Pulmonary Metastatic Disease

Question 1

Indications for pulmonary metastasectomy

Answer 1

• Resectible intrathoracic disease
• No extrathoracic disease
• Adequate cardiopulmonary reserve

Question 2

MC location of pulmonary mets

Answer 2

Subpleural and located in outer 1/3 of the lung fields

(usually amenable to wedge resection d/t this location)

Question 3

Probability of metastatic disease increased with ___

Answer 3

presence of multiple nodules

Question 4

Diagnostic study of choice to identify and follow suspected metastatic lesions

Answer 4

CT chest

Question 5

Critical diagnostic test to the w/u of metastatic disease

Answer 5

PET-CT scan

• Identification of unsuspected extrathoracic disease

Question 6

Two major surgical principles for treatment of pulmonary mets

Answer 6

1. complete resection of malignancy
2. maximal sparing of normal lung tissue

Question 7

Surgical approach for mets that are more central

Answer 7

Segmentectomy or lobectomy

Question 8

Advantages of VATS approach to PM

Answer 8

• less postop pain
• shorter LOS
• decreased adhesions at reoperation
• better compliance with adjuvant Rx

Question 9

Argument against VATS approach for PM

Answer 9

Manual palpation of deflated lung is esential to identifying all metastatic lesions

No evidence to suggest that the timing of resection of nodules that would be missed at VATS (usually < 5 mm) is critical to final outcomes

Question 10

% of PM cases with hilar or mediastinal LN

Answer 10

5-30%

more common with carcinoma (vs. sarcomatous mets)

negatively impacts survival in the setting of various metastatic tumors

Question 11

Morality rates for PM

5-year survival rates for PM

Answer 11

Similar to primary lung ca resection (0.6-2%)

5-year survival: 30-40%

10-year survival: ~25%

Question 12

Most common primary histology for patients evaluated for PM

Answer 12

1. Colorectal ca (5-year survial=35-45%)
2. Sarcoma (5-year survival = 25-35%)
3. Renal cell ca (5-year survival = 20-50%)
4. Gynecologic ca (5-year survival = 33-76%)
5. Head and Neck ca (5-year survival = 34-84%)

Question 13

Role of PM for breast cancer

Answer 13

Controversial due to other available treatment options (chemotherapy, hormone therapy, targeted molecular therapy)

Question 14

Factors associated with improved survival for patients undergoing PM

Answer 14

Prolonged disase-free interval

Low number of PM

Complete resection (most important)

Question 15

Treatment strategy for isolated recurrence after PM

Answer 15

Repeat PM (affords long-term survival advantage)

(40-80% of PM patients will suffer recurrence)