resection for lung metastases

Resection For Lung Resection For Lung MetastasesMetastasesM62 Coloproctology CourseM62 Coloproctology Course

Lung MetastasesLung Metastases

11stst resection of a single metastases discovered resection of a single metastases discovered during the excision of a chest wall sarcomaduring the excision of a chest wall sarcoma

Elective surgery occasionally offered to Elective surgery occasionally offered to selected patients with single metastases and selected patients with single metastases and long disease free intervallong disease free interval

Only in a few centres has metastasectomy Only in a few centres has metastasectomy been applied systematically to multiple or been applied systematically to multiple or bilateral lesions with or without chemotherapy bilateral lesions with or without chemotherapy


Surgical resection of pulmonary Surgical resection of pulmonary metastases now considered standard metastases now considered standard therapy in properly selected casestherapy in properly selected cases

Many tumours may involve the lung as Many tumours may involve the lung as the unique site of distant spread ‘organ of the unique site of distant spread ‘organ of first encounter’first encounter’

Complete surgical resection of all Complete surgical resection of all pulmonary deposits is often technically pulmonary deposits is often technically feasible with low morbidity and mortalityfeasible with low morbidity and mortality


It is difficult to asses the real proportion It is difficult to asses the real proportion of patients with isolated lung metastases of patients with isolated lung metastases who are candidates for salvage surgery, who are candidates for salvage surgery, what is the denominatorwhat is the denominator

Sarcomas, germ cell tumours prob > 50%Sarcomas, germ cell tumours prob > 50% Epithelial tumours probably far lessEpithelial tumours probably far less


Overall 5 year survival reported as 20-Overall 5 year survival reported as 20-40% for all primary sites40% for all primary sites

Much higher than expected after Much higher than expected after chemotherapy or radiotherapy alonechemotherapy or radiotherapy alone


Controversy remains overControversy remains over Selection of patientsSelection of patients Bilateral surgical stagingBilateral surgical staging Adjuvant chemotherapyAdjuvant chemotherapy Prognostic factorsPrognostic factors


International Registry of Lung International Registry of Lung Metastases reported in 1997Metastases reported in 1997

5290 patients from 18 centres over 50 5290 patients from 18 centres over 50 years!years!

Mean age 44 years (2-93)Mean age 44 years (2-93)


5290 patients5290 patients 43% epithelial43% epithelial 42% sarcomas42% sarcomas 7% germ cell tumours7% germ cell tumours 6% melanomas6% melanomas 2% others2% others


Presentation time of metastasesPresentation time of metastases SynchronousSynchronous 11%11% 0-11 months0-11 months 20%20% 12-35 months12-35 months 36%36% >36 months >36 months 31%31%


Surgical approachSurgical approach ThoracotomyThoracotomy 58%58% Bilateral thoracotomyBilateral thoracotomy 11%11% Median sternotomyMedian sternotomy 27%27% ThoracoscopyThoracoscopy 2%2%


Surgical resectionSurgical resection WedgeWedge

67%67% SegmentectomySegmentectomy

9%9% LobectomyLobectomy

21%21% PneumonectomyPneumonectomy

3%3% + other + other

9%9%


Number of metastasesNumber of metastases SingleSingle 46%46% 4 or more4 or more 26%26% 10 or more10 or more 9%9% 20 or more20 or more 3%3% 1 patient 154!1 patient 154!


Tumour type having multiple metastasesTumour type having multiple metastases SarcomasSarcomas 64%64% Germ cell tumoursGerm cell tumours 57%57% EpithelialEpithelial 43%43% MelanomasMelanomas 39%39%


Mediastinal lymph node involvementMediastinal lymph node involvement Germ cell tumoursGerm cell tumours 11%11% MelanomasMelanomas 8%8% EpithelialEpithelial 6%6% SarcomasSarcomas 2%2%


Radiological accuracy of the number of Radiological accuracy of the number of metastasesmetastases AccurateAccurate 61%61% UnderestimateUnderestimate 25%25% OverestimateOverestimate 14%14%

Unilateral accurateUnilateral accurate 75%75%

Bilateral accurateBilateral accurate 37%37%


Operative mortality overall 1%Operative mortality overall 1%

Incomplete resectionIncomplete resection 2.4%2.4% Complete resectionComplete resection 0.8%0.8% Sub lobar resection Sub lobar resection 0.6%0.6% Lobar resectionLobar resection 1.2%1.2% PneumonectomyPneumonectomy 3.6%3.6%

Overall SurvivalOverall Survival

Complete resectionComplete resection

5yr5yr 36%36% 10yr10yr 26%26% 15yr15yr 22%22% Incomplete resectionIncomplete resection 5yr5yr 13%13% 10yr10yr 7%7% 15yr15yr 7%7%

Survival with Disease Survival with Disease Free IntervalFree Interval

5 year 5 year 10year10year

0-11 0-11 mthsmths

33%33% 27%27%

12-35 12-35 mthsmths

31%31% 22%22%

> 36 > 36 mthsmths

45%45% 29%29%

Survival for Number of Survival for Number of MetastasesMetastases

5 year5 year 10year10year

1 met1 met 43%43% 31%31%

2-3 2-3 metsmets

34%34% 24%24%

>4 >4 metsmets

27%27% 19%19%

5 year5 year 10year10year

Germ Germ cellcell

68%68% 63%63%

EpithelEpithelialial

37%37% 21%21%

SarcoSarcomama

31%31% 26%26%

MelanMelanomaoma

21%21% 14%14%

Adjusted Relative Risk of Adjusted Relative Risk of DeathDeath

>36 months>36 months0.640.64

1 metastases1 metastases0.760.76

Bowel caBowel ca0.830.83

MelanomaMelanoma 2.032.03

Prognostic GroupsPrognostic Groups

Risk FactorsRisk Factors Disease free interval Disease free interval

> 36 months> 36 months Multiple metastasesMultiple metastases

SummarySummary

Radiology not accurateRadiology not accurate Thoracoscopy not adequateThoracoscopy not adequate Multiple metastasectomies may be Multiple metastasectomies may be

requiredrequired Appears to be of value in bowel cancerAppears to be of value in bowel cancer

Soil and SeedSoil and Seed

For colonic cancers the organ of first For colonic cancers the organ of first encounter can be the lung and the liverencounter can be the lung and the liver

Human lung metastases can be cultured Human lung metastases can be cultured in nude rat lungs but not the bowelin nude rat lungs but not the bowel

Togo et al Anti Cancer Research 1995Togo et al Anti Cancer Research 1995


Many studies report a survival advantage Many studies report a survival advantage in large bowel cancerin large bowel cancer Lung metastasesLung metastases 40%40% Lung and liver metastasesLung and liver metastases 30%30%


Same prognostic factorsSame prognostic factors Number of metastases < 4Number of metastases < 4 Disease Free Interval > 3 yearsDisease Free Interval > 3 years No nodal disease at the primary tumour siteNo nodal disease at the primary tumour site

With no risk factors 5 year survival up to With no risk factors 5 year survival up to 90%!90%!

Ishikawa, Dis-Colon-Rectum 2003Ishikawa, Dis-Colon-Rectum 2003


Assessment for surgeryAssessment for surgery Fit for surgery, BTS and SCTS Guidelines Fit for surgery, BTS and SCTS Guidelines

Thorax 2001Thorax 2001 PFT and IHDPFT and IHD Control of the primary tumourControl of the primary tumour No evidence of other metastatic disease No evidence of other metastatic disease

(except liver)(except liver) Brain and bone scanBrain and bone scan


Follow up screeningFollow up screening 325 patient randomised to yearly 325 patient randomised to yearly

colonoscopy, Liver CT and CXRcolonoscopy, Liver CT and CXR Not felt to improve survival from colorectal Not felt to improve survival from colorectal

cancer when added to symptom and simple cancer when added to symptom and simple screening reviewscreening review

Schoemaker et al Gastroenterology 1998Schoemaker et al Gastroenterology 1998

PET scanPET scan


Pattern of recurrencePattern of recurrence Certainly out to 4 yearsCertainly out to 4 years Rectum longer than colonRectum longer than colon Adjuvant chemotherapy may prolong the Adjuvant chemotherapy may prolong the

interval until recurrence and the interval until interval until recurrence and the interval until lung metastases is relatively longerlung metastases is relatively longer

Sadahiro et al, Hepato-gastroenterology 2003Sadahiro et al, Hepato-gastroenterology 2003


Tumour MarkersTumour Markers CEA – sensitive but not specificCEA – sensitive but not specific CEA doubling timeCEA doubling time Stromal Etg-1Stromal Etg-1 Vascular integrin Beta-3Vascular integrin Beta-3


Other treatmentsOther treatments Neoadjuvant and Neoadjuvant and

adjuvant adjuvant chemotherapychemotherapy

RadiotherapyRadiotherapy Isolated lung Isolated lung

perfusionperfusion Ablation under Ablation under

radiological radiological control(BJS 2004)control(BJS 2004)

SummarySummary

Resection is of benefit in selected casesResection is of benefit in selected cases The value of intensive screening is not The value of intensive screening is not

knownknown The majority of patients would be fit for The majority of patients would be fit for

surgerysurgery Surgery should be open ? BilateralSurgery should be open ? Bilateral Lung preserving procedures where Lung preserving procedures where

possiblepossible Redo surgery is of benefitRedo surgery is of benefit

ConclusionConclusion

Resection of lung metastases in patients Resection of lung metastases in patients with carcinoma of the colon and rectum is with carcinoma of the colon and rectum is beneficial in selected cases. Further beneficial in selected cases. Further investigation is required to identify all investigation is required to identify all those patients who would benefit and to those patients who would benefit and to establish the optimal treatment regime establish the optimal treatment regime

resection for lung metastases

Documents

isolated lung metastases

liverhuman lung metastases

lung metastasesmany

lung metastasestumour

lung metastases5290

single metastases

germ cell tumours prob

germ cell tumours6