Impact of COPD on Outcomes After Pulmonary Metastasectomy: A Propensity-Score Matched Analysis

Background: Pulmonary metastasectomy (PM) is an established component of multimodal oncological treatment, but its perioperative safety and long-term outcomes in patients with chronic obstructive pulmonary disease (COPD) remain insufficiently defined. We aimed to evaluate the impact of COPD on perioperative morbidity, mortality and long-term survival after PM. Methods: We retrospectively analysed 692 patients who underwent PM with curative intent. COPD severity was graded using the GOLD spirometric classification. Patients were classified according to their postbronchodilator FEV1/FVC ratio into a COPD group (<0.70) and a control group (≥0.70). Groups were compared regarding clinical and surgical characteristics, postoperative morbidity and mortality, and overall survival (Kaplan–Meier, log-rank). Independent predictors of morbidity and survival were identified via logistic and Cox regression, and a 1:1 propensity-score-matched analysis was performed to account for baseline imbalances. Results: Among 9684 patients, 692 (7.1%) patients underwent PM, of whom 171 (24.7%) had COPD. They were more frequently smokers and had a higher comorbidity burden and worse performance status and, as expected, significantly lower lung function. The main clinically relevant finding was a significantly higher rate of persistent air leak in patients with COPD (8.8% vs. 2.3%, p < 0.001). Overall morbidity and 30-day mortality, however, did not differ. With a median follow-up of 76.7 months, survival was similar between groups (3-year survival 76.5% vs. 78.4%, p = 0.495) and was unaffected by GOLD severity. Independent predictors of worse survival were preoperative systemic therapy (HR 2.18), repeat metastasectomy (HR 1.60) and increasing age (HR 1.02 per year). After propensity matching, survival remained comparable (HR 1.05, p = 0.835). Conclusions: Among carefully selected patients, COPD was not associated with increased mortality or reduced survival after PM, although persistent air leak was significantly more frequent. COPD alone should not, by itself, be considered a contraindication to curative-intent surgery in appropriately selected patients, and these findings should not be generalized to patients with severe or end-stage COPD.