Introduction

Treatment of colorectal pulmonary metastases by means of surgical resection remains a

topic of debate. Despite the available literature, there is considerable risk for national and

international practice variation.

We would like to ask the ESTS members to participate in this online survey to investigates

the current clinical practice among European Society of Thoracic Surgeon (ESTS) members.

The survey is anonymous and will take 7-8 minutes to complete.

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* 1. What is your type of practice?

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* 2. What is your level of practice?

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* 3. Years in practice as a thoracic surgeon?

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* 5. Do you perform pulmonary metastasectomy for colorectal pulmonary metastases in your clinical practice?

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* 6. How many pulmonary metastasecomy cases do you approximately perform in your hospital per year?

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i We adjusted the number you entered based on the slider’s scale.

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* 7. As a proportion of your clinical volume, pulmonary metastasectomy accounts for approximately what percentage of your daily practice?

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* 8. Preoperative workup for colorectal pulmonary metastases (from Question 8 to Question 15)
How do you generally consider the role of pulmonary metastasectomy for colorectal pulmonary metastases?

  YES NO N/A
Improve survival
Improve disease control
Unproven benefit
Quality of life
Obsolete

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* 9. Do you consider the following as absolute contraindication to pulmonary metastasectomy for colorectal pulmonary metastases?

  YES NO N/A
Multiple (>1) colorectal pulmonary metastases
Bilateral colorectal pulmonary metastases
Previous colorectal pulmonary metastases
Synchronous colorectal pulmonary metastases
Concurrent colorectal liver metastases
Poor performance status (Karnofsky score <50%)
Poor lung function (FEV1 or DLCO <40% of predicted)
Pathologically proven mediastinal lymph nodes
Unresectable primary malignancy
Requiring extended resection to other structures (chest wall, diaphragm, vena cava)

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* 10. Do you review pulmonary metastasecomy cases in a multidisciplinary tumor board?

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* 11. Do you perform a PET-CT prior to pulmonary metastasectomy for colorectal pulmonary metastases?

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* 12. Do you routinely measure CEA levels prior to pulmonary metastasectomy for colorectal pulmonary metastases?

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* 13. Would you recommend preoperative invasive lymph node assessment prior to pulmonary metastasectomy for colorectal pulmonary metastases?

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* 14. How would you prefer to assess mediastinal lymph nodes prior to pulmonary metastasectomy for colorectal pulmonary metastases?

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* 15. Would you recommend tissue biopsy of colorectal pulmonary metastases prior to surgical resection?

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* 16. Surgical approach for colorectal pulmonary metastases (from Question 16 to Question 21)
What is your preferred approach to pulmonary metastasectomy for colorectal pulmonary metastases?

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* 17. In which situation would you recommend thoracoscopy

  YES NO N/A
Solitary metastasis
Peripheral metastases
Bilateral metastases
Poor performance status
Advanced age 
Only for diagnosis

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* 18. In which situation would you recommend an open approach

  YES NO N/A
Multiple metastases 
Central metastases
Bilateral metastases
To avoid unnecessary lung resection
Large size pulmonary metastases
I always perform thoracotomy

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* 19. What would you recommend as the preferred approach to resecting unilateral colorectal pulmonary metastases?

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* 20. What would you recommend as the preferred approach to resecting bilateral colorectal pulmonary metastases?

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* 21. In the case of bilateral staged pulmonary metastasectomy, what time interval do you consider between the 2 operations?

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* 22. Extend of resection and surgical technique (from Question 22 to Question 26)
Which type of resection do you prefer for a solitary peripheral colorectal pulmonary metastasis, if all options are possible

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* 23. What type of treatment do you prefer for a centrally located colorectal pulmonary metastasis in an operable patient?

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* 24. What type of treatment do you prefer for colorectal pulmonary metastases in an inoperable patient?

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* 25. Would you perform a pneumonectomy to achieve a complete resection of colorectal pulmonary metastases?

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* 26. What is the absolute maximum number of colorectal pulmonary metastases that you are willing resect, considering that complete resection is possible

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* 27. Lymph node assessment (from Question 27 to Question 31)
What type of lymph node assessment do you routinely perform during pulmonary metastasectomy for colorectal pulmonary metastases?

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* 28. What type of lymph node assessment do you routinely perform during pulmonary metastasectomy for peripheral colorectal pulmonary metastases?

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* 29. What type of lymph node assessment do you routinely perform during pulmonary metastasectomy for central (requiring an anatomical resection) colorectal pulmonary metastases?

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* 30. What type of approach do you prefer for colorectal pulmonary metastases with suspect hilar (N1) lymph nodes on preoperative imaging?

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* 31. What type of approach do you prefer for colorectal pulmonary metastases with suspect mediastinal (N2) lymph nodes on preoperative imaging?

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* 32. Chemotherapy (from Question 32 to Question 35)
Do you routinely administer preoperative chemotherapy before pulmonary
metastasectomy for resectable colorectal pulmonary metastases?

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* 33. Would you recommend adjuvant chemotherapy after complete resection of colorectal pulmonary metastases?

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* 34. Would you recommend adjuvant chemotherapy after complete resection of colorectal pulmonary metastases with positive mediastinal lymph nodes?

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* 35. Do you routinely analyze biomarkers (RAS status, BRAF, etc) on pulmonary specimen?

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* 36. Follow-up (Question 36 and 37)
What are your standard investigations during follow-up after pulmonary metastasectomy?

  YES NO N/A
Chest CT scan
PET-CT scan
CEA

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* 37. After pulmonary metastasectomy, at what time intervals do you recommend radiological imaging?

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* 38. Feel free to add any comments/considerations to this questionnaire

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