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Removal or ablation of asymptomatic lung metastases should be reconsidered

BMJ 2023; 383 doi: https://doi.org/10.1136/bmj-2022-073042 (Published 09 November 2023) Cite this as: BMJ 2023;383:e073042
  1. Fergus Macbeth, oncologist1,
  2. Lesley Fallowfield, psycho-oncologist2,
  3. Elizabeth Treasure, patient3,
  4. Irfan Ahmad, radiation oncologist4,
  5. Yan Zheng, thoracic surgeon5,
  6. Tom Treasure, cardiothoracic surgeon6
  1. 1Centre for Trials Research, Cardiff University, Cardiff, UK
  2. 2Sussex Health Outcomes Research and Education in Cancer, University of Sussex, Sussex, UK
  3. 3Patient author, Oxford University Counselling Service, University of Oxford, Oxford, UK
  4. 4Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
  5. 5Department of Thoracic Surgery, Affiliated Cancer Hospital of ZhengZhou University/Henan Cancer Hospital, People’s Republic of China
  6. 6Clinical Operational Research Unit, University College London, London, UK
  1. Correspondence to: T Treasure tom.treasure{at}gmail.com

Fergus Macbeth and colleagues argue that the surgical removal or ablation of lung metastases is not supported by good evidence

The lungs are the commonest site of systemic cancer metastases. Surgical resection has been used for over 50 years,1 and since 1995, when the term oligometastases was proposed (box 1), it is increasingly justified by framing it as an “opportunity” for curative local treatment in patients with “oligometastasis.”23 Less invasive treatments—ablation by stereotactic ablative radiotherapy (SABR) or image guided thermal ablation—with the same objective are also being more widely used in Europe and North America. NHS England commissioned ablative radiotherapy for metastases in 2021,4 and in 2023 three international professional societies published clinical practice guidelines on the removal or ablation of lung metastases.56

Box 1

Oligometastases

In 1995 the concept of an intermediate oligometastatic state was proposed for patients with a “few” metastases. It was suggested that cure might be achieved by surgical removal.2 Recently techniques for ablation by radiation, heat, or freezing have been developed and become popular because they are less invasive. Concurrently, use of the term “oligometastatic disease” has increased exponentially.3 There is no agreed definition of how few metastases constitute oligometastases, but it is usually less than five. Debate continues about whether the condition has any biological foundation.3

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The evidence for patient benefit from treating lung metastases is weak. A 2020 guideline on colorectal cancer from the National Institute for Health and Care Excellence (NICE) that recommended considering “metastasectomy, ablation or stereotactic body radiation therapy for people with lung metastases that are suitable for local treatment” cited one retrospective cohort study7 rated as “very low quality” evidence, and “expert opinion” from a committee on which several members including its chair were engaged in treating metastases.8

These guidelines start …

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