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METASTASECTOMY

METASTASECTOMY. Prof. Dr. Mustafa YUKSEL Marmara University Faculty of Medicine Thoracic Surgery Department. Metastasectomy. The lung is the first capillary bed draining most primary sites, therefore lung metastasis is common

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METASTASECTOMY

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  1. METASTASECTOMY Prof. Dr. Mustafa YUKSEL Marmara University Faculty of Medicine Thoracic Surgery Department

  2. Metastasectomy • The lung is the first capillary bed draining most primary sites, therefore lung metastasis is common (the second most common metastatic locus according to studies on autopsy series) • Hematogen and lymphogen metastases are the most common • The lung is the sole site of metastasis in the 20% of the patients

  3. Metastasectomy • “Pulmonary metastasectomy” is a potentially curative surgical procedure, but the role of surgical resection of pulmonary metastases is still disputed by many oncologists on the grounds that systemic disseminated disease is already present. • When the solitary or multiple metastases are only confined to the lungs long-term survival rates are expected. • The first metastasectomy 1882 Weinlechner chest wall sarcoma – single lung metastasis

  4. Metastasectomy • Diagnosis: • First generation CT> 3mm nodule 80% (20% more nodules in surgical exploration) • IRLM* multi-institutional review covering 40 years of metastasectomy; accuracy 61% (in the assessment of the # of mets) exploration 25% more nodules 14% less nodules bilateral exploration accuracy 37% 39% more nodules *IRLM : International Registry of Lung Metastasis

  5. Metastasectomy • Diagnosis: • Spiral CT < 3mm nodule Mediastinal LAP exploration 35% more nodules (Memorial Sloan-Kettering CC) • 16-slice CT more sensitive (higher rate of false-positive lesions) Accuracy in number of metastasis 41(North Carolina U) exploration 22% more nodules 37% false-positive

  6. Metastasectomy • Tissue diagnosis: • It is a must for solitary nodules primary tumor or met? • Biopsy for multiple nodules ?

  7. Metastasectomy Primary tumor locations: • Epithelial • Colorectal • Breast • Kdney • Sarcoma • Osteosarcoma • Soft tissue • Melanoma • Germ cell tumors

  8. Metastasectomy • The ideal candidates for metastasectomy: • Sarcomas • Germ cell tumors • Pediatric malignancies • Some of the epithelial carcinomas

  9. Metastasectomy • Preoperative Staging: • Full examination of the primary site – local relapse • Tumor markers (germ cell tms, etc.) • CT, MRI, endoscopy for gastrointestinal tumors • Liver USG • Cranial CT / MRI

  10. Metastasectomy • PET > 5mm nodule* sensitivity 87% Mediastinal LAP sensitivity 100% (*the reliable limit for the size is twice the limit of the resolution of the machine) • Promising particularly in epithelial tumors which have a higher risk of extrapulmonary deposits or locoregional relapse • PET-CT ?

  11. Metastasectomy • Criteria for metastasectomy: • Local control of the primary tumor • Absence of metastases elsewhere in the patient • If removal of all disease is possible • Adequate pulmonary reserve

  12. Metastasectomy • Prognostic factors: • Histologic cell type of the primary tumor • Complete resectability (the most important indicator) • Disease free interval (DFI>36 months – good prognosis) • Number of metastases (single nodule – good prognosis)

  13. Metastasectomy IRLM* system of prognostic grouping: I resectable, no risk factors; DFI>36 months, single met. (61 months) II resectable, 1 risk factor; DFI<36 months or multiple met.s III resectable, 2 risk factors; DFI<36 months and multiple met.s IV unresectable (14 months) *IRLM : International Registry of Lung Metastasis

  14. Metastasectomy • Surgical Approach: • Open Surgery Despite the constant improvement of pulmonary imaging, radiologically occult lesions are detected by open surgery in 25 – 35% of sarcomas and 15% of nonsarcomatous lesions, and carefull palpation of the entire lung remains the gold standard in most cases. • VATS(?) (Memorial Sloan-Kettering CC – in patients who underwent thoracoscopy followed by immediate thoracotomy, open surgical exploration allowed resection of additional metastases in 56% of the cases)

  15. Metastasectomy • Surgical timing: variable • After the local control of the primary tumor • Lung surgery done first in case of synchronous met.s? (if a complete metastasectomy is a prerequisite to justify a radical approach to the primary tumor – e.g., limb amputation.) • In patients with multiple bilateral met.s, in whom resectability is questionable and prognosis poorer, the absence of new pulmonary met.s during the previous 2 months may be a further selection criterion.

  16. Metastasectomy • Open surgery: • Thoracotomy (single-stage) • Staged bilateral thoracotomies (two-stage) • Sternotomy (single-stage) • Clamshell incision (single-stage)

  17. Metastasectomy • Techniques of resection: (with 1cm margins) • Nodule enucleation / wedge resection • Stapler (wedge resection) • Electrocautery (enucleation) • Laser (enucleation) • RF Ablation ? 980 nm diode red light laser

  18. Metastasectomy • Laser metastasectomy: • Less bleeding • Less air leak • Less tissue damage • Shorter operation duration as suturing is not needed

  19. Laser Metastasectomy Bilateral laser metastasectomy (26y, mixt germ cell tumor)

  20. Metastasectomy • Techniques of resection: (occasional) • For multiple centrally located metastases or for solitary lesions suggestive of a primary tumor, anatomic segmentectomy or lobectomy can be performed. • En-bloc resections of chest wall, pericardium, or diaphragm during lung metastasectomy are still associated with satisfactory long-term survival.

  21. Metastasectomy • Lymph node dissection / sampling: • Different applications in various centers • Lymph node sampling is a must ? (European Institute of Oncology, 2007, 388 cases; lymph node involvement in 2% of cases. 5-year survival was 60% in No, 17% in N1 and 0% in N2 cases.) • Segmental and hilar lymph nodes are sampled if involvement is suspected. • Preoperative routine mediastinoscopy ? • Surgery when lymph nodes are PET-CT-positive?

  22. Metastasectomy • Survival: IRLM(5206 cases from 18 centers in Europe and N. America) • Complete resection 88% • 5-year survival 36%(germ cell tm.s 68%, melanoma 21%) • 10-year survival 26% • 15-year survival 22% • Median survival 35 months

  23. Metastasectomy • Recurrence: • Variable depending on the histology of the primary tumor • IRLM recurrence 53%, median time 10 months • Sarcoma and melanoma 64% • Germ cell tumors 26% • The 5 and 10-year survival rates of patients undergoing a second metastasectomy are little different from that seen after initial metastasectomy.

  24. Metastasectomy • Clinical follow-up: • First year x-ray every mon., CT every 3 mon.s • Untill the end of 3rd year x-ray every 3 – 4 mon.s More intense follow-up for sarcomas • X-ray every 2 – 3 months • CT every 6 months (at least for 5 years)

  25. Metastasectomy • Questions remained unanswered: • Nodal staging ? (Only for epithelial tumors, o for all?) • The role of VATS ? (An acceptable operative strategy, in which cases?) • Way of surgical approach ? (bilateral synchronous or staged unilateral procedures?)

  26. The Marmara Experience • January 1992 – December 2008: • 74 patients (54 M, 20 F) • 42.2 years of age (15 – 81) • 81 surgical intervention

  27. The Marmara Experience • Primary tumor localisation: • Bone and soft tissue sarcoma 16 • Colon 16 • Testis 15 • Urinary tract 9 • Breast 6 • Skin 5 • Lung 3 • Endometrium 3 • Larynx 1

  28. The Marmara Experience • Surgical approach: • Posterolateral thoracotomy 71 (40 R, 31 L) • Sternotomy 4 • VATS 3 • Thoracoabdominal incision 2 • Bilateral thoracotomy 1

  29. The Marmara Experience • Surgical resection: • Nodulectomy 39 • Wedge resection 37 • Lobektomy 4 • Pneumonectomy 1

  30. The Marmara Experience • Histopathological evaluation: • 55 patients had metastases of the known primary sites • 19 patients had nodules with no malignancy

  31. Metastasectomy Pulmonary metastasectomy is an effective surgical procedure, sometimes even as effective as primary tumor surgery, with a positive role in long-term survival rates, when the patient selection is done carefully and when performed meticulously.

  32. Thank You...

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