Survival after lung metastasectomy for colorectal cancer: Importance of previous liver metastasis as a prognostic factor
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)
- et al.
The molecular biology of pulmonary metastases
Thorac Surg Clin
(2006) - et al.
Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases
J Thorac Cardiovasc Surg
(1997) - et al.
Cirugía de metástasis pulmonares en 148 pacientes. Análisis de sus factores pronósticos
Arch Bronconeumol
(2008) - et al.
Pulmonary resection for metastases of colorectal adenocarcinoma
Ann Thorac Surg
(2010) - et al.
Surgical resection of hepatic and pulmonary metastases from colorectal carcinoma
J Am Coll Surg
(2006) - et al.
Simultaneous detection of colorectal carcinoma liver and lung metastases does not warrant resection
J Am Coll Surg
(2001) - et al.
Outcomes after resection of synchronous or metachronous hepatic and pulmonary colorectal metastases
J Am Coll Surg
(2007) Pulmonary metastasectomy for colorectal cancer: weak evidence and no randomized trials
Eur J Cardiothorac Surg
(2008)
Cited by (67)
Prognostic value of KRAS mutation in patients undergoing pulmonary metastasectomy for colorectal cancer: A systematic review and meta-analysis
2021, Critical Reviews in Oncology/HematologyOutcomes and prognostic factors after pulmonary metastasectomy in patients with colorectal cancer with previously resected hepatic metastases
2019, Journal of Thoracic and Cardiovascular SurgeryLung Metastases
2019, Abeloff’s Clinical OncologySurgical treatment of pulmonary metastasis in colorectal cancer patients: Current practice and results
2018, Critical Reviews in Oncology/HematologyCitation Excerpt :Finally, Renaud et al (Renaud et al., 2014) do report that liver metastases associated with LMs carry a significant negative prognosis on overall survival, although they also report that a certain selection bias may have an impact on their results, without modifying their conclusions, nor necessarily disqualifying these patients from surgery. These authors also report that their dataset may have lacked some of the metrics collected by other colleagues (Zabaleta et al., 2011). Overall, the debate seems to be ongoing, with no clear-cut conclusion on the impact of both metastatic locations on survival.
Individual data meta-analysis for the study of survival after pulmonary metastasectomy in colorectal cancer patients: A history of resected liver metastases worsens the prognosis
2018, European Journal of Surgical OncologyCitation Excerpt :The assumption of proportional risk for the main variable given the other variables was tested by introducing a term for interaction with time. We selected 29 papers that met all the selection criteria and divided them into two broad groups: 6 which did not analyse the variable of interest [2,6,7,11–13], that is, whether patients who underwent surgery had a history of resected liver metastases; and the other 23 which did consider this variable [1,5,14–33]. In this second group of 23 papers, there were 21 patient series, 1 prospective [15] and the others retrospective [5,14,16–32], and 2 meta-analyses [1,8] (these including several of the selected patient series).