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Letters to the Editor

The optimal timing to resect pulmonary metastasis

Thoracic Unit, Department of Surgery, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan BA 1710, Brunei Darussalam

Received 10 July 2008; accepted 27 August 2008.

^_* Corresponding author. Tel.: +673 8185962; fax: +673 2333270. (Email: chong_chee_fui{at}hotmail.com).

Key Words: Pulmonary metastasis • Metastectomy • Opportunity for pulmonary resection • Tumour size • Histology

I would like to congratulate Tanaka et al. with regards to their findings on the optimal timing to resect pulmonary metastasis, published recently in the June issue of the European Journal of Cardio-thoracic Surgery [1]. Pulmonary metastectomy has increasingly become a large part of my practice with increasing referrals from our oncology unit and I suspect this is true for most thoracic units worldwide. This is driven by the increasing evidence of the prognostic value of pulmonary metastectomy [2,3].

Tanaka et al. has clearly shown that delaying pulmonary metastectomy at least 3 months after detection of pulmonary metastasis significantly improves the prognosis of patients. However, factors such as tumour (metastasis) size [4], aggressiveness of the tumour [5] and perhaps the use of interim chemotherapy may affect Tanaka’s findings. The former two factors of tumour size and tumour pathology were not addressed in the current study.

Size of metastases has previously been shown to be an independent prognostic factor in pulmonary metastectomy [4]. For small metastases which are less than 1 cm, a delay of 3 months or more may not pose any concern and may even be advantageous as this would allow time for other occult metastases, which are not visible or palpable at the time of diagnosis, to attain a size that are radiologically visible or palpable by the time of resection. However, it may be different for larger metastases (>2 cm) as any delay may predispose to the risk of lymphatic spread to mediastinal lymph nodes. I have frequently been asked by my oncology colleagues to perform VATs biopsy for confirmation particularly in lesions <1 cm for which CT FNAC is not possible or is negative. For this group of patients, I usually perform complete excision in the same setting and we are currently collecting data on the outcome. Tanaka’s group too in this study performed pulmonary metastectomy soon after referrals for pulmonary metastectomy. Hence the delay in group B was due to a delay in referral by the primary physicians. Reasons for the delay in referral by primary physicians were not eluted to in this study. Were the patients in group B receiving interim chemotherapy, which may account for the delay in referral? This will surely influence prognosis and survival found in group B.

In patients with an aggressive or rapidly growing tumour, a delay of 3 months or more may lead to further tumour growth during the observation period and may jeopardise chances of conservative resection as well as cure [5].

Therefore, Tanaka’s conclusion from this study, although valid and shading some light into a growing field, that the decision to wait until 3 months before performing pulmonary metastectomy should also be influenced by other factors such as the size of metastasis at diagnosis as well as the aggressiveness of the tumour. Future studies are needed to address this relationship. If a decision has been made to delay pulmonary metastectomy by at least 3 months, the issue of interim chemotherapy should also be looked into.

References

1. Tanaka Y, Maniwa Y, Nishio W, Yoshimura M, Okita Y. The optimal timing to resect pulmonary metastasis. Eur J Cardiothorac Surg 2008;33(6):1135-1138.[Abstract/Free Full Text]
2. Horan TA, Santiago FF, Araujo LM. The benefit of pulmonary metastectomy for bone and soft tissue sarcomas. Int Surg 2000;85(3):185-189.[Medline]
3. Pfannschmidt J, Muley T, Hoffmann H, Dienemann H. Prognostic factors and survival after complete resection of pulmonary metastases from colorectal carcinoma: experiences in 167 patients. J Thorac Cardiovasc Surg 2003;126(3):732-739.[Abstract/Free Full Text]
4. Iizasa T, Suzuki M, Yoshida S, Motohashi S, Yasufuku K, Iyoda A, Shibuya K, Hiroshima K, Nakatani Y, Fujisawa T. Prediction of prognosis and surgical indications for pulmonary metastasectomy from colorectal cancer. Ann Thorac Surg 2006;82(1):254-260.[Abstract/Free Full Text]
5. Todd TR. Pulmonary metastectomy: current indications for removing lung metastases. Chest 1993;103(4 Suppl.):401S-403S.

This article has been cited by other articles:

				Y. Maniwa Reply to Chong Eur. J. Cardiothorac. Surg., December 1, 2008; 34(6): 1273 - 1273. [Full Text] [PDF]

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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Chee Fui Chong Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chong, C. F. Search for Related Content PubMed Articles by Chong, C. F. Related Collections Lung - cancer Lung - other Mediastinum Lung - basic science