Is palpation in the operating room the best method for surgical planning?

Surgical resection of isolated pulmonary metastatic melanoma improves overall survival in a highly select group of patients. However, the devil is in the details. By that, I mean that a critical examination of how these “selected” patients are identified needs to be made to ensure a benefit from the surgical intervention while sparing those patients with poor outcomes the complications of a thoracic operation. Peterson et al 1 reported a series of more than 1700 patients with pulmonary metastasis from cutaneous melanoma; less than 20% underwent resection of the metastatic disease to the lung. From this and other studies, those patients most likely to benefit harbor solitary lesions; furthermore, incomplete resection offers minimal improvement in survival. Chua et al 2 recently reported a single-institution series of 292 consecutive patients; the median survival for patients undergoing resection of a solitary melanoma metastasis was 35 months, decreasing to 21 months for 2 or 3 melanoma metastases and 10 months for more than 3 distinct lesions, 2 which is not different from the median survival of 8 months for those patients who did not undergo resection of pulmonary metastatic melanoma. 1 Therefore, the preoperative selection of patients is essential to identify those patients most likely to benefit from thoracic surgery and to spare an unnecessary and potentially morbid operation for those who will not benefit. In the current series 3 reported from the group at the John Wayne Cancer Institute in Santa Monica, California,reportedinthisissueofArchives,26%ofpatientstaken to the operating room for a thoracic resection of pulmonary melanoma metastases have more lesions than anticipated based on preoperative imaging using contrastenhancedcomputedtomography.Theseadditionallesions were small (median size of 5 mm) and located in a different lobe than the index lesion in one-third of patients. Although Kidner et al 3 recommend caution when considering a thoracoscopic approach (because the additional lesions were identified by palpation or visual inspection), their data are really a plea for better preoperative imaging for more accurate patient selection. As additional unsuspected lesions are identified during the exploratory phase of the operation, the benefits of resection start to decrease. Although resection of all palpable or noticeable melanomas may seem a surgical success, biologywilltriumphattheendoftheday.Wemuststrive to move from “selected” patients for surgical procedures to “accurately and individually selected” patients. Until then, a surgeon’s hands may be the best tool to facilitate surgical planning.