A perspective on lung metastasectomy: a review of a flawed concept and the failure to use available evidence resulting in an illusion of benefit

Our purpose is to provide a thought provoking challenge to this widespread clinical practice. The forms of evidence recognised as most trustworthy in health care research are randomised controlled clinical trials, meta-analysis of trials and expert analysis of big databases. These have all been used to investigate the clinical effectiveness of lung metastasectomy in its commonest application which is colorectal cancer and they provide no support for it. Little attention has been paid to this evidence, while according to the Society of Thoracic Surgeons’ consensus, there have been over a thousand uncontrolled clinical reports. They continue to appear as can be seen in this special issue. To take the long view we have examined writings in the British Medical Journal and The Lancet from 1890 to 1920 on four topics, commonplace at the time: tuberculosis, pleural effusion, rheumatic mitral stenosis and bloodletting. We have reviewed the available evidence for colorectal cancer lung metastasectomy in present times. Our four historical topics were relevant at various times to the evolving practice of surgery of the chest. In different ways and for different reasons they are no longer thoracic surgical preoccupations. The present evidence for lung metastasectomy is so weak, the magnitude of likely benefit so marginal, and the understanding and treatment of metastasis so amenable to change, that we anticipate that lung metastasectomy will also be consigned to history.