Anatomical Versus Non-Anatomical Pulmonary Metastasectomy: European Multicentre Analysis

Abstract

Simple Summary Pulmonary metastasectomy is a commonly performed surgical procedure, but there is still no agreement on how much lung tissue should be removed to achieve the best outcomes. Some surgeons prefer anatomical resections, while others favour more limited, non-anatomical resections. In this international multicentre study, we compared short- and long-term outcomes of these two surgical approaches in patients undergoing surgery with curative intent for lung metastases. By analysing data from a large European cohort, we aimed to clarify whether one approach offers advantages in terms of survival, disease recurrence, and postoperative complications. Our findings show that non-anatomical resections provide survival outcomes comparable to anatomical resections, with a lower risk of postoperative complications, while anatomical resections may reduce the risk of local recurrence in selected cases. These results support a tailored surgical approach, helping surgeons balance oncological effectiveness with preservation of lung function. Objectives: Pulmonary metastasectomy is not a standardised procedure, with no consensus regarding the optimal extent of lung resection. This international multicentre study aimed at comparing short and long-term outcomes of anatomical versus non-anatomical pulmonary metastasectomy. Methods: Retrospective database including 1647 patients aged >= 18 years, who underwent curative intent pulmonary metastasectomy between January 2010 and December 2018 at 15 European centres. Patients who underwent pneumonectomy, previous metastasectomies, and/or suffered from extrapulmonary recurrence at the time of lung surgery were excluded. Primary endpoint was overall survival. Secondary endpoints were recurrence-free survival and 30-day morbidity. Differences between the two groups were analysed using 3:1 matching. Results: In the matched cohort, 324 patients underwent anatomical resection, and 830 patients underwent non-anatomical resection. Five-year overall survival was 62.0%. Averaged over the entire follow-up, there was no significant difference in overall survival between the two groups (HR = 1.122, 95% CI = 0.909-1.385, p = 0.283). In the early period following pulmonary metastasectomy, anatomical resections were associated with worse overall survival (HR = 1.549, 95% CI = 1.135-2.114, p = 0.006). The difference in any-site recurrence-free survival between the two groups was not significant (HR = 0.832, 95% CI = 0.690-1.002, p = 0.053). Locoregional recurrence-free survival was significantly longer after anatomical resection (HR = 0.651, 95% CI = 0.520-0.817, p < 0.001). Thirty-day morbidity was significantly higher after anatomical resection (22.2% versus 13.7% for non-anatomical resections, p = 0.001). Conclusions: In a highly selected cohort, non-anatomical resection showed comparable survival and lower morbidity compared to anatomical resections, supporting the surgical strategy of favouring limited resections whenever technically and oncologically feasible. Anatomical resections remain a valid option in selected cases with acceptable outcomes.