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

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Presentation on theme: "The 53 rd International Congress of the Egyptian Society of Chest diseases and tuberculosis March 2012 Cairo."— Presentation transcript:

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

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

3 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

4 Surgery in Lung metastases
The most frequent origin Breast colorectal

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

6 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

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

8 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

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

10 Lung metastases imaging
CT scan

11 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

12 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

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

14 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

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

16 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

17 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

18 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

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

20 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

21 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.

22 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

23 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

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

25 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

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

27 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

28 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

29 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

30 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

31 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

32 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

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

34 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

35 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

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

37 Surgery lung metastases
After colorectal resection After first lung metastasectomy

38 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


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