In Iceland every third individual is diagnosed with malignant disease; cancer being the cause of death in one out of four individuals with only cardiovascular diseases being more common cause of death. Approximately one third of cancer patients are diagnosed with lung metastases making the lungs one of the most common metastatic site. In some of these patients a metastasectomy is a treatment option with the intention of improving survival. In this evidence-based review, the indications and outcome of pulmonary metastasectomy are discussed. This review is aimed at doctors within different specialties where Icelandic studies on pulmonary metastasectomy are referred to. 

Vidarsdottir H¹, Moller PH^2,4, Gudbjartsson T^3,4

¹Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden, ²Department of Surgery, Landspítali University Hospital, ³Department of Cardiothoracic Surgery, Landspítali University Hospital, ⁴Faculty of Medicine, University of Iceland, Reykjavík.

Table I.   Incidence of pulmonary metastasis according to primary tumour [4]

	(%)
Osteosarcoma	75
Testicular cancer	70-80
Melanoma	60-80
Breast carcinoma	60
Renal cell carcinoma	50-75
Colorectal carcinoma	20-43
Bladder cancer	25-30
Lung cancer	20-30
Head and neck cancer	13-40

 

 

Table II. Preoperative diagnostic test before deciding pulmonary metastasectomy.

Oncological staging	Other diagnostic tests
CT scan, ultrasound, bone schintigraphy  (PET)	Spirometry
Bronchoscopy	ECG
Special studies based on primary tumour (colonscopy, MRI)	Echocardiography

 

 

Table III. Karnofsky performance index

Able to carry on normal activity and to work; no special care needed.	100	Normal no complaints; no evidence of disease.
	90	Able to carry on normal activity; minor signs or symptoms of disease.
	80	Normal activity with effort; some signs or symptoms of disease.
Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed.	70	Cares for self; unable to carry on normal activity or to do active work.
	60	Requires occasional assistance, but is able to care for most of his personal needs.
	50	Requires considerable assistance and frequent medical care.
Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.	40	Disabled; requires special care and assistance.
	30	Severely disabled; hospital admission is indicated although death not imminent.
	20	Very sick; hospital admission necessary; active supportive treatment necessary.
	10	Moribund; fatal processes progressing rapidly.
	0	Dead

 

 

Figure 1. CT scan that shows a 3.5 cm metastasis (arrow) from colon carcinoma. The patient underwent lobectomy as a sublobar resections were not feasible due to central location of the tumor.

Figure 2. The most common types of resections for pulmonary metastases A) wedge resection, and B) lobectomy.  Figure: Bjarni Thor Petursson.

Figure 3. Anterolateral thoracotomy. Photo: Tómas Guðbjartsson.

Figure 4. Video-assisted thoracoscopic surgery (VATS). Photo: Tómas Guðbjartsson.

Figure 5.  Survival (Kaplan-Meier) after pulmonary metastasectomy for the thress most common pulmonary metastases in Iceland 1984-2008. Five-year survival was 45,2% for colorectal carcinoma, 38,5% for renal cell carcinoma and 18,6% for sarcoma.
CRC, colorectal carinoma, RCC, renal cell carcinoma. Figure adapted from [6]