Pulmonary metastasectomy for selected primary tumors: surgical approach, extent of resection and prognostic factors—a systematic review

Background Pulmonary metastasectomy is widely used in selected patients with lung metastases from extrapulmonary malignancies, although indications, optimal surgical approach, extent of resection, and role of repeated procedures remain incompletely standardized. Methods We performed a systematic review in accordance with PRISMA 2020. PubMed/MEDLINE, Embase, and the Cochrane Library were searched for full-text English-language studies published between 1 January 2000 and 24 September 2026. We included original studies reporting pulmonary metastasectomy for colorectal cancer, sarcoma, breast cancer, renal cell carcinoma, or head and neck tumors, with extractable surgical and/or oncological outcomes. Results Sixty-four studies including 9,006 patients were analyzed. Non-anatomical, parenchymal-sparing resections, such as wedge and precision resections, were the most frequently reported procedures. Open approaches remained common, especially in series in which manual lung palpation was sustained, whereas more recent studies increasingly reported minimally invasive surgery. Among all different tumor types, disease-free interval, completeness of resection, metastatic burden, nodal involvement, and primary-tumor biology were frequently described as prognostic variables, although their relative importance and cut-off values varied substantially between the analyzed histologies. Furthermore, even reported long-term survival varied widely across study groups and designs, preventing a clear estimate of the treatment effect. Conclusions The existing literature supports a histology-specific and multidisciplinary approach to pulmonary metastasectomy. Whenever complete resection is technically feasible, parenchymal-sparing surgery should be evaluated in most cases, as it might have reduced impact on lung functions, thus increasing also the possibility of future repeated resections. The current evidence, however, is predominantly retrospective and heterogeneous, and does not establish a uniform survival benefit nor a single optimal surgical approach across all primary tumors.