HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Inoue, M. Articles by Yasumitsu, T. Search for Related Content PubMed PubMed Citation Articles by Inoue, M. Articles by Yasumitsu, T.

Ann Thorac Surg 2000;70:380-383
© 2000 The Society of Thoracic Surgeons

---

Original articles: general thoracic

Surgery for pulmonary metastases from colorectal carcinoma

^a Department of Surgery, Osaka Prefectural Habikino Hospital, Habikino, Osaka, Japan

Address reprint requests to Dr Inoue, Department of Surgery, Osaka Prefectural Habikino Hospital, Habikino 3-7-1, Habikino-city, Osaka, Japan 583-8588
e-mail: masayoshinoue{at}aol.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. This study aims to clarify which patients would benefit by surgery for pulmonary metastases from colorectal carcinoma.

Methods. A retrospective study was undertaken in 25 patients who had undergone complete resection. In all cases, prethoracotomy carcinoembryonic antigen (CEA) level was measured and mediastinal or hilar lymph nodes were histologically examined.

Results. Overall 5-year survival was 39.2%. The 5-year survival rate for patients with a normal CEA level was 61.1%, as compared with 19.0% for patients with an elevated CEA level (p = 0.0423). The 5-year survival rate for patients without a lymph node metastasis was 49.5%, as compared with 14.3% for patients with a lymph node metastasis (p = 0.0032). No lymph node metastasis was a predictor of longer survival by univariate and multivariate analyses. The primary site, disease-free interval, and number and size of the metastasis were not significant prognostic factors.

Conclusions. A resection for pulmonary metastasis from colorectal carcinoma is effective in patients with a normal CEA level and without a lymph node metastasis.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Blalock first reported a surgical resection for pulmonary metastasis from colorectal carcinoma in 1944 [1]. Since then, the results of this procedure have been reported, and surgery for a resectable pulmonary metastasis from colorectal carcinoma has obtained a general consensus [2]. In this report, we retrospectively analyzed our entire experience with pulmonary resections for metastatic colorectal carcinoma to clarify which patients would benefit from a metastasectomy.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between March 1979 and July 1997, 25 patients (17 males and 8 females; age 40 to 77 years, mean 60.2 years) underwent pulmonary resection for metastatic colorectal carcinoma at the Osaka Prefectural Habikino Hospital, Osaka, Japan. To avoid misinterpretation of a primary lung cancer with a pulmonary metastasis from colorectal carcinoma, those neoplasms were histologically compared with the primary lesions at the Division of Pathology in this hospital. Further, a single pathologist reconfirmed the histology of the surgical specimens at this study. Only those patients whose metastatic sites had been confined to the lung at the metastasectomy were enrolled in this study. A preoperative evaluation was performed using thoracic computed tomography (CT) for pulmonary metastasis. The primary site was confirmed to be not recurrent using an abdominal CT, barium enema, or colonofiberscopy. The record of each patient was reviewed for the primary site, number and the largest diameter of the pulmonary metastases, disease-free interval between the resection of the primary colorectal lesion and the pulmonary metastasectomy, prethoracotomy carcinoembryonic antigen (CEA) level, and lymph node metastases. The mean follow-up period was 108 ± 63 months. Survival after pulmonary resection was estimated according to the method of Kaplan and Meier [3]. The prognostic influence of variables on survival was analyzed using the log-rank test and the proportional hazards model of Cox [4]. A probability value of less than 0.05 was considered significant.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
The patient characteristics are shown in Table 1. The primary lesion was located on the colon in 14 patients and on the rectum in 11 patients. The prethoracotomy CEA level was elevated in 12 patients. A pneumonectomy was performed in 3 patients, lobectomy in 17, segmentectomy or partial lung resection in 9, including repeated metastasectomies and bilateral thoracotomies. Recently, five consecutive cases without lymph node metastasis have undergone a segmentectomy or partial resection. Video-assisted thoracoscopic surgery (VATS) was applied in 3 patients. A repeated thoracotomy for recurrent metastases was performed in 2 patients, and a sequential bilateral metastasectomy was also performed in 2 patients. A solitary metastasis was found in 16 patients and multiple metastases in 9 patients. Eight patients underwent a mediastinal lymph node dissection during the operation, and a sampling was performed in the remaining 17 patients. The extensive lymphadenectomy was performed in the patients who were suspected of lymph node metastasis in preoperative thoracic CT or surgical findings. All of the patients in this study underwent a complete surgical resection.

View larger version (14K): [in this window] [in a new window]   Fig 1. Overall survival curve for 25 patients after a complete resection pulmonary metastasis from colorectal carcinoma. The 5-year probability of survival after the first thoracotomy was 39.2% and the median survival time (MST) was 33 months.

The serum CEA level was measured before the metastasectomy in all of the patients. The cutoff value was 2.5 ng/mL. The 5-year survival and MST for 13 patients with a normal CEA level was 61.1% and 69 months, respectively, as compared with 19.0% and 21 months for the 12 patients with elevated CEA level (Fig 2; p = 0.0423). The prognosis of the patients with a normal CEA level was significantly better than those with an elevated CEA level. The serum CEA level normalized after a pulmonary resection of the metastasis in 9 of the 12 patients. One of these 9 patients had a relapse in the lung with an elevated CEA level after the pulmonary metastasectomy. This patient underwent a repeated thoracotomy and the serum CEA level was then normalized.

View larger version (18K): [in this window] [in a new window]   Fig 2. Survival curves by the prethoracotomy serum CEA level. The 5-year survival and MST for patients with a normal CEA level was 61.1% and 69 months, respectively, as compared with 19.0% and 21 months for patients with an elevated CEA level (p = 0.0423).

View larger version (19K): [in this window] [in a new window]   Fig 3. Survival curves by lymph node metastasis. The 5-year survival rate and MST for patients without a lymph node metastasis was 49.5% and 49 months, respectively, as compared with 14.3% and 16 months for patients with a lymph node metastasis (p = 0.0032).

	Comment

Top Abstract Introduction Material and methods Results Comment References

As for the primary lesion, a significant difference of survival was not found between colon and rectal carcinomas in our series. This result is compatible with several previous reports [5, 6, 8, 10, 11, 13]. The disease-free interval was also not a prognostic factor in this study, as has been reported previously [5–8, 10, 11], although there is one report that noted that the survival rate for patients with a disease-free interval of more than 2 years had been better [12]. It is controversial whether the number of metastatic lesions is one of the prognostic factors. We did not find a significant difference in survival between patients with solitary and multiple lesions. While it has been reported that the survival of cases with a solitary metastasis or less than two lesions is better than cases with multiple lesions, most of these analyses included incompletely resected cases with multiple metastases [6, 8, 9, 11, 13, 14]. We suppose that an operative indication should be considered for cases with resectable multiple metastases. Concerning the size of the metastasis, one report showed a significant difference between cases whose maximal size was 3 cm or more and cases of less than 3 cm [11], although other reports have denied this result [7, 8, 10, 13]. In this study, the survival of patients whose maximal size was less than 3 cm was inclined to be better than patients more than 3 cm, but a statistical significance was not found.

Recently, several reports have revealed that the prognosis of cases with an elevated prethoracotomy serum CEA level was poor [6, 7, 9]. The 5-year survival rate of patients with a normal CEA level was significantly better than those with elevated CEA levels in our series, although a univariate analysis only showed an inclination because of the small number study. We suppose that the surgery is beneficial for survival in patients with a normal CEA level. Additionally, because the CEA level fluctuated with relapse and metastasectomy, serum CEA level may be a useful marker for the follow-up evaluation of patients with an elevated CEA level.

A lymph node metastasis was not so rare in the cases of pulmonary metastasis from colorectal carcinoma [15]. We had examined the mediastinal or hilar lymph nodes in all of the patients in our hospital in order to clarify the incidence of lymph node involvement. The data may give some impact in clinical feature of pulmonary metastasis from colorectal carcinoma. The high incidence of lymph node metastasis in this study might be due to the aggressive surgery such as lobectomy or pneumonectomy. The correspondence of the metastatic node to the regional pulmonary node in this study may suggest that a lymph node metastasis was derived from the pulmonary metastasis. A lobectomy might be required in the cases with lymph node metastasis, while the minimum lung resection is a current standard care. A pneumonectomy should be avoided if possible, because the postoperative status of patient is poor and the survival benefit by this treatment is unclear. However, such an aggressive surgery might be indicated in selected patients with good risk, because another better therapy for pulmonary metastasis from colorectal carcinoma is not currently available. The prognosis of the patients with a lymph node metastasis was worse than those without, and it was a significant prognostic factor. Thus, we believe that a sufficient preoperative evaluation for a mediastinal or hilar lymph node is important and that sampling during the operation is indispensable to predict the prognosis of the patient. Further prospective study is required to investigate whether a lymph node dissection would contribute to the improvement in prognosis for patients with a pulmonary metastasis from colorectal carcinoma.

It has been reported that a repeated operation may be indicated for patients who have a recurrent pulmonary metastasis after pulmonary metastasectomy [16, 17]. Repeated pulmonary metastasectomies were performed in two cases in this series. One patient underwent a right lower lobectomy at the first operation and a partial resection of the right upper lobe 14 months later at the second operation. This patient died of multiple pulmonary metastases 49 months after the second thoracotomy. The other patient underwent a right middle lobectomy with a partial resection of right upper and lower lobes at the first operation and a right completion pneumonectomy 53 months later at the second operation. This patient is currently living, 60 months after the second operation. We also believe that repeated metastasectomies for a recurrent pulmonary metastasis may be considerable in patients without a relapse in another site and with sufficient pulmonary function.

VATS is a currently popular procedure and video-assisted thoracoscopic pulmonary resection for patients with pulmonary metastasis from colorectal carcinoma has been reported [18, 19]. Three cases underwent VATS metastasectomy in this series and two of these had pulmonary metastases in the bilateral lung. All of these patients are alive without a local recurrence, while the follow-up period is short. An accumulation of cases is required to know the propriety of VATS for pulmonary metastasis. A sampling of mediastinal or hilar lymph nodes should be considered in order to predict the prognosis if a VATS metastasectomy is applied.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Blalock A. Recent advances in surgery. N Eng J Med 1944;231:261-267.
2. Murray K.D. Excision of pulmonary metastasis of colorectal cancer. Semin Surg Oncol 1991;7:157-161.[Medline]
3. Kaplan E.L., Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457-481.
4. Cox D.R. Regression models and life-tables. J R Stat Soc (B) 1972;34:187-220.
5. Zanella A., Marchet A., Mainente P., Nitti D., Lise M. Resection of pulmonary metastases from colorectal carcinoma. Eur J Surg Oncol 1997;23:424-427.[Medline]
6. Girard P., Ducreux M., Baldeyrou P., et al. Surgery for lung metastases from colorectal cancer. J Clin Oncol 1996;14:2047-2053.[Abstract/Free Full Text]
7. Baron O., Amini M., Duveau D., Despins P., Sagan C.A., Michaud J.L. Surgical resection of pulmonary metastases from colorectal carcinoma. Eur J Cardiothorac Surg 1996;10:347-351.[Abstract]
8. Yano T., Hara N., Ichinose Y., Yokoyama H., Miura T., Ohta M. Results of pulmonary resection of metastatic colorectal cancer and its application. J Thorac Cardiovasc Surg 1993;106:875-879.[Abstract]
9. McAfee M.K., Allen M.S., Trastek V.F., Ilstrup D.M., Deschamps C., Pairolero P.C. Colorectal lung metastases. Ann Thorac Surg 1992;53:780-786.[Abstract]
10. Mori M., Tomoda H., Ishida T., et al. Surgical resection of pulmonary metastases from colorectal adenocarcinoma. Arch Surg 1991;126:1297-1302.[Abstract]
11. Goya T., Miyazawa N., Kondo H., Tsuchiya R., Naruke T., Suemasu K. Surgical resection of pulmonary metastases from colorectal cancer. Cancer 1989;64:1418-1421.[Medline]
12. Brister S.J., De Varennes B., Gordon P.H., Sheiner N.M., Pym J. Contemporary operative management of pulmonary metastases of colorectal origin. Dis Colon Rectum 1988;31:786-792.[Medline]
13. Mansel J.K., Zinsmeister A.R., Pairolero P.C., Jett J.R. Pulmonary resection of metastatic colorectal adenocarcinoma. Chest 1986;89:109-112.[Abstract/Free Full Text]
14. Sauter E.R., Bolton J.S., Willis G.W., Farr G.H., Sardi A. Improved survival after pulmonary resection of metastatic colorectal carcinoma. J Surg Oncol 1990;43:135-138.[Medline]
15. Okumura S., Kondo H., Tsuboi M., et al. Pulmonary resection for metastatic colorectal cancer. J Thorac Cardiovasc Surg 1996;112:867-874.[Abstract/Free Full Text]
16. Smith J.W., Fortner J.G., Burt M. Resection of hepatic and pulmonary metastases from colorectal cancer. Surg Oncol 1992;1:399-404.[Medline]
17. Kandioler D., Krömer E., Tüchler H., et al. Long-term results after repeated surgical removal of pulmonary metastases. Ann Thorac Surg 1998;65:909-912.[Abstract/Free Full Text]
18. Togo S., Fujii S., Yamaguchi S., Ike H., Ooki S., Shimada H. Thoracoscopic lung resection for lung metastasis of colorectal cancer. Surg Laparosc Endosc 1996;6:480-484.[Medline]
19. McCormack P.M., Bains M.S., Begg C.B., et al. Role of video-assisted thoracic surgery in the treatment of pulmonary metastases. Ann Thorac Surg 1996;62:213-217.[Abstract/Free Full Text]

This article has been cited by other articles:

				T. M. Pawlik, R. D. Schulick, and M. A. Choti Expanding Criteria for Resectability of Colorectal Liver Metastases Oncologist, January 1, 2008; 13(1): 51 - 64. [Abstract] [Full Text] [PDF]

				J. Furak, I. Trojan, T. Szoke, L. Tiszlavicz, J. Eller, and G. Lazar Visceral pleural infiltration as a negative prognostic factor in lung metastasis Interactive CardioVascular and Thoracic Surgery, April 1, 2007; 6(2): 196 - 199. [Abstract] [Full Text] [PDF]

				R. Koga, J. Yamamoto, A. Saiura, T. Yamaguchi, E. Hata, and M. Sakamoto Surgical Resection of Pulmonary Metastases From Colorectal Cancer: Four Favourable Prognostic Factors Jpn. J. Clin. Oncol., October 1, 2006; 36(10): 643 - 648. [Abstract] [Full Text] [PDF]

				T. Iizasa, M. Suzuki, S. Yoshida, S. Motohashi, K. Yasufuku, A. Iyoda, K. Shibuya, K. Hiroshima, Y. Nakatani, and T. Fujisawa Prediction of prognosis and surgical indications for pulmonary metastasectomy from colorectal cancer. Ann. Thorac. Surg., July 1, 2006; 82(1): 254 - 260. [Abstract] [Full Text] [PDF]

				G. Melloni, C. Doglioni, A. Bandiera, A. Carretta, P. Ciriaco, G. Arrigoni, and P. Zannini Prognostic Factors and Analysis of Microsatellite Instability in Resected Pulmonary Metastases From Colorectal Carcinoma Ann. Thorac. Surg., June 1, 2006; 81(6): 2008 - 2013. [Abstract] [Full Text] [PDF]

				J. Pfannschmidt, J. Klode, T. Muley, H. Dienemann, and H. Hoffmann Nodal Involvement at the Time of Pulmonary Metastasectomy: Experiences in 245 Patients Ann. Thorac. Surg., February 1, 2006; 81(2): 448 - 454. [Abstract] [Full Text] [PDF]

				S. Shiono, G. Ishii, K. Nagai, J. Yoshida, M. Nishimura, Y. Murata, K. Tsuta, Y. H. Kim, Y. Nishiwaki, T. Kodama, et al. Predictive Factors for Local Recurrence of Resected Colorectal Lung Metastases Ann. Thorac. Surg., September 1, 2005; 80(3): 1040 - 1045. [Abstract] [Full Text] [PDF]

				M. Inoue Reply Ann. Thorac. Surg., August 1, 2005; 80(2): 791 - 791. [Full Text] [PDF]

				S. Shiono, G. Ishii, K. Nagai, J. Yoshida, M. Nishimura, Y. Murata, K. Tsuta, Y. Nishiwaki, T. Kodama, and A. Ochiai Histopathologic Prognostic Factors in Resected Colorectal Lung Metastases Ann. Thorac. Surg., January 1, 2005; 79(1): 278 - 282. [Abstract] [Full Text] [PDF]

				M. Tamura, M. Oda, Y. Tsunezuka, I. Matsumoto, K. Kawakami, and G. Watanabe Vascular endothelial growth factor expression in metastatic pulmonary tumor from colorectal carcinoma: Utility as a prognostic factor J. Thorac. Cardiovasc. Surg., October 1, 2004; 128(4): 517 - 522. [Abstract] [Full Text] [PDF]

				M. Inoue, M. Ohta, K. Iuchi, A. Matsumura, K. Ideguchi, T. Yasumitsu, K. Nakagawa, K. Fukuhara, H. Maeda, S.-i. Takeda, et al. Benefits of surgery for patients with pulmonary metastases from colorectal carcinoma Ann. Thorac. Surg., July 1, 2004; 78(1): 238 - 244. [Abstract] [Full Text] [PDF]

				R. H.V. Reddy, B. Kumar, R. Shah, S. Mirsadraee, K. Papagiannopoulos, P. Lodge, and J. A.C. Thorpe Staged pulmonary and hepatic metastasectomy in colorectal cancer--is it worth it? Eur. J. Cardiothorac. Surg., February 1, 2004; 25(2): 151 - 154. [Abstract] [Full Text] [PDF]

				J. Pfannschmidt, T. Muley, H. Hoffmann, and H. Dienemann Prognostic factors and survival after complete resection of pulmonary metastases from colorectal carcinoma: Experiences in 167 patients J. Thorac. Cardiovasc. Surg., September 1, 2003; 126(3): 732 - 739. [Abstract] [Full Text] [PDF]

				Y. Saito, H. Omiya, K. Kohno, T. Kobayashi, K. Itoi, M. Teramachi, M. Sasaki, H. Suzuki, H. Takao, and M. Nakade Pulmonary metastasectomy for 165 patients with colorectal carcinoma: A prognostic assessment J. Thorac. Cardiovasc. Surg., November 1, 2002; 124(5): 1007 - 1013. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Inoue, M. Articles by Yasumitsu, T. Search for Related Content PubMed PubMed Citation Articles by Inoue, M. Articles by Yasumitsu, T.