Pulmonary Metastasectomy - Lung Metastasis Surgery

Cancer that has reached the lungs can sometimes still be cut out. Four conditions decide whether it should be.

Pulmonary metastasectomy removes tumors that have spread to the lungs from a cancer elsewhere. The bowel, a sarcoma, the kidney and testicular germ cell tumors send them most often. Surgeons do it through small incisions, take a wedge of lung and keep the lobe, and send patients home within days. In the largest series ever assembled, 5,206 patients from 18 centers, 36 percent were alive five years after complete removal. The one randomized trial in bowel cancer found that patients who were watched instead survived nearly as long, and a serious page has to say so.

What pulmonary metastasectomy is

A metastasis has traveled. Cancer cells from the organ of origin enter the blood, and the lungs, which filter the whole blood supply, catch them more often than any organ except the liver. Pulmonary metastasectomy removes those deposits one by one, each with a rim of healthy lung around it. The surgeon feels for nodules the scan may have missed, cuts each one out with a stapler, and leaves the rest of the lung in place. The cancer keeps the name of the organ it came from. A patient with bowel cancer in the lung still has bowel cancer, and the drugs and the follow-up belong to that disease.

36% at 5 years, 26% at 10, 22% at 15

Survival after complete removal of lung metastases among 4,572 patients in the International Registry of Lung Metastases, compared with 13 percent at five years when removal was incomplete. Pastorino and colleagues, J Thorac Cardiovasc Surg, 1997.

Who is a candidate

Selection decides everything in this operation.

Four conditions, all of them required

Thoracic surgeons have used the same four conditions for fifty years. The 2019 consensus document of the Society of Thoracic Surgeons keeps every one of them.

• The original cancer has been removed or fully controlled, with no sign of return at its site
• Every deposit in the lungs can be removed with the lung function the patient has left, which a CT and breathing tests establish before the operation
• There is no disease outside the lungs, or what exists there has been treated or can be treated with the same intent
• The patient is fit for a general anesthetic and a chest operation, judged on heart, lungs and general condition

Who should wait, and who should not have it

Surgery adds nothing when the cancer is growing quickly in several places at once. Nodules that have doubled in size between two scans a few weeks apart, a rising tumor marker with new lesions elsewhere, or a cancer that returned within months of its removal all argue for chemotherapy first and a fresh look afterward, because an operation in the middle of that would only delay the drugs. Some cancers answer to drugs. Lymphoma, most breast cancers and small cell lung cancer are treated with medicine even when they reach the lung, and the same holds for a growing list of tumors with a targetable mutation. Patients with a nodule that could be a new primary lung cancer need a biopsy first, because a primary and a metastasis are operated on differently.

What the evidence says, cancer by cancer

The registry figures come from 5,206 operations in Europe and North America. They differ sharply by the cancer of origin and by how long it took to reappear.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

3.5 years with surgery, 3.8 years without

Median survival in the PulMiCC trial, which randomized 93 patients with one to six lung metastases from bowel cancer to metastasectomy or to active monitoring. The hazard ratio for death within five years was 0.93, with a range that included no difference. Milosevic and colleagues, Colorectal Dis, 2020. An earlier report of the first 65 patients estimated five-year survival at 38 percent with surgery and 29 percent without, far above the 5 percent that surgeons had long assumed for untreated patients. Treasure and colleagues, Trials, 2019.

What the bowel cancer trial changes

PulMiCC stopped early because too few patients agreed to be randomized, and 93 people cannot settle a question this size. It showed something all the same, something the registries could not. Patients with a small number of slow-growing lung metastases from bowel cancer live for years whether or not the metastases are removed, because their disease is slow, and the survival figures attributed to surgery in single-arm series partly reflect the selection of those patients. A meta-analysis of 25 series by Gonzalez and colleagues found the same selection at work. A short interval before the metastases appeared, more than one metastasis, involved lymph nodes in the chest and a raised carcinoembryonic antigen each doubled the risk of death, more or less. The operation keeps a place in bowel cancer. That place belongs to patients who meet the four conditions, whose disease has been slow, and who understand that the gain comes as a better chance and never as a guarantee.

Where the case for surgery is strongest

Germ cell tumors first, where removing what remains after chemotherapy both treats and stages the disease. Sarcomas next, where the lungs are the only site of spread for many patients, chemotherapy works poorly, and a surgeon who removes every nodule may be the only person offering a chance of cure. Kidney cancer with a solitary late nodule. Then any patient with a single, slowly growing lesion years after a cancer that has otherwise stayed away.

The alternatives to surgery

Three treatments compete with the operation, and a good surgeon names them at the first consultation. Stereotactic body radiotherapy delivers a high dose to a small nodule in three to five sessions without an anesthetic and controls the treated nodule in the large majority of patients, at the cost of not knowing whether the nodule was a metastasis at all and not finding the ones the scan missed. Radiofrequency or microwave ablation burns a nodule through a needle placed under CT guidance. Drugs treat every site at once. Chemotherapy, targeted drugs and immunotherapy have changed the outlook in melanoma and kidney cancer in particular, and for many patients they come first, with surgery reserved for what remains.

The operation, from scan to discharge

Before the day

A thin-slice chest CT within four weeks of surgery. A PET-CT to look for disease outside the chest. Lung function tests, an ECG and blood tests. Blood thinners pause on a schedule agreed with the doctor who prescribed them, and a tumor marker gives a baseline.

Second and third operations

Once is rarely the end.

Metastases come back in a share of patients. A second metastasectomy is accepted practice when the four conditions are met again, most of all in sarcoma, and each operation removes lung, so the surgeon keeps a running account of what is left and says when the account is running low.

Risks and complications

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

The bowel cancer trial recorded no treatment-related deaths or major adverse events, and modern keyhole series report mortality near one percent. A different risk looms larger. An operation can remove what could be seen while the disease was already elsewhere, and the four conditions exist to keep that from happening.

Days in Istanbul, cost and the trip

How long, and when to fly

A keyhole metastasectomy means a length of stay of ten to fourteen days in Istanbul. Two or three days cover the consultation, the scans and the tests. Three to five nights pass in hospital. The surgeon sees you again a week after discharge, checks the wounds, and confirms on a chest X-ray that the lung has stayed up. Open surgery adds several days. Flying after a chest operation needs a clear X-ray, since an air pocket in the chest expands at altitude, and airlines ask for a medical form after recent surgery. Walk the aisle, drink water, and carry the pain tablets in hand luggage.

Cost and the trip

Cost depends on six things. Keyhole or open, one side or both, the number of nodules, the imaging needed before it, the nights in hospital, and your own health through the anesthesia plan. Robotic surgery carries a higher fee than VATS at many centers. Published packages in Istanbul cover the consultation, preoperative tests, the operation, the hospital stay, pathology, an interpreter and transfers, and leave out the hotel, flights, a PET-CT, chemotherapy and the treatment of a complication. A figure follows the surgeon's review of the CT. That review costs nothing. One coordinator from the international patients office handles the case in English, Arabic, French, Russian, Serbian, Romanian or Spanish, or through an interpreter, sends the appointment confirmation and an invitation letter naming the hospital and the treating doctor ten days before travel, and books the hotel and the transfers. Patient rooms have a companion bed. Meals come in halal, vegetarian and diabetic versions, a prayer room is on site, and a female doctor can be requested when you first write.

After you fly home

One operation marks a moment in a disease that will be followed for years. The discharge file serves the oncologist who will do the following. It holds the operation note, the pathology, the CT images, the tumor marker before and after, and a schedule. Once you are back home the coordinator stays reachable on the same WhatsApp number, and clinical questions go to the surgeon, who has the images and the pathology in front of him.

1. A chest CT every three to four months for the first two years, then every six months, because new metastases are common and respond to a further operation or radiotherapy when found small
2. A tumor marker with each scan where the original cancer produces one
3. Chemotherapy or targeted treatment if the pathology or the oncologist calls for it, prescribed at home
4. Breathing exercises for the first month, and walking every day
5. A doctor the same week for breathlessness that is worsening, blood in the sputum, or pain at the wound that increases instead of fading

Pulmonary Metastasectomy - Lung Metastasis Surgery FAQ