Surgical resection of recurrent pulmonary metastases in patients with colorectal cancer is an established treatment option; however, the evidence for repeat resection is limited. The aim of this study was to analyse long-term outcomes from the Dutch Lung Cancer Audit for Surgery. Data from the mandatory Dutch Lung Cancer Audit for Surgery were used to analyse all patients after metastasectomy or repeat metastasectomy for colorectal pulmonary metastases from January 2012 to December 2019 in the Netherlands. Kaplan–Meier survival analysis was performed to determine the difference in survival. Multivariable Cox regression analyses were performed to identify predictors of survival. A total of 1237 patients met the inclusion criteria, of which 127 patients underwent repeat metastasectomy. Five-year overall survival was 53 per cent after pulmonary metastasectomy for colorectal pulmonary metastases and 52 per cent after repeat metastasectomy (P = 0.852). The median follow-up was 42 (range 0–285) months. More patients experienced postoperative complications after repeat metastasectomy compared with the first metastasectomy (18.1 per cent versus 11.6 per cent respectively; P = 0.033). Eastern Cooperative Oncology Group performance status greater than or equal to 1 (HR 1.33, 95 per cent c.i. 1.08 to 1.65; P = 0.008), multiple metastases (HR 1.30, 95 per cent c.i. 1.01 to 1.67; P = 0.038), and bilateral metastases (HR 1.50, 95 per cent c.i. 1.01 to 2.22; P = 0.045) were prognostic factors on multivariable analysis for pulmonary metastasectomy. Diffusing capacity of the lungs for carbon monoxide less than 80 per cent (HR 1.04, 95 per cent c.i. 1.01 to 1.06; P = 0.004) was the only prognostic factor on multivariable analysis for repeat metastasectomy. This study demonstrates that patients with colorectal pulmonary metastases have comparable median and 5-year overall survival rates after primary or recurrent pulmonary metastasectomy. However, repeat metastasectomy has a higher risk of postoperative complications.

Routine lymphadenectomy during metastasectomy for pulmonary metastases of colorectal cancer has been recommended by several recent expert consensus meetings. However, evidence supporting lymphadenectomy is limited. The aim of this study was to perform a systematic review of the literature on the impact of simultaneous lymph node metastases on patient survival during metastasectomy for colorectal pulmonary metastases (CRPM). A systematic review was conducted according to the PRISMA guidelines of studies on lymphadenectomy during pulmonary metastasectomy for CRPM. Articles published between 2000 and 2020 were identified from Medline, Embase and the Cochrane Library without language restriction. Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the risk of bias and applicability of included studies. Survival rates were assessed and compared for the presence and level of nodal involvement. Following review of 8054 studies by paper and abstract, 27 studies comprising 3619 patients were included in the analysis. All patients included in these studies underwent lymphadenectomy during pulmonary metastasectomy for CRPM. A total of 690 patients (19.1%) had simultaneous lymph node metastases. Five-year overall survival for patients with and without lymph node metastases was 18.2% and 51.3%, respectively (p < .001). Median survival for patients with lymph node metastases was 27.9 months compared to 58.9 months in patients without lymph node metastases (p < .001). Five-year overall survival for patients with N1 and N2 lymph node metastases was 40.7% and 10.9%, respectively (p = .064). Simultaneous lymph node metastases of CRPM have a detrimental impact on survival and this is most apparent for mediastinal lymph node metastases. Therefore, lymphadenectomy during pulmonary metastasectomy for CRPM can be advised to obtain important prognostic value.

Background: Pulmonary metastasectomy and stereotactic ablative radiotherapy (SABR) are both guideline-recommended treatments for selected patients with oligometastatic colorectal pulmonary metastases. However, there is limited evidence comparing these local treatment modalities in similar patient groups. Methods: We retrospectively reviewed records of consecutive patients treated for colorectal pulmonary metastases with surgical metastasectomy or SABR from 2012 to 2019 at two Dutch referral hospitals that had different approaches toward the local treatment of colorectal pulmonary metastases, one preferring surgery, the other preferring SABR. Two comparable patient groups were identified based on tumor and treatment characteristics. Results: The metastasectomy group comprised 40 patients treated for 69 metastases, and the SABR group had 60 patients who were treated for 90 metastases. Median follow-up was 38 months (IQR: 26–67) in the surgery group and 46 months (IQR: 30–79) in the SABR group. Median OS was 58 months (CI: 20–94) in the metastasectomy group and 70 months (CI: 29–111) in the SABR group (p = 0.23). Five-year local recurrence-free survival (LRFS) was 44% after metastasectomy and 30% after SABR (p = 0.16). Median progression-free survival (PFS) was 15 months (CI: 3–26) in the metastasectomy group and 10 months (CI: 6–13) in the SABR group (p = 0.049). Local recurrence rate was 12.5/7.2% of patients/metastases respectively after metastasectomy and 38.3/31.1% after SABR (p < 0.001). Lower BED Gy₁₀ was correlated with an increased likelihood of recurrence (p = 0.025). Clavien Dindo grade III-V complication rates were 2.5% after metastasectomy and 0% after SABR (p = 0.22). Conclusion: In this retrospective cohort study, pulmonary metastasectomy and SABR had comparable overall survival, local recurrence-free survival, and complication rates, despite patients in the SABR group having a significantly lower progression-free survival and local control rate. These data would support a randomized controlled trial comparing surgery and SABR in operable patients with radically resectable colorectal pulmonary metastases.

Introduction: Local control following stereotactic ablative radiotherapy (SABR) for patients with colorectal pulmonary metastases is reportedly lower than for metastases from other tumors. Such recurrences may still be amenable to salvage therapy. We describe our experience with salvage surgery in 17 patients.Methods: Patients who underwent salvage metastasectomy for a local recurrence following SABR for colorectal pulmonary metastases were identified from the surgical institutional databases of three Dutch major referral hospitals. Kaplan–Meier survival analysis was performed to determine survival.Results: Seventeen patients underwent 20 salvage resections for local recurrence of colorectal pulmonary metastases. All patients had a progressive lesion on consecutive CT scans, with local uptake on ¹⁸fluorodeoxyglucose‐positron emission tomography computed tomography (FDG‐PET CT), and were discussed in a thoracic oncology tumor board. Median time to local recurrence following SABR was 20 months (interquartile range [IQR]: 13−29). Fourteen procedures were performed minimally invasively. Extensive adhesions were observed during three procedures. A Clavien–Dindo grade III–IV complication occurred after four resections (20%). The 90‐day mortality was 0%. The estimated median overall survival and progression‐free survival following salvage resection were 71 months (confidence intervals [CI]: 50–92) and 39 months (CI: 19–58), respectively. Salvage resections were significantly more extensive, compared to the potential resection assessed on pre‐SABR imaging.Conclusions: Our experience with 20 salvage pulmonary metastasectomy procedures for local recurrences following SABR in colorectal cancer patients demonstrates that salvage resection is a feasible option with acceptable morbidity and good oncological outcome in a highly selected cohort.

OBJECTIVES: Surgical management of pulmonary metastases in colorectal cancer patients is a debated topic. There is currently no consensus on this matter, which sparks considerable risk for international practice variation. The European Society of Thoracic Surgeons (ESTS) ran a survey to assess current clinical practices and to determine criteria for resection among ESTS members.METHODS: All ESTS members were invited to complete an online questionnaire of 38 questions on current practice and management of pulmonary metastases in colorectal cancer patients.RESULTS: In total, 308 complete responses were received (response rate: 22%) from 62 countries. Most respondents consider that pulmonary metastasectomy for colorectal pulmonary metastases improves disease control (97%) and improves patients’ survival (92%). Invasive mediastinal staging in case of suspicious hilar or mediastinal lymph nodes is indicated (82%). Wedge resection is the preferred type of resection for a peripheral metastasis (87%). Minimally invasive approach is the preferred approach (72%). For a centrally located colorectal pulmonary metastasis, the preferred form of treatment is a minimally invasive anatomical resection (56%). During metastasectomy, 67% of respondents perform mediastinal lymph node sampling or dissection. Routine chemotherapy is rarely or never given following metastasectomy (57% of respondents).CONCLUSIONS: This survey among the ESTS members underlines the change in practice of pulmonary metastasectomy with an increasing tendency in favour of minimally invasive metastasectomy and surgical resection is preferred over other types of local treatment. Criteria for resectability vary and controversy remains regarding lymph node assessment and the role of adjuvant treatment.

Metastasectomy and stereotactic body radiotherapy (SBRT) are both guideline-recommended treatment modalities for patients with oligometastatic colorectal lung metastases (CLM). Few evidence is available comparing different local therapies in an oligometastatic population. This systematic review aimed to compare the efficacy of metastasectomy with SBRT for patients with oligometastatic CLM. A systematic literature search was performed according to the PRISMA guidelines to identify studies on metastasectomy and SBRT for patients with oligometastatic CLM. Studies published between 2000 and 2023 were identified through Medline, Embase, and the Cochrane databases. Overall survival (OS), progression-free survival (PFS), and local recurrence rate (LRR) were assessed and compared between both groups. The risk of bias was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool. A total of 141 studies on metastasectomy (n = 29932) and 16 studies on SBRT (n = 1381) were included in the final analysis. The pooled five-year OS was 52.2 % (CI: 49.8-54.5) and 45.0 % (CI: 31.2-58.9) following metastasectomy and SBRT, respectively (p = 0.213). The pooled five-year PFS was 35.1 % (CI: 32.2-38.1) following metastasectomy and 11.7 % (CI: 0-38.2) following SBRT (p < 0.001). The pooled LRR was 10.5 % (CI: 5.5-15.5) following metastasectomy and 28.1 % (CI: 20.8-35.4) following SBRT (p < 0.001). The average GRADE score of the included studies was low. The data suggest that patients with oligometastatic CLM have a comparable OS rate after metastasectomy or SBRT, but PFS and LRR favour a surgical approach. This systematic review supports initiating a randomized controlled trial comparing surgery and SBRT in operable patients with oligometastatic CLM.