Pulmonary metastasectomy across primary tumor types: a histology- and treatment-state–calibrated decision framework

Pulmonary metastasectomy (PM) is used across biologically heterogeneous malignancies, although most evidence describes outcomes in selected surgical cohorts. Conventional prerequisites identify technical eligibility more reliably than incremental treatment benefit. The same pulmonary anatomy may represent lung-limited recurrence, post-treatment residual disease, or limited progression during otherwise effective systemic therapy. This structured narrative review proposes a histology- and treatment-state–calibrated decision framework. Initial literature identification and reading began in March 2026, with supplementary searches in July and a pre-submission update on 19 September 2026; targeted evidence checks were undertaken during revision on 20 October 2026. Four descriptive evidence categories distinguish randomized comparisons, nonrandomized comparisons, noncomparative outcomes, and case-based or expert reasoning; they do not grade certainty. Three proposed gates address diagnostic and staging validity, coherence of treatment intent with systemic therapy, and complete local treatment at an acceptable lifetime parenchymal cost. Six domains refine multidisciplinary discussion: intent, systemic-treatment response, kinetics, distribution, resectability, and evidentiary uncertainty. The framework has not been clinically validated. Selected pathways include colorectal cancer, bone and soft-tissue sarcomas, renal cell carcinoma, melanoma, gynecologic and pediatric tumors, germ-cell tumors, breast and prostate cancer, and adrenocortical carcinoma. Selective PM is established practice in colorectal cancer and sarcoma, but its incremental survival benefit remains uncertain. Renal cell carcinoma and melanoma require response-informed sequencing with contemporary systemic therapy. Post-chemotherapy residual disease in nonseminomatous germ-cell tumors follows a distinct protocol-defined pathway. Breast and prostate cancer usually require diagnostic or exceptional-case reasoning. Nodal assessment can inform staging and prognosis without established therapeutic benefit. Surgery, stereotactic body radiotherapy, ablation, systemic treatment, and surveillance require comparison within the same clinical state. PM is most defensible when it addresses a defined therapeutic problem, offers a plausible advantage over alternatives, and preserves future options. Priorities are prospective comparisons and carefully designed observational analyses, including target-trial emulation, with recurrence, survival, functional, and patient-reported outcomes matched to treatment intent.