Substernal hand-assisted thoracoscopy (HATS) has been proposed as a reliable surgical method with which to perform a bilateral lung metastasectomy. Herein, we review our 15-year experience with this approach for the purpose of understanding the long-term results in a large study cohort. Methods: The study cohort was a series of 87 patients that underwent a HATS lung metastasectomy between 1995 and 2010. We focused on the main surgical findings including the ability of this approach to

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... the detection of unexpected pulmonary lesions. Overall and disease-free survival rates were analyzed in a long-term follow up using the Kaplan-Meier method. Results: A total of 219 lesions were removed. Of these, 191 proved to be malignant. This figure accounted for 31 (19.3%) unexpected lung metastases not previously identified at imaging work-up. Eighteen nodules previously suggested as metastatic lesions proved to be benign. On the basis of these findings sensitivity, specificity, positive and negative predictive values for imaging work-up in detecting lung metastases were 79.6%, 41.3%, 86.4%, and 30.5%, respectively. Lesions sized <7 mm showed the highest false negative rate. Postoperatively no major complications occurred. Overall survival rates at 3 and 5 years were 57.9% and 38.4%, respectively. Disease-free interval after primary cancer removal, but not all metastases nor bilateral spread, was related to survival (P = 0.015). Conclusions: In our experience, HATS resulted in a considerable percentage of resected lung metastases not previously detected at imaging work-up. We recommend this approach whenever feasible as it can conciliate low invasiveness and completeness of surgical resection. Substernal HATS makes it possible to detect a considerable number of unexpected lesions in patients undergoing lung metastasectomy with low surgical trauma. This study reinforces the role of this approach in the setting of lung metastasectomy, due to the large patient series and long-term follow-up.t ca_38 45..53 Substernal metastasectomy: 15-years' results F. Tacconi et al.