G. J. Haro1, J. Reza3, A. Sammann1, M. Hudnall2, K. Jones1, D. Jablons1, M. J. Mann1 1University Of California – San Francisco,San Francisco, CA, USA 2Northwestern University,Chicago, IL, USA 3Florida Hospital,Orlando, FL, USA
Introduction:
Pulmonary metastases frequently recur after metastasectomy. There is limited evidence to guide surgical decision-making following recurrence, but a particularly aggressive approach to metastasectomy has been advocated for sarcoma. We studied outcomes associated with an aggressive surgical approach to recurrent pulmonary metastases from sarcoma and other primary malignancies.
Methods:
We retrospectively identified 556 consecutive pulmonary metastasectomies at our center between 1991-2015 among 192 sarcoma and 252 non-sarcoma patients. The most common non-sarcoma subtypes were colorectal adenocarcinoma (n=80), melanoma (n=49), and renal cell carcinoma (n=34). Indications for initial metastasectomy were substantially more liberal for sarcoma than non-sarcoma. Patients were all followed with standard surveillance imaging. Kaplan-Meier analysis with a right-censored dataset assessed recurrence and overall survival from time of metastasectomy. Multivariable Cox proportional hazards models were developed in sarcoma and non-sarcoma patients with recurrent pulmonary metastasis based upon age, sex, race, non-sarcoma cancer type, number/size lesions, time to recurrence, surgery date, anatomic resection, minimally invasive procedure, and chemo/radiotherapy.
Results:
Median survival was 3.1 (95% CI 2.4-3.9) years for sarcoma and 4.7 (95% CI 3.6-6.8) years for non-sarcoma. Seventy percent (135/192) sarcoma and 42.1% (106/252) non-sarcoma patients recurred and sarcoma patients recurred with a greater number of lesions (mean 4.5 vs 2.5). Median time to recurrence was 7.2 (95% CI 4.8-9.6) and 10.8 (95% CI 8.4-13.2) months in sarcoma and non-sarcoma, respectively. In those who recurred, 49.6% (67/135) sarcoma and 38.7% (41/106) non-sarcoma underwent repeat metastasectomy. Sarcoma patients whose recurrences remained resectable experienced similar survival to those who did not recur (Figure, P=0.47), whereas those with resectable recurrence from non-sarcoma had worse survival (P=0.02). Multivariable models identified recurrence <6 months (HR 2.7 95% CI 1.8-4.1) and need for anatomic resection (HR 1.7 95% CI 1.0-2.9) as predictors of worse survival among sarcoma patients. Delayed recurrence >2 years (HR 0.2 95% CI 0.1-0.5; HR 0.4 95% CI 0.2-0.8) and largest lesion <2cm (HR 0.5 95% CI 0.3-0.7; HR 0.6 95% CI 0.4-0.9) were associated with improved survival in sarcoma and non-sarcoma, respectively.
Conclusion:
Although recurrences of pulmonary metastasis tend to be more virulent in sarcoma, aggressive repeat resection when possible may better preserve survival in patients with sarcoma compared to non-sarcoma. Patients with a longer time to recurrence and smaller lesions may be more likely to benefit from repeat surgical resection
