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Dilemma in Pulmonary MetastasectomyDilemma in Pulmonary Metastasectomy: Video-Assisted Thoracoscopic Surgery or Thoracotomy? FREE TO VIEW

Chengwu Liu, MD; Lunxu Liu, MD, PhD
Author and Funding Information

From the Department of Thoracic Surgery, West China Hospital, Sichuan University.

Correspondence to: Lunxu Liu, MD, PhD, No 37, Guoxue Alley, Chengdu, Sichuan, 610041, China; e-mail: lunxu_liu@yahoo.com.cn


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(6):1836-1837. doi:10.1378/chest.13-0258
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To the Editor:

We read with interest the report by Eckardt and Licht1 in a recent issue of CHEST (December 2012). Although we congratulate them for their effort in clarifying the potential superiority of open pulmonary metastasectomy for treatment of patients with resectable pulmonary metastases, we want to share some significant concerns.

Both preoperative imaging and procedure via video-assisted thoracoscopic surgery (VATS) might miss some small metastatic nodules.2 The authors argued that the missed metastases might lead to higher recurrence rate and more mediastinal lymph node involvement, both of which might be detrimental to prognosis of those patients. However, VATS has been shown to be less invasive, with minor pain, trauma, and immune disturbance, and to better preserve quality of life and compliance with subsequent adjuvant therapy.3 In addition, metastasis of malignance is a systematic disease. Some recurrent pulmonary metastases may come from another micrometastasis other than the possibly missed lesions. Also, whether the mediastinal lymph node involvement is due to the pulmonary metastases or other lymphatic micrometastasis is still controversial.4 Moreover, a few retrospective case-control studies concluded that survival after metastasectomy by VATS was not inferior to open surgery.4 Several studies also reported that repeated metastasectomy was performed in 10% to 20% of patients who had undergone metastasectomy for the first time, and the survival curves were equal between the first and the first repeated metastasectomy (24.0% to 56.0% vs 23.0% to 53.8%).4 With regard to this report, VATS should be technically comparable to open thoracotomy in resection of those 55 imaged nodules, even though some of them might not be palpable. Speculatively, we presumed that the four nonpalpable nodules via VATS were not metastatic lesions. Then the ratio of improper resection caused by VATS and thoracotomy was 18.2 (10 of 55) and 35% (28 of 80), respectively (P < .05). Therefore, we have several concerns: (1) Can the total recurrence rate be actually reduced by the relatively radical resection the first time? (2) Is it definitely beneficial at the cost of more invasiveness and such a high rate of excessive treatment caused by open thoracotomy? (3) If resectable recurrent metastases do happen, what can we do for a patient who has undergone an open thoracotomy?

We argue that factors such as efficacy, invasiveness, compliance, and preservation of quality of life should be all taken into consideration when planning a palliative treatment strategy such as pulmonary metastasectomy. We are also looking forward to more prospective randomized trials with more cases included to elucidate all confusions.

References

Eckardt J, Licht PB. Thoracoscopic versus open pulmonary metastasectomy: a prospective, sequentially controlled study. Chest. 2012;142(6):1598-1602. [CrossRef] [PubMed]
 
Detterbeck FC, Grodzki T, Gleeson F, Robert JH. Imaging requirements in the practice of pulmonary metastasectomy. J Thorac Oncol. 2010;5(6)(suppl 2):S134-S139. [CrossRef] [PubMed]
 
Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol. 2009;27(15):2553-2562. [CrossRef] [PubMed]
 
Yano T, Shoji F, Maehara Y. Current status of pulmonary metastasectomy from primary epithelial tumors. Surg Today. 2009;39(2):91-97. [CrossRef] [PubMed]
 

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References

Eckardt J, Licht PB. Thoracoscopic versus open pulmonary metastasectomy: a prospective, sequentially controlled study. Chest. 2012;142(6):1598-1602. [CrossRef] [PubMed]
 
Detterbeck FC, Grodzki T, Gleeson F, Robert JH. Imaging requirements in the practice of pulmonary metastasectomy. J Thorac Oncol. 2010;5(6)(suppl 2):S134-S139. [CrossRef] [PubMed]
 
Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol. 2009;27(15):2553-2562. [CrossRef] [PubMed]
 
Yano T, Shoji F, Maehara Y. Current status of pulmonary metastasectomy from primary epithelial tumors. Surg Today. 2009;39(2):91-97. [CrossRef] [PubMed]
 
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