Pulmonary Metastasectomy Results in Improved Survival: An Analysis of 1,720 Pulmonary Metastatic Melanoma Patients
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Background: The prognosis of patients with metastatic melanoma is poor. While prognostic models have been developed to predict the occurrence of pulmonary metastasis from cutaneous melanoma, little data exist to define the outcomes of these patients once the metastases are detected. The objective of this study was to identify predictors of survival in patients with pulmonary metastatic melanoma.
Methods: We identified 1,720 patients with pulmonary metastases from a prospective comprehensive cancer center database of 14,057 consecutive melanoma patients (1/1/1970 to 6/1/2004). Demographic, histo-pathologic, time and location of recurrences, number of pulmonary nodules, and subsequent therapy (chemotherapy, node dissection, and surgical resection) data were collected. Complete follow-up was available on all patients. Univariate and multivariate Cox proportional hazards models were used to identify predictors of survival in patients with pulmonary metastatic melanoma.
Results: The median interval was 2.4 years between control of the primary lesion and development of pulmonary metastasis (0.1 to 20 years). The median survival was 7.3 months after development of pulmonary metastasis. Significant predictors of survival from the multivariate model included nodular histology, time interval from control of the primary lesion to pulmonary metastasis, number of pulmonary and other distant non-pulmonary metastases, and performance of pulmonary metastasectomy (Table). Interactions were identified between pulmonary metastasectomy and presence of other distant metastases and time interval from initial diagnosis to pulmonary metastasis. In patients without other distant metastases, pulmonary metastasectomy was associated with a survival advantage of 10 months (18 vs. 8 months, p<0.01). In patients who developed pulmonary metastasis beyond 5 years, surgery was associated with a survival advantage of 12 months (19 vs. 7 months, p<0.01).
Conclusions: When all other identified risk factors are controlled for mathematically, metastasectomy maintains a significant survival advantage in patients with pulmonary metastatic melanoma. The greatest benefit from metastasectomy was realized in patients with no evidence of other distant metastases and those patients who developed pulmonary metastasis after 5 years of their initial diagnosis. These data support the role of surgical resection in a select subset of patients with pulmonary metastases.
Multivariate Predictors of Survival in Pulmonary Metastatic Melanoma| Predictor (N) % | Hazard Ratio (95%CI) | p-value |
Histology: Nodular
(N=364) 25% | 1.14 (1.01, 1.3) | 0.033 |
Interval to pulmonary metastasis:
<1 year (N=395) 23%
1-5 years (N=911) 53% | 1.5 (1.3, 1.7)
1.3 (1.1, 1.4) | <0.001
<0.001 |
Number of pulmonary metastases:
>2 (N=1,256) 73% | 1.2 (1.04, 1.35) | 0.012 |
Other distant non-pulmonary metastases:
>1 (N=655) 38% | 1.6 (1.4, 1.7) | <0.001 |
Pulmonary metastasectomy
(N=318) 18% | 0.5 (0.4, 0.6) | <0.001 |
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