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Annals of Thoracic and Cardiovascular... Dec 2019Germ cell tumors (GCTs) are the most common malignancy among young men in the United States. Although prognosis is favorable and response to cisplatin-based chemotherapy... (Review)
Review
Germ cell tumors (GCTs) are the most common malignancy among young men in the United States. Although prognosis is favorable and response to cisplatin-based chemotherapy regimens is good, 10%-20% of patients with thoracic metastases require surgical management following completion of chemotherapy. Pulmonary metastasectomy (PM) has been employed for GCT patients with lung metastases for several decades. Outcomes have been excellent thus far. However, there have been no randomized controlled trials of PM in GCT and, as new surgical techniques are developed, there is variability in management. This article reviews the existing data on current management of pulmonary metastases in GCT, with attention paid to timing of surgery, surgical approaches, and complications.
Topics: Humans; Lung Neoplasms; Male; Metastasectomy; Neoplasms, Germ Cell and Embryonal; Pneumonectomy; Postoperative Complications; Risk Factors; Treatment Outcome
PubMed: 31723083
DOI: 10.5761/atcs.ra.19-00070 -
Thoracic Surgery Clinics Feb 2016Most patients with pulmonary metastases will not be candidates for pulmonary metastasectomy. Preoperative evaluation determines whether a patient is both fit enough for... (Review)
Review
Most patients with pulmonary metastases will not be candidates for pulmonary metastasectomy. Preoperative evaluation determines whether a patient is both fit enough for surgery and has disease that is actually resectable. Both components are necessary for patients who undergo resection with curative intent. In general, to be considered for pulmonary metastasectomy, patients must fit the following criteria: the primary disease site and any extrathoracic disease are both controlled; complete resection of pulmonary involvement is achievable with adequate pulmonary reserve; and there are no effective medical therapies.
Topics: Diagnostic Imaging; Humans; Lung; Lung Neoplasms; Metastasectomy; Neoplasm Staging; Preoperative Period; Risk Assessment; Survival Rate
PubMed: 26611505
DOI: 10.1016/j.thorsurg.2015.09.002 -
Frontiers in Surgery 2022Treatment of metastatic renal cell carcinoma (mRCC) has evolved with the development of a variety of systemic agents; however, these therapies alone rarely lead to a... (Review)
Review
Treatment of metastatic renal cell carcinoma (mRCC) has evolved with the development of a variety of systemic agents; however, these therapies alone rarely lead to a complete response. Complete consolidative surgery with surgical metastasectomy has been associated with improved survival outcomes in well-selected patients in previous reports. No randomized control trial exists to determine the effectiveness of metastasectomy. Therefore, reviewing observational studies is important to best determine which patients are most appropriate for metastasectomy for mRCC and if such treatment continues to be effective with the development of new systemic therapies such as immunotherapy. In this narrative review, we discuss the indications for metastasectomies, outcomes, factors associated with improved survival, and special considerations such as location of metastasis, number of metastases, synchronous metastases, and use of systemic therapy. Additionally, alternative treatment options and trials involving metastasectomy will be reviewed.
PubMed: 35965871
DOI: 10.3389/fsurg.2022.943604 -
Cancer Sep 2018Despite the rapid elaboration of multiple, novel systemic agents introduced for metastatic renal cell carcinoma (mRCC) in recent years, a durable complete response... (Review)
Review
Despite the rapid elaboration of multiple, novel systemic agents introduced for metastatic renal cell carcinoma (mRCC) in recent years, a durable complete response remains elusive with systemic therapy alone. Definitive treatment of the metastatic deposit remains the sole potentially curative option and is a cornerstone of mRCC therapy, offering potential for both local control and palliation of tumor-related symptoms. In this review, the evidence supporting the definitive treatment of mRCC is examined and summarized, including the use of surgical metastasectomy, thermal ablation, radiotherapy, and other minimally invasive options. Multimodal approaches, including the combination of metastasectomy with novel systemic agents, are discussed. Finally, the authors review considerations for patient selection for this type of therapy and summarize available risk-stratification tools that may help guide shared decision making.
Topics: Carcinoma, Renal Cell; Chemotherapy, Adjuvant; Combined Modality Therapy; Evidence-Based Practice; Humans; Kidney Neoplasms; Metastasectomy; Neoplasm Metastasis; Patient Selection; Treatment Outcome
PubMed: 29689599
DOI: 10.1002/cncr.31341 -
British Journal of Cancer Aug 2020Pulmonary metastasectomy is widely and increasingly practiced in the belief that this intervention can cure patients with colorectal cancer, and that without it few...
Pulmonary metastasectomy is widely and increasingly practiced in the belief that this intervention can cure patients with colorectal cancer, and that without it few survive 5 years. No good evidence exists supporting such convictions, indeed recent trial results challenge them. What evidence underpins this acceptance of illusory truths or misconceptions?
Topics: Clinical Trials, Phase II as Topic; Colorectal Neoplasms; Evidence-Based Medicine; Humans; Lung Neoplasms; Metastasectomy; Randomized Controlled Trials as Topic; Standard of Care; Survival Analysis
PubMed: 32541870
DOI: 10.1038/s41416-020-0927-2 -
Chinese Clinical Oncology Sep 2017Oligometastatic cancer describes a disease state somewhere between localized and metastatic cancer. Proposed definitions of oligometastatic disease have typically used a... (Review)
Review
Oligometastatic cancer describes a disease state somewhere between localized and metastatic cancer. Proposed definitions of oligometastatic disease have typically used a cut-off of five or fewer sites of disease. Treatment of oligometastatic disease should have the goal of long-term local control, and in selected cases, disease remission. While several retrospective cohorts argue for surgical excision of limited metastases (metastasectomy) as the preferred treatment option for several clinical indications, limited randomized data exists for treating oligometastases. Alternatively, stereotactic ablative radiotherapy (SABR) is a radiotherapy technique that combines high radiation doses per fraction with precision targeting with the goal of achieving long-term local control of treated sites. Published cohort studies of SABR have demonstrated excellent local control rates of 70-90% in oligometastatic disease, with long-term survival in some series approaching 20-40%. A recent randomized phase 2 clinical trial by Gomez et al. demonstrated significantly improved progression free survival with aggressive consolidative therapy (surgery, radiotherapy ± chemotherapy or SABR) in oli-gometastatic non-small cell lung cancer (NSCLC). As additional randomized controlled trials are ongoing to determine the efficacy of SABR in oligometastatic disease, SABR is increasingly being used within routine clinical practice. This review article aims to sum-marize the history and current paradigm of the oligometastatic state, review recently pub-lished literature of SABR in oligometastatic cancer and discuss ongoing trials and future directions in this context.
Topics: Carcinoma, Non-Small-Cell Lung; Disease-Free Survival; Humans; Lung Neoplasms; Metastasectomy; Neoplasms; Radiosurgery; Radiotherapy; Retrospective Studies; Treatment Outcome
PubMed: 28917254
DOI: 10.21037/cco.2017.06.20 -
World Journal of Surgical Oncology Nov 2020The rate of pulmonary metastasectomy from colorectal cancer (CRC) has increased with recent advances in chemotherapy, diagnostic techniques, and surgical procedures. The...
BACKGROUND
The rate of pulmonary metastasectomy from colorectal cancer (CRC) has increased with recent advances in chemotherapy, diagnostic techniques, and surgical procedures. The purpose of this study was to investigate the prognostic factors for response to pulmonary metastasectomy and the efficacy of repeat pulmonary metastasectomy.
METHODS
This study was a retrospective, single-institution study of 126 CRC patients who underwent pulmonary metastasectomy between 2000 and 2019 at the Gifu University Hospital.
RESULTS
The 3- and 5-year survival rates were 84.9% and 60.8%, respectively. Among the 126 patients, 26 (20.6%) underwent a second pulmonary metastasectomy for pulmonary recurrence after initial pulmonary metastasectomy. Univariate analysis of survival identified seven significant factors: (1) gender (p = 0.04), (2) past history of extra-thoracic metastasis (p = 0.04), (3) maximum tumor size (p = 0.002), (4) mediastinal lymph node metastasis (p = 0.02), (5) preoperative carcinoembryonic antigen (CEA) level (p = 0.01), (6) preoperative carbohydrate antigen 19-9 (CA19-9) level (p = 0.03), and (7) repeat pulmonary metastasectomy for pulmonary recurrence (p < 0.001). On multivariate analysis, only mediastinal lymph node metastasis (p = 0.02, risk ratio 8.206, 95% confidence interval (CI) 1.566-34.962) and repeat pulmonary metastasectomy for pulmonary recurrence (p < 0.001, risk ratio 0.054, 95% CI 0.010-0.202) were significant. Furthermore, in the evaluation of surgical outcomes, the safety of second pulmonary metastasectomy was almost the same as that of initial pulmonary metastasectomy.
CONCLUSIONS
Repeat pulmonary metastasectomy is likely to be safe and effective for recurrent cases that meet the surgical criteria. However, mediastinal lymph node metastasis was a significant independent prognostic factor for worse overall survival.
Topics: Colorectal Neoplasms; Humans; Lung Neoplasms; Metastasectomy; Neoplasm Recurrence, Local; Pneumonectomy; Prognosis; Retrospective Studies; Survival Rate
PubMed: 33256771
DOI: 10.1186/s12957-020-02076-3 -
Deutsches Arzteblatt International Oct 2012Autopsy studies of persons who died of cancer have shown the lungs to be the sole site of metastasis in about 20% of cases. The resection of pulmonary metastases is... (Review)
Review
INTRODUCTION
Autopsy studies of persons who died of cancer have shown the lungs to be the sole site of metastasis in about 20% of cases. The resection of pulmonary metastases is indicated for palliative purposes if they contain a large volume of necrotic tumor, infiltrate the thoracic wall to produce pain, or cause hemoptysis or retention pneumonia. Metastasectomy with curative intent may be indicated for carefully selected patients.
METHODS
This review is based on a selective search of the PubMed database for articles that were published from 2006 to 2011 and contained the keywords "pulmonary metastasectomy," "lung resection of metastasis," and "lung metastasectomy."
RESULTS
No prospective comparative trials have been performed to date that might provide evidence for prolongation of survival by pulmonary metastasectomy; nor have there been any randiomized, controlled trials yielding evidence that would assist in the decision whether to treat pulmonary metastases with surgery, radiotherapy, or chemotherapy (or some combination of these). The indication for surgery is a function of the histology of the primary tumor, the number and location of metastases, the lung capacity that is expected to remain after surgery, and the opportunity for an R0 resection. Favorable prognostic factors include a long disease-free interval between the treatment of the primary tumor and the discovery of pulmonary metastases, the absence of thoracic lymph node metastases, and a small number of pulmonary metastases. The reported 5-year survival rates after pulmonary metastasectomy, depending on the primary tumor, are 35.5% to 47% for renal-cell carcinoma, 39.1% to 67.8% for colorectal cancer, 29% to 52% for soft-tissue sarcoma, 38% to 49.7% for osteosarcoma, and 79% to 94% for non-seminomatous germ-cell tumors. For the latter two types of tumor, chemotherapy is the most beneficial form of treatment for long-term survival.
CONCLUSION
When there is no good clinical alternative, the resection of pulmonary metastases can give some patients long-lasting freedom from malignant disease. Patients should be carefully selected on the basis of clinical staging with defined prognostic indicators.
Topics: Hemoptysis; Humans; Lung Neoplasms; Lymphatic Metastasis; Metastasectomy; Neoplasm Invasiveness; Palliative Care; Pneumonectomy; Prognosis; Survival Rate
PubMed: 23094000
DOI: 10.3238/arztebl.2012.0645 -
Value in Health : the Journal of the... Jan 2022The FACS, GILDA, and COLOFOL trials have cast doubt on the value of intensive extracolonic surveillance for resected nonmetastatic colorectal cancer and by extension...
OBJECTIVES
The FACS, GILDA, and COLOFOL trials have cast doubt on the value of intensive extracolonic surveillance for resected nonmetastatic colorectal cancer and by extension metastasectomy. We reexamined this pessimistic interpretation. We evaluate an alternative explanation: insufficient power to detect a realistically sized survival benefit that may be clinically meaningful.
METHODS
A microsimulation model of postdiagnosis colorectal cancer was constructed assuming an empirically plausible efficacy for metastasectomy and thus surveillance. The model was used to predict the large-sample mortality reduction expected for each trial and the implied statistical power. A potential recurrence imbalance in the FACS trial was investigated. Goodness of fit between model predictions and trial results were evaluated. Downstream life expectancy was estimated and power calculations performed for future trials evaluating surveillance and metastasectomy.
RESULTS
For all 3 trials, the model predicted a mortality reduction of ≤5% and power of <10%. The FACS recurrence imbalance likely led to a large relative bias (>2.5) in the hazard ratio for overall survival favoring control. After adjustment, both COLOFOL and FACS results were consistent with model predictions (P>.5). A 2.6 (95% credible interval 0.5-5.1) and 3.6 (95% credible interval 0.8-7.0) month increase in life expectancy is predicted comparing intensive extracolonic surveillance-routine computed tomography scans and carcinoembryonic antigen assays-with 1 computed tomography scan at 12 months or no surveillance, respectively. An adequately sized surveillance trial is not feasible. A metastasectomy trial should randomize at least 200 to 300 patients.
CONCLUSIONS
Recent trial results do not warrant de novo skepticism of metastasectomy nor targeted extracolonic surveillance. Given the potential for clinically meaningful life-expectancy gain and significant uncertainty, a trial of metastasectomy is needed.
Topics: Colorectal Neoplasms; Humans; Metastasectomy; Neoplasm Recurrence, Local; Proportional Hazards Models; Randomized Controlled Trials as Topic; Time Factors; Tomography, X-Ray Computed
PubMed: 35031098
DOI: 10.1016/j.jval.2021.07.017 -
Clinical Genitourinary Cancer Aug 2022To quantify the magnitude of benefit of metastasectomy as compared to medical treatment alone in patients with metastatic renal cell carcinoma (mRCC). (Observational Study)
Observational Study
INTRODUCTION
To quantify the magnitude of benefit of metastasectomy as compared to medical treatment alone in patients with metastatic renal cell carcinoma (mRCC).
PATIENTS AND METHODS
We therefore conducted a propensity score analysis of overall survival (OS) in 106 mRCC patients with metachronous metastasis, of whom 36 (34%) were treated with metastasectomy, and 70 (66%) with medical therapy alone.
RESULTS
The most frequent metastasectomy procedures were lung resections (n = 13) and craniotomies (n = 6). Median time-to-progression after metastasectomy was 0.7 years (25th-75th percentile: 0.3-2.7). After a median follow-up of 6.2 years and 63 deaths, 5-year OS estimates were 41% and 22% in the metastasectomy and medical therapy group, respectively (log-rank P = .00007; Hazard ratio (HR) = 0.38, 95%CI: 0.21-0.68). Patients undergoing metastasectomy had a significantly higher prevalence of favorable prognostic factors, such as fewer bilateral lung metastases and longer disease-free intervals between nephrectomy and metastasis diagnosis. After propensity score weighting for these differences and adjusting for immortal time bias, the favorable association between metastasectomy and OS became much weaker (HR = 0.62, 95%CI: 0.39-1.00, P = .050). Propensity-score-weighted 5-year OS estimates were 24% and 20% in the metastasectomy and medical therapy group, respectively (log-rank P = .001). In exploratory analyses, the benefit of metastasectomy was confined to patients who achieved complete resection of all known metastases.
CONCLUSION
Within the limitations of an observational study, these findings support the concept of metastasectomy being associated with an OS benefit in mRCC patients. Metastasectomies not achieving complete resection of all known lesions are likely without OS benefit.
Topics: Carcinoma, Renal Cell; Humans; Kidney Neoplasms; Metastasectomy; Nephrectomy; Prognosis; Propensity Score; Retrospective Studies; Survival Rate
PubMed: 35443915
DOI: 10.1016/j.clgc.2022.03.010