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Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC): Prospective Cohort with its Nested Randomized Controlled Trial Provides an Example Distinguishing Causation From Association.

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Pulmonary metastasectomy: limits to credibility.

Tom Treasure1, Fergus Macbeth2

  • 1Clinical Operational Research Unit, University College London, London, UK.

Journal of Thoracic Disease
|May 20, 2021
PubMed
Summary

Pulmonary metastasectomy for lung metastases lacks strong evidence and may cause harm. More research is needed to determine if this cancer treatment benefits patients or offers false hope.

Keywords:
Pulmonary metastasectomycanceroligometastatic diseasethoracic surgery

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Area of Science:

  • Oncology
  • Surgical Oncology
  • Medical Ethics

Background:

  • Lung metastases are a common site for cancer spread, particularly from colorectal cancer.
  • Pulmonary metastasectomy is increasingly advocated for various tumors, despite limited evidence.
  • Emerging treatments like stereotactic radiotherapy and thermal ablation intensify the drive to treat lung metastases.

Purpose of the Study:

  • To critically evaluate the evidence supporting pulmonary metastasectomy for lung metastases.
  • To question the therapeutic rationale and potential harms of the procedure.
  • To highlight the ethical imperative for conducting randomized trials.

Main Methods:

  • Review and critique of existing observational data, focusing on selection bias.
  • Analysis of the biological plausibility and definition of "oligometastases".
  • Examination of the absence of randomized controlled trial (RCT) evidence for survival benefit and presence of harm data.

Main Results:

  • The concept of "oligometastases" is vague and biologically questionable.
  • Observational evidence supporting metastasectomy is flawed due to selection bias.
  • No reliable RCTs demonstrate improved survival; evidence suggests potential harm.

Conclusions:

  • Pulmonary metastasectomy is a procedure driven by "therapeutic opportunity" rather than robust evidence.
  • Current evidence does not justify the use of metastasectomy or newer ablation techniques for lung metastases.
  • Patients may receive false hope of cure and face risks of harm without clear benefit; ethical RCTs are crucial.