Ann Surg Oncol (2011) 18:S224–S225 DOI 10.1245/s10434-010-1306-7

LETTER TO THE EDITOR

The Importance of Preoperative Staging with Chest CT Scan in Patients with Colorectal Cancer

TO THE EDITORS: We write this letter to disagree with the conclusions of the study by Grossmann et al. on the role of preoperative staging with chest computed tomography (CT) in patients with colorectal cancer (CRC).1 The authors conclude that routine staging chest CT in CRC patients is not advocated. The National Comprehensive Cancer Network (NCCN) current clinical practice guidelines for colon as well as rectal cancer recommend the use of chest CT in the preoperative workup.2 There are studies showing good longterm survival following the resection of pulmonary CRC metastases as well as pulmonary and hepatic CRC metastases in the absence of extrapulmonary-hepatic disease.3,4 The recommendations from the present study would be more valid if there were no meaningful treatment options available for pulmonary CRC metastases. Since the authors themselves mention that accurate staging is needed for optimal treatment, it is difficult to accept their conclusion, especially with improving long-term survival after resection of metastases. The present study supports their conclusions with a recent article by Lin et al., while stating ‘‘curative options for synchronous lung metastases are very limited and may be even nonexistent.’’5 However, on close scrutiny, Lin et al. conclude in the same article that ‘‘pulmonary resection, initial or even repeated resection for metastatic tumor from colorectal cancer should be encouraged for selected patients as it can significantly improve survival.’’ The importance of the inclusion of chest CT has also been reported by Choi et al.6 In a prospective study on 103 patients, the impact of chest CT on staging and treatment strategy was assessed. The authors found that chest CT detected pulmonary metastatic lesions that were not visualized by chest X-ray in 44% of patients (4 of 9) who had pulmonary metastasis. If chest CT had not been performed

preoperatively, these 4 patients would have been inaccurately staged. Moreover, the treatment strategy was changed in 3 of the 4 patients as a result of chest CT findings. Finally, the issue of indeterminate lesions found on CT is also important. As the authors report, 16% of the indeterminate lesions in their study eventually turned out to be metastases. They conclude that this is a small number, but we would like to offer a different interpretation. With accumulation of experience by radiologists as well as improvements in different scanning technologies and techniques, the incidence of such lesions will increase.7 Eventually, this will only serve to improve outcomes for our patients. Based on current evidence, we believe patients with CRC should continue to undergo preoperative chest CT to screen for possible lung metastases. Raghava S. Pavoor, MD1, Parul J. Shukla, MS, FRCS2, and Jeffrey W. Milsom, MD1 1 Division of Colon & Rectum Surgery, Weill Cornell Medical College & New York Presbyterian Hospital, New York, NY; 2 Department of Surgery, Weill Cornell Medical College & New York Presbyterian Hospital, New York, NY e-mail: [email protected] Published Online: 14 September 2010 Ó Society of Surgical Oncology 2010

REFERENCES 1. Grossmann I, Avenarius JK, Mastboom WJ, Klaase JM. Preoperative staging with chest CT in patients with colorectal carcinoma: not as a routine procedure. Ann Surg Oncol. 2010;17:2045–50. 2. NCCN Clinical Practice Guidelines in Oncology. (Colon Cancer V.3.2010; Rectal Cancer V.3.2010). Available at: www.nccn.org. 3. Pfannschmidt J, Muley T, Hoffmann H, Dienemann H. Prognostic factors and survival after complete resection of pulmonary metastases from colorectal carcinoma: experiences in 167 patients. J Thorac Cardiovasc Surg. 2003;126:732–9. 4. House MG, Ito H, Go¨nen M, Fong Y, Allen PJ, DeMatteo RP, et al. Survival after hepatic resection for metastatic colorectal cancer: trends in outcomes for 1,600 patients during two decades at a single institution. J Am Coll Surg. 2010;210:744–52, 752–5. 5. Lin BR, Chang TC, Lee YC, Lee PH, Chang KJ, Liang JT. Pulmonary resection for colorectal cancer metastases: duration between cancer onset and lung metastasis as an important prognostic factor. Ann Surg Oncol. 2009;16:1026–32.

Importance of Preoperative Staging with Chest CT Scan 6. Choi DJ, Kwak JM, Kim J, Woo SU, Kim SH. Preoperative chest computerized tomography in patients with locally advanced mid or lower rectal cancer: Its role in staging and impact on treatment strategy. J Surg Oncol. 2010 Jul 6 [Epub ahead of print].

S225 7. Adeyemo D, Hutchinson R. Preoperative staging of rectal cancer: pelvic MRI plus abdomen and pelvic CT. Does extrahepatic abdomen imaging matter? A case for routine thoracic CT. Colorectal Dis. 2009;11:259–63.