European Journal of Cardio-thoracic Surgery 39 (2011) 955—962

www.elsevier.com/locate/ejcts

Review

Current status of pulmonary metastasectomy

Kåre Hornbech *, Jesper Ravn, Daniel Andreas Steinbrüchel
Department of Cardiothoracic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark

Received 27 April 2010; received in revised form 24 September 2010; accepted 6 October 2010; Available online 27 November 2010

Summary

Malignant disease’s ability to metastasize remains one of the major obstacles when treating patients with cancer. The change from loco-
regional to systemic disease usually renders the patient beyond surgical treatment, as local treatment with surgery in a systemic disease is usually
considered without benefit. However, numerous retrospective studies have demonstrated that resection of metastases limited to the lungs may
be associated with prolonged survival. No prospective, randomized studies have been published, and most series compare highly selected
patients with historical data for unresected patients. In this article, we discuss the current status on pulmonary metastasectomy. Preoperative
assessment and selection of surgical candidates is covered. The different surgical strategies including surgical approach, unilateral versus
bilateral exploration, lymph node dissection, and repeat surgery are discussed. Finally, we review some of the common tumors that metastasize
to the lungs, the role of metastasectomy in their treatment and the prognostic factors with impact on survival.
# 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Keywords: Pulmonary metastasectomy; Resection; Surgery; Lung metastases; Cancer; Surgical approach; Thoracoscopic; Preoperative assessment; Survival

1. Introduction tolerable. Since then, numerous studies have demonstrated 5-

Malignant disease’s ability to metastasize remains one of
the major obstacles when treating patients with cancer. The
lungs are one of the most common organs to which cancer
metastasizes, and approximately 30% of all cancer patients
will develop lung metastases at some point [1].
The change from loco-regional to systemic disease usually
renders the patient beyond surgical treatment, as local
treatment with surgery in a systemic disease is usually
considered without benefit. When systemic disease is
present, chemotherapy is the mainstay of treatment and
radiation and/or surgery is reserved for palliative measures
only. However, that is not always the case.
Pulmonary metastasectomy has been performed for
decades; Alexander and Haight [2] published the first series
of pulmonary metastasectomies in 1947, and proposed the first
set of selection criteria for surgery. Thomford [3] revised these
in 1965 and, with minor changes, they remain relevant today.
They are: (1) primary tumor is controlled, (2) no extrathoracic
lesions are present (with the exception of hepatic lesions in
which it is possible to completely remove both hepatic and
pulmonary metastases), (3) the metastases seem technically
resectable, and (4) the general and functional risks are
year survival rates of 30—50% for a large variety of primary
tumors in highly selected patients. These survival rates are far
superior to any other treatment. The landmark study of the
International Registry of Lung Metastases accrued 5206
patients with different primary tumor histologies treated
with pulmonary metastasectomy from 18 thoracic surgical
departments in Europe, the USA and Canada. Survival after
complete metastasectomy at 5, 10, and 15 years was 36%, 26%,
and 22%, respectively, whereas survival after incomplete
metastasectomy was 13% and 7% at 5 and 10 years,
respectively. The discriminatory power of this study confirmed
that pulmonary metastasectomy is potentially curative.
Furthermore, multivariate analysis showed that disease-free
interval (DFI) <36 months and more than one metastasis were
independent risk factors. Numerous subsequent studies have
supported these findings. No prospective, randomized studies
have been published and most series compare highly selected
patients with historical data for unresected patients.
In this article, we discuss the current status on pulmonary
metastasectomy. Preoperative assessment of these patients
and different surgical strategies are covered. Finally, we
review some of the common tumors that metastasize to the
lungs, the prognostic factors with impact on survival and the
role of metastasectomy in their treatment.

2. Method and search strategy

* Corresponding author. Address: Department of Cardiothoracic Surgery,
2152, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark.
Tel.: +45 39 77 25 07. Studies and articles were identified using online
E-mail address: khornbech@hotmail.com (K. Hornbech). searches of The U.S. National Library of Medicine via
1010-7940/$ — see front matter # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcts.2010.10.001

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 956 K. Hornbech et al. / European Journal of Cardio-thoracic Surgery 39 (2011) 955—962

www.Pubmed.com, regarding the topic of pulmonary
metastasectomy. Several searches were conducted to
retrieve all potentially relevant articles; the searches
were performed between October 2009 and January 2010.
Terms and keywords associated with pulmonary metasta-
sectomy were used and included, for example, ‘pulmonary
metastases’, ‘pulmonary resection’, ‘thoracoscopy’, and
‘colorectal and pulmonary metastasectomy’. None of the
retrieved studies were specifically excluded from this
review. However, due to the advancement in surgical and
anesthesiological techniques, we disregarded studies
published before 1980 unless they were of historic value.
All studies identified were retrospective case series and,
thus, no randomized trial has been published.
3. Diagnosis and preoperative imaging
A pulmonary lesion in a patient with a history of cancer
could represent metastatic disease. It should always be
further investigated, as it also could represent a new lung
primary and, thus, a different treatment strategy.
In the preoperative assessment of a patient with a
pulmonary lesion suspected to be a lung metastasis,
computed tomography (CT) has become the standard.
With the invention of fast high-resolution CT (HRCT), the
size of pulmonary nodules detected may be as small as
3 mm, although the sensitivity at this size diminishes.
Margaritora and colleagues [4] evaluated accuracy with
conventional CT or HRCT, and found a sensitivity of 100%
for nodules measuring 10 mm for both types of scans.
However, the sensitivity for nodules measuring less than
6 mm dropped to 62% with conventional CT and to 48% with
HRCT. The overall sensitivity for pulmonary metastases
was 82.1%.
Diederich and colleagues [5] reported a sensitivity of 69%
for nodules smaller than 6 mm with helical CT and 5-mm slice
thickness. For nodules larger than 6 mm, the sensitivity was
95%. Pfannschmidt and colleagues [6] evaluated the slice
thickness of helical CT. They found that reducing the slice
thickness from 5 to 3 mm resulted in statistically more lesions
found during preoperative imaging compared with surgically
resected lesions with an overall sensitivity of 88.8% for 3-mm
slices and 83.7% for 5-mm slices. The sensitivity in the
detection of nodules measuring 1—4 mm was 74.7% for 3-mm
slices and 64.0% for 5-mm slices.
With the improvement in scanning techniques, the need
for perioperative bimanual palpation of the lung has been
questioned. However, with the diminishing sensitivity with
nodule size, bimanual palpation of the lung during surgery
may still detect small lesions missed by preoperative
imaging.
The positron emission tomography (PET) scan is now
widely used in the evaluation of cancer patients because of
its ability to detect malignant disease. The uptake of the
18
F-labeled glucose analog is increased in cells with high
metabolic turnover and is, thus, concentrated in malignant
cells compared with normal tissue. A study by Fortes and
colleagues [7] found an overall sensitivity of 67.5% for the
PET scan in the detection of pulmonary metastases. If the
lesion was greater than 10 mm, the sensitivity increased to
87.8%. For lesions smaller than 10 mm, the sensitivity was
only 29.6%. The sensitivity also varied with primary tumor
histology, as only 44% of sarcoma metastases were positive
in contrast to 93% for squamous cell carcinomas. The
authors conclude that PET scan cannot stand alone in the
detection of pulmonary metastases, but it can be useful as
an adjunct to the CT scan and also to exclude extrathoracic
disease in the selection of patients for surgery.
4. Lymph node status
The question of lymph node sampling and/or involvement
remains controversial. The performance of lymph node
dissection during pulmonary metastasectomy is infrequent
and varies between institutions. Of all the patients in The
International Registry of Lung Metastases, only 4.6% under-
went lymph node dissection. In a recent survey by Internullo
and colleagues [8] amongst the members of the European
Society of Thoracic Surgeons, 55% perform mediastinal lymph
node sampling whereas 33% perform no nodal sampling at all.
The rate of lymph node involvement varies between primary
tumors. Pfannschmidt and colleagues [9] performed systemic
lymph node dissection in concurrence with pulmonary
metastasectomy in 245 patients with metastases from
colorectal carcinoma, renal cell carcinoma and sarcoma.
Nodal involvement was more frequent in renal cell carcinoma
(42.4%) and colorectal carcinoma (31.3%) than sarcomas
(20.3%). Several studies have found the presence of positive
intrathoracic lymph nodes an ominous prognostic factor.
Ercan and colleagues [10] found a 3-year survival of 69% for
patients without lymph node involvement versus 38% in
patients with positive lymph nodes. Saito and colleagues [11]
reported a 5-year survival of 53.6 for patients without hilar or
mediastinal node involvement versus 6.2% at 4 years for
patients with positive nodes.
In remains unclear whether the removal of these lymph
nodes is associated with a survival benefit or merely allows
for a more accurate postoperative staging and guidance for
additional oncological treatment. The above-mentioned
authors proposed the latter.
4.1. Surgical approach
The original surgical approach to pulmonary metasta-
sectomy was simultaneous bilateral thoracotomy or staged
surgery. Posterolateral thoracotomy provides excellent
exposure of the entire lung, and allows total bimanual
palpation of the lung for undetected pulmonary lesions
missed by preoperative imaging. The disadvantage is post-
operative muscle pain and respiratory problems. The midline
sternotomy used in cardiac surgery can provide access to
both lungs while sparing the patient from some of the
postoperative morbidity associated with thoracotomy. How-
ever, access to the posterior parts of the lung is limited,
especially the left lower lobe, and, thus, lesions in these
areas can be technically difficult to resect. The clamshell
incision, which involves bilateral simultaneous thoraco-
tomies and a sternal split, has also been used in pulmonary
metastasectomy. While providing excellent exposure to both
hemithoraces, it combines the worst of thoracotomy and
sternotomy with regard to postoperative morbidity.

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The need for bilateral exploration of the lungs is based
upon the assumption that pulmonary metastases represent a
systemic disease with a great probability of bilateral spread,
even though metastases are not detectable by preoperative
imaging. Thus, unilateral exploration would result in
incomplete resection due to undetected contralateral
lesions. This was successfully challenged by Roth and
colleagues [12] when they found that bilateral exploration
by sternotomy provided no survival benefit when compared
with unilateral exploration by thoracotomy. In a more recent
study, Younes and colleagues [13] investigated the need for
bilateral exploration in patients with unilateral disease from
various primary tumors. They performed 179 unilateral
thoracotomies in patients with unilateral disease and 88
bilateral thoracotomies for bilateral disease, and followed
the patients for contralateral disease-free survival and
overall survival. They found no significant difference in
survival in patients with unilateral disease with recurrence in
the contralateral lung when compared with the patients, who
had undergone bilateral thoracotomy. The authors concluded
that delaying contralateral thoracotomy until disease
becomes radiologically evident does not affect survival
and that bilateral exploration for unilateral disease is not
indicated.
The newest surgical approach to pulmonary metastasect-
omy is by video-assisted thoracoscopic surgery (VATS). This
minimally invasive approach provides excellent exposure of
the lung surface, reduces surgical trauma, minimizes post-
operative pain, provides earlier patient mobilization and
decreases hospital length of stay. Pulmonary metastases are
often small nodules located in the periphery of the lung, well
suited for wedge resection by stapler and the VATS approach.
The disadvantage is the loss of tactile sensation and the
ability to bimanually palpate the entire lung and, hence, miss
lesions undetected by imaging. Thus, the quality of the
preoperative imaging becomes critical to success with VATS
surgery.
McCormack and colleagues [14] have addressed this issue.
They retrospectively reviewed 72 patients, who underwent
pulmonary metastasectomy by thoracotomy. When the
number of metastases removed during surgery was compared
with preoperative imaging, they found a 42% error rate and
that CT scan underreported the number of lesions in 25% of
patients. In another study, they prospectively compared CT
scan results, VATS and confirmatory open thoracotomy with
bimanual palpation and found a 56% failure rate of CT and
VATS to detect all lesions [15]. The study was ended pre-
emptively due to the failure rate, and they concluded that
VATS should be reserved for solely diagnostic purposes.
However, these studies are confounded by the use of older CT
scanners.
More recent studies have demonstrated equal survival
outcomes with VATS surgery as compared with open
thoracotomy. Landreneau and colleagues [16] performed
80 VATS procedures and reported a 5-year survival of 30.8%
for patients with colorectal pulmonary metastases resected.
Mutsaerts and colleagues [17] found no significant difference
in survival in patients who underwent VATS compared with
patients who underwent VATS followed by confirmatory
thoracotomy. Only patients with a single, peripherally
located lesion, and <3 cm, preoperatively detected by a
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957
CT scan were included in this study. Another study by
Mutsaerts and colleagues [18] with VATS followed by
confirmatory thoracotomy found that in patients with only
one lesion detected on preoperative CT, no further lesions
were found by confirmatory thoracotomy. Gossot and
colleagues [19] investigated the VATS approach in patients
with two or less pulmonary metastases from sarcoma and
found a 5-year survival rate of 52.5%.
There is no doubt that open surgical exploration can
detect lesions missed by preoperative imaging. However,
evidence of prolonged survival with the removal of micro-
nodules with a size of 1—2 mm, missed by CT scan and
detected by bimanual palpation, does not exit. The
assumption of this would be that removal of a 1—2-mm
lesion results in survival benefit whereas overlooking a 0.5-
mm lesion has no influence of survival. A lesion of that size
would also be missed preoperatively, even with modern CT.
Another advantage of VATS is the preservation of the
ability to perform repeat operations. VATS results in fewer
pleural adhesions than thoracotomy, and does not complicate
a potential repeat operation by thoracotomy [20].
To date, no randomized studies regarding VATS versus
open surgery have been published. At present, it seems that
VATS can be considered for diagnosis and for pulmonary
metastasectomy in the presence of few, peripherally located
lesions. In case of discrepancy between preoperative imaging
and perioperative findings or inability to achieve radical
surgical margins, conversion to open surgery should be
mandatory.
4.2. Recurrence of disease and repeat surgery
The recurrence of disease after pulmonary metastasect-
omy is not uncommon. In the International Registry of Lung
Metastases [21], the rate of recurrence of disease was 53% for
all patients, who underwent complete resection. The rate of
recurrence varied amongst the different primary tumors,
with sarcomas and melanoma being more frequent (64%) than
epithelial tumors (46%). The site of recurrence also differed
with sarcoma (66%) being the most frequent as regards
intrathoracic relapse in contrast to melanoma where 73%
relapsed extrathoracically. The 5-year survival for all
patients with repeat surgery was 44%.
Several later studies have analyzed the impact on survival
after recurrence of disease and repeated pulmonary
metastasectomy, and have confirmed these findings. In
patients with recurrence of colorectal metastases, studies
by Pfannschmidt [22], Welter [23], and Ogata [24] have
reported a 5-year survival of 54.6%, 46%, and 33%,
respectively. For sarcomas, studies by Briccoli [25], Harting
[26], and Rehders [27] have reported 5-year survival rates of
32%, 22,6%, and 36%, respectively.
Jaklitsch and colleagues [28] investigated the value of
sequential pulmonary metastasectomy from various primary
tumors. As many as 54 patients underwent at least two
metastasectomies and up till six. They found that 5-year
survival was stable (>33%) until the 5th or subsequent
procedure. With the loss of local control due to unresectable
tumor in the thorax, further survival dropped to a 2-year
survival of 19%. The authors concluded that repeated
 958 K. Hornbech et al. / European Journal of Cardio-thoracic Surgery 39 (2011) 955—962
metastasectomy was well justified as long as local control
within the thorax was feasible.
None of the above-mentioned studies have found repeat
surgery to be an ominous prognostic factor. Thus, if a patient
fulfils the initial criteria for pulmonary metastasectomy,
repeat surgery does not have an adverse effect on survival. A
possible explanation for this could be that these patients
represent an even further-selected subgroup of less malig-
nant tumors. Further, the patients must be in good condition
to undergo a second operation and, thus, only good
candidates for surgery are selected.
It remains unclear whether resection of all metastases at
one time is critically important in terms of survival. Naturally,
during each surgery, all malignant disease should be
removed. Lesions undetected by preoperative imaging or
during surgery, but detected during follow-up, may not alter
survival as long as they are resected before they become
unresectable.
The current status and recent results of pulmonary
metastasectomy from various primary tumors are discussed
in the following sections.
4.3. Colorectal cancer
Approximately 10—20% of patients with colorectal cancer
will develop pulmonary metastatic disease [29]. Isolated
pulmonary metastases without extrathoracic disease are,
however, rare and account for as little as 2% of patients with
metastatic colorectal carcinoma [30]. In a recent article,
Pfannschmidt and colleagues [31] evaluated the current
status of surgical resection of pulmonary metastases from
colorectal carcinoma and prognostic factors significant in
patient selection. Inclusion criteria included studies pub-
lished between 1995 and 2006, more than 40 patients and
patients included in the studies should be no later than 1980.
Twenty studies were included.
The overall 5-year survival after pulmonary metasta-
sectomy ranged between 38.3% and 63.7% with a median of
52.5%. They suggested that achieving R0 resection is most
critical for postoperative survival. In their article, two
studies confirmed this and three studies could not. More than
50% of the patients included presented with a single
metastasis and seven studies demonstrated a significantly
better survival with a single lesion versus multiple lesions.
Thus, patients with a single lesion seem to benefit more from
pulmonary metastasectomy than patients with multiple
metastases. An elevated level of prethoracotomy carci-
noembryonic antigen (CEA) had an adverse effect on survival
in the majority of studies. However, patients with an
elevated level of CEA still fared better than unresected
patients, and they concluded that even though an elevated
level of CEA is an ominous prognostic factor, these patients
should not be excluded from pulmonary metastasectomy.
The DFI, one of four different prognostic factors in the
International Registry of Lung Metastases, was only sig-
nificant in two studies and, in the majority of studies, DFI did
not influence survival.
Approximately 15% of patients resected for colorectal
carcinomas can be expected to have hepatic metastases at
the time of exploration [32]. As many as 50% will eventually
develop liver metastases, and liver resection for metastatic
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disease is an established treatment [33]. If control of liver
metastases can be achieved, combined resection for liver and
lung metastases does not have an adverse effect on survival
[34,35].
Shiono and colleagues [36] investigated the prognostic
effect of histopathological variables such as the presence of
aerogenous spread with floating cancer-cell clusters within
the alveoli (ASFCs) and bronchial, vascular, lymphatic or
pleural invasion. They investigated 136 metastatic lesions
from 89 patients. Patients without any of these features had a
remarkable 5-year survival of 93.3% while in patients positive
for both AFSC and vascular invasion it was 24.7%. The
influence of tumor biology on survival seems emphasized by
this study.
4.4. Renal cell carcinoma
Approximately 25—30% of patients with renal cell
carcinoma will have metastatic disease at diagnosis and a
further 30% of patients will eventually develop metastases,
with the lungs being the most common organ [37]. Previous
studies have demonstrated 5-year survival rates between 31%
and 53% from renal cell carcinoma, after pulmonary
metastasectomy [38—40].
Of the studied prognostic factors, completeness of
resection was found to be a significant prognosticator of
survival in all studies. The number and size of metastases also
influenced survival, with few and small metastases having a
positive effect on postoperative survival. Further, with a
longer DFI, a better survival was reported compared with
short DFI. However, the latter prognostic factors could only
be verified in some of the above-mentioned studies.
5. Malignant melanoma
Surgical treatment of lung metastases from melanoma is
controversial, as the expected outcome is much poorer than
for other primary tumors. The ability of malignant
melanoma to disseminate widely causes the number of
patients eligible for pulmonary metastasectomy to be very
small, as patients with isolated pulmonary metastases are
rare. Once malignant melanoma has spread to a distant site,
the median survival is 8 months, and the 5-year survival is
less than 5% [41]. Previous studies with pulmonary metas-
tasectomy from malignant melanoma have demonstrated 5-
year survival rates between 22% and 33% [42—44]. This is,
however, far superior to medical treatment alone. Of the
prognostic factors investigated, completeness of resection
seems to be the strongest, as patients without R0 resection
have a survival similar to non-resected patients. Further,
presence of only a single metastasis and long DFI seem
associated with a positive effect on survival. Given the grim
prognosis for patients with metastatic melanoma, pulmon-
ary resection is a reasonable option in carefully selected
patients.
5.1. Head and neck cancer
Head and neck cancer is comprised of a heterogeneous
group of carcinomas such as squamous cell carcinoma of the
 K. Hornbech et al. / European Journal of Cardio-thoracic Surgery 39 (2011) 955—962
larynx, pharynx and oral cavity, and glandular and adenoid
cystic carcinomas. They usually metastasize to regional
lymph nodes and then to more distant organs, with the
lungs being the most frequent [45]. Ferlito and colleagues
reported an incidence of metastases of 4.2—23.8% in
squamous cell carcinomas and 37.7—58.8% in adenoid
cystic carcinomas. The number of reports evaluating the
benefit of pulmonary metastasectomy in head and neck
cancers is limited. Studies by Mazer [46], Wedman [47], Liu
[48], Chen [49], and Winter [50] have reported 5-year
survival ranging from 20.9% to 59%. Survival varies with
primary tumor histology with best survival reported for
adenoid cystic carcinoma followed by glandular and
squamous carcinoma (84%, 64%, and 34%, respectively in
the study by Liu). Reported prognostic factors with
significant influence on survival were completeness of
resection and long DFI. Due to the small number of studies,
the benefit of pulmonary metastasectomy in head and neck
carcinomas is still unclear. Most authors, however,
advocate resection if the patient fulfils the standard
criteria for pulmonary metastasectomy.
5.2. Breast cancer
The role of pulmonary metastasectomy in metastatic
breast cancer is unclear. Several studies have shown decent
5-year survival ranging from 30% to 54% [51—53]. However, it
is doubtful whether these survival rates are better than those
achieved by modern, systemic oncological treatment with
chemotherapy and/hormone therapy. In a study by Rahman
and colleagues [54] with 1581 patients treated with
chemotherapy, a response rate of 65%, including 16.6%
complete responders, could be demonstrated. The overall
median survival was 21.3 months and 41.8 months for
complete responders. The median survival for resected
patients is not superior to patients treated with modern
chemotherapy.
Planchard and colleagues [55] and Welter and
colleagues [56] found no difference in survival between
complete and incomplete resection, which certainly
questions the impact of surgery on survival. McDonald
and colleagues [57] even found a better 5-year survival for
patients with incomplete resection (41.1%) versus com-
plete resection (35.6%). However, the difference was not
significant.
Of prognostic factors associated with longer survival in
patients with resectable pulmonary disease, a long DFI and
single metastasis have been demonstrated as positive
prognosticators.
The recent study by Welter [56] also investigated hormone
receptor status of the resected nodules and found the
presence of positive estrogen receptor or Her2-neu receptor
status to have a positive impact on survival.
At present, it seems that the value of pulmonary
metastasectomy in patients with breast cancer is of
diagnostic purpose. However, the value of histological
examination of pulmonary lesions cannot be underestimated
to find and resect a possible new lung primary, or, in case of
confirmed breast cancer metastases, direct further treat-
ment with regard to grading, estrogen receptor, and Her2-
neu receptor status.
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5.3. Testicular cancer
Non-seminomatous germ cell tumors are characterized by
a wide dissemination, with the lungs being the most frequent
organ and a high sensitivity to cisplatin-based chemotherapy.
The cure rate has greatly improved to a range of 59—82% over
the past decades [55,58,59]. Metastectomy is performed
after completion of cisplatin-based chemotherapy. Surgery is
directed at removing residual lung disease to determine
further treatment. Therefore, aggressive resection of all
suspicious lesions is required for prognostic assessment. In
case of necrosis/fibrosis or teratoma, no further treatment is
required in contrast to detection of viable cancer cells, which
require additional chemotherapy. The presence of multiple
metastases, elevated tumor marker levels of human
chorionic gonadotropin (hCG) or alpha fetoprotein (AFP) or
the presence of viable tumor cells in the resected nodules
have been demonstrated to be associated with an adverse
effect on survival [60—62].
5.4. Osteosarcoma
Osteosarcoma patients are particularly prone to develop
pulmonary metastases. A total of 10—20% of patients will
have detectable pulmonary lesions at initial diagnosis and up
till 70% of patients will develop pulmonary metastases [63—
65]. Failure to control thoracic disease is the cause of death
of nearly all patients with metastatic osteosarcoma [66]. As
discussed previously, sarcoma predominantly relapses in the
lungs. Therefore, several studies have shown a possible
survival benefit in patients with metastatic osteosarcoma
when pulmonary resection is performed aggressively and
repetitively. Studies by Tsuchiya [67], Kager [68], and Suzuki
[69] have shown 5-year survival rates between 29% and 43%.
In almost all reports, the radicality of resection is a strong
prognostic factor, as patients without R0 resection have a
very poor prognosis. Conflicting data have been reported
with regard to DFI, number of metastases, size of metastases
and laterality, and the prognostic importance of these factors
remains unclear.
Surgery remains the mainstay of treatment in the case of
disseminated osteosarcoma to the lungs, and in non-
metastatic disease, chemotherapy also plays an important
role in prolonging survival [65]. The addition of neo-adjuvant
chemotherapy before pulmonary resection has also been
demonstrated to be associated with a positive effect on
survival, in particular when histologic response to che-
motherapy can be demonstrated. However, patients treated
only with chemotherapy have a very poor prognosis [70], and
surgical resection of metastatic disease to the lungs remains
the most efficient therapy.
5.5. Soft tissue sarcoma
Soft tissue sarcoma (STS) is a heterogeneous group of
malignant tumors with more than 50 histological subtypes
[71]. In metastatic STS, the lungs are the most frequent organ
affected and is seen in 20% of patients [72], less than with
osteosarcoma. Several studies on pulmonary metastasect-
omy for STS have been published and the 5-year survival
ranges from 25% to 43% [73—76]. All these studies showed
 960 K. Hornbech et al. / European Journal of Cardio-thoracic Surgery 39 (2011) 955—962
that complete surgical resection of pulmonary metastases is
a significant prognostic factor of STS. There is less
concordance in terms of other prognostic factors such as
number, size, and laterality of metastases. However, in most
studies, a short DFI was associated with a worse prognosis.
Usually, the many different histologies of STS are grouped
together and reported as a whole. However, studies by
Billingsley [74], and Casson [77] have demonstrated histology
of the primary STS to be a significant prognostic factor of
postoperative survival. Malignant fibrous histiocytoma,
rhabdomyosarcoma, and synovial sarcoma are regarded as
more favorable while liposarcoma or peripheral nerve
sarcomas have a worse prognosis. In general, metastatic
STS is less sensitive to chemotherapy than osteogenic
sarcoma, and the response and survival data with che-
motherapy remain disappointing. Therefore, surgical treat-
ment of metastatic pulmonary STS is the best hope for cure in
selected patients.
6. Conclusion
Patients with untreated metastatic disease have a 5-year
survival rate of less than 5—10% and, for a patient with
isolated metastatic disease to the lungs, pulmonary metas-
tasectomy is often the best hope for cure. It is a safe and
effective treatment that leads to possible cure in selected
patients. Regardless of primary tumor, completeness of
resection is the key to improved survival. Low morbidity and
mortality rates, in contrast with the lack of any other
effective systemic oncological treatment, justify the aggres-
sive approach of surgery. Thoracoscopic resection is a valid
option in selected patients with few, peripherally located
metastases. In case of recurrence of pulmonary disease, and
if the patient fulfils the initial criteria for pulmonary
metastasectomy, repeat surgery should be performed.
Aggressive postoperative follow-up is warranted. The
patients should be treated in close collaboration between
the medical oncologist, diagnostic radiologist and thoracic
surgeon.
However, despite numerous studies and decades of
metastasectomies, the lack of randomized studies continues
to make the effect of pulmonary metastasectomy question-
able. Most studies have been retrospective and the biases are
many: possibly, only patients in good physical condition are
referred; possibly only patients with slow-growing tumors are
referred (time-length bias) or, possibly, earlier detection
through more aggressive follow-up leads to earlier surgery
with a seemingly longer period of survival. Most reports
recommend pulmonary metastasectomy for a properly
selected group of patients. However, the case-mix from
which patients are selected for surgery is rarely described.
Whether the survival of these patients is based on
selection rather than surgery is still not clear. As argued
by Treasure and colleagues [78,79], amongst others, it
remains ‘a common practice based on weak evidence.’
Further, prognostic factors that determine which patients
will benefit from surgery are still not clearly established. To
determine how to select surgical candidates for pulmonary
metastasectomy more precisely, further analysis of prog-
nostic factors is evident and the need for a prospective,
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randomized, multicenter study is clear. The recently opened
Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC)
trial [80], a multicenter and randomized trial, may provide
some answers.
Furthermore, the Lung Metastasectomy Working Group, a
working group under the European Society of Thoracic
Surgeons established in 2006, is working towards evaluating
the evidence and to generate guidance for the future in
pulmonary metastasectomy [81].
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