Surgery Shows Promise In Lung Metastases

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points
These studies were published as abstracts and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
Resection of lung metastases led to recurrence-free survival for a majority of patients during a median follow up of more than 2 years.
Note that the only independent predictor of disease-free survival was tumor-free surgical margins, as neither resection method (surgical or laser) nor number of metastases removed influenced the risk of recurrence.
GENEVA -- Resection of lung metastases led to recurrence-free survival for a majority of patients during a median-follow-up of more than 2 years, a retrospective study showed.

Overall, 57.5% of 301 patients had no recurrence during follow-up. The patients had a median progression-free survival of 12.9 months, ranging as high as 5 years for some patients.

The only independent predictor of disease-free survival was tumor-free surgical margins, as neither resection method (surgical or laser) nor number of metastases removed influenced the risk of recurrence, Thomas Osei-Agyemang, MD, reported here at the European Lung Cancer Conference (ELCC).

"Pulmonary metastasectomy offers a potentially curative treatment option," said Osei-Agyemang, of the University of Freiburg in Germany. "Laser-assisted resection is the favored technique for removal of a high number of lesions, which is associated with no increased morbidity except for pneumonia.

"The number of metastases seems to be of subsidiary importance," he added.

Another study reported at the ELCC showed that repeated removal of pulmonary metastases from colorectal cancer can be performed without severe complications and is associated with a favorable prognosis.

Though widely practiced, metastasectomy has received little attention in the literature. Data have come from primarily from small retrospective case series and observational studies.

The surgery has not been evaluated in randomized trials, and no analyses have included laser treatment or other newer techniques for removing pulmonary metastases, Osei-Agyemang said.

In an effort to inform on the potential risks and benefits of pulmonary metastasectomy, investigators reviewed records of patients who underwent the procedure from 2005 to 2010. Each patient's status at follow up was evaluated by consultation or questionnaire.

The 301 patients included in the analysis consisted of 133 women and 168 men who had a median age of 64 (range of 11 to 86). Their lung metastases arose from more than a dozen types of cancer. Colorectal cancer accounted for a third of cases, followed by renal cell carcinoma (12%), melanoma (7%), breast cancer (6%), soft-tissue sarcoma (6%), head and neck carcinoma (6%), and lung cancer (6%).

In 62 patients, metastases were removed by laser-assisted surgery. The remaining patients underwent wedge or anatomical resections.

A majority of laser-assisted cases (43 of 62) involved removal of more than two metastases, whereas 59 of 234 wedge/anatomical resections involved more than two lesions. The median number of metastases removed was seven with the laser and two without (P<0.01).

Despite removal of more metastases per patient, laser-assisted surgery was not associated with more adverse events (24.2% versus 21.4%), with the exception of pneumonia (11.3% versus 2.9%, P<0.01).

Three-fourths of the procedures resulted in clear surgical margins (R0), which occurred significantly more often with conventional surgery (189 of 234 cases versus 39 of 62 laser-assisted procedures, P<0.01). However, clear margins resulted with similar frequency in patients who had more than two lesions removed (21/43 versus 34/59, P=0.38).

After a median follow up of 27.2 months, 42.5% of patients had recurrent lung metastases, and 29.2% of the patients had died. The median disease-free interval was 12.9 months.

Survival declined significantly as the number of metastases increased (P<0.02). When analyzed by surgical technique, the inverse association between metastasis count and survival held up only for the non-laser procedures (P<0.01).

In a multivariate analysis, only disease-free margin status significantly influenced disease-free survival (P<0.03).

In the second study, South Korean surgeons found that repeated metastasectomy for recurrent pulmonary lesions did not adversely affect survival.

A retrospective review of medical records identified 99 colorectal cancer patients who had surgical procedures to remove lung metastases. The primary tumor site was the rectum in 67 cases and the colon in 32, reported Jinwook Hwang, MD, of the Dongnam Cancer Center Hospital in Busan.

During a median follow-up of 39.7 months, 31 patients had repeat procedures for recurrent pulmonary metastases. Median survival from the initial metastasectomy was 61.8 months, and 5-year overall survival was 50.6%.

Hwang said 12 patients had repeat surgery to remove recurrent pulmonary lesions. They had a median survival of 50.9 months from the second procedure, 3-year survival of 59.5%, and 5-year survival of 34.7%.

Five patients underwent a third metastasectomy, and they had a median survival of 23.5 months from the procedure. One patient subsequently had a fourth procedure to remove recurrent pulmonary metastases.

"Repeated thoracotomy can be performed with low mortality and morbidity," Hwang said. "Repeated surgical interventions provide better survival than with chemotherapy. A broad indication with limited lung resection could be applied to repeated pulmonary metastasectomy in patients with multiple and bilateral pulmonary metastases."

The studies demonstrated that metastasectomy is feasible and associated with low operative mortality and morbidity, Paul Van Schil, MD, PhD, said during a discussion that followed the presentations. However, metastasectomy does not change the underlying biology of the disease, as reflected in the recurrences.

"You are using a mechanical means to treat a systemic disease," said Van Schil, of the University of Antwerp in Belgium.

"In selected patients, the surgery leads to good long-term results -- if complete resection is achieved," he added. "Prospective studies are needed to determine the risks and benefits. Additionally, new techniques -- such as chemoembolization, pulmonary artery infusion, and isolated lung perfusion -- are being evaluated."

Osei-Agyemang, Hwang, and Van Schil had no disclosures.

Primary source: European Lung Cancer Conference
Source reference:
Osei-Agyemang T, et al "Pulmonary metastasectomy: Analysis of technical and oncological outcome in 301 patients" ELCC 2012; Abstract 242O.

Additional source: European Lung Cancer Conference
Source reference:
Hwang J, et al "Outcomes of repeated metastasectomy for pulmonary recurrence in colorectal cancer" ELCC 2012; Abstract 243O.

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