1. Resection For Lung Metastases M62 Coloproctology Course

2. Lung Metastases  1 st resection of a single metastases discovered during the excision of a chest wall sarcoma  Elective surgery occasionally offered to selected patients with single metastases and long disease free interval  Only in a few centres has metastasectomy been applied systematically to multiple or bilateral lesions with or without chemotherapy

3. Lung Metastases  Surgical resection of pulmonary metastases now considered standard therapy in properly selected cases  Many tumours may involve the lung as the unique site of distant spread ‘organ of first encounter’  Complete surgical resection of all pulmonary deposits is often technically feasible with low morbidity and mortality

4. Lung Metastases  It is difficult to asses the real proportion of patients with isolated lung metastases who are candidates for salvage surgery, what is the denominator  Sarcomas, germ cell tumours prob > 50%  Epithelial tumours probably far less

5. Lung Metastases  Overall 5 year survival reported as 20- 40% for all primary sites  Much higher than expected after chemotherapy or radiotherapy alone

6. Lung Metastases  Controversy remains over  Selection of patients  Bilateral surgical staging  Adjuvant chemotherapy  Prognostic factors

7. Lung Metastases  International Registry of Lung Metastases reported in 1997  5290 patients from 18 centres over 50 years!  Mean age 44 years (2-93)

8. Lung Metastases  5290 patients  43% epithelial  42% sarcomas  7% germ cell tumours  6% melanomas  2% others

9. Lung Metastases  Presentation time of metastases  Synchronous11%  0-11 months20%  12-35 months36%  >36 months 31%

10. Lung Metastases  Surgical approach  Thoracotomy58%  Bilateral thoracotomy11%  Median sternotomy27%  Thoracoscopy2%

11. Lung Metastases  Surgical resection  Wedge 67%  Segmentectomy 9%  Lobectomy 21%  Pneumonectomy 3%  + other 9%

12. Lung Metastases  Number of metastases  Single46%  4 or more26%  10 or more9%  20 or more3%  1 patient 154!

13. Lung Metastases  Tumour type having multiple metastases  Sarcomas64%  Germ cell tumours57%  Epithelial43%  Melanomas39%

14. Lung Metastases  Mediastinal lymph node involvement  Germ cell tumours11%  Melanomas8%  Epithelial6%  Sarcomas2%

15. Lung Metastases  Radiological accuracy of the number of metastases  Accurate61%  Underestimate25%  Overestimate14% Unilateral accurate75% Bilateral accurate37%

16. Lung Metastases  Operative mortality overall 1%  Incomplete resection2.4%  Complete resection0.8%  Sub lobar resection 0.6%  Lobar resection1.2%  Pneumonectomy3.6%

17. Overall Survival  Complete resection  5yr36%  10yr26%  15yr22%  Incomplete resection  5yr13%  10yr7%  15yr7%

18. Survival with Disease Free Interval 5 year 10year 0-11 mths 33%27% 12-35 mths 31%22% > 36 mths 45%29%

19. Survival for Number of Metastases 5 year 10year 1 met 43%31% 2-3 mets 34%24% >4 mets 27%19%

20. 5 year 10year Germ cell 68%63% Epithel ial 37%21% Sarco ma 31%26% Melan oma 21%14%

21. Adjusted Relative Risk of Death  >36 months0.64  1 metastases0.76  Bowel ca0.83  Melanoma2.03

22. Prognostic Groups  Risk Factors  Disease free interval > 36 months  Multiple metastases

23. Summary  Radiology not accurate  Thoracoscopy not adequate  Multiple metastasectomies may be required  Appears to be of value in bowel cancer

24. Soil and Seed  For colonic cancers the organ of first encounter can be the lung and the liver  Human lung metastases can be cultured in nude rat lungs but not the bowel  Togo et al Anti Cancer Research 1995

25. Lung Metastases  Many studies report a survival advantage in large bowel cancer  Lung metastases40%  Lung and liver metastases30%

26. Lung Metastases  Same prognostic factors  Number of metastases < 4  Disease Free Interval > 3 years  No nodal disease at the primary tumour site  With no risk factors 5 year survival up to 90%!  Ishikawa, Dis-Colon-Rectum 2003

27. Lung Metastases  Assessment for surgery  Fit for surgery, BTS and SCTS Guidelines Thorax 2001  PFT and IHD  Control of the primary tumour  No evidence of other metastatic disease (except liver)  Brain and bone scan

28. Lung Metastases  Follow up screening  325 patient randomised to yearly colonoscopy, Liver CT and CXR  Not felt to improve survival from colorectal cancer when added to symptom and simple screening review  Schoemaker et al Gastroenterology 1998  PET scan

29. Lung Metastases  Pattern of recurrence  Certainly out to 4 years  Rectum longer than colon  Adjuvant chemotherapy may prolong the interval until recurrence and the interval until lung metastases is relatively longer  Sadahiro et al, Hepato-gastroenterology 2003

30. Lung Metastases  Tumour Markers  CEA – sensitive but not specific  CEA doubling time  Stromal Etg-1  Vascular integrin Beta-3

31. Lung Metastases  Other treatments  Neoadjuvant and adjuvant chemotherapy  Radiotherapy  Isolated lung perfusion  Ablation under radiological control(BJS 2004)

32. Summary  Resection is of benefit in selected cases  The value of intensive screening is not known  The majority of patients would be fit for surgery  Surgery should be open ? Bilateral  Lung preserving procedures where possible  Redo surgery is of benefit

33. Conclusion  Resection of lung metastases in patients with carcinoma of the colon and rectum is beneficial in selected cases. Further investigation is required to identify all those patients who would benefit and to establish the optimal treatment regime