Repeated Resections of Pulmonary Metastases

<b>If pulmonary metastases are completely resected with clear surgical margins, survival time is extended significantly.  Resection of RECURRENT pulmonary metastases, again with clear margins, also extends survival time significantly. </b> See articles described below.

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<b>Selected Medical Journal Annotated References</b>


J Am Coll Surg 2000 Aug;191(2):184-90; discussion 190-1 Comment in: J Am Coll Surg. 2000 Aug;191(2):193-5 
<b>Repeat resection of pulmonary metastases in patients with soft-tissue sarcoma.</b> 
Weiser MR, Downey RJ, Leung DH, Brennan MF. 
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA. 

...<b>Even after an apparent complete resection of sarcomatous pulmonary metastases, 40% to 80% of patients will re-recur in the lung. The benefit of subsequent re-resection is poorly defined. This study examines patient survival after repeat pulmonary exploration for re-recurrent metastatic sarcoma at a single institution. </b>
 ... Between July 1982 and December 1997, data on 3,149 adult in-patients with soft tissue sarcoma were prospectively gathered. Of these, pulmonary metastases were present or developed in 719 patients and 248 underwent at least one resection. Of the patients relapsing in the lung after an apparently complete resection, 86 underwent reexploration. Disease-specific survival (DSS) after re-resection was the end point of the study.... 
<b>* The median DSS after re-resection for all patients undergoing at least two pulmonary resections was 42.8 months with an estimated 5-year survival of 36%. </b> 
<b>* The median DSS[Disease Specific Survival] in patients with complete reresection was 51 months (n = 68) compared with 6 months in patients with an incomplete re-resection (n = 16, p<0.0001). </b>
* Patients with one or two nodules at re-resection (n = 39) had a median DSS of 51 months compared with 20 months in patients with three or more nodules (n = 40, p = 0.003). 
* Patients in whom the largest metastasis re-resected was less than or equal to 2 cm (n = 33) had a median DSS of 44 months compared with 20 months in patients with metastasis greater than 2 cm (n = 43, p = 0.033). 
<b>* Patients with primary tumor high-grade histology (n = 75) had a median DSS of 32 months and patients with low-grade histology (n = 11) had a median DSS that was not reached (p = 0.041).</b> 
* Three independent prognostic factors associated with poor outcomes may be determined preoperatively: > or =3 nodules, largest metastases > 2 cm, and high-grade primary tumor histology. 
* Patients with either zero or one poor prognostic factor had a median DSS > 65 months and patients with three poor prognostic factors had a median DSS of 10 months. 
<b>* ...Re-exploration for recurrent sarcomatous pulmonary metastases appears beneficial for patients who can be completely re-resected. </b>
* 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. 
&&url PMID: 10945362   


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. ... <b>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.</b>  [Adjuvant antiangiogenic treatment might be somewhat effective here. Ed.] 
&&url PMID: 10773147


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.  Publication Types: Review 
&&url PMID: 10063499 


Ann Thorac Surg 1998 Apr;65(4):909-12 Comment in: Ann Thorac Surg. 1998 Sep;66(3):989 
<b>Long-term results after repeated surgical removal of pulmonary metastases. </b>
Kandioler D, Kromer E, Tuchler H, End A, Muller MR, Wolner E, Eckersberger F. 
Department of Cardio-Thoracic Surgery, University of Vienna Medical School, Austria
. 
... Although surgical resection is accepted widely as first-line therapy for pulmonary metastases, few data exist on the surgical treatment of recurrent pulmonary metastatic disease. In a retrospective study, we analyzed patients who were operated on repeatedly for recurrent metastatic disease of the lung with curative intent over a 20-year period. ... From 1973 to 1993, 396 metastasectomies were performed in 330 patients. The study population included patients with any histologic tumor type who had undergone at least two (range, 2 to 4) complete surgical procedures because of recurrent metastatic disease. Surgical and functional resectability of the recurrent lung metastases and control of the primary lesion served as objective criteria for reoperation. A subgroup of 35 patients that included patients with histologic findings such as epithelial cancer and osteosarcoma then was analyzed retrospectively to calculate prognosis and define selection criteria for repeated pulmonary metastasectomy. ... The 5- and 10-year survival rates after the first metastasectomy were 48% and 28%, respectively. The overall median survival was 60 months. A mean disease-free interval (calculated for all intervals, with a minimum of two) of greater than 1 year was significantly associated with a survival advantage beyond the last operation. Univariate analysis failed to show size, number, increase or decrease in number or size, or distribution of metastases as factors related significantly to survival. ...Although patients with different histologic tumor types were included, the study population appeared to be homogeneous in terms of survival benefit and prognostic factors, and it probably represented the selection of biologically favorable tumors in which histology, size, number, and laterality are of minor importance. <b>We conclude that patients who are persistently free of disease at the primary location but who have recurrent, resectable metastatic disease of the lung are likely to benefit from operation a second, third, or even fourth time.</b>  
&&url PMID: 9564899 


Eur J Cardiothorac Surg 1997 Nov;12(5):703-5 
<b>Survival after surgical treatment of recurrent pulmonary metastases. </b>
Groeger AM, Kandioler D, Mueller MR, End A, Eckersberger F, Wolner E. 
Department of Cardio-Thoracic Surgery, University of Vienna, Austria. 

...Resection of lung metastases is a generally accepted therapeutic strategy today. This retrospective study was performed in order to estimate the value of an aggressive surgical approach in recurrent metastatic disease of the lung. ... The survival rates of 42 patients undergoing repeated resectional treatment for recurrent lung metastases (group A) were compared to the outcome of a total of 288 patients after a single surgical intervention for lung metastases (group B). Survival rates and the relative effects of the various prognostic factors were calculated according to Kaplan-Maier and Mantel Cox or Wilcoxon test. Histology of the primary tumors in group A consisted of 18 carcinomas, 22 sarcomas and two melanomas, in group B the distribution was 64% carcinoma, 27% sarcoma and 9% melanoma. The mean follow-up period was 88.5 months for group A and 27 months for group B.... The overall survival rate for group A was 48% at 5 years and 30% at 10 years, the survival rate for group B was 34% at 5 years. ... <b>Long-term survival rates superior to those after single resectional treatment for lung metastases encourage an aggressive surgical approach for this disease.</b> 
&&url PMID: 9458139  


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 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. 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. 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). <b>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

