin SC, McCormack PM, Hoskins WJ, Atkinson EN, Lewis JL Jr. 
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York. 

Long-term survival following resection of pulmonary metastases has been well documented. Variables that are believed to have an effect on survival are site of primary tumor, number and size of metastases, resectability, laterality of the metastases, doubling time, and disease-free interval.... We reviewed 45 patients whose pulmonary metastases from uterine sarcomas were resected at Memorial Sloan Kettering Cancer Center between 1960 and 1989. All cases met carefully defined criteria at time of thoracotomy: prior hysterectomy for uterine sarcoma, no extrathoracic tumor, known disease thought to be resectable, histology consistent with uterine sarcoma, and no medical contraindication to thoracotomy. Seventy-one percent had unilateral lesions, fifty-one percent had one lesion, and seventy percent had nodules greater than 2 cm. Thirty-six percent had incomplete resection at thoracotomy. Actuarial 5- and 10-year survival from hysterectomy for uterine sarcoma was 65 and 50%, respectively, with a mean follow-up of 89 months. Five- and ten-year survival from resection of pulmonary metastases was 43 and 35%, respectively, with a mean follow-up of 25 months. Unilateral vs bilateral disease was a significant predictor of survival after pulmonary resection (P = 0.02). Metastases size, number of metastases, disease-free interval, and patient age were not significant.  Among this carefully selected group of patients undergoing resection of pulmonary metastases from uterine sarcomas, long-term survival was achieved by a substantial proportion of patients. No single risk factor is sufficiently accurate to exclude an individual patient from consideration for pulmonary resection. 
&&url PMID: 1592288 


Int Surg 1992 Jul-Sep;77(3):173-7 
<b>Metastatic lung tumors and extended indications for surgery. </b>
Ishida T, Kaneko S, Yokoyama H, Maeda K, Yano T, Sugio K, Sugimachi K. Department of Surgery II, Faculty of Medicine, Kyushu University, Fukuoka, Japan. 

... The significant predictors of a better long-term survival for metastatic lung tumors were disease-free interval (DFI) greater than 12 months, tumor size less than or equal to 30 mm in diameter, and tumor doubling time (TDT) greater than 40 days (p less than 0.05). The number of nodules and the laterality of the sites of recurrence did not relate to survival time. ...Even in cases of a recurrent pulmonary metastasis, the three-year survival in those with multiple thoracotomies was 16%. <b>We wish to draw attention to the finding that a prolonged survival time can be achieved for patients undergoing regional lymph node dissection or even repeated resections for a recurrent pulmonary metastases. </b>
&&url PMID: 1399363 


Cancer 1990 Apr 15;65(8):1805-11 
<b>Cystic pulmonary metastatic sarcoma.</b> 
Traweek T, Rotter AJ, Swartz W, Azumi N. Sylvia Cowan Laboratory of Surgical Pathology, Division of Pathology, Duarte. 

Neoplastic cavitary lesions are an unusual type of pulmonary metastases. The authors report two cases of cystic metastatic sarcoma of the lungs that illustrate the clinical, radiologic, and pathologic difficulties encountered in the diagnosis of these lesions. In one patient, multiple small, thin-walled cystic metastases from a lower leg leiomyosarcoma were the only manifestation of metastatic disease. The cystic lesions did not change over an 8-month period and a diagnosis of malignancy was not established until spontaneous pneumothorax, presumably due to rupture of the malignant blebs, prompted a thoracotomy. In the second patient, three thin-walled bullae developed after treatment of noncystic pulmonary metastases from a lower-leg synovial sarcoma. In both patients, the cystic lesions were not evident on chest radiographs, but were well visualized with computed tomography (CT), where they mimicked benign bullous disease. However, additional small cavitary lesions not seen with CT were present in resected pulmonary wedge specimens from both patients. A great degree of variability in the cellular composition of the cyst wall lining in both cases, and a lack of any solid neoplastic tissue masses in one case, led to histopathologic difficulties that required immunohistochemical studies for definitive diagnosis of the metastatic disease. <b>These cases show that pulmonary bullae, even though thin-walled and benign-appearing on CT, may be a manifestation of pulmonary metastases. These lesions must therefore be surgically removed from patients in whom a curative resection of pulmonary metastases is warranted. [In addition, several members of the LMS list at ACOR had liver "cysts" prove to be metastatic disease.  LMS metastases can mimic benign cysts.  Ed.] </b> 
&&url PMID: 2156605 


Acta Oncol 1987;26(3):189-92 Erratum in: Acta Oncol 1987;26(6):496 
<b>Growth rate of pulmonary metastases from soft tissue sarcoma. </b>
Rooser B, Pettersson H, Alvegard T. Department of Orthopaedics, University Hospital, Lund, Sweden. 

The growth rate of pulmonary metastases was analyzed in eleven patients with soft tissue sarcoma. In cases where more than two examinations were available the growth rate seemed to be exponential. In all but one case microscopic pulmonary spread was calculated to be present when the primary tumor was diagnosed. Tumor doubling time varied between 8 and 198 days in different patients. <b>The variation in growth rate between various nodules in the same patient was much less pronounced but nevertheless considerable, which might, at least partly, be explained by tumor cell polyclonality. Computed tomography of the chest may detect pulmonary metastases earlier than conventional radiography and is therefore recommended in the preoperative work-up in soft tissue sarcoma.</b> 
&&url PMID: 2820448 


Minerva Med 1986 Nov 30;77(45-46):2159-62 
<b>[Cryotherapeutic destruction of invasive tracheo-bronchial tumors. Personal case histories]. [Article in Italian] </b>
Astesiano A, Aversa S, Ciotta D, Galietti F, Gandolfi G, Giorgis GE, Oliaro A, Scappaticci E, Pepino E. 

<b>Data are presented on 15 cases of invasive tracheobronchial tumours subjected to cryotherapy in 1984-85. The technique is indicated in patients who cannot be given surgical or radiation treatment and in cases of asphyxial syndrome requiring faster deobstruction than is obtainable with radiation treatment.</b>  
&&url PMID: 3025779 


Clin Radiol 1986 Nov;37(6):579-81 
<b>Soft tissue sarcoma: two cases of solitary lung metastasis more than 15 years after diagnosis. </b>
Going JJ, Brewin TB, Crompton GK, McLelland J. 

Soft tissue sarcomas may behave unpredictably. We present two adult cases in which solitary pulmonary metastases have occurred, 18 and 16 years after diagnosis. In both cases the primary disease was successfully controlled by conservative surgery combined with radiotherapy.  
&&url PMID: 3791857 


Cancer 1985 Mar 15;55(6):1361-6 
<b>Differing determinants of prognosis following resection of pulmonary metastases from osteogenic and soft tissue sarcoma patients. </b>
Roth JA, Putnam JB Jr, Wesley MN, Rosenberg SA. 

A study was performed to determine if prognostic factors could be used preoperatively to predict outcome following resection of metastases. Sixty-seven soft tissue sarcoma (STS) patients (median follow-up, 36 months) and 39 osteogenic sarcoma patients (OGS) (median follow-up, 29 months) underwent thoracic exploration at the first indication of pulmonary metastases, and the results for each group were reviewed. 
For the STS group:
* The number of metastatic nodules, disease-free interval (DFI), and tumor doubling time (TDT) significantly correlated with postoperative survival for STS patients. 
* Patients with four or fewer nodules on preoperative linear tomograms survived longer (median, 23 months) than patients with more than four nodules (median, 6 months; P less than 0.005). 
* Patients with a DFI greater than 12 months had a longer survival (median, 30 months) than patients with a DFI less than or equal to 12 months (median, 10 months; P less than 0.005). 
* Patients with a TDT greater than or equal to 20 days had a longer survival (median, 22 months) than patients with a TDT less than 20 days (median, 6 months; P less than 0.005).   ...  
&&url PMID: 3855684 


J Clin Oncol 1985 Mar;3(3):353-66 
Patterns of recurrence in patients with high-grade soft-tissue sarcomas. 
Potter DA, Glenn J, Kinsella T, Glatstein E, Lack EE, Restrepo C, White DE, Seipp CA, Wesley R, Rosenberg SA. 

From July 1975 to December 1982, 563 patients were referred to the Surgery Branch of the National Cancer Institute with the diagnosis of soft-tissue sarcoma. Three hundred and seven of these patients had fully resectable, localized high-grade soft-tissue sarcomas and were treated at the National Cancer Institute using standard protocols with surgery alone, or in combination with chemotherapy and/or radiotherapy. An aggressive surgical approach was undertaken in the management of patients who subsequently developed recurrent disease. These 307 cases have been reviewed, with a median duration of follow-up of 30 months, to determine the frequency of recurrent disease, the patterns of recurrence, and the impact of surgery on the survival of patients who developed recurrent disease. 

* Disease recurred in one hundred seven patients (107/307, 35%), with a median disease-free interval of 18 months (range, 0.5 to 72.0 months). 
* The frequency of recurrence by site of primary sarcoma was extremity, 31% (65/211); head and neck, 33% (4/12); trunk, 40% (17/42); retroperitoneum, 47% (17/36); and breast, 67% (4/6). 
* Isolated pulmonary metastatic disease was the most common pattern of initial recurrence (56/107, 52%) followed by isolated local recurrence (21/107, 20%). 
* Single other sites of recurrence and multiple concurrent sites of recurrence each accounted for 14% (15/107) of all initial recurrences. The relative frequency of each of these four patterns of recurrence varied with the site of the primary sarcoma. 
* The outcome for patients with recurrent disease depended on the site of recurrence, rather than on the site of the primary sarcoma.  
* Sixty-six patients (66/107, 62%) with recurrent disease were rendered surgically disease-free with the first recurrence, including 40 (40/56, 72%) patients with isolated pulmonary metastases, 20 patients (20/21, 96%) with isolated local recurrences, five patients (5/15, 33%), with isolated other sites of recurrence and one patient (1/15, 7%) with multiple sites of initial recurrence. Following surgical resection, the actuarial three-year survival for the 66 patients rendered disease-free was 51%. 
* The median survival for the 41 patients not rendered surgically disease-free with the first recurrence was only 7.4 months. 
* Thirty of the sixty-six patients (30/66, 45%) rendered disease-free with the first recurrence remained disease-free at follow-up, with a median follow-up of 28 months from the time of resection of the first recurrence. 
* The remaining 36 patients (36/66, 55%) subsequently recurred, with a median disease-free interval of 7.3 months.  
&&url PMID: 3973646 


Arch Intern Med 1983 Jul;143(7):1462-4 
<b>Pulmonary metastatic leiomyosarcoma coexisting with pulmonary chondroma in Carney's triad. </b>
Chahinian AP, Kirschner PA, Dikman SH, Rammos KS, Holland JF. 

The diagnosis of Carney's triad requires the coexistence of at least two of three rare disorders, including gastric epithelioid leiomyosarcoma, pulmonary chondroma, and functioning extra-adrenal paraganglioma. Seventeen cases have been reported so far, occurring predominantly in young female patients. We report herein the 18th case of this entity and the first case, to our knowledge, where pulmonary metastases from a gastric leiomyosarcoma coexisted in a patient with benign pulmonary chondromas. 
&&url PMID: 6307197 


Am J Surg Pathol 1979 Aug;3(4):325-42 
<b>Pulmonary metastases (with admixed epithelial elements) from smooth muscle neoplasms. Report of nine cases, including three males.</b> 
Wolff M, Silva F, Kaye G. 
This study pertains to an entity characterized by the presence of multiple intrapulmonary nodules, which consist of an admixture of bundles of well-differentiated smooth muscle cells and epithelial-lined spaces. These lesions have been frequently interpreted as a variant of hamartomas. However, in this review of the literature, and careful analysis of nine cases of this entity, we concluded that they should be considered metastases from smooth muscle tumors which incorporate some structures of mature lung parenchyma as they slowly expand. We affirm that the designation "fibroleiomyomatous hamartoma" should be discarded. Our cases occurred in six female and three male patients. In all but one female the primary source for lung metastases was uterus, while the male patients had primary lesions in the saphenous vein, diaphragm, and soft tissues. These lung lesions increase in size and number and are potentially fatal, though this may take many years. Even though the smooth muscle cells of the lung nodules appear bland on light microscopy, we were always able to demonstrate mitotic activity; electron microscopy indicated immaturity of the cells. For these reasons, we believe the tumors to represent metastatic leiomyosarcomas. Review 
&&url PMID: 395847 


Am J Roentgenol 1976 Sep;127(3):441-6 
<b>Pulmonary metastases from benign-appearing smooth muscle tumors of the uterus. </b>
Bachman D, Wolff M. 

A 42-year-old woman was found to have multiple pulmonary nodules 7 years after hysterectomy for leiomyoma. Thoracotomy revealed multiple well differentiated smooth muscle masses containing epithelial inclusions. This patient is similar to others previously reported as examples of "multiple pulmonary fibroleiomyomatous hamartoma" on the basis of slow-growth, benign-appearing histology, and the presence of epithelial elements. Evidence is presented which suggests that these cases represent metastasis from well differentiated leiomyosarcomas. There is a frequent association with uterine smooth-muscle tumor, cases with equally benign-appearing histology have shown lymph node metastasis, the nonmesenchymal elements have been shown to represent engulfed bits of adjacent pulmonary tissue, and the histologic differentiation of benign from malignant mesenchymal tumors is known to be unreliable in some cases. Unlike more anaplastic leiomyosarcomas, this condition may be associated with few symptoms and prolonged survival despite widespread disease. 
&&url PMID: 183531 


Cancer 1975 Aug;36(2):471-4 
<b>Growth rate of pulmonary metastases in human sarcomas. </b>
Band PR, Kocandrle C. 
The growth rate of spherical pulmonary metastases was studied in 15 patients with osseous and soft tissue sarcoma. The median volume doubling time (Dt) was 25 days. The time from diagnosis of the primary tumor to occurrence of pulmonary metastases correlated directly with the length of Dt. No correlation between Dt and tumor histology was observed. The effect of therapy on the tumor growth curve was studied in 1 patient. The therapeutic implications derived from the quantitative evaluation of tumor growth rate are discussed. 
&&url PMID: 1057449 
