(Chest. 1999;115:1441-1443.)
© 1999
American College of Chest Physicians
Thoracoscopic Resection of Solitary Lung Metastases From Colorectal Cancer Is a Viable Therapeutic Option*
Tiziano De Giacomo, MD;
Erino A. Rendina, MD;
Federico Venuta, MD;
Anna Maria Ciccone, MD and
Giorgio Furio Coloni, MD
*
From the University of Rome "La Sapienza," Department
of Thoracic Surgery, Rome, Italy.
Correspondence to: Tiziano De Giacomo, MD, University of Rome "La Sapienza," Department of Thoracic Surgery, Policlinico Umberto I, V.le Policlinico 155, 00161, Rome, Italy; e-mail: tdegiac{at}tin.it
 |
Abstract
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Study objectives: The reported 5-year survival rate
after pulmonary metastasectomy from colorectal carcinoma, usually
accomplished through thoracotomy or median sternotomy, ranges from 9 to
47%. Video-assisted thoracoscopy (VAT) is employed routinely for many
thoracic surgical procedures, but the main concern about this approach
for resection of lung metastases is that VAT does not allow complete
lung palpation to identify and remove metastases not detected by
preoperative radiologic examinations.
Design: In this
study, we reviewed our experience with thoracoscopic resection of
single peripheral lung metastases from colorectal carcinoma with
potentially curative intent.
Patients and
interventions: From July 1992 to September 1998, 24 patients (15
male, 9 female) with a mean age of 56 years, who previously had
undergone resection for colorectal carcinoma and had a single limited
and peripheral lung lesion identified by high-resolution CT, underwent
thoracoscopic wedge resection of the lesions.
Results:
No intraoperative complications developed. Three patients had minor
postoperative complications successfully treated. In one case, we found
a benign lesion, and this patient was excluded from the analysis. In
the remaining cases, metastases from colorectal cancer were confirmed.
The median follow-up was 29 months, ranging from 3 to 67 months.
Thirteen patients (56.5%) developed recurrence of the disease, and 5
of them (21.7%) had local recurrence. Cumulative 5-year survival
estimated by Kaplan-Meier method was 49.5%, not really different from
the data reported in the literature.
Conclusions:
Thoracoscopic resection of single peripheral lung metastases from
colorectal cancer with potentially curative intent seems effective and
justified since the ultimate outcome of this highly selected group of
patients seems to be not different from that obtained after a more
invasive approach.
Abbreviation:
VAT = video-assisted thoracoscopy
Key Words: colorectal carcinoma • lung metastasis • thoracoscopy
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Introduction
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Colorectal
carcinoma remains one of the most common neoplastic diseases. Of all
patients who had curative resection, 10 to 20% will develop pulmonary
metastases1
2
and 10% of them have the lung as the sole
metastatic site.3
Pulmonary metastases from colorectal
cancer are usually resected by wedge resection,4
5
usually
accomplished through a thoracotomy, median sternotomy, or clam shell
incision.6
7
8
The reported postresection 5-year survival
ranges from 9 to 47% independently from the access
employed.9
10
11
Introduction of video-assisted thoracoscopy
(VAT) has increased interest in using this minimally invasive approach
for many thoracic surgical procedures, including resection of
metastatic lesions.12
Nevertheless, the main concern about
this approach is that, although VAT allows an excellent exposure of the
lung surfaces, it does not permit complete lung palpation to identify
and remove metastatic lesions not detected by the radiologic imaging.
Colorectal carcinoma produces lung metastases that are often solitary,
and in most of these patients, resection through thoracotomy fails to
demonstrate additional foci of malignancy not detected by preoperative
evaluation.13
VAT resection might therefore be fully
justified if the ultimate outcome does not differ from that obtained
after a more invasive approach.
In this study, we reviewed our experience with thoracoscopic resection
of single peripheral lung metastases from colorectal carcinoma, with
potentially curative intent.
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Materials and Methods
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From July 1992 to September 1998, VAT was employed for
potentially curative treatment in 24 patients who had previously
undergone resection for colorectal carcinoma with a single and
peripheral new lung lesion identified by high-resolution CT of the
chest. Nine patients were female and 15 were male with a mean age of 56
years (range, 32 to 78 years). Three patients had bad nutritional
status, and two had severe impairment of pulmonary function with
preoperative FEV1 < 35% of predicted. Criteria for
thoracoscopic lung resection were as follows: primary tumor completely
controlled; absence of extrathoracic metastases; and high-resolution CT
scan evidence of a single limited metastasis located within the
periphery of the lung.
Two patients had developed hepatic metastases that were completely
resected before VAT. In two cases, lung metastases were synchronous
with the primary tumor. The primary tumor at the resection was staged
as Duke's A in 7 patients, Duke's B in 12, Duke's C in 3, while in
the remaining 2 cases it was unknown. Mean disease-free interval time
was 19 months. Thoracoscopy was performed under general anesthesia with
double-lumen intubation, generally using three to four intercostal
accesses. After careful exploration of the pleural cavity, the lung was
inspected and palpated with an endoscopic clamp. Digital palpation
through the intercostal incision was often employed to identify the
lesion and to evaluate the presence of unidentified supplementary
nodules. Lung resection was performed with an endoscopic stapler taking
with it 0.5 to 1 cm of normal tissue around the lesion. The specimen
introduced into an endoscopic bag was removed from the chest through
one of the intercostal accesses. Intraoperative frozen section was
employed in all cases to confirm the nature of the lesion and to check
the surgical resection margins. The survival after thoracoscopic
metastasectomy was estimated by the method of
Kaplan-Meier.14
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Results
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No intraoperative complications developed. Conversion to open
thoracotomy was not necessary. We thoracoscopically performed 24 wedge
resections. Three patients (12%) had postoperative minor complications
(one cardiac arrhythmia, one retention of secretions, and one
superficial trocar site infection) successfully treated. Mean chest
tube duration was 2.6 days (range, 1 to 4 days) and mean postoperative
hospital stay was 4.3 days (range, 2 to 6 days). Median follow-up was
29 months (range, 3 to 67 months). In one patient, the nodule was
benign (4%), and this patient was excluded from the analysis. Thirteen
patients (56.5%) developed recurrence of the disease, and five of them
(21.7%) had local recurrence within the chest: two in the same lobe
and both patients underwent new resection through thoracotomy; three
patients had recurrence in the same hemithorax (different lobe or
mediastinum). Of this group of patients, only one underwent new
resection while the remaining two were treated only by radiation
because of poor general condition. Eight patients (34.7%) developed
multiple visceral metastases. All of these patients underwent
chemotherapy and radiation. Ten patients died with disease, 3 are alive
with disease, and 10 do not present any evidence or recurrence.
Cumulative 5-year survival estimated by Kaplan-Meier method is 49.5%
(Fig 1) .
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Discussion
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Surgical resection of pulmonary metastases from colorectal
carcinoma still remains a valid treatment option. Although thoracotomy
or median sternotomy represents the approach of choice for multiple and
bilateral lesions, we investigated the role of VAT in the treatment of
patients with single and peripheral lung metastases. Our data, although
in a limited series of patients with relatively short follow-up, showed
a 5-year survival rate of 49.5%. These results are not really
different from data reported in the literature, documenting
postthoracotomy 5-year survival rate ranging from 36.8 to 54.3%, after
resection of single lung metastases from colorectal
carcinoma.4
5
6
14
15
The main concern raised by some
authors is that this minimally invasive approach, although allowing an
excellent exposure of the lung surfaces, does not permit lung palpation
that can be helpful for discovering supplementary lesions not
identified by CT scan. McCormack and coworkers13
demonstrated that chest CT scan was accurate only in 74% of cases in
detecting pulmonary metastases, underestimating the number of malignant
nodules in 25% of cases. Thus, the inability to palpate the lung
during VAT raises the possibility of an incomplete resection. However,
it is not infrequent for the surgeon to palpate and resect small
lesions within the lungs, not detected by CT scan, which are negative
for malignancy. The use of spiral CT scan and positron emission
tomography will be helpful for better identification and
characterization of lung lesions suspected to be metastases.
Nevertheless, the VAT approach seems to be reasonable in the treatment
of selected patients with single lung metastasis from colorectal cancer
for the following reasons:
- The majority of patients with metastases from colorectal
carcinoma present with a solitary nodule as confirmed at
thoracotomy.5
15
16
17
18
- A new pulmonary nodule in a patient who previously had a
cancer is not necessarily a metastasis but it can be benign or a new
primary tumor. If the primary tumor was colorectal cancer, there is
only about a 50% chance that the new nodule is a metastasis. One
patient in our series had a benign lesion.
- For the potential presence of inapparent metastatic lesions
also in the contralateral lung, neither thoracotomy nor VAT can
approach this problem without a bilateral procedure.
- In the majority of patients with visceral malignancy,
metastasectomy for multiple pulmonary nodules is often of diagnostic
value only, in consideration that the more pulmonary metastases exist,
the more micrometastases are latent in the lungs and in other
organs.8
14
15
Our results, although based on a limited number of patients, raise
an interesting consideration. The incidence of local recurrence after
thoracoscopic metastasectomy (21.7%) is similar or even lower than
those observed after open approach.15
17
Eight patients
had systemic recurrence, and four of them had recurrence at the primary
colorectal site, probably due to the locally advanced primary lesions
(Duke's B and C).
In conclusion, although thoracotomy or median sternotomy remains the
procedure of choice for the management of multiple or bilateral
lesions, thoracoscopic resection of peripheral pulmonary metastases
from primary colorectal carcinoma appears to be a reasonable and
effective management alternative to open approach. Thoracoscopy can
also be offered to patients who are in poor general condition and have
impairment of pulmonary function in whom an open approach is
contraindicated. Conversion to open thoracotomy is mandatory when the
lesion identified preoperatively is not found, when technical problems
may lead to compromise of surgical resection margins, and when VAT is
not feasible.
Received for publication October 14, 1998.
Accepted for publication December 21, 1998.
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Abstract
Introduction
