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Eur J Cardiothorac Surg 2008;33:470-472. doi:10.1016/j.ejcts.2007.10.028
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Comparison of the number of pre-, intra- and postoperative lung metastases

Corinna Ludwiga,*, Julio Cerinzab, Bernward Passlickb, Erich Stoelbena

a Lungenklinik, Kliniken der Stadt Köln gGmbH, Ostmerheimerstr. 200, 51109 Köln, Germany
b Department of Thoracic Surgery, University Hospital, Freiburg, Germany

Received 21 August 2007; received in revised form 16 October 2007; accepted 29 October 2007.

* Corresponding author. Tel.: +49 221 890713157; fax: +49 221 89073533. (Email: ludwigc{at}kliniken-koeln.de).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Aim: To compare the number of lung metastases seen preoperatively on computed tomography in patients with a previous history of malignant disease with the number of resected pulmonary nodules and the number of histologically proven lung metastases. Patients and methods: Between 1998 and 2003, we operated on 281 patients with suspected lung metastases. The histology of the primary tumour, the number of preoperatively diagnosed nodules, the number of lesions removed during surgery and the number of histologically confirmed metastases of 276 patients are presented. Results: Resection of lung metastases was performed in 276 patients. The median age was 62 years (21–86 years). The mean number of nodules seen on the CT scan was 1.9 (total: 515 nodules), 2.9 pulmonary lesions were removed (total: 835 nodules) and 2.1 nodules were confirmed as lung metastases (total: 560). In 39%, the number of lesions found and removed during the operation was higher than counted on the preoperative CT scan. These extra nodules found during the operation were confirmed as lung metastases in 16% of all patients. A benign solitary lesion was found in 15.2% of the patients and in 7.9% a primary carcinoma of the lung was diagnosed. In patients with a solitary nodule we found no metastasis in 16.4%, one lung metastasis in 76.7% and more than one lung metastasis in 6.9%. In patients with more than one nodule on the preoperative CT scan, an identical number of lung metastases were histologically confirmed in 35% of the patients, a larger number in 27.4% and a smaller number in 37.6%. Conclusions: In patients with a previous history of malignant disease, 15.2% of the pulmonary lesions are benign. Video-assisted thoracoscopic surgery (VATS) is a safe diagnostic and therapeutic method for solitary lesions, with little discomfort for the patient. In patients with more than one nodule on the CT scan, manual exploration of the lung is necessary to detect further lesions.

Key Words: Solitary and multiple pulmonary nodules • Lung metastases • VATS


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Lung metastases are common in patients with a previous history of malignant disease. Resection of pulmonary nodules in these patients is indicated when there is no evidence of recurrent primary tumour, the lung is the only location of metastases and complete resection is possible. Video-assisted thoracoscopic surgery (VATS) is considered the method of choice to determine the nature of solitary or multiple pulmonary nodules [1,2]. However, in patients with a history of malignant disease the method of resection (VATS vs thoracotomy) is determined by the aspect and location of the lesion [3–10].

The aim of this retrospective study was to determine if the number of suspected pulmonary nodules on the computed tomography is coherent with the number of lesions surgically removed and the number of histologically proven lung metastases. In patients with solitary pulmonary lesions, manual exploration of the lung may not be necessary and VATS resection is an adequate method for radical resection of lung solitary metastases. This may help to select patients with a previous history of malignant disease for VATS resection.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 Appendix A
 References
 
Between 1998 and 2003, we performed resection of pulmonary nodules in 280 patients with a previous tumour history. The data were collected from the patient records which were complete in 276 cases. The histology of the primary tumour (Fig. 1 ), the number of preoperatively diagnosed pulmonary nodules, the number of lesions removed during surgery and the number of histologically confirmed metastases was recorded.


Figure 1
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  		Fig. 1. Histology of primary tumour.

 
Preoperative staging included a chest X-ray, helical computed tomography of the chest, lung function test and arterial blood gases. Bronchoscopy was performed in all patients.

All procedures were performed under general anaesthesia and single lung ventilation. The surgical approach was by anterolateral, posterolateral or bilateral anterolateral thoracotomy according to the number of pulmonary lesions and their location. Manual palpation to localise the lesion in the lung, gentle fixation in a clamp at the site of the nodule, which is then removed by precise excision. Pulmonary lesions were removed either by standard wedge resection or extended resection when necessary (Table 1 ). At the end of the operation one or two chest tubes were placed under visual control. The number of pulmonary nodules seen on the preoperative computed tomography, as well as those removed during surgery, were documented and compared with the total number of lung metastases histologically proven.


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  		Table 1 Side and type of lung resection performed
 

   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 Appendix A
 References
 
There were 161 men (58.1%) and 115 women (41.9%), age 21–86 years (median age 62 years). The origin of the primary tumour varied as shown in Fig. 1. The operation was performed in a right lateral position 110 times (39.8%), in a left lateral position 110 times (39.8%) and on both sides in 56 patients (20.2%). The type of resection performed is demonstrated in Table 1.

In three patients (1.8%), no lung metastases were found at operation, instead pleural or lymph node metastases were discovered. In patients with a history of malignant disease, 42 (15.2%) had one or more pulmonary nodules which turned out to be benign and therefore had no evidence of metastatic disease. When a single pulmonary nodule was present on the preoperative computed tomography, 6.9% of the patients had >1 metastases, whereas 16.4% had no histological evidence of lung metastases (Table 2 ). Even in patients with multiple lesions in the computed tomography 8.6% (10/117) had no histological evidence of malignant disease. Patients with suspected multiple lung metastases finally had less metastases than preoperatively expected in 37.6% and more than expected in 24.7% (Table 2).


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  		Table 2 Comparison of the number of metastases seen on the CT scan compared with the number of lesions resected and histologically proven
 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
Appendix A
 References
 
Resection of lung metastases is an established treatment which has shown a better prognosis in patients with a disease-free interval greater than 36 months and single metastases [11,12]. Our aim in this retrospective analysis was to compare the preoperative number of pulmonary nodules seen on computed tomography with the situation found intraoperatively and the actual number of histologically proven metastases. Furthermore, we investigated how this could influence our choice of surgical approach (VATS vs thoracotomy) of patients with suspected pulmonary metastases.

The role of PET in the diagnosis of solitary or multiple lung metastases has yet to be defined and was not part of the preoperative work-up between 1998 and 2003. Of our patients with a previous history of malignant disease 42 (15.2%) patients had a benign pulmonary lesion. A primary carcinoma of the lung was found in 7.9% (22/276). Although not accepted as the method of choice for resection of multiple pulmonary metastases, VATS can be an appropriate technique for the resection of solitary nodules, even metastatic, without compromising the patients’ long-term survival. Limitations of this method are the size of the tumour (<3 cm) and its location which should be peripheral to permit VATS resection. VATS is a safe method, with little discomfort for the patient; it allows recurrent resection in patients with potentially metastatic disease and clarifies the origin of a pulmonary lesion thus potentially avoiding unnecessary further treatment [13–17].

Since in our experience, in patients with solitary lesions on the CT scan only 6.9% have more than one lesion when explored, we can recommend VATS resection as a diagnostic and therapeutic technique. Even in patients with multiple pulmonary nodules in the computed tomography there were 10/117 (8.5%) without lung metastases. This information alone is sufficient to recommend histological diagnosis of lung nodules in patients with previous history of malignant disease before any further treatment is commenced. Furthermore, digital palpation of the lung found more lesions than expected (51.3%) in this group which were confirmed histologically in 27.4%.

Since 16% of all pulmonary nodules are benign, we recommend that histologically proven lung metastases are mandatory in all patients with a previous history of malignant disease when the lung is the only site of recurrence. A solitary lung lesion is not a lung metastasis until the contrary is proven. VATS resection is the method of choice in patients with a peripheral solitary pulmonary nodule. In patients with suspicion of multiple lung metastases, thoracotomy is necessary to permit palpation of the lung as in a quarter of the patients more lesions are found than expected.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
References
 
Conference discussion

Dr D. Branscheid (Hamburg, Germany): What approach did you chose? Do you explore both lungs with your hands, or just only one side?

Dr Ludwig: In 30% right side only, 30% on the left side and the rest are both sides.

Dr Branscheid: What about those where you had only the right side tested and you did not explore the other side?

Dr Ludwig: If you don’t have a lesion on the CT, I would not explore them on the other side; it is not necessary. I would keep controlling them.

Dr Bransheid: But you showed that there might be some on the other side as well.

Dr Ludwig: But these patients do get a follow-up. They get a follow-up after surgery.

Dr H. Hansen (Copenhagen, Denmark): If you had to have some impact of your study, you must discuss whether you should do a bilateral procedure on the patients with multiple metastasis.

Dr G. Leschber (Berlin, Germany): You said that the CT scans were helical CT scan in most of the cases. There is now technology in CT also emerging that radiologists use, I think it is called CAT where a automatic program checks CTs by the computer to find more lesions than the radiologists could find. Do you expect any use of this? Will this help us with finding the lesions intra-operatively?

Dr Ludwig: I don’t think I can comment on this, a radiologist could comment on this question.

Dr P. Goldstraw (London, UK): Did any of your patients have pre-operative chemotherapy for their primary tumour?

Dr Ludwig: In about 12%.

Dr Goldstraw: There is a real problem for our pathologists when you remove a lesion that is necrotic or fibrotic. They do not classify them as a metastasis, but they probably were a metastasis before the chemotherapy.

Dr Ludwig: Like you said before, an osteosarcoma.

Dr Goldstraw: So that could have an impact on the validity of your conclusions about a satisfactory approach even for a single nodule.

Dr Ludwig: I would have to take them out probably, if I want to be precise.

Dr Goldstraw: But you may find more than just one deposit, that is what I am saying.


   Footnotes
 
{star} Presented at the 15th European Conference on General Thoracic Surgery, Leuven, Belgium, June 3–6, 2007.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 

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