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Eur J Cardiothorac Surg 2007;32:354-355. doi:10.1016/j.ejcts.2007.04.027
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Guy's Hospital London, Department of Thoracic Surgery, London SE1 9RT, UK
* Tel.: +44 20 71 88 1034. (Email: tom.treasure{at}gmail.com).
Surgical resection of pulmonary metastases is now common place and is a routine part of thoracic surgical practice. It represents an increasing component of the work load of many surgeons and is the subject of an ongoing working group of the European Society of Thoracic Surgeons (ESTS). In this issue of the European Journal of Cardiothoracic Surgery, Menon and colleagues from Leeds, UK [1] make an important contribution to this subject in two ways:
Whenever we operate on a patient, we should think very clearly about the precise objectives. The gain we expect should be clear in our own minds and made explicit to the patient. If the patient is blind due to cataract the objective of surgery is clear: patients expect to be able to see afterwards. If the patient is immobilised and in pain due to an osteoarthritic hip, success is judged by a reduction in pain and better walking. Relief of symptoms is a common indication for surgery and because the patient owns the symptom and can judge its relief, the basis of the discussion is clear and explicit.
Metastasectomy is not performed with the primary objective of relieving specific symptoms. Indeed a patient with symptoms attributable to metastases is likely to be excluded. It is perhaps reasonable therefore that reports of series of metastases do not offer a change in symptoms as a beneficial measure of outcome but none of the series report any measure of the overall well being of the patient. I am very happy to be corrected if I have overlooked some significant work but in the course of a systematic review we have yet to find quality of life reporting in the evaluation of the outcomes of metastasectomy. Worse still, for an operation, which involves thoracotomy and loss of at least some lung parenchyma, the detrimental effect in terms of breathing is generally not reported. Rolle who is a major contributor in this field [2] does provide FEV1 in his MMCTS seminar on the topic [3].
The only sense in which symptomatic relief is given primary consideration is that some claim psychological benefit to the patient having metastases removed. Again I have yet to see any semblance of psychological assessment, any reported measures of anxiety and depression before and after, or anything else resembling scientific support for this tenet. Aberg has also challenged this years ago [4,5]. If we are doing operations for psychological reasons we should evaluate our results. Are psychologists even authors on metastasectomy papers? Again, I would welcome correction on this point with reference to the scientific reporting. If the perception of psychological benefit is based on a false assumption of cancer cure on the part of the patient, that belief should be dispelled or what is the meaning of informed consent?
Let us leave symptoms aside; the reporting of metastasectomy places all its emphasis on cure by eradication of residual cancer. It is all to do with survival. Data are presented in terms of Kaplan–Meier plots and summarised as median time to death. The emphasis is on R0 versus R1 resections, better survival with single or few metastases, and other indicators that the operation can eradicate all disease. This is the rhetoric of surgical cure. If the operation is being performed to improve expectation of life we should be able to estimate, for a group of patients similar to the one under consideration, the likely survival without surgery to set it against the improved expectation of life if we do operate. If there is any beneficial difference then we should estimate the risks entailed, which must be proportionate to the likely gain.
It is debatable whether it is useful to group metastases from various cancer types in the same report. There may be particular considerations in thyroid, kidney, bony sarcomas and germ cell tumours. On the other hand metastasectomy is not a common practice for the two most common cancers, i.e. breast and lung. In the case of breast it is because that cancer is generally regarded as potentially disseminated from the outset and the place of surgery is limited to local control and staging. I will not waste space setting out for thoracic surgeons why most of us do not reoperate to remove lung cancer secondaries in the lung; on this matter many have more knowledge and experience than I. My point is that if all cancers are grouped in reports we get what I call ‘partridge in a pear tree’ papers after the popular Christmas song the Twelve Days of Christmas (Table 1 ). When you have all those people – Lords and Ladies, maids, drummers and pipers (N = 50 out of a total of 78) – will one, two or three assorted small birds add or detract from the message? Surgeons are reluctant to leave these out.
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If the benefit we offer is that we cure some and that these are the only ones who benefit (we only harm the others) then we should pay great attention to ensuring that we do not operate on patients in whom we will leave behind disease we cannot reach. At present there may be 10% of patients who could be spared this unavailing lung resection if we were to stage the mediastinum (Table 2 ). Thanks to the work of the UK's NICE lung cancer guideline development group access to PET is now general in Britain (pace Menon) so some of these patients can be spared an operation that cannot help. Where we consider mediastinoscopy before lung cancer resection appropriate, would not the same apply to pulmonary metastasectomy as advocated by Menon.
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  J. Nakajima, T. Murakawa, T. Fukami, and S. Takamoto Is thoracoscopic surgery justified to treat pulmonary metastasis from colorectal cancer? Interactive CardioVascular and Thoracic Surgery, April 1, 2008; 7(2): 212 - 217. [Abstract] [Full Text] [PDF]
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