Post on 16-Jan-2016
The 53 rd International Congress of the Egyptian Society of Chest diseases
and tuberculosisMarch 2012
Cairo
Surgical Indications and techniques for lung
metastases
ALAIN BISSON Thoracic Surgery and Lung
TransplantationHOPITAL FOCH
PARIS
Surgery in Lung metastases
IncidenceIn autopsy studies of patients who
died of extra-thoracic malignancies
20-50 % had pulmonary metastases
10-15 % had metastatic disease limited to the lung
Surgery in Lung metastases
The most frequent origin Breastcolorectal
Surgery in lung metastases
Incidence in other cancers
- Hepato carcinoma 40 – 60 %
- Testis 15 %- ORL 10 – 35 %- Uterus 22 %- Melanoma 12 %- Thyroïd 10 %
Physiopathology
Via the pulmonary arteries and the capillary beds
Less commonly : consequence of the lymphatic spread
Spread to mediastinal lymph nodes (breast and colorectal cancer)
18 % involving bronchi3 % bronchoscopic detection
Surgery in lung metastases
Surgery in lung metastases
Imaging and diagnosis
Patients followed for extra-thoracic malignancies : new lung lesions
Metastases 46 % Primary lung tumors 32 %Benign disease 18 %
Imaging and diagnosis
- Thoracic XR : The first document, non specific
- Chest CT imaging : optimal method- 10 mm 100 %- 6-10 mm 66 %- < 6 mm 48 %
- Pet scan • Confirm diagnosis • Spread of the disease
- Biopsy – Tissu sampling
Surgery in Lung metastases
Lung metastases - imaging
CXRay- Often first indicator of lung metastases - Lung nodules
‘cannonball lesions’- Segmental collapse- Mediastinal/hilar nodal disease- Pleural effusion
Lung metastases imaging
CT scan
Surgery in lung metastases
Selection Criteria- The primary tumor has been
controlled
- No evidence of widespread extra-pulmonary metastases
- The patient is in good condition for surgery with a good post-operative pulmonary function expected
Surgery in lung metastases
Other indications for resection
Need to confirm diagnosisRemoval of residual tumors after
chemotherapyObtention of biomedical tissue or
immunohistochemical studies
Surgery in lung metastases
International Registry of lung metastases
- 4572 complete surgical resections- Follow up 46 months- Peri-operative mortality 0.8 %
Survival 5 years 10 years 15 years
Complete resection
36 % 26 % 22 %
Surgery in lung metastases
Surgery in lung metastases
Primary tumors : sarcomasOsteo sarcomas : 30 %Survival 5 years : 38 %
Survival 5 years after 2nd resection: 32 %
Sarcomas soft tissu 20 %Survival 5 years : 36 %Survival 5 years after 2nd resection 32 %
Bricolli : Cancer 2005/ Sternberg : Sem Oncol 2007
Surgery in lung metastases
Primary tumors : Colorectal cancer
15-20 % metastases
Survival rate : 5 years : 30-55 %Survival rate after 2nd resection : 20-
30 %
Sternberg B.
Sem. Oncol 2007
Surgery in lung metastases
Primary tumor : Breast cancer
- Rare surgical indications - Rarely found isolated (bone or hepatic
metastases)- Other thoracic lesions : nodes, pleural, chest
wall
Chang Am. Journ. Surgery 2006
Surgery in lung metastases
ChemotherapyPreferred treatment
- for chemosensitive tumors- for primaries that metastasise
else whereVariety of agents
- traditionnal cytotoxics- Hormonal eg. Tamoxifen- Molecular therapics eg.
Herceptin
Surgery in lung metastases
Radiotherapy
- Rare indication * Whole lung R.T for micrometastases
- Risk of pneumonitis- No proven benefit
* Focal radiotherapy on symptomatic lesions.May be used to control local symptomsairway compression – hemoptysis- pain
Pre-RF 1 month 3 months 6 months
Radio frequency ablation
Surgery in lung metastases
Criteria and prognosis
Indications - Metastatic disease limited to lung- Primary cancer definitively controlled- Patient is a good candidate for lung
resectionPrognosis factors
- age- disease ???- Histology and grade for primary tumor- Number of metastases resected
Surgery in lung cancers
Principles of Surgical treatment
Aim : - Obtain clear margins with removal of as little normal lung tissu as possible- Inadequacy of margins mandates new
resection
- Most metastases tend to be peripherically located = wedge resection is usually sufficient.
Surgery in lung metastases
Uni or bilateral?
Bilateral exploration for unilateral disease is not indicated
Delaying controlateral thoracotomy until disease becomes apparent does not affect survival
Surgery in lung metastases
Mediastinal nodes
Presence of metastatic nodal involvement : a direct negative effect on survival
3 year survival 69 % vs 38 %
Systematic mediastinal and hilar node dissection should be performed routinely with metastasectomy
- accurate staging can guide post-operative treatment
Surgery in lung metastases
Approach- Median sternotomy- Clamshell incision- Postero-lateral thoracotomy- Video Assisted Thoracic surgery (VATS)
Surgery in lung metastasesMedian sternotomy
Exploration of both thoracic cavities
(lung, hilar, chest wall)
But difficult to expose- postero costo-vertebral
lung field- left lower lobe
Surgery in lung metastases
Clamshell incision
Excellent exposure of the posterior aspect of both lungs
But agressive and painful approach
Surgery in lung metastases
Postero lateral thoracotomyStandard approach for unilateral pulmonary resection
Adequate access to all areas of the hemithorax
Allows wedge or anatomic resection under direct vision
Surgery in lung metastases
VATS- Loss of ability to palpate the lung to
detect metastasesPossibly leading to incomplete
resection- Interest of pre-op imaging
- Considered for diagnosis and for resection - a small number of peripherically
located tumors- Necessity of pre operative marking of tumors
Surgery in lung metastases
Type of resection
Iterative resections
- Presuming that the patient remains free of wide spread metastases to other sites
- Survival was fairly stable untill the fourth procedure
- DFI greater than 40 months between metastasectomies has significant survival advantage
Surgery lung metastases
Osteogenic sarcoma
When the sarcoma is diagnosed : 10 – 20 % of patients have metastases
• 85 % of these have lung metastases
2 predictive factors - Number of nodules on preoperative CT
scan correlated- Histologic response to pre-op
chemotherapy
Surgery lung metastases
Soft tissue sarcoma
The lung is often the only site of metastases
- Surgical excision is considered first line therapy
assuming that complete resection is possible
- When pulmonary metastases recur reoperation may yield good outcomes
Surgery lung metastases
Surgery in lung metastases
Authors years Nb pts Post op mortality 5 years survival
Higashiyama 1981-2001 100 - 52,3%
Lee 1994-2004 59 0% 50,3%
Melloni 1991-2004 31 0% 44%
Moore 1984-1997 47 1,7% 24%
Pfannschmidt 1985-2000 167 1,8% 32,4%
Rena 1980-2000 80 2,02% 41%
Saito 1990-2000 165 0% 39,6%
Sakamoto 1986-2000 47 1,7% 48%
Shiono 1992-2002 87 0% 61,4%
Vogelsang 1984-1997 75 0% 27%
Wang 1981-2000 68 - 36,1%
Watanabe 1992-2000 49 0% 56%
Headrick 1980-1998 58 0% 30%
Kobayaschi 1988-1996 47 - 31%
Surgical Resection of Pulmonary Metastases From Colorectal Cancer : A Systematic Review of Published SeriesPfannschmidt J, Ann Thorac Surg 2007
Colo rectal cancer
Colorectal cancer
- C.R cancers spread systematically into liver or lungs
- Pulmonary metastases are found at a median of 37.5 months after primary colo rectal resection
- Prognosis factors - presence of a single metastasis
- DFI > 36 months
- Normal preoperative CEA level
Surgery lung metastases
Colorectal cancer
- Metachronous vs synchronous resection of liver and lung metastases
- Patient with metachronous resection had longer survival
- 70 vs 22 months
- Lung resection support aggressive pulmonary metastasectomy even in the presence of hepatic metastases
Surgery lung metastases
Surgery lung metastases
After colorectal resection
After first lung metastasectomy
- Metastases limited to the lung may be resected with prolonged survival
- Selection criteria :- The pulmonary tumor is
controlled - No evidence of wide-
spread extra-pulmonary metastases- Good surgical candidates
- Prognostic factor : complete resection
Conclusion