Info

Breast (clinical T1, T2, 1977 1,079 NO)

Squamous cell cancer 1980 75

of oral cavity (clinical T1-3, NO)

Extremity melanoma 1977 553

(clinical NO)

Melanoma (clinical NO) 1986 171

Melanoma (intermediate 1996 740 thickness; clinical NO)

Truncal melanoma 1998 240

(>1.5mm thickness; clinical NO)

Total mastectomy vs. total 21 years mastectomy and RTa vs. radical mastectomy

Elective neck dissection 5 years vs. therapeutic neck dissection

Elective lymphadenectomy 5 years vs. therapeutic lymphadenectomy

No lymphadenectomy vs. 4.5

elective lymphadenectomy years vs. delayed lymphadenectomy

Elective lymphadenectomy vs. 7.4 therapeutic lymphadenectomy years

Elective lymphadenectomy vs. 11 years therapeutic lymphadenectomy

No significant differences between groups in overall or disease-free survival

No significant differences between groups in overall or disease-free survival

No significant differences between groups in overall or disease-free survival

No significant differences between groups in overall or disease-free survival

No significant differences between groups in overall or disease-free survival

No significant differences between groups in overall or disease-free survival

aRT, radiation therapy to chest wall, internal mammary, axillary, and supraclavicular lymph nodes.

clinical studies documenting the survival benefit of surgical resection of isolated metastases, there is a significant body of retrospective evidence indicating that this approach can result in significant long-term benefit in patients with either lung or liver metastases. Aside from the regional lymph nodes, both lung and liver represent the next most common sites to which solid tumors metastasize.

The resection of metastases to the lung in patients with osteogenic or soft tissue sarcomas has been established from numerous retrospective reports. Both osteogenic and soft tissue sarcomas have a propensity to metastasize to the lung as the only site. Computed tomography studies of the lung are capable of identifying lesions that are a few millimeters in size. Multiple wedge excisions can be performed utilizing stapling devices without compromise of pulmonary function. Pulmonary metastasectomies for bone and soft tissue sarcoma can result in 5-year overall survival rates of approximately 35% if all disease is resected.26,27 The resection of metastases for adenocarcinomas is not so well documented. Primary adenocarcinomas often metastasize to multiple sites and do not result in isolated lung metastases. When they are confined to the lung, the metastases are often too numerous to consider wedge resections. There are retrospective reports indicating that, in select patients with metastatic adenocar-cinomas to the lung (i.e., colorectal primaries), resection can result in long-term survival benefit.28,29

A large body of retrospective evidence documents the benefit of resecting isolated liver metastases; this is especially the case for colorectal primary cancers. These cancers appear to have a pattern of spread that involves the liver as the initial site of metastasis. Resection of solitary or multiple colorec-tal liver metastases has resulted in a 25% to 40% overall 5-year survival rate, depending on the extent of liver involvement. Factors that have been associated with better survival are node-negative primary cancers, prolonged disease-free interval from time of primary resection to diagnosis of liver metastases, negative margins of hepatic resection, and fewer numbers of hepatic metastases (see Chapter 95). Current trials are under way to determine if adjuvant therapies given after hepatic metastasectomies further improve survival in this patient group. Besides colorectal liver metastases, the resection of noncolorectal liver metastases also can be therapeutic or palliative for selected individuals. For example, the resection of functional neuroendocrine metastases to the liver can result in palliation and prolonged survival of patients.30 These tumors tend to be indolent in their growth rate; however, the symptoms associated with the metastatic lesion can often be detrimental to the quality of life of the patient. For other nonneuroendocrine, noncolorectal liver metastases, resection can result in survival benefit as well. Patients with isolated genitourinary or gynecologic primary malignancies with a prolonged disease-free interval have been reported to benefit from aggressive resection of hepatic metastases.31

Both liver and lung represent the majority of the evidence that resection of visceral metastases can result in long-term survival. These results have been observed usually in the absence of adjuvant systemic therapies. Our current concept that solid malignancies are systemic at their onset (i.e., breast cancer) would have us surmise that, with the presence of bulky visceral metastases, there must also be micrometasta-tic disease present at the time the bulky disease is resected.

Nevertheless, approximately 20% to 25% of individuals remain disease free for many years. This finding begs the notion that perhaps an immune mechanism is involved in preventing disease relapse in a subset of these patients. Besides liver and lung sites, there are clearly anecdotes and published series indicating that the resection of isolated metastases to skin, bowel, adrenal glands, pancreas, and other sites can result in survival benefit. One of the roles of the surgical oncologist is to know when it is appropriate to offer surgical resection of metastatic disease as a palliative or therapeutic option.

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