Pulmonary metastasectomy and the use of molecular and radiological markers: is this a way to reduce unavailing surgery?

Pulmonary metastasectomy and the use of molecular and radiological markers: is this a way to reduce unavailing surgery? Pulmonary metastasectomy is now one of the commonest thor-acic operations and is a major part of a Thoracic Department's workload. The report by Schweiger et al. [1] in this issue of EJCTS provides a comprehensive update concerning biological and radiological markers. They note that these are not routinely used and propose that more information is needed in order to treat patients with pulmonary metastases adequately. The review from colleagues in Vienna is timely. Confidence in knowing which patients can gain benefit from pulmonary metas-tasectomy has been shaken by a recent analysis by colleagues from Switzerland concerning the most common application of metastasectomy in colorectal cancer [2]. The selection of patients for pulmonary metastasectomy has relied predominately on pre-operative factors known to be associated with longer survival: fewer metastases, a longer elapsed time since the primary operation and raised carcinoembryonic antigen (CEA). The significance of these features has been confirmed in a meta-analysis of studies published since 2001 including 2925 patients [2]. This analysis argues for stringent selection. Based on state-of-the-art statistical methods and large numbers of patients, the metastasectomy failure (i.e. early recurrence) was seen to double for each of these three preoperative factors [2]. The Swiss analysis [2] confirms the importance of the most familiar of the biological markers, CEA. Elevated CEA nearly doubles the likelihood of failure of metastasectomy due to early recurrence [hazard ratio (HR) = 1.91, 95% confidence interval (CI) 1.57–2.32]. The principal application of serum markers is in monitoring the treatment response of cancers [3], but earlier detection is pointless unless we can use the information for patient benefit. In the early years of hepatic resection for metastases [4], a CEA assay was proposed for surveillance: its elevation triggered a 'second-look' laparotomy for exploration of the colonic anasto-mosis, lymph nodes, the retroperitoneum and mobilization of the liver with the intent of removing any further cancer discovered. Effectiveness was tested in a randomized controlled trial. Patients were randomly assigned to have CEA elevation concealed or revealed to the surgeon. Patients whose CEA elevation was not disclosed survived longer than those who had it revealed [HR = 0.85, 95% CI 0.62–1.13, not significant] [5]. It is seductive to think that the more we know about the biology of a cancer the better we can select patients for further treatment. …