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ORIGINAL ARTICLES |
From the Department of Thoracic Surgery, Tor Vergata University, Rome, Italy.
Correspondence: Address for correspondence and reprints: Prof. Tommaso Claudio Mineo, Cattedra di Chirurgia Toracica, Ospedale S. Eugenio, p.le Umanesimo 10, 00144 Rome, Italy; Fax: 39-06-592-2681; E-mail: mineo{at}med.uniroma2.it
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONREFERENCES |
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Methods: Between March 1987 and December 1994, surgery was performed on nine patients with non–small-cell lung cancer with synchronous, solitary, extracranial, or distant metastasis: adrenal (n = 5), cutaneous (n = 2), axillary lymph node (n = 1) and kidney (n = 1). Criteria for operating on these patients included: primary tumor that was locally resectable in a radical manner, non–small-cell histology, no preoperative evidence of N2 disease, complete resection of histologically proven metastasis, and absence of other metastases found with computed tomography or bone scan.
Results: Resection of the primary tumor and solitary metastases was achieved in all patients. Primary tumor was always resected by lobectomy. No mortality or major morbidity was reported. Five-year survival rate was 55.6%. Five patients who had adrenal (n = 3), or skin (n = 1), or axillary (n = 1) metastases, survived more than 5 years. All N2 patients (n = 2) died.
Conclusions: The presence of solitary, distant metastasis should not be considered, per se, a factor for denying surgery for locally resectable, non–small-cell lung cancer. Unexpected, prolonged survival was demonstrated in our limited series.
Key Words: Lung cancer • Adrenal metastasis • Skin metastasis • Surgery
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INTRODUCTION |
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The finding of long-term survival in our patients who underwent simultaneous resection of metastasis and non–small-cell lung cancer stimulated our interest in the role of surgery in this particular situation. We analyzed our experience by focusing attention on the effects of surgical excision on long-term survival.
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MATERIAL AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONREFERENCES |
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Lung cancer patients whose cancer had direct involvement of the chest wall and the skin were excluded from the study. No metastases on the site of surgical incisions were recorded. Evidence of other potentially metastasizing malignancies was excluded for all the patients belonging to the study group. In all patients, primary surgery implied radical cancer resection and systematic dissection of mediastinal lymph nodes (Table 1).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONREFERENCES |
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Mean maximal diameter of adrenal metastasis was 7.0 cm (range 5–10 cm). Skin metastases resection was simple in all patients and did not require rotation flap or major plastic surgery. The ipsilateral axillary lymph node was resected before lung surgery. Nephrectomy was accomplished 14 days after the lung procedure and the patient was discharged 7 days later. No mortality or major morbidity was reported in any of the patients. Adjuvant chemotherapy was performed in all patients for 6 months after surgery; only one patient refused the treatment. Radiotherapy was performed in only one case at the site of nephrectomy because of unclear resection margins.
Mean 5-year survival rate was 55.6%. Five patients are alive and free of disease at more than 5 years from the operation: adrenal (n = 3), skin (n = 1), and axillary (n = 1). All four patients who developed reprise of disease died shortly after the diagnosis. The pattern of the first recurrence after metastasectomy is described in Table 1. Both patients with N2 disease died after 18 and 36 months, respectively.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONREFERENCES |
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The possibility of having a sole site of extracranial metastases in patients with operable lung cancer and proven single metastasis is generally considered quite low. Ettinghausen and Burt13 deemed the rate of solitary adrenal metastases to be around 1.62% and La Porte et al. at 3.5%.14 On the other hand, Luketich et al.15 observed that 7% of the patients with metastatic disease from NSCLC have a solitary metastasis after full evaluation. Furthermore, Quint et al.16 have recently discovered that in a total of 72 patients with M1 disease with newly diagnosed lung cancer, more than 50% of the patients (n = 48) had metastasis restricted to one body part.
According to this last report, surgery for extracranial solitary metastases may have a rationale. The finding of long-term survival in our study of patients who underwent simultaneous resection of metastasis and NSCLC stimulated our interest in the role of surgery for this situation. The long-term survival of our highly selected cohort of patients is quite encouraging. We observed five out of nine patients who are still alive and free of disease after a follow-up longer than 5 years.
The adrenal gland is a frequent site of metastases from NSCLC. CT scans of the abdomen performed during the staging of NSCLC revealed adrenal metastases in 5% to 10% of patients.17–19 There are several reports in the literature of long-term survivors after adrenalectomy for isolated metastasis.20–22 Ayabe et al.20 suggested that adrenalectomy may provide good results when all of the following conditions are present: controlled or controllable primary tumor, no evidence of other distant metastatic lesion, unilateral and completely resectable adrenal metastasis, and good physical condition of the patient.
Reports of simultaneous removal of metastatic distant lymph nodes are uncommon. Luketich et al.15 described resection of metachronous metastatic lymph nodes from different sites in six patients: supraclavicular (n = 2), cervical (n = 2), groin (n = 1), and axillary (n = 1). In the present series, patients with supraclavicular lymph nodes were not considered because they did not belong to the M1 disease category. There were, however, two patients with positive ipsilateral supraclavicular nodes who survived more than 1 year after presumed radical surgery. The only patient we operated on who had positive ipsilateral axillary nodes is still alive and free of tumor after 96 months from the procedure (Table1).
The presence of skin metastases is another condition that is considered a sign of an inoperable disease. Nevertheless, for cases with ascertained solitary deposits, there seems to be a rationale for surgery: indeed it might be limited to only one site and amenable to surgical treatment.
Observations have shown that a few patients have survived for many years23,24 in spite of the bad prognosis related to the presence of skin metastases. In our opinion, the conditions for longer survival are related not only to the primary tumor (tumor node stage and total eradication), but also to the characteristics of metastasis: solitary, resectable lesions in the absence of other extracutaneous deposits. As for adrenal metastasis, skin metastasectomy may also be performed to provide pain-relief.
This study sample was obviously small and therefore no significant statistical evaluation is possible. The tumor node status strongly influenced prognosis: both patients with N2 disease died with a median survival of 27 months. This finding suggests the necessity of routine mediastinoscopy to assess N2 disease in patients with M1 disease even in the absence of positive imaging. The presence of N2 disease in these patients should result in a decision to avoid surgical resection.
In conclusion, the presence of a solitary, distant metastasis should not be considered in itself as a factor for denying surgery for locally, resectable NSCLC. Our experience of prolonged survival confirms that metastasectomy and radical resection should be performed for the primary tumor in the absence of N2 involvement.
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Acknowledgments |
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Received for publication September 6, 2000. Accepted for publication June 20, 2001.
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REFERENCES |
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 D. G. Pfister, D. H. Johnson, C. G. Azzoli, W. Sause, T. J. Smith, S. Baker Jr, J. Olak, D. Stover, J. R. Strawn, A. T. Turrisi, et al. American Society of Clinical Oncology Treatment of Unresectable Non-Small-Cell Lung Cancer Guideline: Update 2003 J. Clin. Oncol., January 15, 2004; 22(2): 330 - 353. [Full Text] [PDF]
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