0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Intraoperative Lavage Cytologic Analysis of Surgical Margins as a Predictor of Local Recurrence in Pulmonary Metastasectomy FREE

Masahiko Higashiyama, MD; Ken Kodama, MD; Koji Takami, MD; Naozumi Higaki, MD; Hideoki Yokouchi, MD; Tomio Nakayama, MD; Kohei Murata, MD; Masao Kameyama, MD; Jun-ichi Ashimura, CT; Yasuyoshi Naruse, CT; Sachiko Nagumo, CT
[+] Author Affiliations

From the Departments of Thoracic Surgery (Drs Higashiyama, Kodama, Takami, Higaki, and Yokouchi), Respiratory Medicine (Dr Nakayama), Surgery (Drs Murata and Kameyama), and Cytology (Messrs Ashimura and Naruse and Ms Nagumo), Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.


Arch Surg. 2002;137(4):469-474. doi:10.1001/archsurg.137.4.469.
Text Size: A A A
Published online

Hypothesis  Cytologic analysis of intraoperative lavage at the surgical margin during wedge or segmental resection for pulmonary metastatic lesions predicts postoperative local failure at the surgical margin of the pulmonary parenchyma.

Design  Prospective nonrandomized trial.

Settings  Institution-based study.

Patients  Fifty-one consecutive patients undergoing wedge or segmental resection for 87 pulmonary metastatic lesions of various primary tumor types from November 1, 1997, through January 31, 2001, were prospectively enrolled.

Interventions  An intraoperative lavage cytologic technique at the surgical margin for each pulmonary metastasis was performed as described previously.

Main Outcome Measures  Incidence of positive cytologic findings and postoperative local recurrence at the surgical margin.

Results  Of the examined lesions, 10 (11%) showed positive cytologic results at the surgical margin, despite a macroscopically safe margin in the attempted resection. Of these, metastasectomy was converted to segmentectomy in 3. An additional wedge resection and evaporation using an Nd:YAG laser in the surgical margin were performed in 1 and 4 lesions, respectively. Complications precluded further treatment in 2 lesions. By July 2001, although no local recurrence at the surgical margin area was found among the lesions with negative cytologic results, recurrence at the surgical margin occurred in 2 with positive cytologic results, including 1 receiving no treatment and 1 receiving Nd:YAG laser evaporation, indicating that a significant difference in the recurrence rate according to lavage cytologic status (P<.001).

Conclusions  This intraoperative lavage cytologic technique in wedge or segmental resection of pulmonary metastases of various primary tumors may be a useful predictor of local recurrence at the surgical margin. With these test results, local recurrence at the surgical margin may be controllable in patients undergoing pulmonary metastasectomy.

Figures in this Article

THE RECENT increasing incidence of aggressive surgery for pulmonary metastases of a variety of primary tumor sites has resulted in prolonged survival in some patients with such diseases.19 At our institution, metastasectomy for pulmonary metastases in more than 250 cases has been performed with modifications and advances in surgical techniques, and a portion of this population may be cured.8

Although consideration of the operation for metastasectomy should include lesion size, number, and anatomical location, pulmonary metastases have principally come to require less invasive surgery, such as wedge resection or segmentectomy, with open thoracotomy or video-assisted thoracic surgery (VATS). For example, in cases of multiple metastatic lesions in different pulmonary lobes, such less invasive operations may be a practical selection.4,5,8,10,11

One of the unfavorable recurrent patterns after a wedge or segmental resection for pulmonary metastases is local failure, found at the surgical margin of the pulmonary parenchyma. Because pulmonary metastasis in itself may be a manifestation of systemic disease, this failure is not always a major problem. Few reports describe this failure,10,11 and even its clinical rate remains unknown. Nevertheless, this type of local failure should be avoided technically during metastasectomy.

Wedge or segmental resections usually are performed while technically maintaining a safe surgical margin. A tumor-free surgical margin is checked macroscopically and, if necessary, by means of frozen-section histological diagnosis. However, these checking systems are unsatisfactory and unreliable, because resected fresh specimens are often obtained using staplers, which are too unmanageable to cut the margin precisely, and the whole surgical margin cannot be examined. In patients with lung cancer who are undergoing limited surgery, the rate of local recurrence in the surgical margin was 2% for an intentional resection,12 23.5% for patients with compromised indications,13 and up to 34% in a study by Martini et al,14 although the conditions under which limited surgery was performed were different.

We recently developed a novel test, the lavage cytologic method, for checking the surgical margin in patients with lung cancer who are undergoing limited surgery, and its usefulness in performing wedge or segmental resection has been preliminarily proposed.15 In this study, we applied this method to the surgical treatment of pulmonary metastases of primary tumors of various organs and evaluated its clinical significance.

CHARACTERISTICS

From November 1, 1997, through January 31, 2001, metastasectomy by means of limited operations, including wedge and segmental resections, was attempted prospectively in 51 consecutive patients. We performed 56 operations for 87 metastatic lesions in the Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan. Lesions for which lobectomy or pneumonectomy were first performed were excluded in this analysis. The patients, aged 16 to 80 years (mean age, 56.6 years), included 29 men and 22 women. Thirty-seven metastatic lesions in 18 patients were due to colorectal cancer; 18 in 13 patients, bone or soft tissue sarcoma; 10 in 5 patients, renal cell carcinoma; 7 in 4 patients, testicular tumor; 4 in 4 patients, breast cancer; 3 in 2 patients, urinary bladder cancer; 2 in 2 patients, hepatocellular cancer; 3 in 1 patient, thyroid cancer; 2 in 1 patient meningioma; and 1 in 1 patient, salivary gland cancer. Tumor size varied from 2 to 60 mm (median size, 12 mm). Thirty-four lesions were 10 mm or smaller; 33, 11 to 20 mm; 14, 21 to 30 mm; and 6, larger than 30 mm.

ATTEMPTED OPERATION AND CUTTING METHOD

For the 87 metastatic lesions, wedge resection surgery (n = 69) or segmentectomy (n = 18) was initially attempted by means of open thoracotomy (n = 69), minithoracotomy with a skin incision of less than 10 cm (n = 13), or VATS (n = 5). These operative techniques have been described previously.8,12,1618 We used staplers, an Nd:YAG laser, and/or electric scissors to cut into the pulmonary parenchyma with a macroscopically safe margin of more than 10 mm, if possible, or at least more than 5 mm from the lesion. We resected 50 lesions using staplers; 5, staplers with VATS; 11, electric scissors; 11, the Nd:YAG laser; and 10, a combination of staplers and an Nd:YAG laser or electric scissors. In all lesions except 1, we performed pleural lavage cytologic analysis immediately after thoracotomy to avoid tumor cell contamination of the surgical margin.19 The exceptional case showed severe adhesion in the pleural cavity.

LAVAGE CYTOLOGIC TECHNIQUE AT THE SURGICAL MARGIN

The lavage cytologic technique at the surgical margin for each lesion was performed as described previously.15 Briefly, when surgery was performed using staplers alone, all fired staples were washed in 200 mL of isotonic sodium chloride solution. When tumor excision was performed using the Nd:YAG laser or the electric scissors alone or in combination with staplers, the resected specimens were similarly washed in 200 mL of isotonic sodium chloride solution without flooding of the pleural surface. When tumors were resected using combined methods, the fired cartridges and the resected samples were washed. These lavage techniques were carefully performed before obtaining cross sections of the specimens.

After centrifugation, the sediment was immediately fixed with Saccomanno solution,20 and then smeared on a glass slide with Cytospin (Shandon Cytospin; JEOL Trading Co, Ltd, Tokyo, Japan). Next, after final refixation with ethanol and diethyl ether, the sediment was stained using the Papanicolaou method. The cytologic results were judged to be positive or negative by a cytologist (J.A., Y.N., or S.N.), and were immediately reported in the operating room at approximately 20 to 25 minutes after the beginning of the procedure.

POSTOPERATIVE HISTOLOGICAL ANALYSIS OF THE SURGICAL MARGIN

For lesions with positive cytologic results obtained by means of the lavage cytologic technique, we reviewed the histological findings of the surgical margin. We used the formalin-fixed specimens obtained during the initial operation.

POSTOPERATIVE FOLLOW-UP INVESTIGATIONS AND DIAGNOSIS OF LOCAL RECURRENCE

Postoperative follow-up investigations in the chest were principally performed by means of chest radiography every 2 to 4 months and computed tomography every 6 months for at least 2 years. Local recurrence at the surgical margin of the pulmonary parenchyma was usually carefully checked by means of computed tomography and was finally diagnosed by means of radiological findings, clinical course, or, if possible, surgical resection. The final follow-up date was July 30, 2001. The median follow-up for surviving patients was 22 months (range, 5-44 months).

STATISTICAL ANALYSIS

We used the Fisher exact probability test to determine the statistical significance of any differences.

Of the 87 examined lesions, 10 (11%) (in 10 patients) showed positive cytologic results at the surgical margin, despite a macroscopically safe margin in the attempted operation. Five lesions were due to colorectal cancer; 3, bone or soft tissue sarcoma; and 1 each, a testicular tumor and a hepatocellular carcinoma (Table 1). Lesions larger than 10 mm showed significantly more frequent positive findings than those 10 mm or smaller (P = .045; Table 1). The incidence of positive findings was significantly higher in surgery that used the Nd:YAG laser or staplers combined with the Nd:YAG laser or electric scissors, compared with the other methods (P = .005; Table 1).

Table Graphic Jump LocationTable 1. Positive Finding of Lavage Cytologic Analysis at the Surgical Margin

Table 2 summarizes the surgical results of these 10 lesions. Wedge resection was converted to segmentectomy (completion segmentectomy) in 3 lesions (lesions 1, 4, and 9); additional wedge resection was performed in 1 (lesion 5), and as much evaporation as possible using the Nd:YAG laser at the surgical margin16,18 was added in 4 (lesions 2, 3, 6, and 8). New surgical margins in the 3 patients undergoing completion segmentectomy and the 1 patient undergoing additional wedge resection were checked using the lavage cytologic technique, and negative cytologicresults were finally achieved. Surgical margin status in the 4 lesions for which Nd:YAG laser evaporation was added was unestimated due to technical problems. In the remaining 2 lesions, no additional resection was performed because of noncurative resection due to pleural dissemination (lesion 7) or positive cytologic findings of pleural lavage at the time of thoracotomy19 (lesion 10).

Table Graphic Jump LocationTable 2. Surgical Results of Lesions With Positive Findings of Lavage Cytologic Analysis*

Postoperative histological findings of the surgical margin in the specimens obtained from the initial operations were analyzed in lesions with positive cytologic lavage results. In the histological review, the nearest distance between the tumor front and cutting line was less than 5 mm for all 10 lesions, but focal tumor exposure on the line of the surgical margin was demonstrated in results of histological examination only in 4 lesions (lesions 2, 4, 7, and 8), despite macroscopically tumor-free appearance.

By July 2001, recurrence was found at the surgical margin in 2 lesions (Table 2). Of these, 1 patient (lesion 7) was given no additional treatment. The other patient with pulmonary metastases due to colorectal cancer (lesion 3) showed local recurrence at the surgical margin 10 months after surgery, although evaporation using the Nd:YAG laser was performed toward the surgical margin with positive cytologic findings (Figure 1). Subsequently, this patient underwent a completion lower lobectomy 3 months after recurrence. On the other hand, no local recurrence was found at the surgical margin among the 81 lesions with final negative cytologic results, whereas 2 (33%) of the other 6 lesions had surgical margin recurrence. A significant difference was found in the rate of postoperative surgical margin recurrence (Fisher exact probability, 0.004; P<.001).

Place holder to copy figure label and caption
Figure 1.

Postoperative local recurrence at the surgical margin in a patient undergoing wedge resection for pulmonary metastasis due to sigmoid colon cancer. The patient underwent 4 wedge resections using an Nd:YAG laser for 4 pulmonary metastases; of these, the lesion in the right S10 segment (A) (arrow) showed a positive result of intraoperative lavage cytologic analysis of the surgical margin. Therefore, evaporation using the Nd:YAG laser was performed on this cutting surface area. On computed tomographic scan 4 months after surgery, a scarlike shadow was observed at this surgical margin area (B) (arrow), but local recurrence at this area was detected 10 months after surgery (C) (arrow). Subsequently, this patient underwent a completion lower lobectomy 3 months after recurrence and was alive 15 months after the initial metastasectomy.

Graphic Jump Location

The cytologic and clinical summary of the enrolled lesions is schematically illustrated in Figure 2.

Place holder to copy figure label and caption
Figure 2.

Schematic illustration of recurrence at the surgical margin according to results of lavage cytologic analysis. The cytologic and clinical summary of the enrolled pulmonary metastases in the present series is shown.

Graphic Jump Location

At present, surgeons who routinely perform metastasectomy should be confident in the interpretation of preoperative radiographic evaluation mainly by means of computed tomography, so that they can plan a complete resection with consideration of location, number, and size of lesions.4,5,9 The operation mode should be decided on the basis of these conditions and the pulmonary function status of the patients, but in principle, less invasive surgery may be performed. Therefore, wedge or segmental resection of the lung is the most commonly applied technique for metastasectomy.4,5,9 Most operations for metastasectomy with such limited resection were also performed at our institution.8

However, wedge or segmental resection potentially carries the risk for local recurrence at the surgical margin. We previously experienced this trouble in 2% of patients with lung cancer undergoing limited surgery on an intentional indication.12 Thus, the incidence of this frustrating recurrence was found by several investigators to be surprisingly high after limited surgery for primary lung cancer.13,14

To overcome this problem, we developed a novel technique to check the residual tumor cells at the surgical margin during wedge or segmental resection.15 This technique offers some advantages compared with conventional techniques. During the operation, the whole area of the resected margin can be examined, and, if necessary, each margin can be separately checked in a relatively short time. In addition, any aspects of the surgical margin, regardless of cutting method, can be easily examined. We proposed that this novel system for checking surgical margins could provide useful information during limited surgery for lung cancer.15

In this study, we applied this checking technique clinically in metastasectomy for pulmonary metastases of various origins. We found a rate of positive findings of 11% when using this lavage cytologic method. This incidence was almost the same as that experienced in primary lung cancer,15 suggesting that even if the surgical margin appears macroscopically safe, about 10% of the resections may be microscopically incomplete, regardless of tumor type. In fact, among pulmonary metastases of various origins, no significant difference in positive results was found, but the size and locations of the resected lesions were more notable. Lesions larger than 10 mm showed more frequent positive results than those that were 10 mm or smaller (P = .045). In our institution, metastatic lesions larger than 30 mm are considered to be an appropriate indication for lobectomy. The present data suggest that even smaller lesions should be carefully resected when performing limited resection.

The incidence of positive cytologic findings in surgery using the Nd:YAG laser alone or combined with staplers was significantly higher than that in other types of surgery. Previous studies have reported the usefulness of metastasectomy using the Nd:YAG laser, especially for deep-seated lesions located in the pulmonary pleura.12,1618 Therefore, this finding may be strongly associated with technical handicaps because of tumor location.

When positive cytologic results in such limited surgery with macroscopically tumor-free margins are proven by means of this technique, the surgeon should note whether a tumor truly exposes on the cutting surface. In the present series, only 4 lesions were histologically diagnosed as tumor exposure by means of postoperative formalin-fixed specimens. However, considering that the distance of the surgical margin in all these specimens was histologically insufficient (<5 mm) to maintain tumor-free status, minute tumor exposure that cannot be observed by means of macroscopic or postoperative histological analysis may occur elsewhere in the surgical margin surface. In this respect, we believe that the present intraoperative lavage cytologic technique is superior to the other examination techniques.

The problem of whether a tumor recurs in the surgical margin with positive cytologic findings is clinically interesting. In the present series to date, no local recurrence has been observed in cases with negative cytologic findings, whereas surgical margin relapse occurred in 2 lesions, one with a positive cytologic result (lesion 7) and another with a finally unknown result (lesion 3), suggesting that negative cytologic results obtained by means of this novel lavage technique may be a useful predictor of local completeness of resection at the surgical margin area. In addition, in a retrospective study using 57 surgically resected pulmonary metastases of primary colorectal cancer before introduction of this lavage cytologic technique at our institution, local recurrence at the surgical margin area occurred at a 9% incidence rate in the total number of examined resected lesions (data not shown). This rate almost coincided with the present rate (14% in metastasectomy for primary colorectal cancer) of positive lavage cytologic data. Thus, the lavage cytologic status determined by means of this novel checking system may prevent local recurrence at the surgical margin by conversion of the operation when positive cytologic results are found.

In practice, we ultimately performed a converted operation in 4 lesions (segmentectomy in 3 and additional wedge resection in 1) and evaporation using the Nd:YAG laser in 4 lesions because of positive cytologic results. In primary lung cancer, the conversion from limited surgery on an intentional indication to standard resection, ie, lobectomy, was aggressively completed without any difficulties.12,15,17 In metastasectomy, however, such conversion should be carefully and systematically decided after consideration of lesion number and location, pulmonary function, general condition, and prognosis. In practice, segmentectomy can be maximally performed to achieve potentially complete resection. A lavage cytologic check should be conducted for the new safe margin in the case of a converted operation.

In contrast, 1 case (lesion 3) showed recurrence at the surgical margin, although evaporation using the Nd:YAG laser was performed. Evaporation using the Nd:YAG laser in the surgical margin may be a promising therapeutic modality for compromised cases.16,18 However, since tumor residue cannot be accurately evaluated, this therapeutic mode leaves further room for technical improvement to complete local control.

Recently, pulmonary metastasectomy has been aggressively performed with VATS.10,11,21 However, the completeness of local curability remains controversial, as with limited surgery with VATS for lung cancer.22,23 Lin et al10 reported local recurrence that was attributed to technical failure of VATS for metastasectomy. In this study, only 5 lesions were successfully resected with VATS when negative cytologic results occurred at the surgical margin. If is fortunate that all of these lesions were smaller and located almost beneath the pulmonary surface. We think that metastasectomy with VATS may be indicated for smaller pulmonary metastases located almost beneath the pulmonary surface, and, for confirmation, this novel checking system for local curability in the surgical margin should be routinely used.

According to many analyses of the prognostic factors regarding metastasectomy for pulmonary metastases of various organ origins, the following prognostic factors were proposed: number of metastases, disease-free interval from the resection of the primary tumor to the detection of pulmonary metastases, tumor type, tumor doubling time, intrathoracic node status, prethoracotomy serum carcinoembryonic antigen level, extrathoracic metastases, and complete resectability.1,2,49,2427 Although repeated metastasectomy for new pulmonary metastases has been conducted in selected patients with a promising favorable prognosis,4,5,25,28,29 to our knowledge, no large-scale study has reported repeated resection for local failure at the surgical margin. In patients with local failure at the surgical margin, more invasive surgery, such as a completion lobectomy or a more aggressive operation, is often necessary. Therefore, postoperative local failure at the surgical margin of the lung may be avoided. This novel intraoperative lavage cytologic technique is a promising test to predict local recurrence at the surgical margin in patients with pulmonary metastases as well as primary lung cancer. Further analysis is required to evaluate its clinical usefulness in long-term follow-up.

This study was supported in part by grants-in-aid 10-11 for cancer research from the Ministry of Health, Labour, and Welfare of Japan, Tokyo.

Corresponding author and reprints: Masahiko Higashiyama, MD, Department of Thoracic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinariku, Osaka 537-8511, Japan (e-mail: higamasa@rj8.so-net.ne.jp).

Goya  TMiyazawa  NKondo  HTsuchiya  RNaruke  TSuemasu  K Surgical resection of pulmonary metastases from colorectal cancer: 10-year follow-up. Cancer. 1989;641418- 1421
Link to Article
Sauter  ERBolton  JSWillis  GWFarr  GHSardi  A Improved survival after pulmonary resection of metastatic colorectal carcinoma. J Surg Oncol. 1990;43135- 138
Link to Article
McCormack  PMBurt  MeBains  MSMartini  NRusch  VWGinsberg  RJ Lung resction for colorectal metastases: 10-year results. Arch Surg. 1992;1271403- 1406
Link to Article
Pogrebniak  HWPass  HI Initial and reoperative pulmonary metastasectomy: indications, technique, and results. Semin Surg Oncol. 1993;9142- 149
Link to Article
Rusch  VW Pulmonary metastasectomy: current indications. Chest. 1995;107(suppl)322S- 332S
Link to Article
Robert  JHAmbrogi  VMermillod  BDahabreh  DGoldstraw  P Factors influencing long-term survival after lung metastasectomy. Ann Thorac Surg. 1997;63777- 784
Link to Article
Kandioler  DKromer  ETuchler  H  et al.  Long-term results after repeated surgical removal of pulmonary metastases. Ann Thorac Surg. 1998;65909- 912
Link to Article
Kodama  KDoi  OHigashiyama  MYokouchi  HKuriyam  K Surgical treatment of metastatic lung tumors: recent changes in techniques and indications. Surg Today. 1997;271123- 1130
Link to Article
Pastorino  UBuyse  MFriedel  G  et al.  Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg. 1997;11337- 49
Link to Article
Lin  JCWiechmann  RJSzwerc  MF  et al.  Diagnostic and therapeutic video-assisted thoracic surgery resection of pulmonary metastases. Surgery. 1999;126636- 642
Link to Article
Landreneau  RJDe Giacomo  TMack  MJ  et al.  Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases. Eur J Cardiothorac Surg. 2000;18671- 677
Link to Article
Kodama  KDoi  OHigashiyama  MYokouchi  H Intentional limited resection for selected patients with T1 N0 M0 non–small-cell lung cancer: a single-institution study. J Thorac Cardiovasc Surg. 1997;114347- 353
Link to Article
Yano  TYokoyama  HYoshino  I  et al.  Results of a limited resection for compromised or poor-risk patients with clinical stage I non–small cell carcinoma of the lung. J Am Coll Surg. 1995;18133- 37
Martini  NBains  MSBurt  ME  et al.  Incidence of local recurrence and second primary tumors in resected stage I lung cancer. J Thorac Cardiovasc Surg. 1995;109120- 129
Link to Article
Higashiyama  MKodama  KYokouchi  HTakami  KNakayama  THorai  T A novel test of the surgical margin in patients with lung cancer undergoing limited surgery: lavage cytologic technique. J Thorac Cardiovasc Surg. 2000;120412- 413
Link to Article
LoCicero  J  IIIFrederiksen  JWHartz  RSMichaelis  LL Laser-assisted parenchyma-sparing pulmonary resection. J Thorac Cardiovasc Surg. 1989;97732- 736
Kodama  KDoi  OYasuda  THigashiyama  MYokouchi  H Radical laser segmentectomy for T1 N0 lung cancer. Ann Thorac Surg. 1992;541193- 1195
Link to Article
Kodama  KDoi  OHigashiyama  MTatsuta  MIwanaga  T Surgical management of lung metastases: usefulness of resection with the neodymium:yttrium-aluminum-garnet laser with median sternotomy. J Thorac Cardiovasc Surg. 1991;101901- 908
Higashiyama  MDoi  OKodama  K  et al.  Pleural lavage cytology immediately after thoracotomy and before closure of the thoracic cavity for lung cancer without pleural effusion and dissemination: clinicopathological and prognostic analysis. Ann Surg Oncol. 1997;4409- 415
Link to Article
Saccomanno  GSunders  RPEllis  HArcher  VEWood  BGBeckler  PA Concentration of carcinoma or atypical cells in sputum. Acta Cytol. 1963;7305- 310
Dowling  RDLandreneau  RJMiller  DL Video-assisted thoracoscopic surgery for resection of lung metastases. Chest. 1998;z(suppl)2S- 5S
Link to Article
Lewis  RJ The role of video-assisted thoracic surgery for carcinoma of the lung: wedge resection to lobectomy by simultaneous individual stapling. Ann Thorac Surg. 1993;56762- 768
Link to Article
Ishida  TIshii  TYamazaki  K  et al.  Thoracoscopic limited resection of bronchogenic carcinoma in patients over the age of 80. Int Surg. 1996;81237- 240
Yano  THara  NIchinose  YYokoyama  HMiura  TOhta  M Results of pulmonary resection of metastatic colorectal cancer and its application. J Thorac Cardiovasc Surg. 1993;106875- 879
Shirouzu  KIsomoto  HHayashi  ANagamatsu  YKakegawa  T Surgical treatment for patients with pulmonary metastases after resection of primary colorectal carcinoma. Cancer. 1995;76393- 398
Link to Article
Okumura  SKondo  HTsuboi  M  et al.  Pulmonary resection for metastatic colorectal cancer: experiences with 159 patients. J Thorac Cardiovasc Surg. 1996;112867- 874
Link to Article
Girard  PDucreux  MBaldeyrou  P  et al.  Surgery for lung metastases from colorectal cancer: analysis of prognostic factors. J Clin Oncol. 1996;142047- 2053
Mori  MTomoda  HIshida  T  et al.  Surgical resection of pulmonary metastases from colorectal adenocarcinoma: special reference to repeated pulmonary resections. Arch Surg. 1991;1261297- 1302
Link to Article
Groeger  AMKandioler  DMueller  MREnd  AEckersberger  FWolner  E Survival after surgical treatment of recurrent pulmonary metastases. Eur J Cardiothorac Surg. 1997;12703- 705
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Postoperative local recurrence at the surgical margin in a patient undergoing wedge resection for pulmonary metastasis due to sigmoid colon cancer. The patient underwent 4 wedge resections using an Nd:YAG laser for 4 pulmonary metastases; of these, the lesion in the right S10 segment (A) (arrow) showed a positive result of intraoperative lavage cytologic analysis of the surgical margin. Therefore, evaporation using the Nd:YAG laser was performed on this cutting surface area. On computed tomographic scan 4 months after surgery, a scarlike shadow was observed at this surgical margin area (B) (arrow), but local recurrence at this area was detected 10 months after surgery (C) (arrow). Subsequently, this patient underwent a completion lower lobectomy 3 months after recurrence and was alive 15 months after the initial metastasectomy.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Schematic illustration of recurrence at the surgical margin according to results of lavage cytologic analysis. The cytologic and clinical summary of the enrolled pulmonary metastases in the present series is shown.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Positive Finding of Lavage Cytologic Analysis at the Surgical Margin
Table Graphic Jump LocationTable 2. Surgical Results of Lesions With Positive Findings of Lavage Cytologic Analysis*

References

Goya  TMiyazawa  NKondo  HTsuchiya  RNaruke  TSuemasu  K Surgical resection of pulmonary metastases from colorectal cancer: 10-year follow-up. Cancer. 1989;641418- 1421
Link to Article
Sauter  ERBolton  JSWillis  GWFarr  GHSardi  A Improved survival after pulmonary resection of metastatic colorectal carcinoma. J Surg Oncol. 1990;43135- 138
Link to Article
McCormack  PMBurt  MeBains  MSMartini  NRusch  VWGinsberg  RJ Lung resction for colorectal metastases: 10-year results. Arch Surg. 1992;1271403- 1406
Link to Article
Pogrebniak  HWPass  HI Initial and reoperative pulmonary metastasectomy: indications, technique, and results. Semin Surg Oncol. 1993;9142- 149
Link to Article
Rusch  VW Pulmonary metastasectomy: current indications. Chest. 1995;107(suppl)322S- 332S
Link to Article
Robert  JHAmbrogi  VMermillod  BDahabreh  DGoldstraw  P Factors influencing long-term survival after lung metastasectomy. Ann Thorac Surg. 1997;63777- 784
Link to Article
Kandioler  DKromer  ETuchler  H  et al.  Long-term results after repeated surgical removal of pulmonary metastases. Ann Thorac Surg. 1998;65909- 912
Link to Article
Kodama  KDoi  OHigashiyama  MYokouchi  HKuriyam  K Surgical treatment of metastatic lung tumors: recent changes in techniques and indications. Surg Today. 1997;271123- 1130
Link to Article
Pastorino  UBuyse  MFriedel  G  et al.  Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg. 1997;11337- 49
Link to Article
Lin  JCWiechmann  RJSzwerc  MF  et al.  Diagnostic and therapeutic video-assisted thoracic surgery resection of pulmonary metastases. Surgery. 1999;126636- 642
Link to Article
Landreneau  RJDe Giacomo  TMack  MJ  et al.  Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases. Eur J Cardiothorac Surg. 2000;18671- 677
Link to Article
Kodama  KDoi  OHigashiyama  MYokouchi  H Intentional limited resection for selected patients with T1 N0 M0 non–small-cell lung cancer: a single-institution study. J Thorac Cardiovasc Surg. 1997;114347- 353
Link to Article
Yano  TYokoyama  HYoshino  I  et al.  Results of a limited resection for compromised or poor-risk patients with clinical stage I non–small cell carcinoma of the lung. J Am Coll Surg. 1995;18133- 37
Martini  NBains  MSBurt  ME  et al.  Incidence of local recurrence and second primary tumors in resected stage I lung cancer. J Thorac Cardiovasc Surg. 1995;109120- 129
Link to Article
Higashiyama  MKodama  KYokouchi  HTakami  KNakayama  THorai  T A novel test of the surgical margin in patients with lung cancer undergoing limited surgery: lavage cytologic technique. J Thorac Cardiovasc Surg. 2000;120412- 413
Link to Article
LoCicero  J  IIIFrederiksen  JWHartz  RSMichaelis  LL Laser-assisted parenchyma-sparing pulmonary resection. J Thorac Cardiovasc Surg. 1989;97732- 736
Kodama  KDoi  OYasuda  THigashiyama  MYokouchi  H Radical laser segmentectomy for T1 N0 lung cancer. Ann Thorac Surg. 1992;541193- 1195
Link to Article
Kodama  KDoi  OHigashiyama  MTatsuta  MIwanaga  T Surgical management of lung metastases: usefulness of resection with the neodymium:yttrium-aluminum-garnet laser with median sternotomy. J Thorac Cardiovasc Surg. 1991;101901- 908
Higashiyama  MDoi  OKodama  K  et al.  Pleural lavage cytology immediately after thoracotomy and before closure of the thoracic cavity for lung cancer without pleural effusion and dissemination: clinicopathological and prognostic analysis. Ann Surg Oncol. 1997;4409- 415
Link to Article
Saccomanno  GSunders  RPEllis  HArcher  VEWood  BGBeckler  PA Concentration of carcinoma or atypical cells in sputum. Acta Cytol. 1963;7305- 310
Dowling  RDLandreneau  RJMiller  DL Video-assisted thoracoscopic surgery for resection of lung metastases. Chest. 1998;z(suppl)2S- 5S
Link to Article
Lewis  RJ The role of video-assisted thoracic surgery for carcinoma of the lung: wedge resection to lobectomy by simultaneous individual stapling. Ann Thorac Surg. 1993;56762- 768
Link to Article
Ishida  TIshii  TYamazaki  K  et al.  Thoracoscopic limited resection of bronchogenic carcinoma in patients over the age of 80. Int Surg. 1996;81237- 240
Yano  THara  NIchinose  YYokoyama  HMiura  TOhta  M Results of pulmonary resection of metastatic colorectal cancer and its application. J Thorac Cardiovasc Surg. 1993;106875- 879
Shirouzu  KIsomoto  HHayashi  ANagamatsu  YKakegawa  T Surgical treatment for patients with pulmonary metastases after resection of primary colorectal carcinoma. Cancer. 1995;76393- 398
Link to Article
Okumura  SKondo  HTsuboi  M  et al.  Pulmonary resection for metastatic colorectal cancer: experiences with 159 patients. J Thorac Cardiovasc Surg. 1996;112867- 874
Link to Article
Girard  PDucreux  MBaldeyrou  P  et al.  Surgery for lung metastases from colorectal cancer: analysis of prognostic factors. J Clin Oncol. 1996;142047- 2053
Mori  MTomoda  HIshida  T  et al.  Surgical resection of pulmonary metastases from colorectal adenocarcinoma: special reference to repeated pulmonary resections. Arch Surg. 1991;1261297- 1302
Link to Article
Groeger  AMKandioler  DMueller  MREnd  AEckersberger  FWolner  E Survival after surgical treatment of recurrent pulmonary metastases. Eur J Cardiothorac Surg. 1997;12703- 705
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 8

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles