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Pulmonary metastasectomy in colorectal cancer: Time for a trial

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Abstract

Pulmonary metastasectomy is undertaken for a range of cancers. The questions we raise here are specifically related to colorectal cancer, the commonest tumour for which pulmonary metastasectomy is undertaken. The primary objective of metastasectomy is to increase survival. There are no randomised trials in support of this practice nor are there any other forms of controlled studies. We present a critical look at the assumption of efficacy for this surgery and propose that a trial is needed and suggest a trial design.

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Background

Thoracic surgeons are aware that there is an increasing demand for pulmonary metastasectomy1, most commonly for colorectal cancer, but the practice is not supported by high level evidence for effectiveness.2 This is of concern since morbidity can be considerable if surgery is pursued with sufficient thoroughness to achieve the stated objective which is R0 resection. It is argued that there are metastases not evident on imaging that can be detected by palpation and hence that minimal access

The nature of claims for effectiveness of pulmonary metastasectomy in colorectal cancer (PMCC) and their weaknesses

There are many surgical follow-up studies of PMCC included in a surgeon's or an institution's experience in a range of cancer types. Since the reports often include sarcomas, germ cell tumours and epithelial malignancies in the same results tables, along with one, two or three patients with less common cancers, they defy useful analysis. There are over 50 reports confined to colorectal cancer. Pfannschmidt used a selected 20 in his systematic review.5 Using less restrictive criteria we have

The design of the proposed trial

We propose a randomised controlled trial comparing PMCC to any other management. The “PICO” (population, intervention, comparison and outcome) can be summarised as follows:

  • P: patients with lung metastases from colorectal cancer,

  • I: pulmonary metastasectomy,

  • C: any other treatment apart from resection or ablation,

  • O: survival, patient reported outcome, and quality of life.

We do not want to include radiofrequency ablation (RFA) because it does not offer proveable R0 resection and our research

Conflict of interest

None of the authors has any financial or other conflict of interests to disclose.

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