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Current Standards in Pulmonary Metastasectomy:
A European Survey of ESTS Practice

Dear ESTS Colleague,

Pulmonary metastasectomy is a cornerstone of thoracic surgery. The ESTS Pulmonary Working Group has created this survey to assess current clinical practices within the society.

The project is divided into two parts:

1. Core Survey: questions regarding general practice, indications, and surgical techniques.

2. Expert Case Module (optional): at the end of the survey, you will be invited to participate in a second, focused section featuring 7 clinical scenarios (vignettes) with imaging to explore real-world decision-making in complex cases. If agreed, this part will be sent to you in next weeks.

We would be grateful if you could complete the core questionnaire and consider providing your expert input on the clinical cases.

Thank you for your time and contribution.

On behalf of the Authors,

Dr Marcin Ostrowski
ESTS Survey Coordinator
1.For authorship purposes only, please write your full name, email address and affiliation, as you would like it to appear in the manuscript (these details will be dealt with confidentiality).
Those who opt not to write their name will not be listed among the collaborators.
General Information
2.In what country do you work?(Required.)
3.Which of the following best describes your primary institution?(Required.)
4.What is your level of practice?(Required.)
5.What is your total number of years of experience in thoracic surgery?
(including both training and post-specialization practice)(Required.)
General Practice and Indications
6.Do you perform pulmonary metastasectomy in your clinical practice?(Required.)
7.What is the estimated, annual number of pulmonary metastasectomies performed in your institution?(Required.)
8.What percentage of your surgical work involves pulmonary metastasectomy?(Required.)
9.What are your main goals in performing pulmonary metastasectomy? (multiple answers allowed)(Required.)
10.How do you decide on patient selection? (multiple answers allowed)(Required.)
Preoperative Assessment
11.Do you discuss metastatic cases in a multidisciplinary tumor board?(Required.)
12.In metastatic cases, what preoperative imaging do you routinely perform? (multiple answers allowed)(Required.)
13.Do you perform biopsy of suspected pulmonary metastasis before surgery?(Required.)
14.Do you measure serum tumor markers before metastasectomy?(Required.)
15.Do you perform preoperative lymph node assessment (EBUS, mediastinoscopy)?(Required.)
16.Do you use percutaneous fiducial markers to guide lesion localization?(Required.)
17.In selected cases, do you recommend a period of observation before surgery to assess tumor biology (progression)?(Required.)
Contraindications and Patient Selection
18.In your opinion, which of the following are contraindications to metastasectomy? (multiple answers allowed)(Required.)
19.Would you operate in the presence of extrapulmonary metastases if they are controlled or resectable?(Required.)
20.Is there a maximum number of metastases you would resect?(Required.)
21.Do you perform repeat pulmonary metastasectomy for recurrence?(Required.)
Surgical Technique and Approach
22.What is your preferred approach for unilateral pulmonary metastasectomy?(Required.)
23.What is your preferred approach for bilateral metastases?(Required.)
24.Under what conditions do you prefer thoracotomy over VATS? (multiple answers allowed)(Required.)
25.Do you use palpation of the lung during surgery?(Required.)
26.What extent of resection do you consider appropriate? (multiple answers allowed)(Required.)
27.Which devices do you typically use for metastatic resections? (multiple answers allowed)(Required.)
Lymph Node Management
28.When do you perform lymph node sampling?(Required.)
29.When do you perform lymph node dissection?(Required.)
Systemic and Local Adjuvant Therapies
30.Do you recommend preoperative systemic therapy (chemotherapy/immunotherapy)?(Required.)
31.Do you recommend adjuvant systemic therapy after complete resection?(Required.)
32.Have recent advances in systemic therapy influenced your surgical approach?(Required.)
Alternative and Combined Treatments
33.What non-surgical local treatments do you consider as alternatives to surgery? (multiple answers allowed)(Required.)
34.Would you consider combining surgery with non-surgical local therapies?(Required.)
Follow-up and Future Perspectives
35.What is your standard follow-up protocol after metastasectomy?(Required.)
36.What do you think will shape the future of pulmonary metastasectomy? (multiple answers allowed)(Required.)
Tumor Specific Considerations
Colorectal Cancer
37.For patients with resectable synchronous colorectal cancer lung metastasis, what is your preferred sequence?(Required.)
38.When would you perform pulmonary metastasectomy in metachronous colorectal cancer?(Required.)
39.In terms of synchronous hepatic and pulmonary metastases do you perform metastasectomy?(Required.)
Renal Cell Carcinoma
40.In oligometastatic renal cell carcinoma, what is your preferred strategy? (multiple answers allowed)(Required.)
41.With which of the following statements do you agree, regarding the dissection of ipsilateral mediastinal lymph node metastases in patients with pulmonary metastasis from renal cell carcinoma? (multiple answers allowed)(Required.)
Sarcoma
42.What factors guide pulmonary metastasectomy in sarcoma? (multiple answers allowed)(Required.)
43.Do you perform pulmonary metastasectomy in patients with multiple lung nodules from sarcoma? (multiple answers allowed)(Required.)
Germ Cell Tumors
44.Is normalization of tumor markers (AFP, β-HCG) always required before proceeding with pulmonary metastasectomy?(Required.)
45.Do you perform lymph node dissection for bulky hilar or mediastinal metastases that appear resectable on preoperative CT after neoadjuvant therapy?(Required.)
46.Do you perform surgery if tumor markers are negative and lung lesions are <1 cm and regressing?(Required.)
47.Do you perform subsequent, contralateral metastasectomy, if primary histopathological results shows necrosis on the primary operation side?(Required.)
Miscellaneous
48.In the following cases, when do you consider pulmonary metastasectomy appropriate? (multiple answers allowed)(Required.)
Before systemic therapy
After partial/complete systemic response
Only for isolated lung disease
Never indicated
Melanoma
Pancreatic cancer
Breast cancer
Oesophageal and/or gastric cancer
49.Interested in clinical cases? We have 7 additional scenarios for further evaluation. If you wish to receive them, please mark "Yes", otherwise leave it blank.
Many thanks for sharing your insights with us.
Results from this survey will be published and further discussed.

The Authors