The role of minimally invasive approaches in the management of pulmonary metastases

The practice of performing pulmonary metastasectomies has been changed by the advent and subsequent evolution of minimally invasive approaches. Historically, the standard surgical approach for pulmonary metastases was thoracotomy with bimanual palpation, which can result in considerable incisional pain and postoperative respiratory complications. Conventional thoracoscopic surgery, now followed by robotic-assisted thoracoscopic surgery and uniportal video-assisted thoracic surgery have mitigated the pain and complications associated with the open approach. As such, modern minimally invasive platforms have yielded opportunities to pursue more aggressive strategies.

These enhancements to patient care in the form of modern minimally invasive surgery were enabled not only by new surgical techniques alone, but also by concomitant strides in diagnostic technologies and other adjuncts to surgery. Refinements in multidetector high-resolution computed tomography (CT) scanning have yielded more precise imaging to detect smaller nodules. The identification of smaller nodules has led to the greater use of various localization techniques which in turn have allowed for improvements in the intraoperative detection of tumors that were previously dependent on direct palpation. Other technologies, such as electromagnetic navigation bronchoscopy and robotic-assisted bronchoscopy have further expanded the armory of localization techniques.

Paralleling these surgical advances, noteworthy progress in other treatment modalities also have arrived. The introduction of targeted therapy and the immunotherapy have improved survival of cancers, in general, and have arguably resulted in the more judicious use of local therapy for recurrent or advanced malignancies that perhaps were not considered previously as having a surgical option. Moreover, there is an increasing frequency of the use of stereotactic body radiation therapy (SBRT) and different ablative therapies for pulmonary metastases. These advances are now emerging as options for several collaborative tools that can be employed together to improve the patient outcomes, in a manner more effective that using a singular modality exclusively on its own. One commonly employed hybrid approach is that of addressing the combination of peripheral and central pulmonary metastases. In this circumstance surgical resection may be performed for the superficial lesions and SBRT may be reserved for the centrally located lesion obviating the need to resect a greater amount of lung parenchyma. In this era, the surgeons are more prudently deciding upon the indication for metastasectomy without excluding other treatment modalities to achieve the best possible survival outcomes.

The rubric of this special series on pulmonary metastasectomy generally can be divided into two broad areas: surgical approaches to or strategies for pulmonary metastases and pulmonary metastasectomy for specific pathologies. Under the first area, Gagto et al. discuss the hybrid approach for pulmonary metastasis (1). The improved detection of metastases coupled with a more aggressive mindset toward utilizing surgery lends themselves to the need to better understand hybrid approaches and the various treatment modalities available. In keeping with the theme of an aggressive yet gentle minimally invasive approach to pulmonary metastasectomy, Yuhara et al. excellently report on the rationale, benefit, and associated with a variety of surgical techniques used in simultaneous bilateral pulmonary metastasectomies (2). In light of the recent enthusiasm for sublobar resections, de la Fuente Añó et al. review the indications and the benefits of minimally invasive segmentectomies for pulmonary metastases (3). Balasubbiah et al. provide a comprehensive and modern literature review involving the survival advantages resulting from repeat metastasectomy for metastases arising from different primary sources (4). Finally for this section, Wang et al.’s timely contribution discussing various localization techniques and other surgical adjuncts may serve as an overview and guide to enhance the surgical strategy planning and the decision-making process ufor pulmonary metastasectomies (5).

The technological advances in thoracic surgery, in general, and for pulmonary metastasectomy, specifically, either have strengthened the justification or given rise to expanded indications for its role. Hence, the second part of this special series is intended to inform the minimally invasive thoracic surgeon of the role of pulmonary metastasectomy for different types of secondary malignancies through providing comprehensive reviews of many of the common and uncommon pulmonary metastases encountered. Sheth et al. report upon the recent updates for pulmonary metastases from colorectal cancer with comments on the nuanced controversies surrounding its benefit (6). Palleiko et al. introduce the novel use of intraoperative molecular imaging for pulmonary metastases from sarcoma and also report on the recent advancements in metastasectomy for other cutaneous and soft tissue malignancies (7). Salami et al. also discuss pulmonary metastasectomy for head and neck cancer with a thorough review of the existing literature and explaining the prognostic factors in this population in terrific detail (8). Given the paucity of discussion centering on metastasectomy in the pediatric population, Huerta et al. raise awareness and provide outstanding perspective regarding the less frequently observed and treated pulmonary metastasectomy in the pediatric population for various pathologies (9). Liang et al. offer insight into the relatively controversial role of pulmonary metastasectomy for esophageal cancer including special considerations that should be taken into account when performing metastasectomy in this population (10).

Cumulatively, the contributions in this special series provide a wealth of information that strengthens the collective knowledge associated with managing pulmonary metastases surgically. This knowledge, thereby, augments the rationale behind more aggressive approaches to pulmonary metastases and allows the minimally invasive thoracic surgeon to push the limits regarding the surgical indications for them. Pursuing more scientific investigation in this field most assuredly will establish a greater foundation to expand the boundaries even farther regarding what, why, when and how pulmonary metastasectomies are performed. For the time being, we are excited to present to you a series of concise yet comprehensive reviews that summarize a tremendous amount of content regarding contemporary approaches to pulmonary metastasectomy.

Takashi Harano

Anthony W. Kim

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery for the series “The Role of Minimally Invasive Approaches in the Pulmonary Oligometastases”. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-10/coif). The series “The Role of Minimally Invasive Approaches in the Pulmonary Oligometastases” was commissioned by the editorial office without any funding or sponsorship. A.W.K. and T.H. served as the unpaid Guest Editors of the series. A.W.K. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from September 2022 to August 2024. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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