Beyond survival after pulmonary metastasectomy: functional preservation, patient-reported outcomes, and the cumulative burden of repeat resection

Pulmonary metastasectomy (PM) is used in selected patients with pulmonary metastatic disease, but survival-focused reporting incompletely describes recovery and cumulative treatment burden. Following the parenchymal-preservation and repeatability principles discussed by Scanagatta et al. in 2024, this narrative review examines pulmonary function, patient-reported outcomes, repeat resection, treatment sequencing, and retained local-treatment options. A purposive synthesis was updated with six focused PubMed searches on 8 October 2026, including recent surgical studies and function and quality-of-life evidence for non-surgical local treatments. Functional cohorts document early impairment and variable recovery after PM; pulmonary-function data after stereotactic radiotherapy also caution against assuming that avoidance of resection means avoidance of functional loss. Contemporary repeat-resection and modality-comparison studies remain predominantly retrospective and do not establish equivalent recovery or causal survival benefit. Colorectal, sarcoma, and mixed-primary evidence is interpreted separately. We propose “future local-treatment eligibility” as a modality-specific record of technical feasibility, physiological tolerability, and oncological appropriateness, accompanied by a separate assessment of informed patient preference. “Future operability” denotes the surgical component. This organizing construct is unvalidated. Treatment-related limitations must be distinguished from progression, competing illness, patient choice, and access barriers; non-receipt of treatment cannot establish loss of capacity. Candidate longitudinal outcomes and illustrative assessment windows are proposed for stakeholder consensus and feasibility testing, not as an established core outcome set. Histology-specific prospective cohorts with serial function and symptom measurements, inclusive recurrence denominators, and explicit reasons for treatment decisions are needed to evaluate what patients retain after initial and repeat PM.