What Are the Considerations in the Surgical Approach in Pulmonary Metastasectomy?

There are four matters of uncertainty considered in this working group report, which are distilled into four clinical questions: (1) What is the evidence for the need for palpation of the lung in modern era of imaging? (2) Is there evidence of a difference in outcome for an open versus a closed approach? (3) Is there evidence of a difference in outcome for an initial policy of bilateral versus unilateral exploration? (4) In patients with known bilateral disease, is there a difference in outcome with a simultaneous versus a staged approach? We searched the literature formally and supplemented this with knowledge from all other sources. We provide evidence tables on the first two questions by relying on a group consensus and frame recommendations for the other two. There are no randomized trials to guide us but there are comparative studies addressing the need for palpation and the need to and open operation in all cases. The evidence is equivocal, and opinions are divided in the literature. Palpation of the lung is still seen as necessary in a therapeutic metastasectomy as opposed to a diagnostic procedure when videothoracoscopy is adequate. However, the importance of palpation becomes less clear with advances in imaging. Routine bilateral exploration for unilateral disease was not favored. For bilateral disease, an initial median sternotomy has a place for some cases but sequenced thoracotomy was preferred.