[The place of surgery in metastatic non-small cell lung cancer]

Metastatic lung cancer may be M1a (contralateral lung nodule, malignant pleural or pericardial effusion or pleural nodules) or M1b (distant metastases). Surgery is not usually considered in their treatment.

After exclusion of contralateral lung nodules, we reviewed the demographics, management, survival and prognostic factors in M1 patients, among a total of 4668 patients who underwent surgery for lung cancer between January 1983 and December 2006.

There were 164 patients (70 M1a, 94 M1b). Surgical procedures included exploratory thoracotomy (n=40), lobectomy (n=88), and pneumonectomy (n=38). Histology revealed adenocarcinoma (n=97), squamous cell carcinoma (n=36) or other (n=27). Nodal extension was N0 (n=60), N1 (n=23), N2 (n=64), or not available (n=17). Overall median survival was 14 months and 5-year survival was 12.7%. In M1a median survival was 15 months and 5-year survival 9%. In M1b, median survival was 11 months and 5-year survival 15%, regardless of whether the metastasis was resected or not. The 5-year survival rates were 0% after exploratory thoracotomy, 3.9% after pneumonectomy, 14.8% after lobectomy; 15.2% in adenocarcinoma, 30.4% after induction chemotherapy, and 31.5% in N0 patients. In cases of M1a disease, complete surgical resection resulted in a 5-year survival rate of 16.2%. In case of M1b disease undergoing pulmonary resection, surgical metastasis management did not change the prognosis, with 5-year survival rates of 16.7% in case of metastasis resection (n=66) versus 15.6% without resection (n=19, P=0.67).

In patients with M1a disease, complete surgical resection allowed some long-term survivals, suggesting that surgery may be underestimated. Conversely, in patients with M1b disease undergoing pulmonary resection, surgical resection of the metastasis is not associated with better survival than non-surgical management, suggesting that surgery may be overestimated.