Ann Thorac Surg 1998;66:218-219
© 1998 The Society of Thoracic Surgeons
Original articles: general thoracic
Invited commentary
Jonathan C. Nesbitt, MDa
a Cardiovascular Surgery Associates, PC, St. Thomas Medical Bldg, Suite 501, 4230 Harding Rd, Nashville, TN 37205, USA
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Invited commentary
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 Invited commentary
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Regnard and colleagues give an interesting report on a surgical dilemma that is seldom reported in the literature. They describe their experience with 43 patients who underwent resection of pulmonary metastases and who had undergone previous resection of hepatic metastases from their colorectal carcinoma. There were no operative deaths. Median survival from pulmonary resection was 19 months. The 5-year survival for their patients who underwent resection for metastatic disease to only the lungs was slightly lower than that observed in other reported series, 27% versus 30% to 45%, respectively. An important finding was the 5-year survival seen for the focus group of 43 patients, which was not statistically different from the 5-year survival for their patients with lung-only metastases. Although 10-year actuarial survival was poor, the early survival benefit suggests the advantage of resection.
Hepatic and pulmonary metastases from colorectal carcinoma reflect portal or systemic spread of a disease whose aggressiveness is determined primarily by its biology. Resection is regarded as the standard of care for isolated metastases to either the lung or the liver. Optimal surgical management, however, is less clear when metastatic disease involves both organs, as in this group described by Regnard and colleagues. Selection of patients for resection is difficult. The tumors in such patients are usually more biologically active and the potential for finding unresectable metastases is high. Although one may try to extrapolate that patients with involvement of both organs (synchronously or metachronously) are also best treated by resection, only a few patients are reasonable candidates for resection. How, then, should we as thoracic surgeons advise our patients who present with this problem?
Until there is conclusive evidence to direct therapy for this unique problem, we must use the data gathered from our various experiences to guide us. Quality measures and outcomes are also important factors that must be addressed in our decision making. Based on current information, specific criteria for selection of appropriate surgical candidates can be outlined. Poor candidates include those with synchronous lesions, a short latency period, high carcinoembryonic antigen levels, and a low probability of complete resection; other therapy should be offered to these patients. Patients with adequate pulmonary function, the absence of poor clinical prognostic factors, and no distant disease should be considered for resection, which can be performed safely and with low mortality. When considering an operation, we must recognize the limitations of resection for patients with metastatic disease. Resection will only succeed long-term in those patients in whom all disease can be grossly identified and completely resected. Unfortunately, most patients with metastases will not benefit long-term from resection because concurrent micrometastases are present. Although the subset described by Regnard and colleagues comprises a small collection of patients, they can benefit from resection. A surgical approach is feasible in this group and has the potential to provide, at least, satisfactory short-term survival.
