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Ann Thorac Surg 1999;68:795-796
© 1999 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland USA
Address reprint requests to Dr Sonett, Division of Cardiothoracic Surgery, University of Maryland Medical Center, 22 S Greene St, Suite N4W94, Baltimore, MD 21201
e-mail: jsonett{at}surgery1.ab.umd.edu
Video-assisted thoracic surgery (VATS) has been thrust upon thoracic surgeons and patients as a technologic advancement that will improve the overall quality and treatment of patients with thoracic maladies. However, as with many of our recent technologic and operative techniques, the long-term consequences and impact of our changing techniques are not fully appreciated or studied prospectively. The use of VATS in the therapeutic treatment of pulmonary metastases, an approach with vocal critics and proponents, provides an excellent opportunity to understand the biology of metastatic cancer and our therapeutic surgical interventions.
The surgical resection of pulmonary metastases has come to be accepted as standard treatment for patients with isolated pulmonary metastases. Although no prospective studies have ever been performed to clearly assess the benefit of pulmonary metastasectomy, there is an abundance of retrospective data that indicates long-term survival benefits of complete pulmonary metastasectomy over historic control patients without resection [1–3]. The strongest prognostic variable from these retrospective studies has been complete resection of all identifiable lesions. These data have been used to support aggressive unilateral and bilateral open explorations for resection, and therapeutic VATS resection has been considered inadequate. Despite this aggressive approach, there is still a recurrence rate of more than 50%. Presently, historic data and improved imaging and surgical techniques, as well as the biology of pulmonary metastases, now support the use of therapeutic VATS as an operative technique that may yield the same disease-free survival as an open approach, but with less overall morbidity, cost, and pain to the patient.
Critical review of the historic data collected on pulmonary metastasectomy supports the use of VATS as an operative approach. Data collected from patients with soft tissue and bony sarcomas, and more recently, a collective review by the International Registry of Lung Metastases (a collective review of 5,207 patients), show a greater than 50% recurrence rate of pulmonary metastases despite open complete resection. Concurrently, the long-term survival of the patients who undergo repeat metastasectomy has been unchanged compared with patients who did not require repeat metastasectomy [2, 4, 5]. Thus, patients with pulmonary metastases may face multiple complete surgical resections, despite open techniques with palpation of the lung. It is thus important to not equate the open resection of pulmonary metastases with a complete biologic resection of all metastatic deposits.
Additional historic data support the use of less invasive approaches in pulmonary metastases. A study by Roth and colleagues [5], comparing median sternotomy with open unilateral thoracotomy, showed no difference in patient survival. This was despite the finding that bilateral exploration, with only evidence of unilateral metastases, found additional tumor in approximately 40% of the patients. This implies that each patient originally had a finite number of metastases, that when removed (even if serial resections were required) resulted in long-term survival. The literature therefore supports the potential use of less invasive procedures (VATS) in patients with isolated pulmonary metastases.
An argument against a VATS approach is that malignant nodules may be missed; this has been shown to be true by McCormack and associates [6]. Their data led to the early closure of Cancer and Leukemia Group B (CALGB 9336), a study directly comparing the ability of VATS versus thoracotomy to detect metastatic lesions not identified on preoperative screening. However, these studies were conducted before the availability of spiral computed tomography (CT) scanners. Spiral CT scanners have been found to reliably detect additional pulmonary nodules when directly compared with traditional CT scanners [7]. Spiral CT scans may detect an additional 40% more lesions [7], a similar number to that documented to be found by open technique in the study by McCormack and co-workers [6]. Spiral CT scans performed with 5-mm cuts and a 1.5-mm pitch with reconstructions will reliably identify lesions as small as 3 mm, which may be difficult to palpate. In addition, this argument would demand the use of bilateral open exploration for all patients undergoing metastasectomy, an approach found by Roth and associates [5] not to affect survival, and which does not address the biology of metastatic disease.
The biology of pulmonary metastases may favor VATS resection on the basis of the following arguments: (1) the metastases have been present from before treatment of the primary lesion, and in that sense have been missed for a significant period of time already; (2) as noted previously, multiple resections do not adversely affect the overall outcome of patients with metachronously detected metastases; (3) patients who have recurrences with unresectable disease will not be subject to a larger operation; (4) VATS resection may be less stressful for patients and therefore result in less immunosuppressive factor production, resulting in a more favorable disease course; and (5) VATS may allow patients to return to their regular work or family schedules significantly earlier than an open approach; this effect may be multiplied in a patient who requires multiple resections. Currently, there is no evidence that resection of pulmonary metastases at the time that they become radiographically apparent is any less efficacious than open procedures that remove all nodules, benign and malignant, before their radiologic identification.
Other considerations include quality of life and cost of treatment. The decrease in the quality of life in patients undergoing VATS procedures may be substantially less than those undergoing full thoracotomy or median sternotomy. Although the cost of VATS procedures is not clearly less expensive than open procedures, this has not been compared in the context of pulmonary metastases. These lesions generally are peripheral and often ideal nodules for VATS wedge resection. Often these patients can be discharged in 24 to 48 hours, and return to work in 1 to 2 weeks. This differs substantially from the 3- to 7-day hospitalization often required after a median sternotomy or thoracotomy, and cessation of work for up to 6 weeks. These issues are ideally assessed in the context of a randomized trial of minimally invasive techniques, such as VATS, and standard open procedures.
With these factors in mind, a minimally invasive approach may very well be able to achieve the same outcome as a more radical open approach. A newly activated multiinstitutional (intergroup) supported phase III study comparing open resection (thoracotomy or median sternotomy) versus minimally invasive (video-assisted) resection will prospectively study the efficacy of VATS and open approaches in the treatment of pulmonary metastases. This will allow surgeons and oncologists, for the first time, to prospectively study the prognostic indicators and survival of patients with resectable pulmonary metastases. It will also enable the prospective evaluation of a new surgical technique in relation to quality of life, cost, and oncologic outcome. Support of the thoracic surgery community to this and other cooperative group studies is paramount to the collective understanding and improvement of cancer therapeutics.
References
This article has been cited by other articles:
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  A. Nakas, M. N. Klimatsidas, J. Entwisle, A. E. Martin-Ucar, and D. A. Waller Video-assisted versus open pulmonary metastasectomy: the surgeon's finger or the radiologist's eye? Eur. J. Cardiothorac. Surg., September 1, 2009; 36(3): 469 - 474. [Abstract] [Full Text] [PDF]
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M. C. Kang, C. H. Kang, H. J. Lee, J. M. Goo, Y. T. Kim, and J. H. Kim Accuracy of 16-channel multi-detector row chest computed tomography with thin sections in the detection of metastatic pulmonary nodules Eur. J. Cardiothorac. Surg., March 1, 2008; 33(3): 473 - 479. [Abstract] [Full Text] [PDF]
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 T. C. Mineo, V. Ambrogi, M. Paci, N. Iavicoli, E. Pompeo, and I. Nofroni Transxiphoid Bilateral Palpation in Video-Assisted Thoracoscopic Lung Metastasectomy Arch Surg, July 1, 2001; 136(7): 783 - 788. [Abstract] [Full Text] [PDF]
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