Hybrid approaches to pulmonary metastasectomy: a narrative review

Background and Objective: Pulmonary metastasectomy (PM) is a common surgical resective procedure performed by thoracic surgeons to improve long-term survival in selected patients with metastatic tumors in the lung. In the past, thoracotomy was the preferred surgical approach but in recent years, treatment options have expanded to include minimally invasive approaches, thermal ablation therapy, stereotactic body radiation therapy (SBRT), and combinations of these techniques. With rapid advances in chemotherapy, immunotherapy, and molecular-targeted therapy, thoracic surgeons should review the indications and approaches to pulmonary metastases. This article aims to review the evolution of PM and the different modalities currently available to the stage IV patient. Methods: A narrative review of the literature from 1959 to 2023 was conducted using a variable combination of the following terms: “lung metastasectomy” or “pulmonary metastasectomy”, “thoracic surgery” or “lung surgery”, “radiosurgery” or “stereotactic ablative radiotherapy” or “stereotactic body radiotherapy”, “chemotherapy” and “ablation”. Hand searching and citation chaining were used to include relevant articles that were not indexed in the initial search strategy. Included articles were those of human subjects and published in English language. Key Content and Findings: A hybrid approach to PM brought about by interdisciplinary collaboration between the fields of thoracic surgery, interventional radiology, radiation oncology and medical oncology has expanded the indications for which this potentially curative procedure can be applied. Conclusions: Open and minimally-invasive surgical resection, ablation, SBRT, chemotherapy, immunotherapy and targeted therapy can be used synergistically when applied in combination to provide local and systemic control of oligometastases. A highly individualized and multidisciplinary approach has the potential to maximize survival outcomes in patients with pulmonary metastases.