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Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, PO Box 19638, 800 N Rutledge, Room D319, Springfield, IL 62794
(Email: shazelrigg{at}siumed.edu).
This article [1] is valuable because it compiles a relatively large series of patients with lung metastases (when one considers it is limited to only sarcomas and patients with two or less peripheral metastases). Although this represents important information, I would submit that the numbers are still too small to draw any firm conclusions with regard to survival data.
The entire subject of resection of pulmonary metastases has been frequently debated. Dr Gossot and colleagues [1] have attempted to address the debate of video-assisted thoracoscopic surgery (VATS) versus open (thoracotomy) resection. The debate has largely centered on whether VATS allows identification and resection of all potential metastases. We know from past data that there can be additional metastases found at the time of surgery not appreciated on the preoperative work-up. The central premise of pulmonary metastasectomy has been to achieve complete resection of known disease while preserving pulmonary parenchyma as much as possible.
Open procedures allow bimanual palpation of the lung, which is believed to be more likely to identify these small unsuspected lesions. The counter argument to this has been twofold. One is that with improved scans, the incidence of missed lung nodules is markedly diminished. The second point is that there really is no clear data that would suggest that if a very small metastasis is missed and later resected that prognosis is negatively impacted. An open thoracotomy may allow bimanual palpation of one lung, but it certainly leaves the contralateral lung vulnerable. In an often quoted article by Roth and colleagues [2], they identified no survival difference in sarcoma patients undergoing unilateral versus bilateral resection when only unilateral disease was recognized preoperatively.
Although this article [1] does not clearly answer the question of whether a VATS approach alters survival, it does clearly show that this surgical approach is associated with a more rapid recovery for the patient. This fact is not insignificant when one considers that more than 40% of these patients will require another chest resection. The thoracoscopic approach is more likely to be accepted by patients and physicians when multiple surgeries are required.
In our own review of patients with lung metastases from many different primary cancers, we found that almost 70% of recurrences were distant [3]. This and other data would suggest that tumor biology is the most important factor in the outcome for these patients.
I believe the authors have added additional data on pulmonary metastasectomy. This data clearly does not terminate the debate, but I believe it weighs in favor of the VATS approach being a valuable and appropriate option for lung resection in patients with parenchymal metastases.
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