Surgical removal of asymptomatic pulmonary metastases: time for better evidence

Patients with cancer are routinely screened to detect recurrence. The lungs are the commonest site of metastases, where they are readily detected by computed tomography, prompting consideration of their removal.1 Operative risk is minimised by selecting fitter patients and using less invasive surgical techniques such as videothoracoscopy2 or ablative techniques such as radiofrequency ablation. When surveyed, the majority of European thoracic surgeons reported performing metastasectomy often and with liberal indications.3 However, the lung metastasectomy working group of the European Society of Thoracic Surgeons (ESTS) concluded that “although there was great experience in performing this surgery, the belief in its benefit relied on clinical case series and registry reports. Evidence fell well short of evidence based medicine standards and robust guidance could not be produced on this basis.”4 A missing component of the ESTS report was a review of the evidence for metastasectomy for sarcoma: one was commissioned but not delivered. Evidence for the practice in the literature is indeed lacking, as we found in a subsequent systematic review of clinical reports of pulmonary metastasectomy for sarcoma published in BMJ Open.5

Sarcoma occurs in a younger age group than the common carcinomas and metastasises to the lung in 50-60% of cases. These two features prompted surgeons at Memorial Sloan-Kettering Cancer Center, New York, to perform pulmonary metastasectomy from the mid-1960s, and in 1971 they advocated this surgery as the “treatment of choice” for osteogenic sarcoma.6 The practice was taken up widely and is included in the National Institute for Health and Clinical Excellence (NICE) guidance Improving Outcomes …