Personalized approach for video-assisted thoracic surgery lung metastasectomy

Background: Nowadays, video-assisted thoracic surgery (VATS) has become a valid alternative to open thoracotomy for pulmonary metastasectomy (PM) in selected patients. The aim of this study was to analyze our personalized approach for VATS PM in term of postoperative outcomes and prognostic factors of recurrence and survival. Methods: Retrospective analysis of all consecutive patients who underwent VATS PM between 2003 and 2018 in our institution. All patients were individually discussed during a multidisciplinary meeting. Results: In total, 189 patients (female/male: 84/105) with a median age of 64 years underwent VATS PM for solitary (77.2%) or multiple (22.8%) metastases in the context of colorectal carcinoma (30.2%), melanoma (20.1%), sarcoma (14.3%) or other primary tumors (35.4%). Surgical resection was performed by wedge resection in 156 (82.5%), segmentectomy in 15 (7.9%) and lobectomy in 18 cases (9.5%). The overall 30-day post-operative mortality and morbidity rates were 0% and 7.9% respectively. During a median follow-up of 33 months (IQR 17-56 months) after PM, recurrence was identified in 120 patients (63.5%). Colorectal cancer (HR 0.56) was identified as a protective factor against recurrence, whereas age <70 years (HR 1.73) and previous extra-thoracic metastases (HR 1.53) were identified as risk factors of recurrence. Repeated PM (RPM) was performed in 43 patients (22.8%), of which 16 (8.5%) underwent ipsilateral lung surgery. VATS approach was preferred in 76.7% of RPMs and wedge resections in 62.8%. Post-operative 30-day cardiopulmonary complication rate was 18.6% after RPM. The 5-year OS rate after first PM was 63%. Colorectal cancer (HR 0.41) and RPM (HR 0.34) were identified as individual prognostic factors for better survival. Conclusions: Individualized approach for VATS PM yields low post-operative morbidity and favorable oncological outcomes.