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Ann Thorac Surg 1998;66:1930-1933
© 1998 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Institut Mutualiste Montsouris, Paris, France
Accepted for publication June 4, 1998.
Address reprints requests to Dr Spaggiari, Department of Thoracic Surgery, European Institute of Oncology, via Ripamonti 435 20141, Milan, Italy
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Abstract |
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Methods. From 1985 to 1995, 42 patients underwent pneumonectomy for PM. Twenty-nine patients had PM from sarcomas, 12 patients from carcinomas, and 1 patient from melanoma. The indications for pneumonectomy were pulmonary recurrences in 12 patients, PM centrally located in 26 patients, and high number of PM in 4 patients. There were 11 intrapericardial and 6 extended pneumonectomies. The average number of PM resected was 3. Twenty-two patients (52%) had lymph nodes involvement.
Results. There were 2 postoperative deaths (4.8%) related to pneumonectomy and one death within 30 days for rapidly evolving disease; 4 patients (9.5%) had major postoperative complications that were medically treated. Five patients (12%) were operated on for recurrences on the residual lung. At the completion of the study, 12 patients were still alive, 8 without recurrences. The median survival was 6.5 months (range, 1 to 144 months); the 5-year survival was 16.8%.
Conclusions. Pneumonectomy should not be considered an absolute contraindication in patients with PM, but the poor outcome of our series suggests strict criteria of selection.
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Introduction |
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The extent of the pulmonary resection is one of the most important open questions; particularly, the role of pneumonectomy (pn) is not yet established because it is infrequently performed and the benefits are uncertain.
Few publications concerning the use of pn for the treatment of PM are available in literature and they are affected by limited series. Recently, The International Registry of Lung Metastases [1] reported data concerning 5,206 cases of lung metastasectomy including "only" 133 cases of pn with a postoperative mortality of 3.6% but without any mention concerning survival. Putnam and colleagues [2] published a series of 19 patients who underwent pn for PM; they reported a median survival of 27 months with a postoperative mortality of 10.5%. McGovern and associates [3] presented a series of 20 patients who underwent completion pn with an exceptional 5-year survival of about 40% without postoperative mortality. Therefore, at present, no series is available to evaluate the curative value of pn in patients with PM.
Therefore, it appeared of interest to review the postoperative outcome and the long-term results of a relatively large series of patients who underwent pn for PM.
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Material and methods |
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There were 21 male and 21 female patients, with a mean age of 48 years (range, 4 to 69 years) at the time of pneumonectomy.
There were 29 carcinoma (11 colorectum, 2 breast, 3 kidney, 4 head and neck, 2 bladder, 3 uterus, 2 testicular, 1 genital, 1 adrenal gland carcinomas), 12 sarcoma (10 soft tissue, 2 osteogenic sarcoma), and 1 melanoma patient.
All patients were surgically treated and completely resected at the time of primary malignancy. Five patients were operated on for an extrapulmonary metastases (2 liver and 3 bone) before pn.
Eligibility for pn included: (1) sterilized primary tumor; (2) no detectable metastatic localization at the time of thoracotomy other than lung on high-resolution computed tomographic brain and abdominal scan; (3) absence of bulky mediastinal adenomegaly on high-resolution computed tomographic thoracic scan; (4) no potentially curative treatment other than operation; (5) planned resection with an acceptable predicted postoperative cardiorespiratory function (predicted postoperative forced expiratory volume in 1 second not less than 35% of the theoretical values) and no echographic signs of pulmonary hypertension; and (6) young and highly motivated patients.
The indications for pn were (1) pulmonary metastatic recurrences in 12 patients (ie, completion pneumonectomy); and (2) PM centrally located or in the main bronchus in 26 patients, and high number of PM not amenable with a less extended resection in 4 patients.
Sixteen patients underwent neoadjuvant chemotherapy before operation.
There were 26 left and 16 right pns. All procedures were performed through a standard posterolateral thoracotomy except 1 patient in which median sternotomy was preferred for bilateral disease. Pneumonectomy was intrapericardial in 11 patients; extended pn was performed in 6 patients (carina, n = 2; vena cava, n = 1; left atrium, n = 1; chest wall, n = 2). The median number of metastases resected at the time of pn was 3, ranging from 1 to 20; in 15 patients metastases were solitary and unilateral, in 26 patients multiple but unilateral, and in 1 patient multiple and bilateral.
Mediastinal lymph node dissection was performed in all patients and 22 patients (52%) had nodal metastases. There were 2 cases with lobar, 8 with interlobar, and 12 with mediastinal node involvement. The percentage of lymph node involvement according to the different tumor types were 50% in sarcoma (6 of 12 patients) and 55% in carcinoma (16 of 29) patients.
Twenty-eight patients underwent pn for PM as first procedure, whereas 14 patients received a previous lung metastasectomy before pn. In this last group, 2 patients had pn after contralateral wedge resections, whereas 12 patients had the previous resection on the same side of pn (ie, completion pn). Among these, 8 patients had only one operation before pn consisting of wedge resection (n = 2), segmentectomy (n = 2), and lobectomy (n = 4). Three patients received two procedures for PM before pn: two had a double wedge resection homolateral to the pn and 1 patient had a contralateral wedge resection followed by lobectomy on the same side as the pn. Finally, 1 patient had multiple bilateral wedge resections (n = 4) followed by lobectomy on the same side as the pn. Thus, 6 patients had a lobectomy and 4 had more than one operation on the same side before pn.
The median interval between the last pulmonary resection and the current pn was 9 months (range, 1 to 31 months).
Statistical analysis
Estimate probability of survival was calculated from the date of pn by means of the actuarial method, including postoperative deaths; Rothman’s formula was used to calculate 95% confidence interval. Log rank test was used to compare the survival results.
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Results |
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Four patients (9.5%) had major complications (pyothorax, n = 2; pulmonary embolism, n = 1; hemorrhage, n = 1) and were treated medically. The remaining 35 patients had an uneventful postoperative course.
The median overall hospital stay was 12 days.
Twenty-two patients underwent adjuvant medical treatment after operation (chemotherapy, n = 16; radiotherapy, n = 5; chemoradiotherapy, n = 1).
During the follow-up, 5 patients (12%) were reoperated on the residual lung for recurrences. Table 1 lists their main characteristics.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Two important principles should be regarded during operation for lung metastases: (1) the gold standard surgical procedure is the removal of PM with the most limited parenchymal sacrifice permitting a radical operation; and (2) the related postoperative morbidity and mortality must be very low.
Pneumonectomy has been infrequently used in the treatment of PM, mainly for the following oncologic and cardiorespiratory considerations: first, aggressive and extended lung metastasectomies are sometimes oncologically considered an over-treatment and thus not accepted worldwide; second, patients with multiple lung metastases requiring pneumonectomy often have a rapidly evolving disease; third, patients with previous contralateral lung resections for PM have a limited cardiorespiratory reserve that contraindicates pn; fourth, these patients often have been submitted to different heavy chemotherapeutic protocols that diminish the cardiorespiratory reserve; finally, pn is related to a higher postoperative mortality and morbidity compared to simple wedge resections.
The results in terms of postoperative outcome and long-term survival arising from this series must be interpreted very carefully.
The mortality rate related to operation in this study is similar to that reported in historical series of surgical treatment for lung cancer. Nevertheless, considering that the cumulative surgical mortality reported for operation for PM is about 1% [1], the mortality recorded in the present series (4.8%) should prompt stricter preoperative selection criteria and is supported by the poor results in terms of cumulative 5-year survival (16.8%).
This report considers different types of tumors known to have different prognoses. Thus, because of the limited number of patients in each group, an attempt has been made to separate two main groups with similar characteristics: carcinoma and sarcoma patients. In fact, the main "histologic" breakpoint is situated between these two groups of patients because less than 10% of patients with metastatic carcinoma have "lung only metastases" [4], as compared with about 70% patients with metastatic sarcoma [5]. Therefore, the probability that metastases from sarcoma are confined to the lung is reasonably high, whereas the same probability is low in carcinoma patients. Thus, these findings suggest that pn is better indicated in patients with PM from sarcoma. To strengthen this statement, it is important to underline that extended and iterative resections have been proved to be effective to achieve long disease-free survival in sarcoma patients [6–9]; moreover, the number of PM resected did not influence the prognosis in this group, that is, in contrast, heavily conditioned by the quality of the resection [8].
The selection of carcinoma patients should be more restrictive [8]. Only young and well-motivated patients with solitary or multiple, but few, PM and normal carcinoembryonic antigen levels (in case of PM from colorectal cancer) [10] must be considered for resection.
In addition, the good surgical candidate for pn should also have a long disease-free interval between the treatment of the primary tumor and the recurrence in the lung [1]. In this view we suggest the use of chemotherapy before operation because, even if its therapeutic role is not demonstrated yet, it can exclude from operation patients with rapidly evolving metastatic disease.
The data regarding lymph node involvement are interesting. No statistically significant differences concerning survival were observed between the two groups (positive versus negative nodes); in addition, the percentage of nodal involvement was similar between sarcoma (50%) and carcinoma (55%) patients. However, the nodal involvement was always minimal and ispilateral and, although there are no data arising from the present study suggesting that metastases themselves metastasized, these results are intriguing and provocative.
Our results in terms of survival are insufficient to support pn for the treatment of PM, however, as few long-term disease-free survivors are observed; pn should not be considered a definitive contraindication in patients with otherwise resectable PM.
However, more restrictive and severe selection criteria must be used before pn is indicated for PM and further evaluation in a larger group of patients is needed before the therapeutic value, if any, of this extreme operation could be established.
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