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Ann Thorac Surg 2007;83:234-235
© 2007 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Invited commentary

Department of Surgery, Thoraxklinik am Universitatsklinikum Heidelberg, Amalienstr 5, Heidelberg, 69126 Germany

(Email: joachim.pfannschmidt{at}thoraxklinik-heidelberg.de).

The article by de Pas and colleagues [1] describes the management of stage IV lung cancer with a solitary metastasis in the positron-emission tomographic scan era. Previous studies have reported that whole-body positron-emission tomography (PET) for lung cancer staging detected occult distal metastases in 6% to 17% of patients for whom conventional clinical methods failed to identify [2, 3]. Indeed the incidence of patients with synchronous solitary metastatic deposits evaluated by conventional work-up and PET is small. For this highly selective subset of 10 of a total of 1,509 patients, the investigators found a potential for long-term survival after a multidisciplinary treatment approach including local complete resection of the primary lung cancer. In this setting, the experience mirrors what thoracic surgeons go through at some point. We are supported by the literature in acknowledging the negative prognosis of patients with stage IV nonsmall cell lung cancer, but an individualized indication for a subset of patients with singular metastatic lesions suggests that surgical resection in a multidisciplinary treatment approach may be beneficial and can achieve prolonged survival.

Few investigators have reported patients who have undergone a curative treatment regimen for oligometastatic lung cancer. The rarity of solitary metastatic disease in patients who are candidates for surgical resection of the primary lung cancer makes it unlikely for larger randomized prospective trials to compare different treatment regimens. The absence of prognostic factors that could predict survival benefit makes it impossible to preoperatively identify the subgroups of patients who would benefit from an aggressive treatment regimen. For now it seems reasonable to recommend that if complete resection of the primary lung cancer can be achieved, the solitary hematogenous metastasis should be considered for further localized therapeutic modalities. The role of chemotherapy in a combined treatment protocol remains unclear in this subset of patients [4].

Given the relatively poor results reported with radiation and chemotherapy in adrenal metastases, an aggressive surgical approach may be warranted even as a palliative procedure [5].

The 18-fluorine-fluorodeoxyglucose (¹⁸FDG) PET scan is needed in this subset of patients to restrict surgery as a multimodality treatment to those who will potentially benefit from this type of treatment. As the authors conclude, the ¹⁸FDG-PET scan is recommended to help screen out patients with nonsmall cell lung cancer who are erroneously diagnosed with single metastatic disease.

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1. de Pas TM, de Braud F, Catalano G, et al. Oligometastatic non-small cell lung cancer: a multidisciplinary approach in the position emission tomographic scan era. Ann Thorac Surg 2007;83:231–5.
2. Hellwig D, Ukena D, Paulsen F, Bamberg M, Kirsch CM. Meta-analysis of the efficacy of positron emission tomography with F-18-fluorodeoxyglucose in lung tumorsBasis for discussion of the German Consensus Conference on PET in Oncology 2000. Pneumologie 2001;55:367-377.[Medline]
3. Lardinois D, Weder W, Hany TF, et al. Staging of non-small-cell lung cancer with integrated positron-emission tomography and computed tomography N Engl J Med 2003;348:2500-2507.[Abstract/Free Full Text]
4. Downey RJ, Ng KK, Kris MG, et al. A phase II trial of chemotherapy and surgery for non-small cell lung cancer patients with a synchronous solitary metastasis Lung Cancer 2002;38:193-197.[Medline]
5. Higashiyama M, Doi O, Kodama K, Yokouchi H, Imaoka S, Koyama H. Surgical treatment of adrenal metastasis following pulmonary resection for lung cancer: comparison of adrenalectomy with palliative therapy Int Surg 1994;79:124-129.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Author home page(s): Joachim Pfannschmidt Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Pfannschmidt, J. Search for Related Content PubMed PubMed Citation Articles by Pfannschmidt, J. Related Collections Lung - cancer Esophagus - cancer Related Article