Pulmonary Metastasectomy for Colorectal Cancer: Recent Reports Prompt a Review of the Available Evidence

Pulmonary metastasectomy for colorectal cancer is commonplace surgery, but the practice has grown on the basis of follow-up studies. These studies base their conclusion on the effectiveness of metastasectomy on the survival rates at 5 years of very highly selected patients. Three publications in the last year, a registry study, a meta-analysis and a randomised controlled trial of monitoring and early detection of cancer recurrence, prompted a review of the evidence. A critical examination of the evidence suggests that much of the apparent benefit may be due to selection of patients most likely to survive on the basis of well-known prognostic features, explicitly stated in the clinical record. Clinicians also assess their patients over time and do not offer surgery to those with faster progression. Such clinical judgements are of their nature often subtle and undocumented and thus cannot be retrieved from the clinical record. Although some patients may have long survival following pulmonary metastasectomy, and indeed their survival might be believed to be due to resection of pulmonary metastases, how many patients must be operated on to find these survivors? What is the number 'needed to treat'? It may be that of the patients having metastasectomy, for the greater proportion it does not materially alter their survival. A randomised controlled trial to resolve this uncertainty is in progress. The Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) trial is recruiting in Britain and Europe.