Hello, I'm Philip Carrott, one of the thoracic surgeons the University of Michigan. And this lecture on thoracic oncology is metastectomy for cancer that has spread to the lung. We'll be talking about different strategies for resecting cancer and when we should consider it. Our objectives today for pulmonary metastasectomy, what patient factors are important and considering this type of resection. What cancer factors are important in considering this and what can we do about lung preservation. So our pre lecture question, which cancers are reasonable to consider resecting if there's a pulmonary metastasis? Colorectal, sarcoma, melanoma, or all of the above? In mentsectomy, I think it's important to have really, a good idea of what the oncology principles are. And Blake Katie is a surgical oncologist, from the east coast. And his principles of surgical oncology, He has this quote. Biology is King; and selection of cases is Queen, and the technical details of the surgical procedures are the princes and princesses of the realm, who frequently try to overthrow the powerful forces of the King and Queen, usually to no apparent long term avail, although with some temporary apparent victories. And this is really key to the consideration of taking on a pulmonary metastasis. Biology will dictate the survival in most cancers, and really, do you feel lucky in this patient selection. Is it a Hail Mary, or is it really just careful selection of a good candidate. So, in cancer biology, there's a number of aggressive cancers. Most of them can have some benefit although an aggressive cancer like a biliary cancer is unlikely to benefit. Sarcomas are commonly metastasized to the lung. And if it is a really all a go, very few metastasis could benefit. The same with melanoma which can metastasize anywhere, may benefit. And then some cancers, renal cell, there's a very likely benefit if there are few metastases. And colorectal cancer is very common, so we do see it frequently, but patients may in fact benefit from pulmonary metastasectomy. Other cancers that have pulmonary metastases may not be cured with metasectomy but can be treated in this strategy. Other times it's just for diagnosis. Is there in fact metastatic cancer, or is it a primary lung cancer? These are highly selected cases where there may be some benefit if it is a solitary metastasis or a very low number of metastasis. Some of these may also have some component of plural disease, which is frequently seen in breast cancer or ovarian cancer. But there could be cases that benefit from matesectomy. So how do you go about selecting these cases? It's mostly tumor biology, as we said. So the disease free interval should be long. Or it's a very solitary disease, peripheral location, but really there's no bullet proof guidelines in this case selection. Basically you're balancing morbidity of the lung wedge resection with remaining treatment options, and patient health or age. If it is really a very young patient that may have a long disease for interval. They may benefit very well. In addition, the location should be considered, the number metastases, where they are or the central peripheral on the lung as well as the tumor biology and other sites of disease. If their metastasis is in the liver, as well as the lung doesn't make sense to try to go to after all of them. This case we had recently has two metastases, the one on the right side is somewhat more subtle and smaller but is also more central. The left sided one is bigger, but it is more peripheral. So what kind of strategy can we use to preserve as much lung for this patient as possible and try to go after all the disease. This right-sided one, as we mentioned, is very close on the pulmonary artery. If we did have a wedge type resection, we need to be taking most of the right upper lobe, or at least half of it. But it may render some of the lung tissue useless in trying to take such a big wedge or section, so what are our alternatives? And really, the local therapies that can be used in this kind of disease process, mainly radiation. And then possibly radio-frequency ablation done from a CC guided approach. But both of these have been used with success in this preservation of lung tissue type of strategy. So further lung preservation may need to even perform an open thoracotomy in order to feel small metastasis and get the smallest wedge possible. Balancing wedge resection and lobectomy for central lesions or do use a SBRT type of approach. I think the main key of lung preservation is you want greater than 40% of predicted. If you do one after resection, if your taking a lobe and the wedge or have multiple sites of disease. So very good review article of metastasectomy, it comes from the Thoracic Surgery Clinics recently. And in this the authors outline as general criteria the primary disease should be controlled. The extra thoracic disease is also controlled and that the patient have adequate pulmonary reserve. In addition they talk about having really no other options. Although this could be debatable in our era of targeted therapy for different diseases. Particularly melanoma and lung cancer. So in our discussion which cancers are reasonable to consider resecting for pulmonary metastasis, is it renal, colorectal, sarcoma? I would say almost any type of cancer provided the biology is appropriate, could be considered for resection. So our take home points really at is location, location, location and biology biology, biology, in terms of consideration for resection. You should preserve as much lung as we can and each case is really different. There is no good guidelines to guide every single case. And is really worth consideration especially in long term survivors. Thank you.