The 53 rd International Congress of the Egyptian Society of Chest diseases and tuberculosis March 2012 Cairo

Surgical Indications and techniques for lung metastases ALAIN BISSON Thoracic Surgery and Lung Transplantation HOPITAL FOCH PARIS

Surgery in Lung metastases Incidence In autopsy studies of patients who died of extra- thoracic malignancies 20-50 % had pulmonary metastases 10-15 % had metastatic disease limited to the lung

Surgery in Lung metastases The most frequent origin Breast colorectal

Surgery in lung metastases Incidence in other cancers - Hepato carcinoma 40 – 60 % - Testis 15 % - ORL 10 – 35 % - Uterus 22 % - Melanoma 12 % - Thyroïd 10 %

Surgery in lung metastases Physiopathology Via the pulmonary arteries and the capillary beds Less commonly : consequence of the lymphatic spread Spread to mediastinal lymph nodes (breast and colorectal cancer) 18 % involving bronchi 3 % bronchoscopic detection

Surgery in lung metastases Imaging and diagnosis Patients followed for extra-thoracic malignancies : new lung lesions Metastases 46 % Primary lung tumors 32 % Benign disease 18 %

Surgery in Lung metastases Imaging and diagnosis - Thoracic XR : The first document, non specific Chest CT imaging : optimal method 10 mm 100 % 6-10 mm 66 % < 6 mm 48 % - Pet scan Confirm diagnosis Spread of the disease - Biopsy – Tissu sampling

Lung metastases - imaging CXRay - Often first indicator of lung metastases - Lung nodules ‘cannonball lesions’ - Segmental collapse - Mediastinal/hilar nodal disease - Pleural effusion

Lung metastases imaging CT scan

Surgery in lung metastases Selection Criteria - The primary tumor has been controlled - No evidence of widespread extra-pulmonary metastases - The patient is in good condition for surgery with a good post-operative pulmonary function expected

Surgery in lung metastases Other indications for resection Need to confirm diagnosis Removal of residual tumors after chemotherapy Obtention of biomedical tissue or immunohistochemical studies

Surgery in lung metastases International Registry of lung metastases - 4572 complete surgical resections - Follow up 46 months - Peri-operative mortality 0.8 % Survival 5 years 10 years 15 years Complete resection 36 % 26 % 22 %

Surgery in lung metastases Primary tumors : sarcomas Osteo sarcomas : 30 % Survival 5 years : 38 % Survival 5 years after 2nd resection: 32 % Sarcomas soft tissu 20 % Survival 5 years : 36 % Survival 5 years after 2nd resection 32 % Bricolli : Cancer 2005/ Sternberg : Sem Oncol 2007

Surgery in lung metastases Primary tumors : Colorectal cancer 15-20 % metastases Survival rate : 5 years : 30-55 % Survival rate after 2nd resection : 20-30 % Sternberg B. Sem. Oncol 2007

Surgery in lung metastases Primary tumor : Breast cancer - Rare surgical indications - Rarely found isolated (bone or hepatic metastases) - Other thoracic lesions : nodes, pleural, chest wall Chang Am. Journ. Surgery 2006

Surgery in lung metastases Chemotherapy Preferred treatment - for chemosensitive tumors - for primaries that metastasise else where Variety of agents - traditionnal cytotoxics - Hormonal eg. Tamoxifen - Molecular therapics eg. Herceptin

Surgery in lung metastases Radiotherapy - Rare indication * Whole lung R.T for micrometastases - Risk of pneumonitis - No proven benefit * Focal radiotherapy on symptomatic lesions. May be used to control local symptoms airway compression – hemoptysis- pain

Radio frequency ablation Pre-RF 1 month 3 months 6 months

Surgery in lung metastases Criteria and prognosis Indications - Metastatic disease limited to lung - Primary cancer definitively controlled - Patient is a good candidate for lung resection Prognosis factors - age - disease ??? - Histology and grade for primary tumor - Number of metastases resected

Surgery in lung cancers Principles of Surgical treatment Aim : - Obtain clear margins with removal of as little normal lung tissu as possible - Inadequacy of margins mandates new resection - Most metastases tend to be peripherically located = wedge resection is usually sufficient.

Surgery in lung metastases Uni or bilateral? Bilateral exploration for unilateral disease is not indicated Delaying controlateral thoracotomy until disease becomes apparent does not affect survival

Surgery in lung metastases Mediastinal nodes Presence of metastatic nodal involvement : a direct negative effect on survival 3 year survival 69 % vs 38 % Systematic mediastinal and hilar node dissection should be performed routinely with metastasectomy - accurate staging can guide post-operative treatment

Surgery in lung metastases Approach Median sternotomy Clamshell incision Postero-lateral thoracotomy Video Assisted Thoracic surgery (VATS)

Surgery in lung metastases Median sternotomy Exploration of both thoracic cavities (lung, hilar, chest wall) But difficult to expose - postero costo-vertebral lung field - left lower lobe

Surgery in lung metastases Clamshell incision Excellent exposure of the posterior aspect of both lungs But agressive and painful approach

Surgery in lung metastases Postero lateral thoracotomy Standard approach for unilateral pulmonary resection Adequate access to all areas of the hemithorax Allows wedge or anatomic resection under direct vision

Surgery in lung metastases VATS - Loss of ability to palpate the lung to detect metastases Possibly leading to incomplete resection - Interest of pre-op imaging - Considered for diagnosis and for resection - a small number of peripherically located tumors - Necessity of pre operative marking of tumors

Surgery in lung metastases Type of resection - Wedge is the usual resection - However it can be extented from wedge to pneumonectomy - Median survival and disease free survival does not differ based on extent of operation - Endobronchical and located near bronchio-trached structures can lead to pneumonectomy

Surgery lung metastases Iterative resections - Presuming that the patient remains free of wide spread metastases to other sites - Survival was fairly stable untill the fourth procedure - DFI greater than 40 months between metastasectomies has significant survival advantage

Surgery lung metastases Osteogenic sarcoma When the sarcoma is diagnosed : 10 – 20 % of patients have metastases 85 % of these have lung metastases 2 predictive factors - Number of nodules on preoperative CT scan correlated - Histologic response to pre-op chemotherapy

Surgery lung metastases Soft tissue sarcoma The lung is often the only site of metastases - Surgical excision is considered first line therapy assuming that complete resection is possible - When pulmonary metastases recur reoperation may yield good outcomes

Surgery in lung metastases Colo rectal cancer Authors years Nb pts Post op mortality 5 years survival Higashiyama 1981-2001 100 - 52,3% Lee 1994-2004 59 0% 50,3% Melloni 1991-2004 31 44% Moore 1984-1997 47 1,7% 24% Pfannschmidt 1985-2000 167 1,8% 32,4% Rena 1980-2000 80 2,02% 41% Saito 1990-2000 165 39,6% Sakamoto 1986-2000 48% Shiono 1992-2002 87 61,4% Vogelsang 75 27% Wang 1981-2000 68 36,1% Watanabe 1992-2000 49 56% Headrick 1980-1998 58 30% Kobayaschi 1988-1996 31% Surgical Resection of Pulmonary Metastases From Colorectal Cancer : A Systematic Review of Published Series Pfannschmidt J, Ann Thorac Surg 2007

Surgery lung metastases Colorectal cancer C.R cancers spread systematically into liver or lungs Pulmonary metastases are found at a median of 37.5 months after primary colo rectal resection Prognosis factors - presence of a single metastasis - DFI > 36 months - Normal preoperative CEA level

Surgery lung metastases Colorectal cancer - Metachronous vs synchronous resection of liver and lung metastases - Patient with metachronous resection had longer survival - 70 vs 22 months - Lung resection support aggressive pulmonary metastasectomy even in the presence of hepatic metastases

Surgery lung metastases Colon cancer with lung and liver metastases Metachronous Synchronous <10 >10

Surgery lung metastases After colorectal resection After first lung metastasectomy

Conclusion - Metastases limited to the lung may be resected with prolonged survival - Selection criteria : - The pulmonary tumor is controlled - No evidence of wide-spread extra- pulmonary metastases - Good surgical candidates - Prognostic factor : complete resection