Symposium Paper For reprint orders, please contact: reprints@futuremedicine.com Precision surgery in lung metastasectomy Michel Gonzalez* ,1 , Matthieu Zellweger 1 , Marco Nardini 2 & Marcello Migliore 2 1 Service of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland 2 Service of Thoracic Surgery, University Hospital of Catania, Italy *Author for correspondence: Tel.: +41 21 314 2402; Fax: +41 21 314 2358; Michel.Gonzalez@chuv.ch The value of pulmonary metastasis (PM) resection in the context of controlled primary tumor sites was shown to improve survival of patients if complete resection could be achieved. The surgeon’s approach can be modulated by various parameters pertaining to safety margins including local growth properties, size, spread and location of PMs. Lymph node dissection and assessment is recommended although its impact on survival remains unclear. Thoracoscopic surgery combined to thin slice chest CT scans has shown results comparable to thoracotomy in patients with few PMs. The management of PMs should therefore be discussed on an individual, interdisciplinary basis to offer the best possible oncological and surgical results as well as to maximize long term patient survival rates. First draft submitted: 13 September 2018; Accepted for publication: 3 April 2019; Published online: 20 December 2019 Keywords: colorectal cancer • FDG-PET • pulmonary anatomical resection • pulmonary metastasectomy • pulmonary metastases • thoracoscopy Since the first lung metastasectomy performed by Weinlechner in 1882, continuous adjustments have been proposed for the management of pulmonary metastatic patients [1,2]. Even if the metastatic state remains poorly understood, the pathophysiology of metastases includes several identified steps [3]. Initially, after local growth, the primary cancer cells will detach, migrate through the systemic circulation and stop in the lungs. Pulmonary metastases (PMs) receive their blood supply from the pulmonary arteries (84%) or bronchial arteries (16%) [4]. Then, depending on their microenvironment, the tumor cells may proliferate and form metastases. More than 30% of patients with cancer will develop PM and their management is generally based on palliative chemotherapy, due to frequent metastatic invasion of other organs. In rare instances, surgery may be justified for palliation in highly selected patients for uncontrollable pain associated to chest wall invasion, massive hemoptysis or retention pneumonia due to centrally located metastases. Nevertheless, there is a group of patients with pulmonary metastases who may potentially benefit from curative surgical resection provided that some criteria are met: complete resection of all lesions is possible, exclusion of extra-thoracic lesions and control of the primary tumor. Thus, the surgical approach is widely proposed in this group of oligometastatic patients which is defined by a state of limited systemic metastatic tumors for which local ablative could be potentially curative [5]. The main objective of lung metastasectomy has traditionally been to confirm the metastatic nature of the disease while achieving complete resection of all detectable lesions with bimanual palpation through thoracotomy. However, PM may have various origins, histological characteristics, numbers and size. The surgeon must also decide how to adjust the resection method and surgical technique in the current context of development of less invasive technique such as video-assisted thoracoscopy surgery without compromising the oncological outcomes. In addition, the personalized oncological approach has also redefined the role of surgery as a provider of metastatic tissue for analysis of biomarkers or resistance patterns. The aim of this review is to focus on recent advances in the context of pulmonary metastasectomy. Rationale for surgery Although a randomized trial confirming the real benefit of surgery in the context of PM has yet to be published, surgery is nowadays considered a valid curative option in selected patients [4]. Several retrospective studies tend to validate the surgical approach by demonstrating an increased survival for patients who underwent complete resection of PM in comparison to retrospective series of patients who did not benefit from surgery [6–8]. Histological confirmation of metastatic lesion is of paramount importance since PM may be difficult to differentiate from primary lung tumors or benign lesions due to different radiological appearances. Development of new pulmonary nodules Future Oncol. (Epub ahead of print) ISSN 1479-6694 10.2217/fon-2018-0713 C  2019 Future Medicine Ltd