Metastatik Akciğer Tümörleri
Özet
Akciğerin metastatik tümörleri, toraks içindeki veya dışındaki primer hastalıkların sistemik hale geldiğinin bir göstergesidir. Metastaz tedavisinde multidisipliner bir yaklaşım şarttır; çünkü komplet rezeksiyon sağlanabilen vakalarda bile mikro metastazlar nedeniyle beş yıllık sağkalım oranı %30-40 civarında kalmaktadır. Tanı ve takip süreçlerinde 3-5 mm kesitli spiral BT altın standart kabul edilirken, histolojik ayırıcı tanı ve parankim koruyucu minimal invaziv yaklaşımlar ön plana çıkmaktadır. Primer tümörün cinsine göre (sarkom, kolorektal, meme, jinekolojik vb.) tedavi protokolleri ve sürvi oranları değişkenlik gösterir. Genel uzman uzlaşısına göre, 3 veya daha az sayıda pulmoner metastaz varlığı, komplet rezeksiyon edilebilirlik, mediastinal lenf nodu tutulumunun olmaması ve 36 aydan fazla hastalıksız sağkalım süresi en önemli iyi prognoz belirteçleridir. Cerrahi sınırların temiz olması esas olup, gelecekte gelişebilecek nüksler için parankim alanlarını korumak amacıyla kama veya segmentektomi gibi minimal rezeksiyonlar tercih edilmektedir.
Metastatic lung tumors indicate that intra- or extrathoracic primary diseases have progressed into a systemic stage. A multidisciplinary management approach is essential; even after achieving complete resection, the five-year survival rate remains around 30-40% due to the definitive impact of micro-metastases. While 3-5 mm spiral CT is the gold standard for diagnosis and monitoring, histological differentiation and parenchyma-sparing minimal invasive techniques are highly prioritized. Treatment protocols and survival outcomes vary substantially depending on the primary tumor type, such as sarcoma, colorectal, breast, or gynecological cancers. According to expert consensus, having 3 or fewer pulmonary nodules, complete resectability, absence of mediastinal lymph node involvement, and a disease-free interval exceeding 36 months represent the most significant favorable prognostic indicators. Achieving negative surgical margins remains critical, and limited resections like wedge or segmentectomy are preferred to preserve remaining lung functions for potential future recurrences.
Referanslar
Treasure T, Internullo E, Utley M. Resection of pulmonary metastasis; a growth industry. Cancer Imaging 2008;8:121-124)
Pastorino U, Buyse M, Friedel G ve ark.Long-term results of lung metastasectomy: Prognostic analyses based on 5206 cases.The J Thorac Cardiovasc Surg. 1997;113(1):37-49)
Potter DA, Glenn J, Kinsella T ve ark. J Clin Patterns of recurrence in patients with high-grade soft-tissue sarcomas.1985;3(3):353-366).
Putnam JB, Suell DM, Natarajan G ve ark. Extended resection of pulmonary metastases: is the risk justified? Ann Thorac Surg 1993;55(6):1440-1446
Govindan R. Cancer. Attack of the clones. Science 2014;346(6206):169-170
Sardari Nia, Hendriks J, Friedel G ve ark.Distinct angiogenic and non‐angiogenic growth patterns of lung metastases from renal cell carcinoma. Histopatology 2007;51(3).354-361)
Snyder BJ, Pugatch RD. Imaging characteristics of metastatic disease to the chest. Chest Surgery Clin N Am, 1998;8(1):29-48
Veronesi G, Landoni C, Pelosi G ve ark. Fluoro-deoxi-glucose uptake and angiogenesis are independent biological features in lung metastases Br J Cancer 2002;86(9) 1391-1395
Parsons AM Detterbeck FC Parker LAAccuracy of Helical CT in the Detection of Pulmonary Metastases: Is Intraoperative Palpation Still Necessary? Ann Thorac Surg 2004;78(6):1910-1916 ,
Parsons AM Ennis EK Yankaskas BC ve ark.Helical computed tomography inaccuracy in the detection of pulmonary metastases: can it be improved? Ann Thorac Surg 20047;84(6):1830-1836
Althagafi KT, Alashgar OA, Almahgrabi HS ve ark Missed pulmonary metastasis.Asian Cardiovasc Thorac Surg 2014;22(2):183-186
Wittenbach R, Vock P, Tschappeler H Cross-sectional imaging with CT and/or MRI of pediatric chest tumors.Eur Radiol 1998;8 (6):1040-1046
Woodard PK Dehdasti F Putman CE Radiologic diagnosis of extrathoracic metastases to the lung.Oncology 1998;12(3):431-438
Seo JB, Im JM, Goo JG ve ark.Atypical Pulmonary Metastases: Spectrum of Radiologic Findings. RadioGraphics 2001;21:403-417
Putnam JB .Jack A. Roth JA Prognostic indicators in patients with pulmonary metastases Semin Surg Oncol 1990;6(5):291-296
Mc Cormack PM Bains MS Beattie EJ ve ark.Pulmonary Resection in Metastatic Carcinoma Chest 1978;73(2):163-166
Mountain JF, McMurtrey MJ, Hermes KE Surgery for Pulmonary Metastasis: A 20-Year Experience Ann Thorac Surg 1984 ;38(4):323-330
Ercan S, Nichols FC,Trasek VF ve ark. Prognostic significance of lymph node metastasis found during pulmonary metastasectomy for extrapulmonary carcinoma Ann Thorac Surg 2004;77(5):1786-1791
Szoke T, Kortner A, Neu R.Is the mediastinal lymphadenectomy during pulmonary metastasectomy of colorectal cancer necessary Interact CardioVasc Thorac Surg 2010;10(5):694–698
Johnston MR.Median sternotomy for resection of pulmonary metastases.J Thorac Cardiovasc Surg 1983;85(4): Pages 516-522
Roth JA .Margaret HI,Wesley N ve ark. Comparison of Median Sternotomy and Thoracotomy for Resection of Pulmonary Metastases in Patients with Adult Soft-Tissue Sarcomas. Ann Thorac Surg 1986 ;42:134-138
Molnar TF, Gebitekin C, Turna A What Are the Considerations in the Surgical Approach in Pulmonary Metastasectomy?J Thorac Oncol 2010;5(6) Supp 2: 140-144
McCormack PM Bains MS Begg JB Role of video-assisted thoracic surgery in the treatment of pulmonary metastases: Results of a prospective trial. Ann Thorac Surg.1996;62(1):213-217
Mutsaerts EL Zoetmulder FA Meijer SA ve ark.Outcome of thoracoscopic pulmonary metastasectomy evaluated by confirmatory thoracotomy.Ann Thorac Surg.2001;72(1): 230-233
Spaggiari L, Grunenwald DH, Girard P,Pneumonectomy for lung metastases: indications, risks, and outcome Ann Thorac Surg 1998;66(6):1930-1933
Heslin MJ, Casper ES, Boland PS Preoperative Identification and Operative Management of Intraatrial Extension of Lung Tumors Ann Thorac Surg 1998;65(2):544-546
Schuman RL Primary pulmonary sarcoma with left atrial extension via left superior pulmonary vein: En bloc resection and radical pneumonectomy on cardiopulmonary bypass The Journal of Thoracic and Cardiovascular Surgery 1984;88(2):189-192
Celenk C, Elmalı M, Polat V Huge left atrial extension of metastatic lung tumor via pulmonary vein: report on the third case of osteosarcoma. J Med Cases. 2013;4(2):116-119
Yonemoto T, Tatezaki S, IshiiT ve ark.,Prognosis of osteosarcoma with pulmonary metastases at initial presentation is not dismal Clinical Orthopaedics and Related Research 1998(349):194-199
Putnam JB Jr, Roth JA , Wesley MN ve ark Survival following aggressive resection of pulmonary metastases from osteogenic sarcoma: analysis of prognostic factors Ann Thorac Surg 1983;36(5):516-523
Bacci G, Ferrari S, Longhi A ve ark Pattern of relapse in patients with osteosarcoma of the extremities treated with neoadjuvant chemotherapy Eur J Cancer 2001; 37(1):32-38
Ferrari S, Briccoli A, Mercuri M ve ark, Postrelapse survival in osteosarcoma of the extremities: prognostic factors for long-term survival. J Clin Oncol 2003;21(4):710-715-122
Billingsley KG, Lewis JJ, Leung DHY ve ark Multifactorial analysis of the survival of patients with distant metastasis arising from primary extremity sarcoma Cancer 1999;85(2):389-395
Jablons D, Steinberg SM , Roth J, ve ark.Metastasectomy for soft tissue sarcoma: further evidence for efficacy and prognostic indicators. J Thorac Cardiovasc Surg 1989;97(5):695-705
Casson AG, Putnam JB, Natarajan G ve ark Efficacy of pulmonary metastasectomy for recurrent soft tissue sarcoma J Surg Oncol 1991;47(1):1-4
Hong NJL, Hornicek FJ, Harmon DC,ve ark Neoadjuvant chemoradiotherapy for patients with high-risk extremity and truncal sarcomas:a 10-year single institution retrospective study. Eur J Cancer 2013;49(4):875-883
Gonzalez M, Poncet A, Combescure C ve ark.Risk factors for survival after lung metastasectomy in colorectal cancer patients: a systematic review and meta-analysis. Ann Surg Oncol 2013;20(2):572-579
Salah S, Watanabe K, Welter S, ve ark. Colorectal cancer pulmonary oligometastases: pooled analysis and construction of a clinical lung metastasectomy prognostic model Ann Oncol 2012;23(10):2649-2655.
Milosevic M. Edwards J,Tsang D ve ark.Pulmonary Metastasectomy in Colorectal Cancer: updated analysis of 93 randomized patients – control survival is much better than previously assumed. Colorec Dis 2020;22(10):1314-1324
Macbeth F, Fallowfield L.The myth of pulmonary metastasectomy.Brit J Cancer 2020;123:499-500
Internullo E, CassiviSD, Raemdonck DV ve ark.Pulmonary Metastasectomy: A Survey of Current Practice Amongst Members of the European Society of Thoracic Surgeons J Thorac Oncol 2008;3(11):1257-1266
Kulkarni RP, Reynolds KW, Newlands ES ve ark Cytoreductive surgery in disseminated non-seminomatous germ cell tumors of testis.Br J Surg 1991;78(2):226-269
Carter GE, Lieskovsky G , Skinner DG ve ark.Reassessment of the role of adjunctive surgical therapy in the treatment of advanced germ cell tumors. J Urol 1987;138(6):1397-1401
Gels ME, Hoekstra HJ , Sleijfer DT, ve ark. Thoracotomy for postchemotherapy resection of pulmonary residual tumor mass in patients with nonseminomatous testicular germ cell tumors: aggressive surgical is justified. Chest 1997;112(4):967-973
Shiromizu K, Kasamatsu T, Takahash M ve ark.A clinicopathological study of postoperative pulmonary metastasis of uterine cervical carcinomas. J Obstet Gynaecol Res 1999;25(4):245-249
Leitao MM, Brennan MF , Hensley M , ve ark.Surgical resection of pulmonary and extrapulmonary recurrences of uterine leiomyosarcoma. Gynecol Oncol 2002;87(3):287-294
Barter JF, Soong SJ, Hatch KD, ve ark. Diagnosis and treatment of pulmonary metastases from cervical carcinomaGynecol Oncol 1990;38(3):347-351
Schott G, Weissmüller J, Vecera E Methods and prognosis of the extirpation of pulmonary metastases following tumor nephrectomy.Urol Int 1988;43(5):273-275
Piltz S, Meimarakis G, Wichmann MM, ve ark. Long-term results after pulmonary resection of renal cell carcinoma metastases. Ann Thorac Surg 2002;73(4):1082-1087
Fischer CG, Schmid HP. Operative therapy in disease progression and local recurrence of renal cell carcinoma. Urol Int 1999;63(1):10-15
Fourquier P, Regnard JF, Rea S ve ark. Lung metastases of renal cell carcinoma: results of surgical resection. Eur J Cardiothorac Surg1997;11(1):17-21
van der Poel HG , Roukema JA, Horenblas S ve ark. Metastasectomy in renal cell carcinoma: A multicenter retrospective analysis.Eur Urol 1999;35(3):197-203
Ollila DW, Morton DL .Surgical resection as the treatment of choice for melanoma metastatic to the lung.Chest Surg Clin N Am 1998;8(1):183-196
Allen PJ, Coit DG.The role of surgery for patients with metastatic melanoma Curr Opin Oncol 2002;14(2):221-226
Nibu K, Nakagawa K, Kamata S, ve ark.Surgical treatment for pulmonary metastases of squamous cell carcinoma of the head and neck. Am J Otolaryngol 1997;18(6):391-395
Sihoe ADL, Van Schil P Non-small cell lung cancer: when to offer sublobar resection.Lung Cancer, 2014;86(2):115-120
Handy JR, Bremmer RM Crocenzi TS, ve ark Expert consensus document on pulmonary metastasectomy. Ann Thorac Surg 2019;107(2):631-649
