Keywords
metastases/metastasectomy - thoracoscopy/VATS - surgery/incisions
Introduction
Pulmonary metastasectomy is safe and has curative potential for properly selected
patients with lung metastases.[1]
[2] However, there is controversy with regard to whether open surgery or video-assisted
thoracoscopic surgery (VATS) is a better approach in terms of metastatic foci harvested,
complications, recovery, recurrence, and survival.[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
Recently, VATS has been more widely utilized due to its numerous benefits. Studies
have shown VATS to be associated with less postoperative pain, fewer postoperative
complications, faster recovery, and better quality of life compared with open thoracotomy,
as reported in both nonrandomized and randomized studies for primary lung cancer.[15]
[16]
[17]
Few studies thus far on one-stage bilateral pulmonary metastasectomy have reported
the feasibility, safety, and additional financial benefits compared with staged operations
in the relevant cohorts.[18]
[19]
[20]
[21] Furthermore, none of these studies described the differences in outcome between
open surgery and VATS. It is unknown whether these two surgical approaches employed
in patients with bilateral pulmonary metastases would produce similar efficacy.
Therefore, we performed a retrospective cohort study to explore patients undergoing
simultaneous bilateral pulmonary metastasectomy by comparing open surgery against
VATS. Similar articles were not found in the literature. The primary objective was
to investigate the perioperative safety and morbidity, while the secondary aim was
to analyze the oncological results including recurrence-free survival (RFS) and overall
survival (OS).
Materials and Methods
Study Design
This retrospective cohort study was conducted from January 2011 to April 2020 at a
single medical center. The Institutional Review Board of Kaohsiung Medical University
Hospital approved this study and the requirement for written informed consent was
waived (KMUHIRB-E(I)-20200228). Fifty patients were consecutively enrolled receiving
simultaneous bilateral surgery for pulmonary metastases. Seven patients were excluded,
four with surgical approaches combined sternotomy or ipsilateral thoracotomy and contralateral
VATS, and three with diagnostic purposes of suspected metastatic lesions. After exclusion,
43 patients surgically treated with therapeutic intent were divided into two groups,
(1) sixteen patients receiving simultaneous bilateral open thoracotomy (open group)
and (2) twenty-seven patients receiving simultaneous bilateral VATS (VATS group) ([Fig. 1]). Patients' data including demographic characteristics, perioperative data, and
postoperative oncological outcomes from electronic medical records were collected.
High-resolution computed tomography (HRCT) scan examinations were performed using
the Optima CT660 system (GE, Tokyo, Japan) throughout the study period. Although the
reconstruction thickness had been 5 mm in axial sections before 2016, it had been
adjusted to thinner 1 to 2 mm slices in the past 5 years (2016–2020). The positron
emission tomography and computed tomography(CT) scan was performed when needed. All
patients were evaluated preoperatively in an interdisciplinary tumor board setting
to reach a consensus on surgical treatment. In addition, indications for metastasectomy
were evaluated with Rusch's criteria[22]: (1) the primary tumor is controllable, or it can be resected totally at the time
of resecting the metastases; (2) metastatic disease can be resected completely; (3)
the patient can tolerate the extent of pulmonary resection required to remove all
lesions; (4) no extrathoracic metastases are present.
Fig. 1 Flow diagram of patient recruitment. VATS, video-assisted thoracic surgery.
Operative Procedure
Open thoracotomy with ∼12 cm incisions via posterolateral approach and thoracoscopic
assistance had been the standard surgical approach for pulmonary metastasectomy, which
allowed for the complete inspection and palpation of the whole lung. Since 2013, two-port
VATS (no rib spreading) has been implemented in our center for pulmonary metastasectomy
in selected patients. One lung anesthesia via a double-lumen endotracheal tube has
also been routinely performed. The bilateral operations were all performed in the
lateral decubitus position and sequentially repositioned either in the open group
or in the VATS group. The plan was to prioritize the side requiring lesser lung parenchyma
sacrifice, permitting a safe resection of the contralateral side afterwards. Wedge
resections via stapler devices were performed mostly in both surgical approaches,
unless the lesions were centrally located and adequate margin cannot be ensured. Additionally,
in a handful of patients from the open group with tiny metastatic foci identified
with finger palpation, pneumotomy was performed using electrocautery followed by direct
suture. However, mediastinal lymph node dissection or sampling was not routinely performed.
For the most part, case selection for open surgery or VATS was down to the following
factors; the surgeon's preference, technical considerations, and the aim of preserving
as much lung parenchyma as possible, in which preoperative radiological imaging was
utilized.
Perioperative Management
In 2012, we implemented the enhanced recovery after surgery (ERAS) protocol for the
improvement of postoperative recovery of patients who received major thoracic operations
as previously reported for esophagectomy and reconstruction.[23] Therefore, patients with planned one-stage bilateral pulmonary metastasectomy were
advised to receive thoracic epidural analgesia (TEA), and respiratory rehabilitation
program was routinely performed. For patients without TEA, intravenous patient-controlled
anesthesia was administered. It should be noted that although available on request,
both analgesic options were paid out of pocket by the patients themselves. Additional
doses of intravenous Parecoxib were used for intolerable pain during postoperative
hospital stay. Pain scores were assessed using a numerical rating scale (NRS), 0 (no
pain) to 10 (excruciating pain), every 8 hours with the patient at rest on postoperative
day 1 (POD1) and then on each day until discharge. Chest drains were removed in both
groups if there were no air leaks and if the drainage was <200 mL within 24 hours.
Postoperative Follow-Up
All patients were advised to receive outpatient clinic follow-up. For each patient,
a base-line HRCT scan was conducted after metastasectomy at 3 months postoperatively
and every 3 months for 2 years, then every 6 months for each subsequent year. RFS
and OS after metastasectomy were assessed as well as the site of first recurrence.
In June 2021, an investigation was performed regarding either death or date of last
follow-up for living patients.
Statistical Analysis
Categorical variables were expressed as numbers with percentages and compared by the
chi-squared test. Non-normally distributed data were described by medians with interquartile
range (IQR) and were analyzed using Mann–Whitney U test. Survival was estimated by
the Kaplan–Meier method. Log-rank test was used to examine the differences between
treatment groups. All statistical operations were performed using MedCalc Statistical
Software version 19.2.6 (MedCalc Software bv, Ostend, Belgium; https://www.medcalc.org; 2020). A p-value from two-tailed test and less than 0.05 was considered significant.
Results
As shown in [Table 1], patient characteristics in the two groups with regard to age, body mass index,
sex, smoking, or preoperative pulmonary function test were found to be similar. Among
patients in both groups, regarding the American Society of Anesthesiologists (ASA)
physical status and primary tumor histology, a slight majority were ASA grade III
(75 vs. 63%, open vs. VATS, p = 0.51) and colorectal cancer (38 vs. 38%, open vs. VATS, p = 0.44). The time period of surgery regarding operated cases throughout the study
cohort (early vs. late) was analyzed ([Fig. 2]). Although no significant differences were identified, it appeared that more cases
tend to be operated on in VATS group (14/27, 52%) than that of open group (6/16, 37%)
over the recent years. This finding may demonstrate the change of our surgical policy
due to advancements in VATS technique and CT imaging within this time period. In terms
of perioperative variables ([Table 2]
), all patients in open group underwent wedge resections, while most patients in VATS
group underwent wedge resections except for 4 patients who received a greater extent
of ipsilateral resections (2 lobectomies and 2 segmentectomies, respectively). The
operative time and estimated blood loss were greater in the open group than those
in the VATS group (median 280 vs. 180 minutes, p < 0.001 and 30 vs. 20 mL, p = 0.009). When the percentage of TEA usage in the open group was compared with the
VATS group, the difference was significant (88 vs. 30%, p < 0.001). However, the early postoperative NRS pain score was higher in the open
group than in the VATS group on POD1 (median 6 vs. 5, p = 0.03), but insignificant on POD2 and POD3.
Fig. 2 Patients of bilateral one-stage metastasectomy per year. VATS, video-assisted thoracic
surgery.
Table 1
Demographic data
|
Variables
|
Open
(n = 16)
|
VATS
(n = 27)
|
p-Value
|
|
Age, y
|
59 (36–65)
|
58 (49–66)
|
0.37
|
|
BMI, kg/m2
|
23 (21.3–28)
|
25 (23–26.8)
|
0.48
|
|
Sex
|
|
|
0.22
|
|
Male
|
11 (69)
|
13 (48)
|
|
|
Female
|
5 (31)
|
14 (52)
|
|
|
Ever smoker
|
2 (13)
|
6 (22)
|
0.43
|
|
FEV1, L
|
2.6 (2–2.9)
|
2.4 (1.8–2.8)
|
0.37
|
|
FEV1 (% predicted)
|
86 (83.5–93.2)
|
85 (79–99.5)
|
0.93
|
|
ASA physical status
|
|
|
0.51
|
|
Grade II
|
4 (25)
|
10 (37)
|
|
|
Grade III
|
12 (75)
|
17 (63)
|
|
|
Time period of surgery
|
|
|
0.37
|
|
2011–2015
|
10
|
13
|
|
|
2016–2020
|
6
|
14
|
|
|
Primary tumor histology
|
|
|
0.44
|
|
Colorectal cancer
|
6 (38)
|
10 (38)
|
|
|
Sarcoma
|
4 (25)
|
3 (11)
|
|
|
Renal cell cancer
|
1 (6)
|
5 (18)
|
|
|
Liver cancer
|
3 (19)
|
2 (7)
|
|
|
Breast cancer
|
1 (6)
|
3 (11)
|
|
|
Head and neck cancer
|
0
|
2 (7)
|
|
|
Testicular cancer
|
1 (6)
|
0
|
|
|
Ovarian cancer
|
0
|
1 (4)
|
|
|
Thymic cancer
|
0
|
1 (4)
|
|
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; FEV1, forced expiratory volume in the first second of expiration; VATS, video-assisted
thoracic surgery.
Data are expressed as median (interquartile range, IQR) for continuous variables and
number (%) for categorical variables, unless specified otherwise.
Table 2
Perioperative outcome
|
Variables
|
Open
(n = 16)
|
VATS
(n = 27)
|
p-Value
|
|
Extent of resection
|
|
|
0.28
|
|
W/W
|
16 (100)
|
23 (86)
|
|
|
W/S + W
|
0
|
2 (7)
|
|
|
W/L + W
|
0
|
2 (7)
|
|
|
Operation time (min)
|
280 (240–310)
|
180 (145–248)
|
<0.001
|
|
Estimated blood loss (ml)
|
30 (27.5–50)
|
20 (20–30)
|
0.009
|
|
NRS pain score on POD1
|
6 (5–6.5)
|
5 (4–6)
|
0.03
|
|
NRS pain score on POD2
|
4 (4–5)
|
4 (3–4.75)
|
0.45
|
|
NRS pain score on POD3
|
3 (2.5–4)
|
3 (3–4)
|
0.06
|
|
Thoracic epidural analgesia
|
14 (88)
|
8 (30)
|
<0.001
|
|
Mean ICU stay (day) (range)
|
0.3 (0–4)
|
0.3 (0–3)
|
0.87
|
|
Postoperative length of stay (day)
|
6 (6–8)
|
5 (4–7)
|
0.05
|
|
Previous lung resection
|
5 (31)
|
3 (11)
|
0.13
|
|
Unilateral
|
1
|
3
|
|
|
Bilateral
|
4
|
0
|
|
|
In-hospital mortality
|
0
|
0
|
1.0
|
|
Complication (Clavien–Dindo classification)
|
2 (12)
|
3 (11)
|
1.0
|
|
Grade I and II
|
2
|
3
|
|
|
Prolonged air leak (> 5 days)
|
0
|
2
|
|
|
Atrial fibrillation
|
0
|
1
|
|
|
Poor wound healing
|
1
|
0
|
|
|
Urinary tract infection
|
1
|
0
|
|
|
Grade III and IV
|
0
|
0
|
|
|
Surgical margin status
|
|
|
0.37
|
|
R0 resection
|
15 (94)
|
27 (100)
|
|
|
R1 resection
|
1 (6)
|
0
|
|
|
Hospital charges (USD)
|
10,713 (9928–13,214)
|
10,107 (9611–11,553)
|
0.52
|
Abbreviations: ICU, intensive care unit; L, lobectomy; NRS, numerical rating scale;
POD, postoperative day; S, segmentectomy; VATS, video-assisted thoracic surgery; W,
wedge resection.
Data are expressed as median (interquartile range, IQR) for continuous variables and
number (%) for categorical variables, unless specified otherwise.
Prior pulmonary resection was not an absolute contraindication for performing bilateral
simultaneous metastasectomy, although not statistically different, the open group
entailed a higher number of previous lung resections than those in the VATS group
(31 vs. 11%, p = 0.13), and delineated the concern of open surgery due to the probable intrapleural
adhesions. There were no significant differences in length of hospital stay, intensive
care unit stay, and complications between the groups. Furthermore, the most frequent
Clavien-Dindo grade I-II complication was persistent air leakage (persisting for >5
days postoperatively), followed by arrhythmia, poor wound healing, and urinary tract
infection. However, there was no need to reoperate for any of these complications.
Comparing medical expenditures, hospital charges were similar between the two groups
(open: 10,713 USD and VATS: 10,107 USD). While another 36 patients who underwent two-stage
bilateral metastasectomy via VATS were added to the study for further analysis, the
median hospital charges for the group of two-stage VATS were 16,464 USD. Interestingly,
this group was significantly costlier than the other one-stage groups (p = 0.006) ([Fig. 3]). As described in [Table 3], the median number of the preoperatively image-detected, intraoperatively resected,
and pathologically confirmed metastatic lung nodules were significantly greater in
the open group than those in the VATS group (9.5 vs. 3, 12.5 vs. 3, 9.5 vs. 3, respectively,
all p < 0.001). However, the maximum diameter of the metastatic lesions did not substantially
differ between the two groups. [Fig. 4] demonstrated the representative cases receiving simultaneous bilateral metastasectomy
either in open surgery or VATS. It is worth mentioning that the highest number of
resected metastatic nodules in our series was 42 and the patient is still disease
free after 114 months. Moreover, Kaplan–Meier analysis in [Fig. 5] showed that RFS and OS were comparable between open and VATS groups (Log-rank test,
p = 0.52 and p = 0.73, respectively). Median RFS was 15 months (IQR: 6–21.6) vs. 18 months (IQR,
7.5–47.4) and median OS was 27.6 months (IQR, 13.8–43.8) vs. 28.8 months (IQR, 14.7–54.3)
during the similar follow-up periods (28 vs. 29 months, p = 0.73). Comparing recurrence patterns, no difference was found regarding the pulmonary
recurrence (44 vs. 29%, p = 0.42) and the reoperated pulmonary metastasectomies (25 vs. 19%, p = 0.71).
Fig. 3 Box plot of hospital charges per treatment groups. VATS, video-assisted thoracic
surgery.
Fig. 4 The representative cases receiving simultaneous bilateral metastasectomy in either
open surgery or VATS. (A) One patient received bilateral open thoracotomy for pulmonary metastases from sarcoma
with 25 resected nodules and overall survival of 12.2 months. (B) One patient received bilateral open thoracotomy for pulmonary metastases from sarcoma
with 21 resected nodules and overall survival of 66.8 months. (C) One patient received bilateral open thoracotomy for pulmonary metastases from testicular
cancer with 42 resected nodules, overall survival of 114 months, and he is still living
well at the time of paper submission. (D) One patient received bilateral VATS for pulmonary metastases from breast cancer
with six resected nodules and overall survival of 15.4 months. The largest lesion
was 4.5 cm. VATS, video-assisted thoracic surgery; RUL, right upper lobe; RML, right
middle lobe; RLL, right lower lobe; LUL, left upper lobe; LLL, left lower lobe.
Fig. 5 Kaplan–Meier analysis showing recurrence-free and overall survival of patients receiving
bilateral pulmonary metastasectomy in open and VATS group. VATS, video-assisted thoracic
surgery
Table 3
Oncological outcome between the two surgical approaches
|
Variables
|
Open
(n = 16)
|
VATS
(n = 27)
|
p-Value
|
|
Preoperatively image-detected nodules on HRCT
|
|
|
<0.001
|
|
Bilateral single lesions (n = 2)
|
0
|
7 (26)
|
|
|
Number of lesions (3–5)
|
3 (19)
|
14 (52)
|
|
|
Number of lesions (6–10)
|
5 (31)
|
4 (15)
|
|
|
Number of lesions (11–20)
|
7 (44)
|
2 (7)
|
|
|
Number of lesions (>20)
|
1 (6)
|
0
|
|
|
Intraoperatively resected nodules
|
|
|
0.004
|
|
Bilateral single lesions (n = 2)
|
0
|
5 (18)
|
|
|
Number of lesions (3–5)
|
4 (25)
|
15 (56)
|
|
|
Number of lesions (6–10)
|
4 (25)
|
6 (22)
|
|
|
Number of lesions (11–20)
|
4 (25)
|
1 (4)
|
|
|
Number of lesions (>20)
|
4 (25)
|
0
|
|
|
Pathologically confirmed metastatic nodules
|
|
|
<0.001
|
|
Bilateral single lesions (n = 2)
|
0
|
11 (41)
|
|
|
Number of lesions (3–5)
|
4 (25)
|
13 (48)
|
|
|
Number of lesions (6–10)
|
4 (25)
|
2 (7)
|
|
|
Number of lesions (11–20)
|
5 (31)
|
1 (4)
|
|
|
Number of lesions (>20)
|
3 (19)
|
0
|
|
|
Number of image-detected nodules, (range)
|
9.5 (3–28)
|
3 (2–16)
|
<0.001
|
|
Number of resected nodules, (range)
|
12.5 (3–42)
|
3 (2–12)
|
<0.001
|
|
Number of confirmed metastatic nodules, (range)
|
9.5 (3–39)
|
3 (2–12)
|
<0.001
|
|
Diameter of largest lesion
|
|
|
0.75
|
|
< 10 mm
|
3 (19)
|
4 (15)
|
|
|
10–19 mm
|
8 (50)
|
13 (48)
|
|
|
20–29 mm
|
5 (31)
|
6 (22)
|
|
|
≧30 mm
|
0
|
4 (15)
|
|
|
Pattern of first recurrence after surgery
|
|
|
0.42
|
|
Lung only
|
7 (44)
|
8 (29)
|
|
|
Lung and other sites
|
7 (44)
|
14 (52)
|
|
|
Free from recurrence
|
2 (12)
|
5 (19)
|
|
|
Reoperated metastasectomy
|
4 (25)
|
5 (19)
|
0.71
|
|
Follow-up (month)
|
28 (14–44)
|
29 (15–54)
|
0.73
|
Abbreviations: HRCT, high-resolution computed tomography; VATS, video-assisted thoracic
surgery.
Data are expressed as median (interquartile range, IQR) for continuous variables and
number (%) for categorical variables, unless specified otherwise.
Discussion
In recent years, simultaneous bilateral surgery has gained popularity and proven to
be efficacious for thoracic diseases including the treatment of primary spontaneous
pneumothorax (PSP) with contralateral blebectomy and resecting bilateral multifocal
ground-glass nodules suggestive of early primary lung cancer.[24]
[25]
[26] The literature suggested that not only was the psychological burden circumvented,
but reductions were observed in contralateral occurrence in PSP, progression of the
contralateral tumor as well as medical expenditures.
In patients with bilateral disease, the original indications for pulmonary metastasectomy
have been broadened. Although the prognosis deteriorates as the number of pulmonary
metastases increases, if all lesions are potentially resectable, surgical treatment
should be considered.[2]
[27] Consequently, several studies have suggested that one-stage surgery in managing
bilateral pulmonary metastases is as safe as unilateral-side surgery.[18]
[19]
[20]
[21] Despite this, an increased operative time was observed in the bilateral groups compared
with the unilateral groups, while the length of postoperative hospital stays and complications
were comparable between groups. Furthermore, in properly-matched comparisons, one-stage
surgery may confer benefits to the reduced hospitalization costs and also to the medical
resources restrained by the coronavirus disease 2019 pandemic.[18]
[19]
To the best of our knowledge, our study was the first to compare the outcomes between
open surgery and VATS in simultaneous bilateral pulmonary metastasectomy. Traditionally,
one-stage bilateral thoracotomy is not preferred because of the potential for increased
postoperative morbidity. Conversely, VATS enables minimally invasive resection of
lung metastases and is associated with less patient discomfort with smaller incisions,
absent rib spreading, and shorter hospitalization. In particular, we ensured all the
surgical candidates had good pulmonary function reserves and were of appropriate physical
fitness for either approach. Regarding the extent of resection, only four patients
in the VATS group (4/27) had pulmonary segmentectomy or lobectomy, all others in both
groups received a smaller extent of resection (wedge resection or pneumotomy in some
of the open group). Hence, there was no respiratory insufficiency or pneumonia in
complications with the aforementioned measures in place.
From our perspective, pain control plays a vital role in postoperative care. Based
on our ERAS protocol implemented for major thoracic operations, more patients in the
open group received TEA than in the VATS group, which could explain the subtle differences
in the early postoperative pain scores, whereby only greater pain on POD1 in the open
group was present but insignificant on POD2 and POD3. Bayman et al[28] reported no differences between the average NRS pain score for the 3 days after
surgery in thoracotomy patients compared with patients undergoing VATS. Likewise,
Feldman et al[18] demonstrated that pain was not significantly different in the cohort undergoing
simultaneous resection when compared with pain experienced by individuals undergoing
staged procedures. With this in mind, it is feasible to attain an equivalent outcome
on postoperative wound pain following aggressive pain control even for patients receiving
simultaneous bilateral open metastasectomy. Nonetheless, conditions such as borderline
cardiopulmonary reserve, poor performance status, or patient's requests should be
taken into consideration as indicators of lacking suitability for one-stage bilateral
surgery. Due to the rigorous selection of surgical candidates and ERAS implementation
in our patient cohort, findings were comparable between the open and VATS group in
terms of postoperative recovery, complications, postoperative length of stay, and
even the hospital charges.
Interestingly, there were significantly more resected metastatic nodules in the open
group than those in VATS group in our study (median: 9.5 vs. 3, p < 0.001). Essentially, this finding may be associated with the effectively decreased
tumor burden and disease severity. However, our OS in both groups was comparable ([Fig. 5]) and not inferior to survival results of studies entailing patients with four or
more metastases (27–33.7% at 5 years).[2]
[27] From our perspective, the comparable oncological findings reflect a stronger inclination
toward metastasectomy, regardless of the greater number of image-detected nodules
in the open group. Moreover, there is consensus among thoracic surgeons that a high
number of metastases should not preclude patients from surgery if they are otherwise
good candidates for pulmonary resection. As demonstrated in [Fig. 6], up to 27% of thoracic surgeons from the European Society of Thoracic Surgeons perform
one-stage surgery either by open thoracotomy or VATS for bilateral metastases.[29]
Fig. 6 Result of ESTS survey regarding preferred approach for bilateral pulmonary metastasectomy.
ESTS, European Society of Thoracic Surgeons; VATS, video-assisted thoracic surgery.
Recently, the number of lesions found in HRCT scans was almost the same as those found
during the open surgery. The reason may be due to the better resolution of newer CT
imaging technologies or setting adjustments to thinner slice thicknesses. On a practical
note, we were able to resect more undetected nodules (from imaging) in the open group.
This result is consistent with findings in the literature favoring open thoracotomy
over VATS, because a substantial number of image-undetected metastatic nodules were
found during thoracotomy despite advancements in VATS and CT imaging.[7]
[8]
[9] The aforementioned prospective trials have also demonstrated the merits of manual
palpation in open surgery and indicated the limitations of VATS. However, there are
still difficulties in determining whether aggressive resection of small image-undetected
nodules could improve survival outcomes,[10]
[11]
[12]
[13]
[14] not to mention the more complex condition of bilateral metastases.
The main limitation of this study is its retrospective design without randomization
of subjects. Therefore, some selection bias does invariably exist, including the variation
of HRCT slice thickness, interpretation for occult metastatic foci, operation method
(open thoracotomy vs. VATS), and patients' or surgeons' sentiments toward one-stage
bilateral surgery. Additionally, we did not analyze the subgroup risk factors associated
with different tumor histologies due to the small sample size.
In conclusion, one-stage surgery for managing a wide array of thoracic diseases has
proven its safety and efficacy,[18]
[19]
[20]
[21]
[24]
[25]
[26]
[30] with the advantages of circumventing the risk of progression of contralateral tumor,
comparable wound pain to the unilateral-side surgery, decreased medical expenditures,
and lessened psychologic burden. Despite receiving simultaneous bilateral metastasectomy
in the open group, patients seemed to harbor greater tumor burden than those in the
VATS group. The RFS and OS outcomes did not differ according to Kaplan–Meier survival
analyses between the two groups. Our findings suggest that one-stage bilateral pulmonary
metastasectomy from either open or VATS to be a viable option for selected patients
with noncompromised perioperative safety and reduced medical expenditures.
