METASTASECTOMY

1. METASTASECTOMY Prof. Dr. Mustafa YUKSEL Marmara University Faculty of Medicine Thoracic Surgery Department

2. Metastasectomy • The lung is the first capillary bed draining most primary sites, therefore lung metastasis is common (the second most common metastatic locus according to studies on autopsy series) • Hematogen and lymphogen metastases are the most common • The lung is the sole site of metastasis in the 20% of the patients

3. Metastasectomy • “Pulmonary metastasectomy” is a potentially curative surgical procedure, but the role of surgical resection of pulmonary metastases is still disputed by many oncologists on the grounds that systemic disseminated disease is already present. • When the solitary or multiple metastases are only confined to the lungs long-term survival rates are expected. • The first metastasectomy 1882 Weinlechner chest wall sarcoma – single lung metastasis

4. Metastasectomy • Diagnosis: • First generation CT> 3mm nodule 80% (20% more nodules in surgical exploration) • IRLM* multi-institutional review covering 40 years of metastasectomy; accuracy 61% (in the assessment of the # of mets) exploration 25% more nodules 14% less nodules bilateral exploration accuracy 37% 39% more nodules *IRLM : International Registry of Lung Metastasis

5. Metastasectomy • Diagnosis: • Spiral CT < 3mm nodule Mediastinal LAP exploration 35% more nodules (Memorial Sloan-Kettering CC) • 16-slice CT more sensitive (higher rate of false-positive lesions) Accuracy in number of metastasis 41(North Carolina U) exploration 22% more nodules 37% false-positive

6. Metastasectomy • Tissue diagnosis: • It is a must for solitary nodules primary tumor or met? • Biopsy for multiple nodules ?

7. Metastasectomy Primary tumor locations: • Epithelial • Colorectal • Breast • Kdney • Sarcoma • Osteosarcoma • Soft tissue • Melanoma • Germ cell tumors

8. Metastasectomy • The ideal candidates for metastasectomy: • Sarcomas • Germ cell tumors • Pediatric malignancies • Some of the epithelial carcinomas

9. Metastasectomy • Preoperative Staging: • Full examination of the primary site – local relapse • Tumor markers (germ cell tms, etc.) • CT, MRI, endoscopy for gastrointestinal tumors • Liver USG • Cranial CT / MRI

10. Metastasectomy • PET > 5mm nodule* sensitivity 87% Mediastinal LAP sensitivity 100% (*the reliable limit for the size is twice the limit of the resolution of the machine) • Promising particularly in epithelial tumors which have a higher risk of extrapulmonary deposits or locoregional relapse • PET-CT ?

11. Metastasectomy • Criteria for metastasectomy: • Local control of the primary tumor • Absence of metastases elsewhere in the patient • If removal of all disease is possible • Adequate pulmonary reserve

12. Metastasectomy • Prognostic factors: • Histologic cell type of the primary tumor • Complete resectability (the most important indicator) • Disease free interval (DFI>36 months – good prognosis) • Number of metastases (single nodule – good prognosis)

13. Metastasectomy IRLM* system of prognostic grouping: I resectable, no risk factors; DFI>36 months, single met. (61 months) II resectable, 1 risk factor; DFI<36 months or multiple met.s III resectable, 2 risk factors; DFI<36 months and multiple met.s IV unresectable (14 months) *IRLM : International Registry of Lung Metastasis

14. Metastasectomy • Surgical Approach: • Open Surgery Despite the constant improvement of pulmonary imaging, radiologically occult lesions are detected by open surgery in 25 – 35% of sarcomas and 15% of nonsarcomatous lesions, and carefull palpation of the entire lung remains the gold standard in most cases. • VATS(?) (Memorial Sloan-Kettering CC – in patients who underwent thoracoscopy followed by immediate thoracotomy, open surgical exploration allowed resection of additional metastases in 56% of the cases)

15. Metastasectomy • Surgical timing: variable • After the local control of the primary tumor • Lung surgery done first in case of synchronous met.s? (if a complete metastasectomy is a prerequisite to justify a radical approach to the primary tumor – e.g., limb amputation.) • In patients with multiple bilateral met.s, in whom resectability is questionable and prognosis poorer, the absence of new pulmonary met.s during the previous 2 months may be a further selection criterion.

16. Metastasectomy • Open surgery: • Thoracotomy (single-stage) • Staged bilateral thoracotomies (two-stage) • Sternotomy (single-stage) • Clamshell incision (single-stage)

17. Metastasectomy • Techniques of resection: (with 1cm margins) • Nodule enucleation / wedge resection • Stapler (wedge resection) • Electrocautery (enucleation) • Laser (enucleation) • RF Ablation ? 980 nm diode red light laser

18. Metastasectomy • Laser metastasectomy: • Less bleeding • Less air leak • Less tissue damage • Shorter operation duration as suturing is not needed

19. Laser Metastasectomy Bilateral laser metastasectomy (26y, mixt germ cell tumor)

20. Metastasectomy • Techniques of resection: (occasional) • For multiple centrally located metastases or for solitary lesions suggestive of a primary tumor, anatomic segmentectomy or lobectomy can be performed. • En-bloc resections of chest wall, pericardium, or diaphragm during lung metastasectomy are still associated with satisfactory long-term survival.

21. Metastasectomy • Lymph node dissection / sampling: • Different applications in various centers • Lymph node sampling is a must ? (European Institute of Oncology, 2007, 388 cases; lymph node involvement in 2% of cases. 5-year survival was 60% in No, 17% in N1 and 0% in N2 cases.) • Segmental and hilar lymph nodes are sampled if involvement is suspected. • Preoperative routine mediastinoscopy ? • Surgery when lymph nodes are PET-CT-positive?

22. Metastasectomy • Survival: IRLM(5206 cases from 18 centers in Europe and N. America) • Complete resection 88% • 5-year survival 36%(germ cell tm.s 68%, melanoma 21%) • 10-year survival 26% • 15-year survival 22% • Median survival 35 months

23. Metastasectomy • Recurrence: • Variable depending on the histology of the primary tumor • IRLM recurrence 53%, median time 10 months • Sarcoma and melanoma 64% • Germ cell tumors 26% • The 5 and 10-year survival rates of patients undergoing a second metastasectomy are little different from that seen after initial metastasectomy.

24. Metastasectomy • Clinical follow-up: • First year x-ray every mon., CT every 3 mon.s • Untill the end of 3rd year x-ray every 3 – 4 mon.s More intense follow-up for sarcomas • X-ray every 2 – 3 months • CT every 6 months (at least for 5 years)

25. Metastasectomy • Questions remained unanswered: • Nodal staging ? (Only for epithelial tumors, o for all?) • The role of VATS ? (An acceptable operative strategy, in which cases?) • Way of surgical approach ? (bilateral synchronous or staged unilateral procedures?)

26. The Marmara Experience • January 1992 – December 2008: • 74 patients (54 M, 20 F) • 42.2 years of age (15 – 81) • 81 surgical intervention

27. The Marmara Experience • Primary tumor localisation: • Bone and soft tissue sarcoma 16 • Colon 16 • Testis 15 • Urinary tract 9 • Breast 6 • Skin 5 • Lung 3 • Endometrium 3 • Larynx 1

28. The Marmara Experience • Surgical approach: • Posterolateral thoracotomy 71 (40 R, 31 L) • Sternotomy 4 • VATS 3 • Thoracoabdominal incision 2 • Bilateral thoracotomy 1

29. The Marmara Experience • Surgical resection: • Nodulectomy 39 • Wedge resection 37 • Lobektomy 4 • Pneumonectomy 1

30. The Marmara Experience • Histopathological evaluation: • 55 patients had metastases of the known primary sites • 19 patients had nodules with no malignancy

31. Metastasectomy Pulmonary metastasectomy is an effective surgical procedure, sometimes even as effective as primary tumor surgery, with a positive role in long-term survival rates, when the patient selection is done carefully and when performed meticulously.

32. Thank You...