Interact CardioVasc Thorac Surg 2008;7:809-812. doi:10.1510/icvts.2008.180778
© 2008 European Association of Cardio-Thoracic Surgery
Institutional report - Pulmonary |
Pulmonary resection for metastasis from esophageal carcinoma
Fengshi Chen,
Kiyoshi Sato,
Hiroaki Sakai,
Ryo Miyahara,
Toru Bando,
Kenichi Okubo,
Toshiki Hirata and
Hiroshi Date*
Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
Received 28 March 2008;
received in revised form 22 May 2008;
accepted 26 May 2008
*Corresponding author. Tel.: +81-75-751-3835; fax: +81-75-751-4647.
E-mail address: hdate{at}kuhp.kyoto-u.ac.jp (H. Date).
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Abstract
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Pulmonary metastasectomy has become the standard therapy for various metastatic malignancies to the lungs; however, few data have been available regarding lung metastasectomy for esophageal carcinoma. To confirm a role for resection of pulmonary metastases for such tumors, we reviewed our institutional experience. Between 2001 and 2007, five patients with pulmonary metastases from esophageal carcinoma underwent complete pulmonary resection. All patients had undergone curative resection of their primary esophageal carcinomas and also had obtained locoregional control of their primaries. Disease-free interval varied from 13 to 56 months, with a median of 21 months. In three patients, lung metastases were found to be unilateral and solitary. The other two patients presented several metastases in the unilateral or bilateral lungs. All patients underwent wedge resection or segmentectomy. Currently, four patients are alive without evidence of disease and one patient has died of disease. All patients undertook or were going to undertake chemotherapy after the pulmonary metastasectomy. Three patients with solitary metastasis are all alive without disease 13, 48, and 90 months after the first pulmonary metastasectomy, respectively. Pulmonary metastasectomy for esophageal carcinoma with postoperative chemotherapy was seemingly justified. Solitary pulmonary metastasis might be a good candidate for favorable prognostic factor.
Key Words: Esophageal carcinoma; Pulmonary metastasis; Metastasectomy
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1. Introduction
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Esophageal carcinoma is known as a highly lethal disease, and the reported 5-year survival rate ranges from 20% to 36% after intentionally curative surgery due to a high rate of either local or distant recurrence [1]. Approximately 50% of patients present with metastatic disease and most patients with localized esophageal carcinoma will have local recurrence or develop metastases, despite potentially curative local therapy [2]. The most common sites of distant recurrence are represented by lung, liver and bone [3], but there are almost no reports as to the available therapeutic modalities and their outcomes for pulmonary recurrence after the curative resection of esophageal carcinoma. Furthermore, although pulmonary metastasectomy has become the standard therapy for various metastatic malignancies to the lungs [4–7], there have been almost no studies examining the role of pulmonary metastasectomy for patients with esophageal carcinomas. In order to accumulate the data of this entity of patients, we therefore conducted a retrospective study on the surgical treatment of pulmonary metastasis of esophageal carcinoma in our institution.
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2. Patients and methods
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A retrospective analysis of patients with lung metastases from esophageal carcinomas, who were referred for pulmonary resection to Kyoto University Hospital between April 2001 and March 2007, was performed. In this period, complete resection of pulmonary metastases from esophageal cancers was performed on five patients. Chest X-rays or CT-scans were considered positive if they showed new, rounded pulmonary lesions without calcifications in patients previously known to have esophageal carcinomas. Further examinations were also performed to exclude extrapulmonary metastases. For example, in all patients, head, chest and abdominal CT-scans and bone scintigraphy were performed. All patients but one (Patient 1) also underwent positron emission tomography preoperatively. All specimens obtained from metastasectomies were reviewed by several pathologists. The pulmonary lesions were only considered metastatic if the pathologists could exclude the possibility of a primary lung malignancy and define the tumor as metastatic based upon histologic similarity to the primary tumor. In every patient we collected data on primary treatment, and on the interval between primary surgical treatment for the primary esophageal lesions and the detection of pulmonary metastases (disease-free interval=DFI). Further data were collected on the characteristics of metastases, on the method of treatment, and on details concerning the metastasectomy.
All patients who underwent resection of their pulmonary metastases met the following criteria: (1) pulmonary lesions were deemed resectable by not only the radiological examinations but also by the patients' general conditions; (2) metastatic disease was limited to the lungs; and (3) locoregional control of their primary esophageal lesions was obtained or obtainable. Five patients met these criteria and metastasectomy was performed. Complete clinical and pathological data were reviewed.
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3. Results
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Five patients with pulmonary metastases from primary esophageal cancer underwent a thoracotomy and resection. Three patients were male and two were female (Table 1). The median age was 57 years, with a range of 45–72 years. In all cases, the primary cancers had been completely resected. No patients received chemotherapy before the resection of esophageal carcinoma, and only one patient received chemotherapy with 5-fluorouracil and cisplatin. No patients showed the lymph node involvements in the primary lesions. DFI varied from 13 months to 56 months, with a median of 21 months. In no patient, recurrence of esophageal carcinoma was observed before the detection of pulmonary metastases. In four patients, lung metastases were found to be unilateral (Table 2). Three patients had a solitary pulmonary metastasis, while the other two patients had 3–5 metastases. The number of metastases which was evaluated preoperatively by CT was consistent with that confirmed intraoperatively. The median diameter of the largest metastasis was 24 mm (range, 12–34 mm). Since four patients had unilateral tumors, they underwent a unilateral thoracotomy. One patient with bilateral lesions underwent staged bilateral thoracotomies. An attempt was made to conserve as much lung tissue as possible. This was reflected by the fact that wedge resection or segmentectomy were the most common procedures performed (Table 3). Only one case of wedge resection was performed by video-assisted thoracoscopic surgery, while one case of wedge resection was done through ordinary thoracotomy due to the pleural adhesion. Three cases of segmentectomy were performed by ordinary thoracotomy. No patients died directly of surgery and all the patients were discharged home without any lesions after surgery. No patients received chemotherapy before the pulmonary metastasectomy, while all the patients but one (Patient 5) received chemotherapy, mainly with nedaplatin and docetaxcel after the pulmonary metastasectomy. Patient 5 is also going to undertake postoperative chemotherapy soon.
The median time at follow-up examination was 24 months (range 11–90 months). Two patients remained free of disease after their first thoracic operation, while three patients developed recurrences. To be specific, one patient (Patient 1) developed ipsilateral pulmonary recurrence 13 months after the first pulmonary metastasectomy. He underwent a curative resection of the recurrent tumor and received chemotherapy. He is now free of disease 77 months after the second pulmonary metastasectomy. Another patient (Patient 2), who revealed a multiple nodal involvement in the first metastasectomy, developed contralateral pulmonary recurrence approximately one year after the first pulmonary metastasectomy, although he had received adjuvant chemotherapy. He could undergo the second curative pulmonary resection. He undertook chemotherapy again, and he is now free of disease one year after the second lung surgery. The other patient (Patient 3) developed lymph node recurrence in the right neck four months after the first pulmonary metastasectomy. He underwent a radical resection of the right lymph nodes, but developed multiple lung metastases soon after. He also presented multiple brain metastases five months later and finally died of disease 11 months after the pulmonary resection.
Disease-free survival time ranged between 4 and 48 months with a mean of 13 months, while overall survival time ranged from 11 to 90 months with a mean of 24 months. The sites of tumor recurrence were lungs in three cases, neck lymph node in one case, and brain in one case. Now, four patients are alive without evidence of disease and one patient died of disease.
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4. Discussion
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Many studies have been performed for pulmonary metastasectomy for various primary cancers, such as colorectal cancer, breast cancer, and osteosarcoma [4, 5], and pulmonary metastasectomy has become the standard therapy for various metastatic malignancies to the lungs. However, almost no studies have been published in the English-language literature about surgical resection of pulmonary metastases from esophageal carcinomas, and the indications for these procedures and the prognostic factors have not yet been known well. Generally, the prognosis of patients with recurrent esophageal carcinoma is poor, but in some cases surgical resection, chemotherapy or radiotherapy has been proven effective.
The rate of recurrence of esophageal carcinoma even after curative surgery was found to be high in most reports [8–10]. In general, the combination therapy of resection or irradiation and combined chemotherapy has been recommended as a treatment for patients with recurrent esophageal carcinoma, but there are no established regimens as to these available therapeutic modalities [11]. The most frequent type of recurrence of esophageal carcinoma was locoregional, followed by hematogenous recurrence [12]. However, hematogenous recurrence, such as pulmonary and hepatic metastases, was unlikely to be completely treated by surgical resection because of the high possibility of tumor development or coexistence of other metastatic lesions [8]. Nonetheless, there exists an entity of patients with a localized or isolated pulmonary metastasis, and, therefore, we investigated the role of pulmonary metastasectomy of esophageal carcinoma, focusing on these patients.
In our study, 3 of 5 patients were solitary metastasis, and interestingly enough, all patients are well without disease at present. Two of them did not show the tumor recurrence. Although one patient showed ipsilateral pulmonary recurrence 13 months later, he survived without any other recurrent diseases 77 months after the second pulmonary metastasectomy. By contrast, the remaining two patients recurred in a relatively early time after metastasectomy, and one patient died within one year after the pulmonary resection. Since the number of patients was so small, no definite conclusion could be led by our study; however, our experience suggests that when functional status is good and metastases are technically resectable, surgical excision with postoperative chemotherapy should be considered in selected patients. It has been reported that the mean survival period after lung metastasis was 6–10 months [13]. In comparison with such historical data, our data were apparently better in survival, and, therefore, it would strongly support our current practice on such entity of patients. Our data also suggested that patients with solitary metastasis would possibly be a good candidate who might have a benefit from the pulmonary metastasectomy in the long run. Accumulation of cases is necessary to determine the criteria of pulmonary metastasectomy for such patients. In addition, in our study, three patients (Patient 1, 2, and 4) received right thoracotomy, while two patients did not receive thoracotomy because of the cervical lesion. Two of three patients with right thoracotomy showed right pulmonary metastasis. Because of the small number of patients, it is very difficult to say that the lung metastasis could have been seeding from the initial surgery, and thus, accumulation of cases is also inevitable.
There are several limitations to our analysis. Since the number of patients for pulmonary metastasectomy of esophageal carcinoma was so small in one institution, a large-scale prospective study with many institutions is absolutely needed. Furthermore, chemotherapeutic regimens have evolved substantially, varied among institutions, and continue to be highly individualized based on unique patient.
In conclusion, current practice of pulmonary metastasectomy with postoperative chemotherapy for esophageal carcinoma in our institution was seemingly justified since we experienced patients with long-term survival. Solitary pulmonary metastasis would be a good candidate for favorable prognostic factor in our study; however, the accumulation of cases is necessary to evaluate a prognostic factor properly and to determine the selection criteria for resection.
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References
|
|---|
- Lerut T, De Leyn P, Coosemans W, Van Raemdonck D, Scheys I, Le Saffre E. Surgical strategies in esophageal carcinoma with emphasis on radical lymphadenectomy. Ann Surg 1992;216:583–590.[Medline]
- Posner MC, Forastiere AA, Minsky BD. Cancer of the esophagus. In: De Vita VT, Jr, Hellman S, Rosenberg SA, editors, Cancer principles and practice of oncology, 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:861–909.
- Enzinger PC, Ilson DH, Kelsen DP. Chemotherapy in esophageal cancer. Semin Oncol 1999;26:12–20.[Medline]
- McCormack P. Surgical resection of pulmonary metastases. Semin Surg Oncol 1990;6:297–302.[CrossRef][Medline]
- Patel AN, Lamb J, Patel N, Santos RS, Stavropoulos C, Landreneau RJ. Clinical trials for pulmonary metastasectomy. Semin Thorac Cardiovasc Surg 2003;15:457–463.[CrossRef][Medline]
- Pastorino U. History of the surgical management of pulmonary metastases and development of the international registry. Semin Thorac Cardiovasc Surg 2002;14:18–28.[CrossRef][Medline]
- Sternberg DI, Sonett JR. Surgical therapy of lung metastases. Semin Oncol 2007;34:186–196.[CrossRef][Medline]
- Carlisle JG, Quint LE, Francis IR, Orringer MB, Smick JF, Gross BH. CT evaluation after esophagectomy. Radiology 1993;189:271–275.[Abstract/Free Full Text]
- Law SYK, Fok M, Wong J. Pattern of recurrence after oesophageal resection for cancer. Clinical implications. Br J Surg 1996;83:107–111.[Medline]
- Flamen P, Lerut A, Van Cutsem E, Cambier JP, Maes A, De Wever W, Peeters M, De Leyn P, Van Raemdonck D, Mortelmans L. The utility of positron emission tomography for the diagnosis and staging of recurrent EC. J Thorac Cardiovasc Surg 2000;120:1085–1092.[Abstract/Free Full Text]
- Malthaner RA, Wong RK, Rumble RB, Zuraw L. Members of the Gastrointestinal Cancer Disease Site Group of Cancer Care Ontario's Program in Evidence-based Care. Neoadjuvant or adjuvant therapy for resectable esophageal cancer: a systemic review and meta-analysis. BMC Med 2004;2:35.[CrossRef][Medline]
- Wu YK, Huang GJ, Shao LF, Zhang YD, Lin XS. Progress in the study and surgical treatment of cancer of the esophagus in China. 1940–80. J Thorac Cardiovasc Surg 1982;84:325–333.[Medline]
- Bhansali M, Fujita H, Kakegawa T, Yamana H, Ono T, Hikita S, Toh Y, Fujii T, Tou U, Shirouzu K. Pattern of recurrence after extended radical esophagectomy with three- field lymph node dissection for squamous cell carcinoma in the thoracic esophagus. World J Surg 1997;21:275–281.[CrossRef][Medline]
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Abstract
1. Introduction