Pulmonary Metastasectomy for Melanoma: Beyond the Standard of Care

In recent years, the controversial role of pulmonary metastasectomy for melanoma has been re-addressed by several authors with the intent to show that surgical resection of these lesions is associated with better survival when compared with medical therapy. In addition, prognostic factors have been put forth to show that surgery is associated with better results in carefully selected patients with resectable pulmonary metastases. Although at best these data represent years of prospectively gathered information from respected institutions, validation of results from large randomized trials will never be achieved due to poor accrual. In ‘‘Stage IV Melanoma and Pulmonary Metastases: Factors Predictive of Survival’’, Neuman and colleagues present results collected prospectively at Memorial Sloan Kettering Cancer Center since 1995 from a series of 122 patients. This is a rather contemporary and ‘‘pure’’ cohort, consisting of patients they have followed since the initial diagnosis of melanoma with subsequent development of pulmonary metastasis, or of those who already had stage-IV disease with the lungs representing the only site of distant metastasis at the time of referral (M1b). As one can surmise, these are rather special and infrequent circumstances, with their study population representing less than 2% of the 7500+ melanoma cases in their databank, and only 0.5% getting resection for pulmonary metastases. Another unique characteristic of this study was the absence of thoracic surgery collaboration and possible additional study patients. Presumably, this was done, in part, to exclude referral bias at a tertiary center, where patients may have been referred directly to the thoracic surgery service that was better equipped for pulmonary resection and/or wanted a more aggressive and ‘‘non-traditional’’ approach to their metastasis. However, it cannot be overlooked that patients with less than ideal performance status (as a result of other therapies) and who have failed other treatments are also referred for pulmonary metastasectomy. Although Neuman et al. do not present novel data or selection criteria for pulmonary metastasectomy, they do present the longest median survival (40 months) and one of the higher 5-year survival rates (29%) published to date. Interestingly, nearly 80% of their cohort did not undergo metastasectomy; although some generalization was made (such as the presence of extrathoracic disease), it was not totally apparent why those patients with even solitary pulmonary nodules were not offered surgery. The authors are to be commended for their unique objectives of presenting this ‘‘pure’’ population, extensive work, and reporting unbiased pulmonary surgical data from their viewpoint as opposed to that traditionally published by thoracic surgeons. The post-resectional data represents only 26 patients and, thus, undergoes the scrutiny of a comparatively small study with respect to other published reports in the last 10 years. One of the landmark articles regarding pulmonary metastases came in 1997 from Pastorino and the International Registry of Pulmonary Metastases (IRPM). This database of 5208 Received May 28, 2007; accepted May 29, 2007; published online: August 3, 2007. Address correspondence and reprint requests to: Stephen C. Yang, MD; E-mail: syang@jhmi.edu