Usefulness of lung palpation through thoracotomy for metastasectomy in patients with non-imaged pulmonary nodules

Aim: Lung metastases (LMs) are a common finding in patients with cancer, and pulmonary metastasectomy represents the standard therapy for several advanced cancers. The advantages of complete excision of all LMs is well established but, unfortunately, preoperative imaging studies are not able to demonstrate all the suspicious pulmonary nodules. The aim of this study was to evaluate the usefulness of bimanual lung palpation in patients undergoing open pulmonary metastasectomy. Methods: Forty-five patients (28 men, 17 women, median age 66 years, range 31-78 years) with LMs were enrolled in the study. The main primary sites of the primary cancer were colorectal (N = 22, 49%), urinary tract (N = 11, 24%), breast and ovary (N = 7, 16%). All patients underwent preoperative multidetector CT scan, using slice thickness 2.5-3mm, 1 mm collimation, and 1.5-3 mm interval, before and after iodinated contrast administration. Multiple metastasectomy through thoracotomy, after a careful bimanual lung palpation, was performed in all patients. Results: Overall, 91 suspicious nodules (median 1.5, range 1-11 nodules per patient) were removed, of which 22 (24.2%) were not imaged preoperatively. Seventy-nine nodules (86.8%) were malignant at final pathology, of which 59 out of 69 (85.5%) and 18 out of 22 (81.8%) detected and undetected by CT scan, respectively (χ2 = 0.44, OR = 0.74, 95%CI= 0.35-1.59, p = 0.56). The maximum diameter of the removed LMs detected and undetected by CT scan was significantly different (17 ± 8 mm vs. 11 ± 7 mm, p = 0.002). The most part of non-imaged LMs were found in patients with urinary tract (N = 17, 77%) and breast or ovary (N = 4, 18%) cancers. Conclusions: Lung palpation through thoracotomy can allow the removal of LMs that would otherwise remain in place, but it is unclear whether the removal of a greater number of metastases can improve the quality of life or survival of these patients, who are in a very advanced stage of the disease.