Clin Colon Rectal Surg 2009; 22(4): 233-241
DOI: 10.1055/s-0029-1242463
© Thieme Medical Publishers

Surgical Management of Colorectal Lung Metastasis

P. James Villeneuve1 , R. Sudhir Sundaresan1
  • 1Division of Thoracic Surgery, The Ottawa Hospital, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
Further Information

Publication History

Publication Date:
06 November 2009 (online)


Colon cancer is a systemic disease in 19% of patients and metastasizes most frequently to the liver and the lung. Survival is enhanced with complete surgical resection of pulmonary metastases. Comprehensive restaging and verification of preoperative fitness must precede resection. The operative approach is dictated by the anatomic location of the metastases, whereas the extent of resection remains a balance between complete removal of metastatic deposits while preserving as much lung parenchyma as possible. The presence of metastatic involvement of hilar and mediastinal lymph nodes is ominous. Multidisciplinary care is highly recommended. An evidence-based algorithm for the identification assessment and treatment of patients with pulmonary metastases is proposed.


  • 1 Horner M, Ries L, Krapcho M et al.. SEER Cancer Stat Fact Sheets. SEER Cancer Statistics Review, 1976–2006. Atlanta, GA; Centers for Disease Control and Prevention, Division of Cancer Prevention and Control 2009
  • 2 Pfannschmidt J, Dienemann H, Hoffmann H. Surgical resection of pulmonary metastases from colorectal cancer: a systematic review of published series.  Ann Thorac Surg. 2007;  84(1) 324-338
  • 3 The International Registry of Lung Metastases . Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases.  J Thorac Cardiovasc Surg. 1997;  113(1) 37-49
  • 4 Weinlechner J. Tumoren an der brustwand und deren behnadlung resection der rippeneroffnung der brusthohle und partielle entfernung der lunge.  Wien Med Wochenschr. 1882;  32 589-591
  • 5 Divis G. Einbertrag zur operativen, Behandlung der lungengeschuuliste.  Acta Chir Scand. 1927;  62 329-334
  • 6 Edwards A. Malignant disease of the lung.  J Thorac Surg. 1934;  4 107-124
  • 7 Barney J D, Churchill E D. Adenocarcinoma of the kidney with metastases to the lung: cured by nephrectomy and lobectomy.  J Urol. 1939;  43 269-276
  • 8 Blalock A. Recent advances in surgery.  N Engl J Med. 1944;  231 261-267
  • 9 Rusch V W. Pulmonary metastasectomy. Current indications.  Chest. 1995;  107(6, Suppl) 322S-331S
  • 10 NCCN Colon Cancer Panel .Practice Guidelines in Oncology - Colon Cancer. Vol. 2. Fort Washington, PA; National Comprehensive Cancer Network 2009: 1-71
  • 11 Klippenstein D L, Lamonica D M. Preoperative imaging for metastasectomy.  Surg Oncol Clin N Am. 2007;  16(3) 471-492, vii
  • 12 Pastorino U, Veronesi G, Landoni C et al.. Fluorodeoxyglucose positron emission tomography improves preoperative staging of resectable lung metastasis.  J Thorac Cardiovasc Surg. 2003;  126(6) 1906-1910
  • 13 Hung G U, Shiau Y C, Tsai S C, Chao T H, Ho Y J, Kao C H et al.. Value of 18F-fluoro-2-deoxyglucose positron emission tomography in the evaluation of recurrent colorectal cancer.  Anticancer Res. 2001;  21(2B) 1375-1378
  • 14 Beets G, Penninckx F, Schiepers C et al.. Clinical value of whole-body positron emission tomography with [18F]fluorodeoxyglucose in recurrent colorectal cancer.  Br J Surg. 1994;  81(11) 1666-1670
  • 15 Cerfolio R J, McCarty T, Bryant A S. Non-imaged pulmonary nodules discovered during thoracotomy for metastasectomy by lung palpation.  Eur J Cardiothorac Surg. 2009;  35(5) 786-791 discussion 791
  • 16 Ciriaco P, Negri G, Puglisi A, Nicoletti R, Del Maschio A, Zannini P et al.. Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization.  Eur J Cardiothorac Surg. 2004;  25(3) 429-433
  • 17 Gonfiotti A, Davini F, Vaggelli L et al.. Thoracoscopic localization techniques for patients with solitary pulmonary nodule: hookwire versus radio-guided surgery.  Eur J Cardiothorac Surg. 2007;  32(6) 843-847
  • 18 Lenglinger F X, Schwarz C D, Artmann W. Localization of pulmonary nodules before thoracoscopic surgery: value of percutaneous staining with methylene blue.  AJR Am J Roentgenol. 1994;  163(2) 297-300
  • 19 Mayo J R, Clifton J C, Powell T I et al.. Lung nodules: CT-guided placement of microcoils to direct video-assisted thoracoscopic surgical resection.  Radiology. 2009;  250(2) 576-585
  • 20 Sortini D, Feo C V, Carcoforo P et al.. Thoracoscopic localization techniques for patients with solitary pulmonary nodule and history of malignancy.  Ann Thorac Surg. 2005;  79(1) 258-262 discussion 262
  • 21 Chen W, Chen L, Yang S et al.. A novel technique for localization of small pulmonary nodules.  Chest. 2007;  131(5) 1526-1531
  • 22 Grogan E L, Jones D R, Kozower B D, Simmons W D, Daniel T M. Identification of small lung nodules: technique of radiotracer-guided thoracoscopic biopsy.  Ann Thorac Surg. 2008;  85(2) S772-S777
  • 23 Dennis J L, Hvidsten T R, Wit E C et al.. Markers of adenocarcinoma characteristic of the site of origin: development of a diagnostic algorithm.  Clin Cancer Res. 2005;  11(10) 3766-3772
  • 24 Bapoje S R, Whitaker J F, Schulz T, Chu E S, Albert R K. Preoperative evaluation of the patient with pulmonary disease.  Chest. 2007;  132(5) 1637-1645
  • 25 Greelish J P, Friedberg J S. Secondary pulmonary malignancy.  Surg Clin North Am. 2000;  80(2) 633-657
  • 26 Conlon N P, Shaw A D, Grichnik K P. Postthoracotomy paravertebral analgesia: will it replace epidural analgesia?.  Anesthesiol Clin. 2008;  26(2) 369-380
  • 27 Ginsberg R J. Alternative (muscle-sparing) incisions in thoracic surgery.  Ann Thorac Surg. 1993;  56(3) 752-754
  • 28 Thomford N R, Woolner L B, Clagett O T. The surgical treatment of metastatic tumours in the lungs.  J Thorac Cardiovasc Surg. 1965;  49 357-363
  • 29 Alexander J, Haight C. Pulmonary resection for solitary metastatic sarcomas and carcinomas.  Surg Gynecol Obstet. 1947;  85 129-146
  • 30 Pfannschmidt J, Klode J, Muley T, Dienemann H, Hoffmann H. Nodal involvement at the time of pulmonary metastasectomy: experiences in 245 patients.  Ann Thorac Surg. 2006;  81(2) 448-454
  • 31 Bains M S, Ginsberg R J, Jones II W G et al.. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor.  Ann Thorac Surg. 1994;  58(1) 30-32 discussion 33
  • 32 van der Veen A H, van Geel A N, Hop W C, Wiggers T. Median sternotomy: the preferred incision for resection of lung metastases.  Eur J Surg. 1998;  164(7) 507-512
  • 33 Sternberg D I, Sonett J R. Surgical therapy of lung metastases.  Semin Oncol. 2007;  34(3) 186-196
  • 34 Roth J A, Pass H I, Wesley M N, White D, Putnam J B, Seipp C et al.. Comparison of median sternotomy and thoracotomy for resection of pulmonary metastases in patients with adult soft-tissue sarcomas.  Ann Thorac Surg. 1986;  42(2) 134-138
  • 35 Togo S, Fujii S, Yamaguchi S, Ike H, Ooki S, Shimada H et al.. Thoracoscopic lung resection for lung metastasis of colorectal cancer.  Surg Laparosc Endosc. 1996;  6(6) 480-484
  • 36 Nakajima J, Murakawa T, Fukami T, Takamoto S. Is thoracoscopic surgery justified to treat pulmonary metastasis from colorectal cancer?.  Interact Cardiovasc Thorac Surg. 2008;  7(2) 212-216 discussion 216-217
  • 37 Landreneau R J, De Giacomo T, Mack M J et al.. Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases.  Eur J Cardiothorac Surg. 2000;  18(6) 671-676 discussion 676-677
  • 38 Johnstone P A, Rohde D C, Swartz S E, Fetter J E, Wexner S D. Port site recurrences after laparoscopic and thoracoscopic procedures in malignancy.  J Clin Oncol. 1996;  14(6) 1950-1956
  • 39 Saisho S, Nakata M, Sawada S et al.. Evaluation of video-assisted thoracoscopic surgery for pulmonary metastases: 11-years of experience.  Surg Endosc. 2009;  23(1) 55-61
  • 40 Spaggiari L, Grunenwald D H, Girard P, Solli P, Le Chevalier T. Pneumonectomy for lung metastases: indications, risks, and outcome.  Ann Thorac Surg. 1998;  66(6) 1930-1933
  • 41 Grunenwald D, Spaggiari L, Girard P, Baldeyrou P, Filaire M, Dennewald G et al.. Completion pneumonectomy for lung metastases: is it justified?.  Eur J Cardiothorac Surg. 1997;  12(5) 694-697
  • 42 Pennathur A, Abbas G, Qureshi I et al.. Radiofrequency ablation for the treatment of pulmonary metastases.  Ann Thorac Surg. 2009;  87(4) 1030-1036 discussion 1036-1039
  • 43 Okuma T, Okamura T, Matsuoka T et al.. Fluorine-18-fluorodeoxyglucose positron emission tomography for assessment of patients with unresectable recurrent or metastatic lung cancers after CT-guided radiofrequency ablation: preliminary results.  Ann Nucl Med. 2006;  20(2) 115-121
  • 44 Mineo T C, Ambrogi V, Tonini G et al.. Longterm results after resection of simultaneous and sequential lung and liver metastases from colorectal carcinoma.  J Am Coll Surg. 2003;  197(3) 386-391
  • 45 Robinson B J, Rice T W, Strong S A, Rybicki L A, Blackstone E H. Is resection of pulmonary and hepatic metastases warranted in patients with colorectal cancer?.  J Thorac Cardiovasc Surg. 1999;  117(1) 66-75 discussion 75-76
  • 46 Veronesi G, Petrella F, Leo F et al.. Prognostic role of lymph node involvement in lung metastasectomy.  J Thorac Cardiovasc Surg. 2007;  133(4) 967-972
  • 47 Higashiyama M, Kodama K, Higaki N et al.. Surgery for pulmonary metastases from colorectal cancer: the importance of prethoracotomy serum carcinoembryonic antigen as an indicator of prognosis.  Jpn J Thorac Cardiovasc Surg. 2003;  51(7) 289-296
  • 48 Tomimaru Y, Noura S, Ohue M et al.. Metastatic tumor doubling time is an independent predictor of intrapulmonary recurrence after pulmonary resection of solitary pulmonary metastasis from colorectal cancer.  Dig Surg. 2008;  25(3) 220-225
  • 49 Shiono S, Ishii G, Nagai K et al.. Immunohistochemical prognostic factors in resected colorectal lung metastases using tissue microarray analysis.  Eur J Surg Oncol. 2006;  32(3) 308-309
  • 50 Shiono S, Ishii G, Nagai K et al.. Histopathologic prognostic factors in resected colorectal lung metastases.  Ann Thorac Surg. 2005;  79(1) 278-282 discussion 283
  • 51 Welter S, Jacobs J, Krbek T, Krebs B, Stamatis G. Long-term survival after repeated resection of pulmonary metastases from colorectal cancer.  Ann Thorac Surg. 2007;  84(1) 203-210
  • 52 Yano T, Fukuyama Y, Yokoyama H et al.. Failure in resection of multiple pulmonary metastases from colorectal cancer.  J Am Coll Surg. 1997;  185(2) 120-122
  • 53 Kim A W, Faber L P, Warren W H et al.. Repeat pulmonary resection for metachronous colorectal carcinoma is beneficial.  Surgery. 2008;  144(4) 712-717 discussion 717-718
  • 54 Pfannschmidt J, Muley T, Hoffmann H, Dienemann H. Prognostic factors and survival after complete resection of pulmonary metastases from colorectal carcinoma: experiences in 167 patients.  J Thorac Cardiovasc Surg. 2003;  126(3) 732-739

R. Sudhir SundaresanM.D. 

Ottawa Hospital–General Campus, 501 Smyth Rd.

Rm. 6361, Ottawa, Ontario, Canada K1H 8L6