Ann Thorac Surg 2005;79:325-326
© 2005 The Society of Thoracic Surgeons
Case report
Long-Term Survival After Salvage Surgery for Colorectal Lung Metastases
Pietro Fabio Presicci, MDa,
Giulia Veronesi, MDa,
Massimiliano D'Aiuto, MDa,
Lorenzo Spaggiari, MD, PhDa,*
a European Institute of Oncology, Division of Thoracic Surgery, Milano, Italy
Accepted for publication August 6, 2003.
* Address reprint requests to Dr Spaggiari, European Institute of Oncology, Division of Thoracic Surgery, 435, Via Ripamonti, 20141 Milan, Italy
lorenzo.spaggiari{at}ieo.it
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Abstract
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We report the case of a patient with an extended pneumonectomy for colorectal lung metastases after the failure of multimodal treatment. Salvage surgery may be useful in highly selected patients to achieve local control, resulting in long-term disease-free survival.
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Introduction
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Although pulmonary metastasectomy for colorectal metastases is now an acceptable therapeutic option that can lead to long-term survival in selected patients [1], the type of lung resection that should be performed is still debated. In selected patients with local recurrence, extended resections have been reported with encouraging results in terms of local disease control [2–7]. We report on a patient with recurrent colorectal lung metastases in whom salvage surgery (extended pneumonectomy) after multimodal treatment (chemotherapy, redo surgery, and radiotherapy) resulted in long-term disease-free survival.
In 1990, a 55-year-old man underwent a left hemicolectomy for colorectal adenocarcinoma, stage Dukes B1. In 1995, a single, right lung deposit infiltrating the middle lobe, pericardium, and the phrenic nerve was diagnosed, and a middle lobectomy with pericardiectomy and resection of the phrenic nerve was performed at another center. Because of the presence of a microscopic residual tumor on the bronchial stump, postoperative radiotherapy at 40 Gy was given, followed by first-line chemotherapy with cisplatin and 5-fluorouracil.
In 1997, a local recurrence in the right lung was suspected and a redo operation was performed, but no malignant tissue was found. In February 1998, a computed tomographic (CT) thoracic scan revealed four nodules in the right lung. Second-line chemotherapy (5-fluorouracil) was initiated, after which the patient was admitted to the European Institute of Oncology for further assessment. On admission, a physical examination failed to find any symptoms. He received a complete preoperative evaluation that included a CT total body scan, colonoscopy, and bone scintigraphy. No extrathoracic deposits were identified. However, the thoracic CT scan showed multiple pulmonary recurrences on the right side that were resectable by extended pneumonectomy (Figs 1A, 1B); thus, a salvage operation was planned.
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Fig 1. Thoracic computed tomographic scan showing the recurrences from colorectal cancer (A, two recurrences; B, one recurrence) in the right lung before extended completion pneumonectomy.
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A cardiorespiratory evaluation showed a forced expiratory volume in 1 second of 1.35 L (34%), with 15% right lung perfusion. Echocardiography was normal without signs of pulmonary hypertension. Thus, the patient met our criteria for salvage metastasectomy, and a right extended (left atrium) completion pneumonectomy with radical lymph node dissection was performed in July 1998. A muscular diaphragmatic flap was used to cover the bronchial stump and, at the same time, close the pericardium. The patient's postoperative course was uneventful, and he was discharged on eighth postoperative day. The resected specimen showed multiple colorectal recurrences. No further therapies were given after surgery. At the latest follow-up in July 2003, the patient was alive, disease-free, and physically active.
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Comment
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Lung metastasectomy by extended "salvage" resections has been proposed in recent years to improve local control of the disease and to maintain a disease-free state of health for a relatively long time [2–7]. The term "salvage surgery" refers to a high-risk operation after the failure of multimodal treatment (chemotherapy, radiotherapy, and redo surgery) in an attempt to achieve local disease control in patients with localized lung disease but no extrathoracic deposits. However, such operations have an uncertain survival advantage. Our selection criteria for salvage surgery are: - young age ( < 65 years),
- the patient is motivated and fully informed about the proposed surgery,
- previous medical and surgical treatments have failed,
- no other effective treatments are available,
- no signs of extrathoracic disease,
- tumor cells are slow growing so that local treatment has a chance of achieving prolonged local control, and
- a careful cardiorespiratory evaluation shows that surgery is feasible.
We have reported previously that completion pneumonectomy for lung metastases may lead to a 5-year survival of 10%, with 12% postoperative mortality [5]. Good results in terms of local control have even been reported for surgery on a single lung after pneumonectomy for metastases [6, 7]. The present case provides a further example of the successful use of salvage surgery to achieve control of recurrent lung malignancy. However, it is not often possible to determine whether the successful outcome in these selected patients is due to the surgery or to the biologic behavior of the slow-growing tumor. In our patient, there has been no sign of disease recurrence for 5 years, which suggests that the surgery itself was effective. We believe that salvage lung metastasectomy should not be considered an absolute contraindication, but it should be reserved for highly selected cases with local relapse of a slow-growing disease after the failure of multimodal treatment.
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References
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Abstract
Introduction
