Thoracoscopic approach to bilateral pulmonary metastasis: is it justified?

There are few reports on optimal surgical approaches to bilateral pulmonary metastasis and the sequences used in the operation. The aim of this study was to evaluate the feasibility of the thoracoscopic bilateral approach to pulmonary metastasis.

From June 2006 to February 2013, 61 patients underwent a planned bilateral pulmonary metastasectomy with one- (n = 52) or two-stage (n = 9) thoracoscopic surgery. We retrospectively analysed the outcomes of this group of patients to define the role and limitation of thoracoscopic surgery in bilateral disease.

In 17 patients with bilateral single lesions on the computed tomography (CT) scans, we were able to resect more nodules than initially imaged in 7 patients (41.2%), and there were 2 patients (11.8%) who had more true metastatic lesions than expected. Among 44 patients who showed more than two bilateral multiple lesions on the CT scan, we were able to resect more than 10 nodules in 2 patients (4.5%). The overall accuracy rate for resected malignant nodules was 76.6%, and 9 patients (14.8%) actually had the disease confined to the unilateral thorax, with solitary (n = 8) and multiple (n = 1) metastases after bilateral exploration. The prognostic factors for unilateral disease were unilateral lesion on the positron emission tomography (PET) scan (P = 0.024). The values of FVC and FEV1 were, respectively, 14.4 and 15.4% reduction at 6 months postoperatively in patients who had three or more nodules resected. Sarcomatous histology (P = 0.039), a diameter larger than 3 cm (P = 0.042) and bilateral lesion on PET (P = 0.035) were the prognostic factors for intrathoracic recurrences.

Bilateral pulmonary metastasectomy was performed safely with thoracoscopy in patients with bilateral oligo-metastatic sub-pleural lesions and the one-stage approach was a feasible option in bilateral single lesions. Preoperative PET scan could help predict intrathoracic recurrence after thoracoscopic metastasectomy.