The 53 rd International Congress of the Egyptian Society of Chest diseases and tuberculosis March...

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


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



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


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


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


Other indications for resection

Need to confirm diagnosisRemoval of residual tumors after

chemotherapyObtention of biomedical tissue or

immunohistochemical studies


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 %



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


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


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


ChemotherapyPreferred treatment

- for chemosensitive tumors- for primaries that metastasise

else whereVariety of agents

- traditionnal cytotoxics- Hormonal eg. Tamoxifen- Molecular therapics eg.

Herceptin


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


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.


Uni or bilateral?

Bilateral exploration for unilateral disease is not indicated

Delaying controlateral thoracotomy until disease becomes apparent does not affect survival


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


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


Clamshell incision

Excellent exposure of the posterior aspect of both lungs

But agressive and painful approach


Postero lateral thoracotomyStandard approach for unilateral pulmonary resection

Adequate access to all areas of the hemithorax

Allows wedge or anatomic resection under direct vision


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


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


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



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


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



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

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