Treatment of Pulmonary Metastases in Oligometastatic Disease with Up to Five Pulmonary Lesions
Clinical Scenario
This protocol applies to patients with pulmonary oligometastatic disease presenting with up to five pulmonary metastatic lesions, in whom the primary tumor has been resected or is under control and there is no unresectable extra-thoracic spread.
Patient Eligibility
All of the following criteria must be met:
- Patient is fit for surgery
- Primary tumor has been resected or is under control
- No extra-thoracic metastases, or any present are amenable to treatment with radical intent
- Macroscopic complete resection of all lesions is feasible
- Adequate residual pulmonary function is expected after surgery
Treatment Approach
The primary intervention is surgical resection of the pulmonary metastases. The type of resection is guided by specific anatomical considerations relating to the lesions. A systemic component may be considered as part of the overall management plan — the complete algorithm and all options are detailed in the structured protocol.
References
DOI: 10.21037/asj-21-81
- In order to consider a patient eligible for pulmonary metastasectomy, the following criteria have been suggested: (I) the patient is fit for surgery; (II) the primary tumor has been resected or is under control; (III) no extra-thoracic metastases are present or, if present, they can be treated with radical intent; (IV) the thoracic surgeon is able to perform a macroscopic complete resection; (V) an adequate residual pulmonary function is expected after surgery; (VI) no other treatments with reduced morbidity and similar benefits are available.
- Despite inconsistencies among different clinical studies, the limit of five lesions can be accepted for oligometastatic state, provided that all the lesions can be radically treated.
- For lung metastases, sub-lobar wedge excisions are preferred as most of these are hematogenous metastases in contrast to early primary lung cancer <2 cm, for which anatomical segmentectomies are indicated.
- Additionally, for the management of pulmonary metastases, in contrast with primary lung cancer, lobectomy is not required for oncologic reasons, although anatomical reasons (such as the size or number of lesions) might make it necessary.
- In this population, the use of adjuvant chemotherapy after metastasectomy strongly affected OS compared to surgery alone (HR =0.35; P=0.014).
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