for many years , the diagnosis of lung metastasis was considered the end stage of the 
 disease course in patients with malignant neoplasms .
initially , the treatment 
 proposed consisted of chemotherapy and hormone therapy , and unsatisfactory responses 
 were seen in more than 70% of cases in 1882 , weinlechner incidentally performed the 
 first lung metastasis resection during the resection of a primary tumor , a procedure 
 in which the metastasis was removed en bloc with the surgical 
 specimen .
( ) since then , 
 various other cases of metastasectomy have been reported , many with positive 
 results . in 1951 , ehrenhaft started selecting candidates for lung metastasis resection , ( ) and , subsequently , it was 
 possible to establish well - defined criteria .
surgical treatment evolved over the 20th century because of greater knowledge about 
 tumors that gave rise to lung metastases only .
surgical treatment of lung metastases 
 has been given a boost in the last 15 years , as has been shown in the literature , 
 and some of the major prognostic factors for this condition , such as disease - free 
 interval and type of resection performed , have been identified , .
( , ) however , in comparison with major centers worldwide , 
 there have been few studies of brazilian patients and this treatment modality in 
 brazil .
therefore , the objective of the present study was to evaluate the results of surgical 
 treatment of lung metastases at a university hospital in the city of campinas , 
 brazil .
this was a retrospective study using surgical records of the department of thoracic 
 surgery of the state university at campinas hospital de clnicas , 
 located in the city of campinas , brazil .
we reviewed all records of resection of 
 lung lesions performed in patients with a previous diagnosis of primary cancer in 
 other organs , as well as all records of complete resection of all lesions and 
 pathological confirmation of metastatic disease , between january 1 , 1997 and 
 december 31 , 2011 .
we included all patients with lung lesions who were selected for surgery on the basis 
 of the thomford et .
al . criteria for surgical treatment of metastatic lung 
 lesions , ( ) namely : a ) 
 complete resection of all metastatic disease should be possible ; b ) the patient 
 should have sufficient pulmonary function to withstand the risk of surgery and 
 survive the postoperative period ; c ) the primary tumor should be ( or can be ) 
 controlled ; d ) there should be no evidence of extrapulmonary metastases , except for 
 colon tumors ; and e ) there should be no effective treatment other than surgery .
pulmonary function was assessed on the basis of arterial blood gas analysis results 
 and pulmonary function test results .
if the pulmonary function test was not 
 technically possible , the six - minute walk test , which has been proven to be well 
 tolerated and safe in the assessment of patient functional capacity , was used .
( ) in addition , the records were reviewed for the postoperative presence of systemic 
 inflammatory response syndrome ( sirs ) , which was defined by the presence of at least 
 two of the following parameters , on the same day , within three days after surgery : 
 an axillary temperature above 38c ; an rr > 24 breaths / min ; an hr > 90 
 bpm ; and a leukocyte count greater than 10,000 cells / mm or less than 
 5,000 cells / mm .
overall survival was defined as the date of first surgery to the last follow - up visit 
 or to death ( from any cause ) . to determine disease - free intervals
, we used the dates 
 of primary cancer treatment and the date of referral for thoracic surgery for 
 treatment of lung metastasis .
we designed a data collection form that was used by two trained physicians to obtain 
 the patient medical record information needed to meet the objectives of the present 
 study .
this form contained the following fields : patient initials ; medical record 
 number ; gender ; race ; date of birth ; date of surgery of the primary tumor ; date of 
 referral for thoracic surgery ; symptoms at diagnosis of metastasis ( dyspnea , cough , 
 hemoptysis , and chest pain ) ; smoking ; anatomical site of the primary tumor ( breast , 
 head , neck , colorectum , kidney , musculoskeletal system , gonads , etc . ) ; presence and 
 type of comorbidity ; history of resection for liver metastasis ; neoadjuvant or 
 adjuvant therapy to treatment of lung metastasis ; number of lung resections ; number 
 and location of nodules found intraoperatively ; date of resection of the metastasis ; 
 type of resection performed ( segmentectomy , wedge resection , nodule resection , 
 lobectomy , bilobectomy , and pneumonectomy ) ; use of a stapler ; extubation in the 
 operating room ; number of chest tubes and side of placement ; unilateral or bilateral 
 approach ; surgical access ( thoracotomy , bilateral sequential thoracotomy , 
 sternotomy , and video - assisted surgery ) ; need for blood transfusion ; postoperative 
 recovery in the icu ; development of sirs ; length of hospital stay ; presence and type 
 of complication within 30 days after surgery ; postoperative day of onset of the 
 complication ; current status of the patient ( alive / dead ) ; date of the last follow - up 
 visit to our facility ; and whether follow - up was conducted at another facility .
data on postoperative complications , defined as any type of event experienced by 
 patients within 30 days after surgery , were extracted from patient medical records . 

these data were grouped by major system or pathology involved , listed by frequency , 
 and stratified as a variable in the overall survival curve .
the present study was approved by the research ethics committee of the state 
 university at campinas school of medical sciences ( protocol no .
for categorical variables , we conducted an exploratory descriptive analysis and , 
 subsequently , we used pearson 's , spearman 's , and fisher 's tests , whereas , for 
 continuous variables , we used the t - test ( two groups ) or the kruskal - wallis test 
 ( more than two groups ) . in cases with missing data , the valid percent of variables 
 was calculated .
the kaplan - meier method was used for survival analyses , and the 
 log - rank test was used for survival comparisons .
cox regression analysis ( by wald 's 
 backward stepwise method ) was performed to identify the predictive variables over 
 time . for univariate and multivariate analyses ,
the level of significance was set at 
 p < 0.10 and p < 0.05 , respectively .
the analyses were performed with the 
 statistical package for the social sciences , version 14.0 ( spss inc . ,
during the study period , 119 patients underwent a total of 154 surgical procedures . 
 among those patients ,
the median 
 age was 52 years ( range , 15 - 75 years ) .
the main sites of origin of the primary tumor 
 were the colorectum , in 47.9% of the patients ; the musculoskeletal system , in 21.8% ; 
 the head and neck , in 7.5% ; and the gonads , in 5.9% .
comorbidities were found in 63 
 patients ( 52.9% ) , and the most common were systemic arterial hypertension , in 69.8% ; 
 diabetes , in 19.0% ; asthma / copd , in 7.9% ; dyslipidemia , in 7.9% ; hyperthyroidism , in 
 6.3% , and heart disease , in 6.3% .
a 
 total of one , two , three , and four surgical procedures , respectively , were performed 
 on 91 ( 76.5% ) , 24 ( 20.2% ) ; 3 ( 2.5% ) , and 1 ( 0.8% ) of the patients . ten patients 
 ( 8.4% ) underwent resection for liver metastasis before the diagnosis of lung 
 metastasis .
likewise , 85 patients ( 71.4% ) underwent chemotherapy and/or radiotherapy 
 before lung metastasis resection .
after resection , 88 patients ( 75.9% ) underwent 
 adjuvant chemotherapy ( table 1 ) .
the median disease - free interval was 23 months 
 ( range , 1 - 172 months ) . 

the mean length of hospital stay was 8 days ( range , 3 - 40 days ) for the 154 surgical 
 procedures .
the preferential location of the resected lesions was the left lower lobe ( in 24.8% ) , 
 followed by the left upper lobe ( in 24.4% ) and the right lower lobe ( in 21.5% ) .
a 
 total of 511 lesions were described . in 25 surgical procedures ( 16.3% ) ,
bilateral lesions were resected during the same 
 surgical session , whereas , in 129 procedures ( 83.7% ) , only one of the lungs was 
 treated .
of those 129 surgical procedures , 20 ( in 10 patients ) were performed on 
 average 2 months apart in order to treat bilateral disease , which was present in 35 
 patients ( 29.4% ) at diagnosis of lung metastasis .
the most common surgical access was thoracotomy , in 78.6% of the cases , followed by 
 sternotomy , in 9.1% ; bilateral sequential thoracotomy , in 8.5% ; and video - assisted 
 surgery , in 3.8% .
bilateral thoracotomy , despite consisting of two different access 
 routes , was considered as a single surgical procedure .
the types of resection performed were wedge resection or segmentectomy , in 51.3% of 
 the cases ; nodule resection , in 29.9% ; lobectomy or bilobectomy , in 15.6% ; and 
 pneumonectomy , in 3.2% . in 107 ( 69.5% ) of a total of 154 surgical procedures , a linear stapler was used to 
 assist in suturing the lung parenchyma . in 10 procedures ( 6.5% )
, the patients were not extubated in the operating room , and , 
 in 12 ( 7.8% ) , the patients did not recover from the immediate postoperative period 
 in the icu environment .
after the surgical procedures , 28 patients ( 18.2% ) developed sirs , and 9 of those 
 patients had some type of perioperative complication . in the perioperative period , 34 patients ( 22.1% ) had some type of complication , the 
 most common being pulmonary conditions ( pneumonia , respiratory failure , prolonged 
 mechanical ventilation , retained clot , pulmonary edema , persistent air fistula ) in 
 25 ( 16.2% ) and extrapulmonary conditions ( heart failure , arrhythmia , urinary 
 tract / urinary tract wall infection , and thromboembolism in 12 ( 7.8% ) . in 3 cases , 
 concomitant pulmonary and extrapulmonary complications were found .
perioperative mortality was 3 patients ( 1.9% ) , 1 of whom died from an irreversible 
 arrhythmia during the procedure and 2 of whom died from pulmonary complications 
 ( table 2 ) . 

table 2 characteristics of the 154 surgical procedures performed during the 
 study period . 
  of
the 119 patients studied , 64 ( 53.8% ) continued with follow - up treatment , whereas 
 22 ( 18.5% ) lost contact with the facility for more than 1 year , and 33 ( 27.7% ) 
 died . 

table 3 shows the overall survival rates of 
 the patients at 12 , 36 , 60 , and 120 months , which were 96% , 77% , 56% , and 39% , 
 respectively .
overall survival for the groups of patients who underwent and who did 
 not undergo chemotherapy / radiotherapy before surgery ( 48% and 72% ) and after surgery 
 ( 51% and 72% ) showed a significant difference ( p = 0.02 ) in favor of those who did 
 not undergo chemotherapy / radiotherapy , but this was not confirmed in the 
 multivariate analysis . a cox analysis in which patients with and without 
 complications within the first 30 days after surgery were compared ( 67% vs. 24% ; p 
 <
0.0001 ) confirmed that the former had poor prognosis ( hazard ratio = 1.81 ; 
 95% ci : 1.09 - 3.06 ; p = 0.02 ; figure 1 ) . 

figure 1 in a , overall survival in the groups of patients who underwent and 
 who did not undergo chemotherapy / radiotherapy ( cht / rt ) before surgery ( n 
 = 119 ) . in b , overall survival in the groups of patients who underwent 
 and who did not undergo cht / rt after surgery ( n = 116 ) . in c , overall 
 survival in the groups of patients who had and who did not have 
 complications within 30 postoperative days ( n = 119 ) . 
 
survival stratification by anatomical site of the primary tumor showed that overall 
 survival at 60 months was 68% for colorectal carcinoma , 26% for musculoskeletal 
 carcinoma , and 56% for the other types of tumor ( which are less common than the 
 former two ; figure 2 ) . 

survival at 60 months in the patients who had up to 6 lesions resected ranged from 
 60% to 76% , whereas , in those who had more than 7 nodules resected , survival at 60 
 months dropped to 13% . in the patients with bilateral disease at diagnosis , overall 
 survival was 63% , and , in those with unilateral disease , overall survival was 55% . 

the present study showed that the population analyzed had characteristics similar to 
 those reported in major studies : there was a slight predominance of males ; the 
 histology of the primary tumor was predominantly colorectal adenocarcinoma ; and 
 there was approximately 30% of bilaterality of disease at diagnosis of lung 
 metastasis .
( ) the most common surgical access in all studies is thoracotomy , and there have been 
 few reports of treatment of the two lungs during the same surgical procedure.(- ) in such cases , we preferentially choose sternotomy ; 
 however , depending on the location of the lesion , bilateral thoracotomy may be the 
 best alternative .
the choice to use video - assisted surgery as access for resection 
 of metastatic lesions remains controversial in the literature , even in single lesion 
 cases , because careful palpation of the entire lung parenchyma is impossible and 
 imaging methods are limited in the preoperative evaluation of such lesions . with the 
 increasing sensitivity of imaging methods , especially in cases in which the lesions 
 are located peripherally ,
we believe that minimally invasive accesses will be more 
 widely in the near future .
the surgical treatment of lung metastases in major studies has followed the principle 
 that all lesions should be completely resected and disease - free margins should be 
 obtained and that resection of lung parenchyma should be as conservative as 
 possible . among the surgical techniques for excision of lesions , wedge resection and 
 segmentectomy were the most commonly used in various studies , followed , in smaller 
 numbers , by lobectomy and pneumonectomy .
( , ) 
 all these data were extensively reviewed in a recent meta - analysis conducted by 
 pfannschmidt et al .
( 2007 ) , in which 20 large studies of surgical treatment of lung 
 metastases from colorectal cancer were compared .
( ) currently , surgery is a significant component of the treatment of lung metastatic 
 disease , and its practice is widely accepted worldwide , resulting in low mortality 
 rates and increased five - year survival rates . in the study by pfannschmidt
( ) the perioperative 
 mortality rate ranged from 0% to 2.02% , whereas , in the study conducted in brazil by 
 younes et al . , ( ) the rate was 
 0.4% .
these results are in good agreement with the value of 1.9% found in the 
 present study , showing the safety of the method .
the overall survival rate at 60 months in our sample , which was approximately 56% , 
 was found to be similar to those reported in the meta - analysis by pfannschmidt et 
 al .
( , ) 
 however , since we calculated survival from treatment of the primary tumor , we 
 observed that various studies reported much lower results , given that , in them , 
 survival was calculated from resection of the metastasis .
( ) survival at 
 60 months ranged from 10% to 40% , depending on the primary tumor site .
the prevalence of colorectal cancer as the site of origin of the lung metastases 
 ( 47.9% in our study ) led us to perform a separate analysis of overall survival in 
 the patients with this type of cancer as compared with those with musculoskeletal 
 cancer and those with cancer in other anatomical sites .
we found that the patients 
 with colorectal cancer had the best survival at 60 months ( 68% ) , whereas those with 
 musculoskeletal cancer had the worst survival ( 26% ) .
the vast majority of studies 
 have investigated disease secondary to colorectal cancer only and reported rates of 
 overall survival at 60 months that range from 24.0% to 62.7% .
( , ) therefore , we believe that further studies comparing 
 treatment of lung metastases from colorectal cancer with that of lung metastases 
 from cancer in other anatomical sites that are less common are needed in order to 
 determine with accuracy the true impact and benefits of this treatment option for 
 specific groups
. in our study , survival at 60 months in the patients who had up to 6 lesions resected 
 ranged from 60% to 76% , whereas , in those who had more than 7 nodules resected , 
 survival at 60 months dropped to 13% .
most studies have evaluated survival by 
 stratifying patients based on the presence of one resected lesion or multiple 
 resected lesions , with better results being found in patients with single 
 lesions .
( , , ) however , those same authors reviewed controversial 
 results from various studies that did not find significant differences in the 
 survival of patients with multiple nodules , ( , ) 
 and the difference in results may lie in the heterogeneity of the biological 
 behavior of the different histological types of tumors studied , suggesting the need 
 for larger , specific studies of this variable .
few studies have addressed laterality of lesions at diagnosis of metastasis and the 
 need for more than one surgical procedure to resect the lesions . in our study , we 
 found that 35 patients ( 29.4% ) were diagnosed with bilateral disease and that 28 
 underwent more than one surgical procedure ( 1 of whom underwent four surgical 
 procedures ) . according to the literature ,
patients undergoing repeat resection of 
 new pulmonary metastatic lesions have increased survival in comparison with those 
 treated with a single surgery ( 48% vs. 34% ) , ( ) which leads us to believe in the benefits of and to 
 continue to recommend surgical treatment of recurrent lesions as long as the patient 
 is clinically fit to undergo the surgical procedure . with regard to the treatment of 
 bilateral lesions
, we found that overall survival was 63% in the patients with 
 bilateral disease at diagnosis and 55% in those with unilateral disease , i.e. , the 
 difference was not statistically significant , which is in agreement with the 
 findings of the few studies that have addressed this issue and highlights the 
 importance of resection in bilateral disease .
( ) another factor that stood out in the analyses of overall survival was the poorer 
 survival of the patients who underwent chemotherapy / radiotherapy as compared with 
 those who did not .
we understand this finding to mean that the need for neoadjuvant 
 and adjuvant treatment indicates disease in more advanced stages and weakness 
 associated with sequential multimodal treatment .
however , this finding is in 
 disagreement with the results reported by younes et al . , ( ) who found a significant improvement in survival 
 in the group of patients who underwent chemotherapy / radiotherapy , as well as with 
 the finding of an absence of significant differences between these two groups in the 
 main studies(- ) reviewed in the meta - analysis by 
 pfannschmidt , ( ) which leads 
 us to agree with the opinion of those authors who claim that the different protocols 
 for the different types of primary tumor may hinder the understanding of the true 
 impact on the survival of patients undergoing complementary treatment .
there have been few studies addressing perioperative complications and survival in 
 this specific group .
however , there was no definition of the parameters used for classifying these 
 events , nor was there an analysis of survival in this group only . in the present 
 study sample ,
the rate of ( minor and major ) complications was 22% , and a cox 
 analysis confirmed a poor prognosis for this group of patients .
therefore , by 
 considering even minor events ( such as air leaks for more than five days ) as a 
 potential morbidity , we emphasize the importance of the fact that even these events , 
 alone or in combination , can be predictive of a poor prognosis for the patient . in conclusion , surgical treatment of lung metastases from different tumor sites is 
 safe and effective , with significant overall survival , especially in patients with a 
 smaller number of lung lesions .
survival was found to be poor in the patients with 
 metastases from sarcomas and in those who underwent neoadjuvant or adjuvant 
 chemotherapy / radiotherapy .
large multicenter prospective studies using better 
 biological and molecular classification should provide a more refined understanding 
 of and new prognostic parameters for these systemic malignant neoplasms .
  descrever caractersticas demogrficas , resultados operatrios , complicaes 
 ps - operatrias e taxa de sobrevida global em pacientes com metstases 
 pulmonares tratados cirurgicamente .
  anlise retrospectiva de 119 pacientes submetidos a um total de 154 
 cirurgias de resseco de metstase pulmonar entre 1997 e 2011 .
  do total de 119 pacientes , 68 ( 57,1% ) eram do sexo masculino , e 108 ( 90,8% ) 
 eram brancos . a mediana de idade foi de 52 anos ( variao , 15 - 75 anos ) . 

nessa amostra , 63 pacientes ( 52,9% ) apresentaram comorbidades , sendo as mais 
 frequentes hipertenso arterial sistmica ( 69,8% ) e diabetes ( 19,0% ) . 

tumores primrios colorretais ( 47,9% ) e musculoesquelticos ( 21,8% ) foram os 
 principais stios de origem das metstases .
aproximadamente 24% dos 
 pacientes foram submetidos a mais de uma resseco das leses , e 71% fizeram 
 tratamento adjuvante prvio  metastasectomia . a taxa de recidiva de 
 metstase pulmonar foi de 19,3% .
a principal via de acesso usada foi toracotomia ( 78% ) , e o tipo 
 de resseco mais frequente foi em cunha e segmentectomia ( 51% ) .
o ndice de 
 complicaes ps - operatrias foi de 22% e o de mortalidade perioperatria 
 foi de 1,9% . as taxas de sobrevida global em 12 , 36 , 60 e 120 meses foram , 
 respectivamente , de 96% , 77% , 56% e 39% .
a anlise de cox confirmou que 
 complicaes nos primeiros 30 dias ps - operatrios associaram - se a pior 
 prognstico ( hazard ratio = 1,81 ; ic95% : 1,09 - 3,06 ; p = 
 0,02 ) .
  o tratamento cirrgico das metstases pulmonares oriundas de diferentes 
 stios tumorais  efetivo e seguro , com boa sobrevida global , especialmente 
 nos casos com um menor nmero de leses pulmonares .
por muitos anos , o diagnstico de metstase pulmonar foi considerado como fase 
 terminal na evoluo do paciente portador de neoplasias malignas .
no incio , a 
 proposta teraputica consistia em quimioterapia e hormonoterapia , com respostas 
 insatisfatrias observadas em mais de 70% dos casos .
( ) em 1882 , weinlechner realizou a primeira 
 resseco de metstase pulmonar , de modo acidental , durante a resseco de um 
 tumor primrio , na qual a metstase foi removida em bloco com a pea 
 cirrgica .
( ) desde ento , 
 foram reportados vrios outros casos de metastasectomia , muitos com resultados 
 positivos .
em 1951 , ehrenhaft iniciou a seleo de pacientes candidatos  resseco de 
 metstases pulmonares ( ) e , 
 posteriormente , foi possvel estabelecer critrios bem definidos .
o tratamento operatrio evoluiu ao longo do sculo xx devido ao maior 
 conhecimento a respeito dos tumores que originavam metstases pulmonares 
 exclusivas .
a terapia cirrgica das metstases pulmonares teve um impulso nos 
 ltimos 15 anos , conforme mostra a literatura mundial , e j foram determinados 
 alguns dos principais fatores prognsticos para essa condio , tais como o 
 intervalo livre de doena e o tipo de resseco utilizada .
( , ) entretanto , poucos so os estudos sobre a casustica 
 nacional e a avaliao dessa modalidade teraputica no brasil em comparao aos 
 principais centros mundiais .
assim sendo , o presente estudo teve por objetivo avaliar os resultados do 
 tratamento cirrgico de metstases pulmonares em um hospital universitrio na 
 cidade de campinas ( sp ) .
o presente estudo retrospectivo utilizou os registros operatrios do servio de 
 cirurgia torcica do hospital de clnicas da universidade estadual de campinas , 
 localizado na cidade de campinas ( sp ) .
foram pesquisados todos os procedimentos 
 de resseco de leses pulmonares com diagnstico prvio de neoplasia primria 
 em outros rgos , assim como de resseco completa de todas as leses e que 
 tiveram confirmao anatomopatolgica de doena metasttica no perodo entre 1 
 de janeiro de 1997 e 31 de dezembro de 2011 .
foram includos todos os pacientes portadores de leses pulmonares que foram 
 selecionados para cirurgia de acordo com os critrios de tratamento cirrgico de 
 leso metasttica pulmonar de thomford et .
al . , ( ) a saber : a ) ressecabilidade completa de toda a 
 doena metasttica ; b ) funo pulmonar capaz de tolerar o risco cirrgico e o 
 ps - operatrio ; c ) o tumor primrio deve estar ( ou pode ser ) controlvel ; d ) no 
 deve haver evidncias de metstases extrapulmonares , com exceo ao tumor de 
 clon ; e e ) no deve haver outra forma de tratamento mais eficaz que a 
 cirurgia .
a funo pulmonar foi avaliada a partir dos resultados de gasometria arterial e 
 de prova de funo pulmonar .
na impossibilidade tcnica de realizao da prova 
 de funo pulmonar , foi utilizado o teste de caminhada de seis minutos , que  
 comprovadamente bem tolerado e eficaz na avaliao da capacidade funcional do 
 paciente .
( ) tambm foi pesquisada , no perodo ps - operatrio , a presena de systemic 
 inflammatory response syndrome ( sirs , sndrome da resposta 
 inflamatria sistmica ) , que foi definida pela presena de pelo menos dois dos 
 seguintes parmetros , verificados num mesmo dia , em um perodo de at trs dias 
 aps o ato cirrgico : temperatura axilar maior que 38c ; fr > 24 
 ciclos / min ; fc > 90 bpm ; leucograma maior que 10.000 clulas / mm 
 ou menor que 5.000 clulas / mm .
definiu - se a sobrevida global a partir da data da primeira cirurgia at a data da 
 ltima consulta ou bito ( por qualquer causa ) .
para o clculo do intervalo livre 
 de doena , foram utilizadas as datas do tratamento da neoplasia primria e a 
 data do encaminhamento  cirurgia torcica para o tratamento da metstase 
 pulmonar .
foi elaborada uma ficha de coleta de dados utilizada por dois mdicos treinados 
 para a obteno das informaes dos pronturios dos pacientes necessrias para 
 os objetivos definidos do estudo .
essa ficha era composta pelos seguintes 
 campos : iniciais do paciente ; nmero do pronturio ; sexo ; raa ; data de 
 nascimento ; data da cirurgia do tumor primrio ; data do encaminhamento para a 
 cirurgia torcica ; sintomas ao diagnstico da metstase ( dispneia , tosse , 
 hemoptise e dor torcica ) ; tabagismo ; stio anatmico do tumor primrio ( mama , 
 cabea , pescoo , colorretal , renal , musculoesqueltico , gnadas , etc . ) ; presena 
 e tipo de comorbidade associada ; resseco de metstase heptica prvia ; terapia 
 neoadjuvante ou adjuvante ao tratamento da metstase pulmonar ; nmero de 
 resseces pulmonares ; nmero e localizao
de ndulos encontrados no 
 intraoperatrio ; data da resseco da metstase ; tipo de resseco utilizada 
 ( segmentectomia , cunha , nodulectomia , lobectomia , bilobectomia e 
 pneumonectomia ) ; uso de grampeador ; extubao em sala cirrgica ; nmero e 
 lateralidade de drenos torcicos ; abordagem uni ou bilateral ; via de acesso 
 ( toracotomia , bitoracotomia sequencial , esternotomia e videocirurgia ) ; 
 necessidade de transfuso sangunea ; recuperao ps - operatria em uti ; 
 desenvolvimento de sirs ; tempo de internao hospitalar ; presena e tipo de 
 complicao at 30 dias da cirurgia ; dia do ps - operatrio em que iniciou a 
 complicao ; situao atual do paciente ( vivo / bito ) ; data da ltima consulta no 
 servio ; e se fez seguimento em outro servio .
as complicaes ps - operatrias foram extradas dos pronturios dos pacientes , 
 definidas como todo e qualquer tipo de evento que tenha ocorrido com o paciente 
 no perodo de 30 dias aps o ato cirrgico .
agrupamos esses dados de acordo com 
 os principais sistemas ou patologias envolvidos , os listamos por frequncia e os 
 estratificamos como uma varivel na curva de sobrevida global .
o presente estudo foi aprovado pelo comit de tica em pesquisa da faculdade de 
 cincias mdicas da universidade estadual de campinas sob o protocolo no . 
 001/2013 .
aplicou - se a anlise descritiva exploratria e , posteriormente , os testes de 
 pearson , spearman e fisher , no caso de variveis categricas , enquanto no caso 
 de variveis contnuas , foram utilizados o teste t ( dois grupos ) ou o teste de 
 kruskal - wallis ( mais de dois grupos ) .
para as anlises de sobrevida , aplicou - se o 
 mtodo de kaplan - meier e , para seus cotejamentos , o teste de log - rank . a 
 regresso de
cox foi aplicada na busca de variveis preditivas no decorrer do 
 tempo , com o mtodo de wald ( backward stepwise ) .
para as 
 anlises univariada e multivariada , o nvel de significncia considerado foi de , 
 respectivamente , p < 0,10 e p < 0,05 .
as anlises foram realizadas 
 atravs do programa estatstico statistical package for the social 
 sciences , verso 14.0 ( spss inc . ,
durante o perodo estudado , 119 pacientes foram submetidos a um total de 154 
 procedimentos operatrios .
desses pacientes , 68 ( 57,1% ) eram do sexo masculino , 
 com uma mediana de idade de 52 anos ( variao , 15 - 75 anos ) , e 108 ( 90,8% ) eram 
 brancos .
os principais stios de origem do tumor primrio encontrados foram 
 colorretal , em 47,9% dos pacientes ; musculoesqueltico , em 21,8% ; cabea e 
 pescoo , em 7,5% ; e gnadas , em 5,9% .
as comorbidades associadas eram presentes 
 em 63 pacientes ( 52,9% ) , sendo as mais frequentes a hipertenso arterial 
 sistmica , em 69,8% ; diabetes , em 19,0% ; asma / dpoc , em 7,9% ; dislipidemia , em 
 7,9% ; hipertireoidismo , em 6,3% ; e cardiopatia , em 6,3% .
o nmero de procedimentos operatrios 
 realizados nos pacientes foi de um , dois , trs e quatro , respectivamente , em 91 
 pacientes ( 76,5% ) , 24 ( 20,2% ) ; 3 ( 2,5% ) e 1 ( 0,8% ) .
foram submetidos  resseco 
 de metstase heptica antes do diagnstico da metstase pulmonar 10 pacientes 
 ( 8,4% ) . da mesma forma , 85 pacientes ( 71,4% ) realizaram quimioterapia e / ou 
 radioterapia antes da resseco da metstase pulmonar .
aps a resseco , 88 
 pacientes ( 75,9% ) realizaram quimioterapia adjuvante ( tabela 1 ) . a taxa de recidiva de metstase pulmonar foi de 
 19,3% .
a mediana do intervalo de tempo livre de doena foi de 23 meses 
 ( variao , 1 - 172 meses ) . 

a mdia de dias de internao hospitalar foi de 8 dias ( variao , 3 - 40 dias ) em 
 relao aos 154 procedimentos operatrios .
a localizao preferencial das leses ressecadas foi no lobo inferior esquerdo 
 ( 24,8% ) , seguida no lobo superior esquerdo ( 24,4% ) e no lobo inferior direito 
 ( 21,5% ) .
com relao ao ato operatrio , foram abordadas leses bilaterais no mesmo tempo 
 cirrgico em 25 procedimentos operatrios ( 16,3% ) , enquanto somente um dos 
 pulmes foi abordado em 129 procedimentos ( 83,7% ) . desses 129 procedimentos 
 cirrgicos , 20 ( em 10 pacientes ) foram realizados em um intervalo mdio de 2 
 meses a fim de tratar doena bilateral , que estava presente em 35 pacientes 
 ( 29,4% ) ao diagnstico da metstase pulmonar . as vias de acesso utilizadas mais comuns foram toracotomia , em 78,6% dos casos , 
 seguida por esternotomia , em 9,1% ; bitoracotomia sequencial , em 8,5% ; e 
 videocirurgia , em 3,8% .
foi considerada somente como um ato operatrio . os tipos de resseces foram resseco em cunha ou segmentectomia , em 51,3% dos 
 casos ; nodulectomia , em 29,9% ; lobectomia ou bilobectomia , em 15,6% ; e 
 pneumonectomia , em 3,2% . de um total de 154 atos operatrios , utilizou - se o grampeador linear para auxlio 

em 10 procedimentos ( 6,5% ) , os pacientes no foram extubados na prpria sala 
 cirrgica , e 12 ( 7,8% ) no fizeram recuperao do ps - operatrio imediato em 
 ambiente de uti .
aps os atos operatrios , 28 pacientes ( 18,2% ) evoluram com sirs , e 9 desses 
 cursaram com algum tipo de complicao perioperatria .
no perodo perioperatrio , 34 pacientes ( 22,1% ) tiveram algum tipo de 
 complicao , sendo as mais comuns os quadros pulmonares ( pneumonia , 
 insuficincia respiratria , ventilao mecnica prolongada , cogulo retido , 
 edema pulmonar , fistula area persistente ) em 25 ( 16,2% ) e quadros 
 extrapulmonares ( insuficincia cardaca , arritmia , infeco de parede / trato 
 urinrio e tromboembolismo ) em 12 ( 7,8% ) .
a mortalidade perioperatria foi de 3 pacientes ( 1,9% ) devida a arritmia 
 irreversvel no intraoperatrio em 1 e a complicaes pulmonares em 2 ( tabela 2 ) . 

tabela 2 caractersticas dos 154 atos operatrios realizados durante o 
 perodo do estudo . 
 
dos 119 pacientes estudados , 64 ( 53,8% ) mantiveram seguimento ambulatorial , 
 enquanto 22 ( 18,5% ) perderam contato com o servio por mais de 1 ano , e 33 
 ( 27,7% ) foram a bito .
a tabela 3 apresenta as taxas de 
 sobrevida global dos pacientes em 12 , 36 , 60 e 120 meses , equivalentes a 96% , 
 77% , 56% e 39% respectivamente . a sobrevida global para os grupos que realizaram 
 ou no quimioterapia ou radioterapia antes ( 48% e 72% ) e depois ( 51% e 72% ) da 
 cirurgia apresentou uma diferena significativa ( p = 0,02 ) a favor daqueles 
 pacientes que no as realizaram , porm sem confirmao na anlise multivariada . 

ao se cotejar os pacientes sem e com complicaes nos primeiros 30 dias aps a 
 cirurgia ( 67% vs. 24% ; p < 0,0001 ) , a anlise de cox confirmou a piora no 
 prognstico ( hazard ratio = 1,81 ; ic95% : 1,09 - 3,06 ; p = 0,02 ; figura 1 ) . 

figura 1 em a , sobrevida global nos grupos de pacientes submetidos ou no 
 a quimioterapia / radioterapia ( qt / rt ) antes da cirurgia ( n = 119 ) .
em 
 b , sobrevida global nos grupos de pacientes submetidos ou no a 
 qt / rt depois da cirurgia ( n = 116 ) . em c , sobrevida global nos 
 grupos de pacientes que apresentaram ou no complicaes nos em at 
 30 dias ps - operatrios ( n = 119 ) . 
 
estratificando a sobrevida pelo stio anatmico do tumor primrio encontramos uma 
 sobrevida global em 60 meses de 68% no carcinoma colorretal , de 26% no carcinoma 
 musculoesqueltico e de 56% nos demais grupos ( menos frequentes que os 
 anteriores ; figura 2 ) . 

figura 2 sobrevida global nos pacientes em funo do tipo de tumor 
 primrio . 
  a sobrevida em 60 meses nos pacientes com at 6 leses ressecadas variou de 60% a 
 76% , enquanto naqueles com mais de 7 ndulos ressecados , a sobrevida em 60 meses 
 caiu para 13% .
nos pacientes com doena bilateral ao diagnstico , a sobrevida 
 global foi de 63% e naqueles com doena unilateral , essa foi de 55% .
o presente estudo demonstrou que a populao analisada seguiu as caractersticas 
 das principais casusticas na literatura : leve predominncia do sexo masculino , 
 histologia do tumor primrio predominantemente de adenocarcinoma colorretal e 
 aproximadamente 30% de bilateralidade da doena ao diagnstico da metstase 
 pulmonar .
( ) a via de acesso mais utilizada em todos os estudos  a toracotomia , sendo que a 
 abordagem dos dois pulmes no mesmo ato operatrio  pouco descrita.(- ) nesses casos optamos preferencialmente pela 
 esternotomia ; porm , dependendo da localizao das leses , a bitoracotomia pode 
 ser a melhor alternativa
. a opo de videocirurgia como via de acesso ainda  
 muito controversa na literatura para a resseco de leses metastticas , mesmo 
 em se tratando de leso nica , devido  impossibilidade da palpao cuidadosa de 
 todo o parnquima pulmonar e  limitao dos mtodos de imagem na avaliao 
 pr - operatria .
com a crescente elevao da sensibilidade dos mtodos de imagem , 
 sobretudo naqueles casos em que ocorre a localizao perifrica das leses , 
 podemos acreditar que os acessos minimamente invasivos podero ser mais 
 utilizados em um futuro prximo .
o tratamento cirrgico das metstases pulmonares nos principais estudos seguiu os 
 princpios de que todas as leses devem ser totalmente ressecadas com margens 
 cirrgicas livres de doena e que a resseco do parnquima pulmonar sempre deve 
 ser a mais econmica possvel .
dentre as tcnicas operatrias para a exrese das 
 leses , as mais frequentemente utilizadas em vrios estudos foram a resseco em 
 cunha e a segmentectomia , seguidas em menor nmero pela lobectomia e 
 pneumonectomia .
( , ) todos esses dados foram 
 extensamente expostos na recente meta - anlise conduzida por pfannschmidt et al . 

em 2007 , na qual 20 grandes estudos sobre o tratamento cirrgico de metstases 
 pulmonares de cncer colorretal foram comparados .
( ) atualmente , a doena metasttica pulmonar tem a cirurgia como parte relevante de 
 seu tratamento , e sua prtica j  difundida em todo o mundo , com baixas taxas 
 de mortalidade e aumento da taxa de sobrevida em cinco anos .
( ) a 
 taxa de mortalidade perioperatria variou de 0% a 2,02% , enquanto , no estudo 
 brasileiro de younes et al . ,
tais resultados apresentam boa 
 concordncia com o nosso valor encontrado de 1,9% , demonstrando a segurana do 
 mtodo . a sobrevida global em 60 meses em nossa casustica , de aproximadamente 56% , se 
 mostrou semelhante s relatadas na meta - anlise de pfannschmidt et al .
( , ) entretanto , como consideramos a sobrevida a partir do 
 tratamento do tumor primrio , observamos que vrios trabalhos tinham resultados 
 bem menores , uma vez que calcularam a sobrevida a partir da resseco da 
 metstase .
como exemplo , temos que , no trabalho de younes et al . , ( ) a sobrevida em 60 meses 
 variou de 10 - 40% , dependendo do stio primrio do tumor .
a prevalncia da neoplasia colorretal como stio de origem das metstases 
 pulmonares ( 47,9% em nosso estudo ) nos levou a estudar em separado a sobrevida 
 global desse grupo em comparao  daqueles com neoplasia musculoesqueltica e 
 em outros stios anatmicos .
encontramos que a melhor sobrevida em 60 meses foi 
 no grupo de pacientes com neoplasia colorretal ( 68% ) , enquanto a pior sobrevida 
 foi no grupo de pacientes com neoplasia musculoesqueltica ( 26% ) . a grande 
 maioria dos estudos avalia exclusivamente a doena secundria  neoplasia 
 colorretal e traz valores de sobrevida global em 60 meses variando de 24,0% a 
 62,7% .
( , ) dessa forma , julgamos 
 necessrios mais estudos comparativos de tratamento de metstase pulmonar de 
 neoplasia colorretal com aquele de metstase pulmonar de outros stios 
 anatmicos que so menos frequentes a fim de poder definir com preciso o real 
 impacto e benefcio dessa opo teraputica para grupos especficos
. em nosso estudo , a sobrevida em 60 meses nos pacientes com at 6 leses 
 ressecadas variou de 60% a 76% , enquanto naqueles com mais de 7 ndulos 
 ressecados , a sobrevida em 60 meses caiu para 13% .
a maioria dos trabalhos 
 avalia a sobrevida estratificando a presena de uma leso ressecada versus a de 
 mltiplas leses ressecadas , encontrando melhores resultados nos pacientes com 
 leses nicas .
( , , ) entretanto , esses mesmos autores levantam os 
 resultados controversos de vrios estudos que no encontraram diferenas 
 significativas na sobrevida de pacientes com mltiplos ndulos , ( , ) podendo essa diferena de resultados residir 
 na heterogeneidade do comportamento biolgico dos diferentes tipos histolgicos 
 dos tumores estudados , sugerindo a necessidade de estudos mais amplos e 
 especficos em relao a essa varivel .
poucos estudos abordam a questo da lateralidade das leses ao diagnstico da 
 metstase e a necessidade de mais de um ato operatrio para ressecar as leses . 
 em nosso estudo , tivemos que 35 pacientes ( 29,4% ) foram diagnosticados com 
 doena bilateral e que 28 foram submetidos a mais de um ato operatrio ( sendo 
 que 1 paciente foi submetido a quatro procedimentos cirrgicos ) .
na literatura , 
 temos que a resseco de novas leses de metstases pulmonares mostra um aumento 
 na sobrevida de pacientes submetidos a mais de um procedimento cirrgico em 
 relao queles tratados com cirurgia nica ( 48% vs. 34% ) , ( ) o que nos impulsiona a acreditar no 
 benefcio e a manter a indicao do tratamento cirrgico das leses recorrentes 
 desde que o paciente apresente condies clnicas para o ato operatrio .
com 
 relao ao tratamento de pacientes portadores de leses bilaterais , a sobrevida 
 global que encontramos foi de 63% no grupo com doena bilateral ao diagnstico e 
 de 55% no grupo com doena unilateral , ou seja , sem diferena estatisticamente 
 significante , concordando com os poucos estudos que abordam esse fator e 
 corroborando a importncia da resseco na doena bilateral .
( ) outro fator que se destacou nas anlises de sobrevida global foi a piora na 
 sobrevida dos pacientes que realizaram quimioterapia / radioterapia em comparao 
 aos que no fizeram .
entendemos esse dado como significado de que a necessidade 
 de tratamento neoajuvante e adjuvante indica doena em estgios mais avanados e 
 debilidade que envolve o tratamento multimodal sequencial .
( ) que encontraram uma melhora na sobrevida no grupo 
 de pacientes submetido a quimioterapia / radioterapia , assim como a ausncia de 
 diferenas significativas entre esses dois grupos nos principais estudos(- , ) levantados na meta - anlise 
 de pfannschmidt , ( ) o que nos 
 leva a concordar com a opinio daqueles autores de que os diferentes protocolos 
 para os diferentes tipos de tumor primrio podem dificultar o entendimento do 
 real impacto na sobrevida de pacientes submetidos ao tratamento 
 complementar .
poucos so os estudos que avaliam a presena de complicaes perioperatrias e 
 sobrevida desse especfico grupo
entretanto , no houve a definio dos parmetros 
 utilizados para a classificao desses eventos nem uma anlise da sobrevida 
 exclusiva nesse grupo .
na casustica apresentada no presente estudo , a taxa de 
 complicaes ( entre maiores e menores ) foi de 22% , e a anlise de cox confirmou 
 a piora do prognstico para esse grupo de pacientes .
( como , por exemplo , escape areo por 
 mais de cinco dias ) como uma potencial morbidade , salienta - se a importncia de 
 que mesmo esses eventos , de forma isolada ou cumulativa , podem ser preditivos de 
 um pior prognstico para o paciente .
conclumos que o tratamento cirrgico das metstases pulmonares oriundas de 
 diferentes stios tumorais  efetivo e seguro , com significativa sobrevida 
 global , especialmente nos casos com um menor nmero de leses pulmonares . 

observou - se menor sobrevida nos casos de metstases a partir de sarcomas e 
 naqueles pacientes que foram submetidos a tratamentos 
 quimioterpicos / radioterpicos neoadjuvantes ou adjuvantes .
estudos prospectivos 
 e multicntricos com maiores casusticas e com melhor estratificao biolgica e 
 molecular devem oferecer uma compreenso mais refinada e novos parmetros 
 prognsticos dessas neoplasias malignas sistmicas .
 objective : to describe demographic characteristics , surgical results , postoperative 
 complications , and overall survival rates in surgically treated patients 
 with lung metastases . methods : this was a retrospective analysis of 119 patients who underwent a total of 
 154 lung metastasis resections between 1997 and 2011 
 . results : among the 119 patients , 68 ( 57.1% ) were male and 108 ( 90.8% ) were white . 
 the 
 median age was 52 years ( range , 15 - 75 years ) . in this sample , 
 63 patients 
 ( 52.9% ) presented with comorbidities , the most common being systemic 
 arterial hypertension ( 69.8% ) and diabetes ( 19.0% ) . primary colorectal 
 tumors ( 47.9% ) and musculoskeletal tumors ( 21.8% ) were the main sites of 
 origin of the metastases . 
 approximately 24% of the patients underwent more 
 than one resection of the lesions , and 71% had adjuvant treatment prior to 
 metastasectomy . 
 the rate of lung metastasis recurrence was 19.3% , and the 
 median disease - free interval was 23 months . 
 the main surgical access used 
 was thoracotomy ( 78% ) , and the most common approach was wedge resection with 
 segmentectomy ( 51% ) . 
 the rate of postoperative complications was 22% , and 
 perioperative mortality was 1.9% . 
 the overall survival rates at 12 , 36 , 60 , 
 and 120 months were 96% , 77% , 56% , and 39% , respectively . 
 a cox analysis 
 confirmed that complications within the first 30 postoperative days were 
 associated with poor prognosis ( hazard ratio = 1.81 ; 95% ci : 1.09 - 3.06 ; p = 
 0.02 ) . 
 conclusions : surgical treatment of lung metastases is safe and effective , with good 
 overall survival , especially in patients with fewer metastases . 
Introduction
Methods
Results
Discussion
OBJETIVO:
MTODOS:
RESULTADOS:
CONCLUSES:
Introduo
Mtodos
Resultados
Discusso