Current role for resection of thoracic metastases in children and young adults--do we need different strategies for this population?

UNLABELLED: A retrospective review of surgical interventions for pulmonary metastases found 44 surgical metastasectomies in patients 20 years old or younger.

OBJECTIVE: Indications for pulmonary metastasectomy are well established in adults, but are not so clear when we are dealing with a younger population.

PATIENTS AND METHODS: A retrospective review of surgical interventions for pulmonary metastases (from December 1996 to October 2001) found 44 surgical metastasectomies in patients considered pediatric or young adults (20 years old or younger). Initial primary tumor, disease-free interval (DFI), previous thoracotomies, tumor histology, number of metastases, surgery performed, postoperative complications, other treatments received, and outcomes were recorded.

RESULTS: Median age was 16.3 years (range 5 to 20 years) with 27 male and 17 female patients. Primary tumors were sarcoma (n = 31), Ewing's tumor (n = 8), Wilms' tumor (n = 3), and testicular carcinoma (n = 2). 27 patients had undergone previous resection of pulmonary metastases. Approaches were posterolateral thoracotomy (n = 18), clamshell incision (n = 8), VATS (n = 7), axillary thoracotomy (n = 9), and others (n = 2). Wedge resections were the procedure of choice (n = 35). In very select cases 1 pneumonectomy, 3 lobectomies, 2 chest wall resections, and 1 spinal surgery (vertebrectomy) were performed. Intra-operative radiotherapy (IORT) was employed in 2 patients. Cardiopulmonary bypass was necessary in 1 patient in order to resect an intra-atrial tumor thrombus. There was no operative mortality. Morbidity was related to prolonged air leaks (3 patients), hemothorax (2 patients), cerebrospinal fluid leak (1 patient), atelectasia (1 patient), peritoneal pain (1 patient), and postoperative fever syndrome (1 patient). Patterns of failure were thoracic (lung-pleura-chest wall) (n = 20), distant (n = 3) and thoracic + distant (n = 6).

CONCLUSION: A close collaboration between oncologists, radiotherapists, and surgeons is mandatory in order to obtain good results. IORT is an interesting option. Better results are obtained if there is a long DFI and probably justifies a more aggressive approach in these specific cases.