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Eur J Cardiothorac Surg 2008;34:1274. doi:10.1016/j.ejcts.2008.08.022
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Letters to the Editor

Pulmonary metastasis resection: is it a question of optimal timing or tumor doubling time?

Olivier N. Pagès*

Service d’histologie tumorale, Université Paris VI, Hôpital Tenon, 4 rue de la Chine, 75020 Paris, France

Received 24 July 2008; accepted 27 August 2008.

* Corresponding author. Tel.: +33 660437710; fax: +33 156017853. (Email: zapoy{at}wanadoo.fr).

Key Words: Pulmonary metastasis • Metastasectomy • Opportunity for pulmonary resection

The recent article titled ‘The optimal timing to resect pulmonary metastasis’ [1] arouses some questions. Management of pulmonary metastasis (PM) is certainly challenging and I agree with authors that standardization is needed for surgical indications.

In a multivariate analysis, the interval from PM detection to resection, and the interval from PM resection until recurrence were significant independent prognostic factors. Then the authors made two groups of patients: those who relapsed within 1 year after PM resection (group A), vs those who did not (group B). Finally, a comparison of mean interval from PM detection to resection between the two groups shows a significant difference: 2.9 months in group A vs 7.1 months in group B, p = 0.003. Authors conclude that performing metastasectomy at least 3 months after detection of PM may significantly improve the prognosis of patients.

In the study, the population of patients has more than 12 different metastatic histologies: colorectal, kidney, lung, esophagus, breast, etc. Thus, a major statistical bias clearly appears here: the population is not homogenous, and comparable groups cannot be created. Another bias is in the discussion; the exclusive reference in the literature consistent with their results is a previous study reported by our authors.

Here are the reasons why I do not share the conclusion of Tanaka et al. In fact, the authors have approached the well known topic that patients with short tumor doubling time (TDT) have worse outcomes than patients with a long TDT in pulmonary metastatic disease [2]. TDT in pulmonary metastasis recently caused new interest, since as demonstrated by Tomimaru et al., it is an independent predictor of intrapulmonary recurrence after pulmonary resection of solitary pulmonary metastasis [3].

Mean metastatic TDT is known to be faster than primary tumor TDT. But contrary to primary tumors [4], survival-related TDT in pulmonary metastasis has not been analyzed by histological sub-groups.

In conclusion, taking into account histology of primary tumor and tumor doubling time appears to be crucial in management of pulmonary metastasis. We will in further randomized and prospective studies have to answer questions such as ‘does it make sense to remove a short-TDT pulmonary metastasis?’

References

  1. Tanaka Y, Maniwa Y, Nishio W, Yoshimura M, Okita Y. The optimal timing to resect pulmonary metastasis. Eur J Cardiothorac Surg 2008;33:1135-1138.[Abstract/Free Full Text]
  2. Joseph WL, Morton DL, Adkins PC. Prognostic significance of tumor doubling time in evaluating operability in pulmonary metastatic disease. J Thorac Cardiovasc Surg 1971;61:23-32.[Medline]
  3. Tomimaru Y, Noura S, Ohue M, Okami J, Oda K, Higashiyama M, Yamada T, Miyashiro I, Ohigashi H, Yano M, Kodama K, Ishikawa O, Murata K, Yokouchi H, Sasaki Y, Kameyama M, Imaoka S. Metastatic tumor doubling time is an independent predictor of intrapulmonary recurrence after pulmonary resection of solitary pulmonary metastasis from colorectal cancer. Dig Surg 2008;25:220-225.[CrossRef][Medline]
  4. Weiss W. Tumor doubling time and survival of men with bronchogenic carcinoma. Chest 1974;65:3-8.[CrossRef][Medline]



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Eur. J. Cardiothorac. Surg., December 1, 2008; 34(6): 1274 - 1274.
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