Surgical Indications and techniques for lung metastases

1. The 53rd International Congress of the Egyptian Society of Chestdiseases and tuberculosisMarch 2012 Cairo

2. Surgical Indications and techniques for lungmetastases ALAIN BISSON ThoracicSurgery and Lung Transplantation HOPITAL FOCH PARIS

3. Surgery in Lung metastases Incidence In autopsy studies of patients who died of extra-thoracic malignancies • 20-50 % had pulmonary metastases • 10-15 % had metastatic disease limited to the lung

4. Surgery in Lung metastases The most frequent origin Breast colorectal

5. Surgery in lungmetastases Incidence in other cancers - Hepato carcinoma 40 – 60 % - Testis 15 % - ORL 10 – 35 % - Uterus 22 % - Melanoma 12 % - Thyroïd 10 %

6. Surgery in lungmetastases 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 bronchi • 3 % bronchoscopic detection

7. Surgery in lungmetastases Imaging and diagnosis Patients followed for extra-thoracic malignancies : new lung lesions • Metastases 46 % • Primary lung tumors 32 % • Benign disease 18 %

8. 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

9. Lung metastases - imaging • CXRay • - Often first indicator of lung metastases • - Lung nodules ‘cannonball lesions’ • - Segmental collapse • - Mediastinal/hilar nodal disease • - Pleural effusion

10. Lung metastases imaging CT scan

11. Surgery in lungmetastases 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

12. Surgeryin lungmetastases Other indications for resection • Need to confirm diagnosis • Removal of residual tumors after chemotherapy • Obtention of biomedical tissue or immunohistochemical studies

13. Surgery in lungmetastases Surgery in lungmetastases International Registry of lung metastases - 4572 complete surgical resections - Follow up 46 months - Peri-operative mortality 0.8 %

14. Surgery in lung metastases Primary tumors : sarcomas Osteo 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

15. Surgery in lungmetastases 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

16. 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 lungmetastases

17. Surgery in lungmetastases Chemotherapy • Preferred treatment - for chemosensitive tumors - for primaries that metastasise else where • Variety of agents - traditionnal cytotoxics - Hormonal eg. Tamoxifen - Molecular therapics eg. Herceptin

18. Surgery in lungmetastases 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 symptoms airway compression – hemoptysis- pain

19. Pre-RF 1 month 3 months 6 months Radio frequency ablation

20. Surgery in lungmetastases Criteria and prognosis Indications - Metastatic disease limited to lung - Primary cancer definitively controlled - Patient is a good candidate for lung resection Prognosis factors - age - disease ??? - Histology and grade for primary tumor - Number of metastases resected

21. 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.

22. Surgery in lungmetastases Uni or bilateral? • Bilateral exploration for unilateral disease is not indicated • Delaying controlateral thoracotomy until disease becomes apparent does not affect survival

23. Surgery in lungmetastases 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

24. Surgery in lungmetastases Approach • Median sternotomy • Clamshell incision • Postero-lateral thoracotomy • Video Assisted Thoracic surgery (VATS)

25. Surgery in lungmetastases Median sternotomy • Exploration of both thoracic cavities (lung, hilar, chest wall) • But difficult to expose - postero costo-vertebral lung field - left lower lobe

26. Surgery in lungmetastases Clamshell incision • Excellent exposure of the posterior aspect of both lungs • But agressive and painful approach

27. Surgery in lungmetastases Postero lateral thoracotomy • Standard approach for unilateral pulmonary resection • Adequate access to all areas of the hemithorax Allows wedge or anatomic resection under direct vision

28. Surgery in lungmetastases VATS - Loss of ability to palpate the lung to detect metastases Possibly 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

29. Surgery in lungmetastases Type of resection - Wedgeis the usualresection - Howeveritcanbeextented fromwedge to pneumonectomy - Mediansurvival and disease free survivaldoes not differ • based on extent of operation - Endobronchical and locatednearbronchio-trached structures canlead to pneumonectomy

30. Surgery lung metastases 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

31. Surgery lung metastases Osteogenic sarcoma Whenthesarcoma 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

32. 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

33. Surgery in lung metastases Colo rectal cancer Surgical Resection of Pulmonary Metastases From Colorectal Cancer : A Systematic Review of Published Series Pfannschmidt J, Ann Thorac Surg 2007

34. Surgery lung metastases 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

35. 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

36. Surgery lung metastases After colorectal resection After first lung metastasectomy

37. Conclusion - 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