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Resection For Lung Metastases

Resection For Lung Metastases. M62 Coloproctology Course. Lung Metastases. 1 st resection of a single metastases discovered during the excision of a chest wall sarcoma Elective surgery occasionally offered to selected patients with single metastases and long disease free interval

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Resection For Lung Metastases

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  1. Resection For Lung Metastases M62 Coloproctology Course

  2. Lung Metastases • 1st resection of a single metastases discovered during the excision of a chest wall sarcoma • Elective surgery occasionally offered to selected patients with single metastases and long disease free interval • Only in a few centres has metastasectomy been applied systematically to multiple or bilateral lesions with or without chemotherapy

  3. Lung Metastases • Surgical resection of pulmonary metastases now considered standard therapy in properly selected cases • Many tumours may involve the lung as the unique site of distant spread ‘organ of first encounter’ • Complete surgical resection of all pulmonary deposits is often technically feasible with low morbidity and mortality

  4. Lung Metastases • It is difficult to asses the real proportion of patients with isolated lung metastases who are candidates for salvage surgery, what is the denominator • Sarcomas, germ cell tumours prob > 50% • Epithelial tumours probably far less

  5. Lung Metastases • Overall 5 year survival reported as 20-40% for all primary sites • Much higher than expected after chemotherapy or radiotherapy alone

  6. Lung Metastases • Controversy remains over • Selection of patients • Bilateral surgical staging • Adjuvant chemotherapy • Prognostic factors

  7. Lung Metastases • International Registry of Lung Metastases reported in 1997 • 5290 patients from 18 centres over 50 years! • Mean age 44 years (2-93)

  8. Lung Metastases • 5290 patients • 43% epithelial • 42% sarcomas • 7% germ cell tumours • 6% melanomas • 2% others

  9. Lung Metastases • Presentation time of metastases • Synchronous 11% • 0-11 months 20% • 12-35 months 36% • >36 months 31%

  10. Lung Metastases • Surgical approach • Thoracotomy 58% • Bilateral thoracotomy 11% • Median sternotomy 27% • Thoracoscopy 2%

  11. Surgical resection Wedge 67% Segmentectomy 9% Lobectomy 21% Pneumonectomy 3% + other 9% Lung Metastases

  12. Lung Metastases • Number of metastases • Single 46% • 4 or more 26% • 10 or more 9% • 20 or more 3% • 1 patient 154!

  13. Lung Metastases • Tumour type having multiple metastases • Sarcomas 64% • Germ cell tumours 57% • Epithelial 43% • Melanomas 39%

  14. Lung Metastases • Mediastinal lymph node involvement • Germ cell tumours 11% • Melanomas 8% • Epithelial 6% • Sarcomas 2%

  15. Lung Metastases • Radiological accuracy of the number of metastases • Accurate 61% • Underestimate 25% • Overestimate 14% Unilateral accurate 75% Bilateral accurate 37%

  16. Lung Metastases • Operative mortality overall 1% • Incomplete resection 2.4% • Complete resection 0.8% • Sub lobar resection 0.6% • Lobar resection 1.2% • Pneumonectomy 3.6%

  17. Overall Survival • Complete resection • 5yr 36% • 10yr 26% • 15yr 22% • Incomplete resection • 5yr 13% • 10yr 7% • 15yr 7%

  18. Survival with Disease Free Interval

  19. Survival for Number of Metastases

  20. Adjusted Relative Risk of Death • >36 months 0.64 • 1 metastases 0.76 • Bowel ca 0.83 • Melanoma 2.03

  21. Prognostic Groups • Risk Factors • Disease free interval > 36 months • Multiple metastases

  22. Summary • Radiology not accurate • Thoracoscopy not adequate • Multiple metastasectomies may be required • Appears to be of value in bowel cancer

  23. Soil and Seed • For colonic cancers the organ of first encounter can be the lung and the liver • Human lung metastases can be cultured in nude rat lungs but not the bowel • Togo et al Anti Cancer Research 1995

  24. Lung Metastases • Many studies report a survival advantage in large bowel cancer • Lung metastases 40% • Lung and liver metastases 30%

  25. Lung Metastases • Same prognostic factors • Number of metastases < 4 • Disease Free Interval > 3 years • No nodal disease at the primary tumour site • With no risk factors 5 year survival up to 90%! • Ishikawa, Dis-Colon-Rectum 2003

  26. Lung Metastases • Assessment for surgery • Fit for surgery, BTS and SCTS Guidelines Thorax 2001 • PFT and IHD • Control of the primary tumour • No evidence of other metastatic disease (except liver) • Brain and bone scan

  27. Lung Metastases • Follow up screening • 325 patient randomised to yearly colonoscopy, Liver CT and CXR • Not felt to improve survival from colorectal cancer when added to symptom and simple screening review • Schoemaker et al Gastroenterology 1998 • PET scan

  28. Lung Metastases • Pattern of recurrence • Certainly out to 4 years • Rectum longer than colon • Adjuvant chemotherapy may prolong the interval until recurrence and the interval until lung metastases is relatively longer • Sadahiro et al, Hepato-gastroenterology 2003

  29. Lung Metastases • Tumour Markers • CEA – sensitive but not specific • CEA doubling time • Stromal Etg-1 • Vascular integrin Beta-3

  30. Other treatments Neoadjuvant and adjuvant chemotherapy Radiotherapy Isolated lung perfusion Ablation under radiological control(BJS 2004) Lung Metastases

  31. Summary • Resection is of benefit in selected cases • The value of intensive screening is not known • The majority of patients would be fit for surgery • Surgery should be open ? Bilateral • Lung preserving procedures where possible • Redo surgery is of benefit

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

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