Survival after lung metastasectomy for colorectal cancer: Importance of previous liver metastasis as a prognostic factor

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Abstract

Aims

To analyse patient survival after the resection of lung metastases from colorectal carcinoma and specifically to verify whether presence of liver metastasis prior to lung metastasectomy affects survival.

Methods

All patients who, between 1998 and 2008, underwent lung metastasectomy due to colorectal cancer were included in the study. Kaplan–Meier survival analysis was performed with the log-rank test and Cox regression multivariate analysis.

Results

During this period, 101 metastasectomies were performed on 84 patients. The median age of patients was 65.4 years, and 60% of patients were male. The 30-day mortality rate was 2%, and incidence of complications was 7%. The overall survival was 72 months, with 3-and 5-year survival rates of 70% and 54%, respectively. A total of 17 patients (20%) had previously undergone resection of liver metastasis. No significant differences were found in the distribution of what were supposed to be the main variables between patients with and without previous hepatic metastases. Multivariate analysis identified the following statistically significant factors affecting survival: previous liver metastasectomy (p = 0.03), tumour-infiltrated pulmonary lymph nodes (p = 0.04), disease-free interval ≥ 48 months (p = 0.03), and presence of more than one lung metastasis (p < 0.01). In patients with previous liver metastasis, the shorter the time between primary colorectal surgery and the hepatectomy, the lower the survival rate after pulmonary metastasectomy (p = 0.048).

Conclusions

A previous history of liver metastasis shortens survival after lung metastasectomy. The time between hepatic resection and lung metastasectomy does not affect survival; however, patients with synchronous liver metastasis and colorectal neoplasia have poorer survival rates than those with metachronous disease.

Introduction

The lung is an ideal metastatic target for haematogenously disseminated cancer cells, given that lung parenchyma cells are very close to the pulmonary intravascular space and it is a nutrient-rich environment, where the blood supply and the partial pressure of oxygen are guaranteed.1

There are no randomised studies that compare the survival after pulmonary metastases with and without surgery.2 However, an analysis of 5206 lung metastasectomies recorded in the International Registry of Lung Metastases reported five-year survival rates of 36% and 13% for complete and incomplete tumour resection, respectively.3

Colorectal cancer is the second most common cancer in most European countries,4, 5 and the disease recurs after curative surgery in approximately half of patients, with the recurrence most often occurring in the liver or lungs.6, 7 The reported five-year survival rate for colorectal cancer patients with pulmonary metastases who did not undergo surgery is less than 5%.5, 6

In recent years, several factors have been found to be associated with prolonged survival after pulmonary metastasectomy in patients with colorectal cancer5, 7, 8: (a) a longer disease-free interval (DFI); (b) low levels of carcinoembryonic antigen (CEA) prior to thoracotomy (<5 ng/ml); (c) a single metastasis less than 3 cm in diameter; and (d) no lymphatic invasion. However, the role of a previous liver metastasectomy in the survival of these patients is controversial.9, 10

Our main objective was to analyse patient survival after the resection of lung metastases from colorectal carcinoma, specifically to assess whether liver metastasectomy prior to pulmonary metastasectomy is an independent factor for predicting survival. In addition, we set out to analyse various factors that might affect the survival of patients with a history of previous liver metastasectomy.

Section snippets

Patient group

Data from all the patients who underwent surgery for pulmonary metastases of colorectal cancer origin from January 1998 to December 2008 were included in the study. The inclusion criteria were: a previous potentially curative resection of colorectal adenocarcinoma (M0 stage and R0 resection of the UICC) and histological confirmation of pulmonary metastasis after thoracic surgery performed with intent to cure (tumour-free resection margins). Cases that represented diagnostic surgery or for which

Results

In the period covered by this study, 101 lung metastasectomies were performed on 84 patients. 71 patients were operated on once, while 9 and 4 patients underwent two and three surgical interventions, respectively. The median age of patients was 65 (range 40–82), and 71% were male.

A total of 17 patients had previously undergone resection of liver metastases. Table 1 shows the main demographic and clinical characteristics of the patients who form the groups with and without history of previous

Prior hepatic metastasectomy

In 2007, Pfannschmidt et al. published5 a systematic review of the prognostic factors after lung metastasectomies of colorectal cancer origin, including 3 papers analysing the possible prognostic significance of a prior history of liver metastases. However, to date, only the study published in 2010 by Landes10 pointed out that a previous liver metastasectomy is an independent prognostic factor for predicting survival after lung metastasectomy associated with colorectal cancer. This author

Conclusion

Previous liver metastasis is a negative survival prognostic factor after lung metastasectomy of colorectal origin. In addition, we found that the time elapsed between liver metastasectomy and the primary colorectal surgery was more significant than the time between metastatic liver resection and lung metastasectomy. Other factors that decrease survival include: presence of more than one lung metastasis, a disease-free interval of less than 48 months and mediastinal lymph node involvement.

References (17)

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