European Multidisciplinary Conference in Thoracic Oncology (EMCTO 2011) 24—26th February 2011, Lugano

Surgical removal of cancerous lung nodules from metastatic patients

Dr Gaetano Rocco (National Cancer Institute, Naples, Italy)

ecancer.tv now turns to surgery, here at the Lugano meeting of the European Multidisciplinary Conference on Thoracic Oncology. Now thoracic oncology, Professor Gaetano Rocco from Naples,  includes looking at metastases to the lungs from other cancers. Can you tell me what you’re doing in this area because it’s quite a controversial area? You can get some real improvements for your patients can you?

Actually we can by surgery and we try to perform surgery as minimally invasively as we can. A real philosophic principle is to keep the resection as conservative as we can in the lung and try to remove as many nodules we find as we can with a very minimally invasive approach. There are two major possibilities in terms of technique – you can do an open thoracotomy or by VATS or a robotic, and whichever approach we use we tend to  be very precise in excising the nodules by saving the remaining lung.

And you can use lymphadenectomy or not?

That’s one of the major controversial issues right now. The lesson learned from the resection of primary lung cancer, tells us maybe a lymphadenectomy could be of advantage and there is recent evidence showing that even for metastases the same may be true.

These patients, though, are quite ill, they have metastatic disease so how controversial is it to treat this disease relatively aggressively?

The idea is that besides the attempt to cure in terms of removing as many nodules as we can, in patients that, yes, they are ill oncologically but sometimes they are not ill in terms of cardiorespiratory function, so they are amenable to a surgical treatment. But the real issue is that we can provide tissue for subsequent immunotherapy and/or chemotherapy in what we call targeted individualised therapy.

Now what different subtypes of lung metastases are there that would help guide your therapy?

We deal basically with epithelial cancers, especially colorectal, kidney, breast are among the most frequent, and sarcomas. That’s the main groups of metastases we remove and the five year survival is slightly better for the epithelial cancers once the primary site is under control. We have the possibility to ensure a 40-60% five year survival for patients with colorectal metastases, whereas it is slightly lower for patients with osteosarcoma, for them the five year survival, these are usually younger patients, as you know,  is around 30%.

And what sort of hard data from big studies do you have on the comparison between the survival with this surgery for metastatic disease and without it?

That’s exactly the point, this is one of the hot topics of the moment. We are setting, in the surgical world, the idea of prompting a trial to understand whether the role of surgery is so decisive because patients with pulmonary mets usually, unless the mets are many and fill completely the lungs, do not have symptoms. So we need to understand whether surgery really has an impact on survival as has been shown in the literature and whether surgery can improve symptoms. But, as I said, many patients do not have symptoms from pulmonary mets.

And there are different kinds of approaches, could you elaborate what they are?

Absolutely.The two main approaches are open, traditional surgery although even the traditional surgery has become less and less invasive as compared to decades ago and video assisted surgery, either conventional like VATS or robotic. But both can use special instruments inside to perform precise excision of the nodules and so leave as much normal lung as we need for further treatment or for the patients to be able to survive.

Alternatively you can do it in a minimally invasive way endoscopically.

Endoscopically yes, it’s the VATS and this is doable because we have articulating instruments that inside the chest allow us to perform the same manoeuvres that we allow from outside.

Now palpation is an issue?

Palpation is an issue but very recently the advancement and refinement of imaging techniques have allowed us, as surgeons, to be able to identify more and more mets in a very early stage so we know most of the time with an accuracy of 80% how many nodules we find. But there is still a possibility that once you operate a patient with pulmonary mets you end up finding more and this possibility is about 15-20%.

What are the markers that would indicate that you should go for an open procedure?

The markers, multiple nodules are usually an indicator for an open procedure because we want to make sure that multiple nodules already prelude to the idea of finding even more so.Whereas when you have one nodule only a thoracoscopy is indicated, also because we need to make a diagnosis, it’s not set in stone that that nodule is a metastasis from the extra-thoracic cancer, it can be a benign disease or a primary lung cancer.

And what about when there are recurrences?

That’s really one of the problems that we are facing and that’s why studies have been conducted to try to understand how far we have to be from the margin of the tumour we resect in order for this tumour not to come back. Obviously there are other alternatives like radiofrequency ablation that can help, even intra-operatively, the surgeon to make sure that the margins are adequate.

So you could have a combined approach?

Absolutely, yes.

All in all, what sort of patients can benefit from this approach?

The fundamental issue is that the primary site has to be under control and there should be no recurrence of the primary site. Obviously patients with a very long disease-free interval are amenable for this treatment with few nodules and small nodules are the ones who really can benefit more. Although the prognosticators of survival are increasing day by day with the development of a biomolecular staging and biomolecular studies, we found every day a way to better specify which ones really will benefit from surgery.

Do you need to have a good performance status?

That’s mandatory because every time we operate on the chest, performance status and cardiorespiratory function is the first system that needs to be investigated.

So at the end of the day, what proportion of patients, average patients, can hope to have this procedure?

Well in theory many, it’s difficult to give you a percentage because it depends on the histotype and the presence of extra-thoracic disease along with the pulmonary mets. But with the idea that cancer is becoming a chronic disease more and more patients will be subjected to surgery.

So you think that life can be extended, perhaps longer and longer, by this sort of procedure?

That’s what we intend to do and that’s our aim when we apply minimally invasive thoracic surgery to these patients.

So to sum up, what would you advise cancer doctors to think about these possibilities?

Well every time there is a situation where you have lung nodules in patients with extra-thoracic cancer, there is, especially those cancers who are prone to give pulmonary metastatic disease, my advice is to consult early a surgeon and see whether, especially if he works in a multidisciplinary setting, whether there is space and room to approach this patient surgically.

Professor Gaetano Rocco, thank you very much for being on ecancer.tv.

Thank you.