Current Role for Resection of Thoracic Metastases in Children and Young Adults - Do we Need Different Strategies for this Population?

Abstract

A retrospective review of surgical interventions for pulmonary metastases found 44 surgical metastasectomies in patients 20 years old or younger. Objective: Indications for pulmonary metastasectomy are well established in adults, but are not so clear when we are dealing with a younger population. Patients and Methods: A retrospective review of surgical interventions for pulmonary metastases (from December 1996 to October 2001) found 44 surgical metastasectomies in patients considered pediatric or young adults (20 years old or younger). Initial primary tumor, disease-free interval (DFI), previous thoracotomies, tumor histology, number of metastases, surgery performed, postoperative complications, other treatments received, and outcomes were recorded. Results: Median age was 16.3 years (range 5 to 20 years) with 27 male and 17 female patients. Primary tumors were sarcoma (n = 31), Ewing's tumor (n = 8), Wilms' tumor (n = 3), and testicular carcinoma (n = 2). 27 patients had undergone previous resection of pulmonary metastases. Approaches were posterolateral thoracotomy (n = 18), clamshell incision (n = 8), VATS (n = 7), axillary thoracotomy (n = 9), and others (n = 2). Wedge resections were the procedure of choice (n = 35). In very select cases 1 pneumonectomy, 3 lobectomies, 2 chest wall resections, and 1 spinal surgery (vertebrectomy) were performed. Intra-operative radiotherapy (IORT) was employed in 2 patients. Cardiopulmonary bypass was necessary in 1 patient in order to resect an intra-atrial tumor thrombus. There was no operative mortality. Morbidity was related to prolonged air leaks (3 patients), hemothorax (2 patients), cerebrospinal fluid leak (1 patient), atelectasia (1 patient), peritoneal pain (1 patient), and postoperative fever syndrome (1 patient). Patterns of failure were thoracic (lung-pleura-chest wall) (n = 20), distant (n = 3) and thoracic + distant (n = 6). Conclusion: A close collaboration between oncologists, radiotherapists, and surgeons is mandatory in order to obtain good results. IORT is an interesting option. Better results are obtained if there is a long DFI and probably justifies a more aggressive approach in these specific cases.

Key words

Pulmonary metastasectomy - sarcoma-therapy - sarcoma-surgery - child

References

• 1 International Registry for Lung Metastases . Long-term results of lung metastasectomy: Prognostic analyses based on 5026 cases.  J Thorac Cardiovasc Surg. 1997;  11 37-49
• 2 Kaplan E, Meier P. Nonparametric estimation from incomplete observation.  J Am Stat Assoc. 1958;  53 457-481
• 3 Torre W, Rabago G, Barba J, Sierrasesumaga L, Baixauli J, Galbis J. Combined surgical approach for sarcoma lung metastasis with atrial involvement.  Thorac Cardiovasc Surg. 1999;  47 125-127
• 4 McCormack P M, Martini N. The changing role of surgery for pulmonary metastases.  Ann Thorac Surg. 1979;  28 139-145
• 5 Takita H, Edgerton F, Karakousis C, Douglass Jr H O, Vincent R G, Beckley S. Surgical management of metastases to the lung.  Surg Gynecol Obstet. 1981;  152 191-194
• 6 Vogt-Moykopf I, Bülzebruck H, Merkle N M, Probst G. Results of surgical treatment of pulmonary metastases.  Eur J Cardiothorac Surg. 1988;  2 224-232
• 7 San-Julian M, Dolz R, Garcia-Barrecheguren E, Noain E, Sierrasesumaga L, Cañadell J. Limb salvage in bone sarcomas in patients younger than age 10: a 20-year experience.  J Pediatr Orthop. 2003;  23 753-762
• 8 Rodgers B M, Talbert J L, Alexander J A. Pulmonary metastases in childhood sarcoma.  Ann Thorac Surg. 1980;  29 410-414
• 9 Galbis J M, Nwose P, Torre W. Reseccion quirurgica de metastasis pulmonares de repeticion.  Arch Bronconeumol. 1988;  34 489-491
• 10 Roth J A, Pass H I, Wesley M N, White D, Putnam J B, Seipp C. Comparison of median sternotomy and thoracotomy for resection of pulmonary metastases in patients with adult soft-tissue sarcomas.  Ann Thorac Surg. 1986;  42 134-138
• 11 Bains M S, Ginsberg R J. Jones WG 2nd . The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor.  Ann Thorac Surg. 1994;  58 30-33
• 12 Pastorino U, Valente M, Gasparini M, Azzarelli A, Santoro A, Tavecchio L, Casali P, Ravasi G. Median sternotomy and multiple lung resections for metastatic sarcomas.  Eur J Cardiothorac Surg. 1990;  4 477-481
• 13 Meyers B F, Sundaresan R S, Guthrie T, Cooper J D, Patterson G A. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications.  J Thorac Cardiovasc Surg. 1999;  117 358-364
• 14 McCormack P M, Bains M S, Begg C B, Burt M E, Downey R J, Panicek D M, Rusch V W, Zakowski M, Ginsberg R J. Role of video-assisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial.  Ann Thorac Surg. 1996;  62 213-216
• 15 Gossot D, Miaux Y, Guermazi A, Celerier M, Frija J. The hook-wire technique for localization of pulmonary nodules during thoracoscopic resection.  Chest. 1994;  105 1467-1469
• 16 Torre W, Rodríguez-Spiteri N, Cortes J, Fernandez O, Lopez-Picazo J M. Is it worth using videoassisted thoracic surgery (VATS) for the resection of thoracic metastases? Istanbul: 9^th European Conference of the ESTS, 2002. 2002
• 17 Landreneau R J, De Giacomo T, Mack M J, Hazelrigg S R, Ferson P F, Keenan R J, Luketich J D, Yim A P, Coloni G F. Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases.  Eur J Cardiothorac Surg. 2000;  18 671-677
• 18 Schroder C, Fisher S, Pieck A C, Muller A, Jaehde U, Kirchner H, Haverich A, Macchiarini P. Technique and results of hyperthermic (41 degrees C) isolated lung perfusion with high doses of cisplatin for the treatment of surgically relapsing or unresectable lung sarcoma metastasis.  Eur J Cardiothorac Surg. 2002;  22 41-46
• 19 Ballantine T V, Wiseman N E, Filler R M. Assessment of pulmonary wedge resection for the treatment of lung metastases.  J Pediatr Surg. 1975;  10 671-676
• 20 Kodama K, Doi O, Higashiyama M, Tatsuta M, Iwanaga T. Surgical management of lung metastases. Usefulness of resection with the neodymium: ytrium-aluminium-garnet laser with median sternotomy.  J Thorac Cardiovasc Surg. 1991;  101 901-908
• 21 Frenckner B, Lannergren K, Soderlund S. Results of surgical treatment of lung metastases in children.  Scand J Thorac Cardiovasc Surg. 1982;  16 201-204
• 22 Torre W, Sierra A, Aristu J, Azinovic I, Cambeiro M. Results of intraoperative radiotherapy (IORT) as an adjunct to resective surgery for treatment of thoracic malignancies. London: 8th European Conference on General Thoracic Surgery (ESTS). 2000