Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer

Current management of acute malignant large bowel obstruction: a systematic review

BACKGROUND

The management of colonic obstruction has changed in recent years. In distal obstruction, optimal treatment remains controversial, particularly after the appearance and use of colonic endoluminal stents. The purpose of this study was to review the current treatment of acute malignant large bowel obstruction according to the level of evidence of the available literature.

METHODS

A systematic search was conducted in PubMed, MEDLINE, Embase, and Google Scholar for articles published through January 2013 to identify studies of large bowel obstruction and colorectal cancer. Included studies were randomized and nonrandomized controlled trials, reviews, systematic reviews, and meta-analysis.

RESULTS

After a literature search of 1,768 titles and abstracts, 218 were selected for full-text assessment; 59 studies were ultimately included. Twenty-five studies of the diagnosis and treatment of obstruction and 34 studies of the use of stents were assessed.

CONCLUSIONS

In view of the various alternatives and the lack of high-grade evidence, the treatment of distal colonic obstruction should be individually tailored to each patient.

Neoadjuvant chemotherapy can improve outcome of colorectal cancer patients with unresectable metastasis

BACKGROUND

The prognosis for colorectal cancer (CRC) patients with unresectable metastases is dismal. This study compared outcomes of different metastatic treatments.

PATIENTS AND METHODS

We collected 653 CRC cases with unresectable metastases including 490 cases receiving primary tumor resection then chemotherapy (surgery group) and 163 patients receiving neoadjuvant chemotherapy then did or did not receive operations (chemotherapy (C/T) group) from 2004 to 2010. The statistical endpoint was overall survival from the date of diagnosis.

RESULTS

In the C/T group, 124 (76%) patients received an operation after 9.0 ± 6.2 months of chemotherapy, including 57 (34.9%) patients with curative surgery. The C/T group had a higher proportion of T4 lesions (37.4%) than the surgery group (26.9%). Survival of the C/T group was longer than that of the surgery group (28.8 ± 8.8 vs. 24.3 ± 7.5 months; p = 0.043). Survival of 57 patients receiving curative surgery was 36.0 ± 6.3 months, which was significantly better than that of the 67 patients receiving palliative resection (25.2 ± 5.6, p < 0.001). In the surgery group, 42 (8.6%) patients received curative metastasectomy after 8.5 ± 7.1 months of postoperative chemotherapy; survival was 30.8 ± 7.8 months, which was significantly better than that of patients who did not receive metastasectomy (22.4 ± 6.3 months). In multivariate analysis, poor differentiation, lymphovascular invasion, isolated cancer nodules, clinical risk score, and curative surgery were independent prognostic factors of overall patient survival.

CONCLUSIONS

Neoadjuvant chemotherapy can improve outcome of CRC patients with unresectable metastases.

Should noncurative resection of the primary tumour be performed in patients with stage iv colorectal cancer? A systematic review and meta-analysis

PURPOSE

Surgical resection of the primary tumour in patients with advanced colorectal cancer (crc) remains controversial. This review compares survival in patients with advanced crc who underwent surgical resection of the primary tumour with that in patients not undergoing resection, and determines rates of post-operative mortality and nonfatal complications, the primary tumour complication rate, the non-resection surgical procedures rate, and quality of life (qol).

METHODS

Reports in the central, medline, and embase databases were searched for relevant studies, which were selected using pre-specified eligibility criteria. The search was also restricted to publication dates from 1980 onward, the English language, and studies involving human subjects. Screening, evaluation of relevant articles, and data abstraction were performed in duplicate, and agreement between the abstractors was assessed. Articles that met the inclusion criteria were assessed for quality using the Newcastle-Ottawa Scale. Data were collected and synthesized per protocol.

RESULTS

From among the 3379 reports located, fifteen retrospective observational studies were selected. Of the 12,416 patients in the selected studies, 8620 (69%) underwent surgery. Median survival was 15.2 months (range: 10-30.7 months) in the resection group and 11.4 months (range: 3-22 months) in the non-resection group. Hazard ratio for survival was 0.69 [95% confidence interval (ci): 0.61 to 0.79] favouring surgical resection. Mean rates of postoperative mortality and nonfatal complications were 4.9% (95% ci: 0% to 9.7%) and 25.9% (95%ci: 20.1% to 31.6%) respectively. The mean primary tumour complication rate was 29.7% (95% ci: 18.5% to 41.0%), and the non-resection surgical procedures rate in the non-resection group was 27.6% (95 ci: 15.4% to 39.9%). No study provided qol data.

CONCLUSIONS

Although this review supports primary tumour resection in advanced crc, the results have significant biases. Randomized trials are warranted to confirm the findings.

Does comorbidity interact with colorectal cancer to increase mortality? A nationwide population-based cohort study

BACKGROUND

It is unknown whether comorbidity interacts with colorectal cancer (CRC) to increase the rate of mortality beyond that explained by the independent effects of CRC and comorbid conditions.

METHODS

We conducted a cohort study (1995-2010) of all Danish CRC patients (n=56963), and five times as many persons from the general population (n=271670) matched by age, gender, and specific comorbidities. To analyse comorbidity, we used the Charlson Comorbidity Index (CCI) scores. We estimated standardised mortality rates per 1000 person-years, and calculated interaction contrasts as a measure of the excess mortality rate not explained by the independent effects of CRC or comorbidities.

RESULTS

Among CRC patients with a CCI score=1, the 0-1 year mortality rate was 415 out of 1000 person-years (95% confidence interval (CI): 401, 430) and the interaction accounted for 9.3% of this rate (interaction contrast=39 out of 1000 person-years, 95% CI: 22, 55). For patients with a CCI score of 4 or more, the interaction accounted for 34% of the mortality (interaction contrast=262 out of 1000 person-years, 95% CI: 215, 310). The interaction between CRC and comorbidities had limited influence on mortality beyond 1 year after diagnosis.

CONCLUSION

Successful treatment of the comorbidity is pivotal and may reduce the mortality attributable to comorbidity itself, and also the mortality attributable to the interaction.

Palliative resection of the primary tumour in patients with Stage IV colorectal cancer: systematic review and meta-analysis of the early outcome after laparoscopic and open colectomy

AIM

Resection of the primary tumour in patients with Stage IV colorectal cancer may be performed to avoid future tumour-related complications whilst on systemic treatment. We compared the safety and efficacy of laparoscopic and open colectomy in this patient group.

METHOD

PubMed, MEDLINE and the Cochrane Library were searched in the English literature for studies between January 2000 and October 2012 dealing with laparoscopic resection of the primary tumour in Stage IV disease. Single-arm laparoscopic studies were systematically reviewed. Prospective and retrospective studies were included for meta-analysis. End-points include safety, complications, mortality and cancer specific outcome including 5-year and median survival.

RESULTS

Eleven studies comprising 1165 patients undergoing palliative laparoscopic colectomy for Stage IV colorectal cancer were included. Five studies were comparative studies of laparoscopic and open colectomy. The former took longer (pooled mean difference (MD) = 41.52, 95% CI = 11.47-71.56, Z = 2.71, P = 0.007), but resulted in a shorter length of stay (pooled MD = -2.41, 95% CI = -3.84 to -0.99, Z = 3.32, P = 0.0009), with fewer postoperative complications (pooled odds ratio = 0.53, 95% CI = 0.32-0.87, Z = 2.51, P = 0.01) and lower estimated blood loss (pooled MD = -47.71, 95% CI = -80.00 to -15.42, Z = 2.90, P = 0.004). Median survival ranged between 11.4 and 30.1 months.

CONCLUSION

Palliative colectomy performed laparoscopically is associated with a better perioperative outcome than open colectomy. Survival is dependent on the response to systemic chemotherapy.

Clinical outcome of IBD-associated versus sporadic colorectal cancer: a matched-pair analysis

PURPOSE

This study assesses the perioperative course and long-term survival of inflammatory bowel disease (IBD)-associated vs. sporadic colorectal cancer (IBD-CRC vs. SCRC) after elimination of known confounders.

METHODS

Between 1991 and 2007, n = 3,299 patients underwent surgery for CRC at our institution. Thirty-three IBD patients were identified and compared to 165 SCRC using a matched-pair analysis (1:5 scenario). As matching parameters were used: age, gender, Union Internationale Contre le Cancer (UICC) stage, site of primary lesion, and date of surgery. After univariate analysis of the perioperative course, a multivariate survival analysis (Cox) of all patients (n = 198) was performed.

RESULTS

Significant differences were shown for preoperative symptoms (p = 0.022), transfusion rate (p = 0.01), ileostomy construction rate (p = 0.001), total complication rate (p = 0.042), and hospital stay (15 vs. 11 days, p < 0.001). Local tumor recurrence was three times higher in IBD-CRC (p = 0.004), and the 5-year survival rate was lower (49 % vs. 67 %, p = 0.03). IBD, advanced UICC stage, and synchronous liver metastasis were identified as independent prognostic factors.

CONCLUSION

We demonstrate for the first time survival differences between IBD-CRC and SCRC after elimination of five known confounders. This might be caused by a difference in tumor biology resulting in a higher local recurrence rate in IBD-CRC.

Multicenter study of short- and long-term outcomes of laparoscopic palliative resection for incurable, symptomatic stage IV colorectal cancer in Japan

BACKGROUND

This Japanese multicenter retrospective study evaluated short- and long-term outcomes of palliative laparoscopic procedures for symptomatic stage IV colorectal cancer compared with conventional open procedures.

METHODS

Of 968 eligible patients with stage IV colorectal cancer enrolled during January 2006-December 2007 from 41 participating surgical units (Japan Society of Laparoscopic Colorectal Surgery Group), we studied 409 patients who underwent palliative resection of symptomatic primary colorectal tumor.

RESULTS

Data from patients with laparoscopic resection (n = 98) and open colorectal resection (n = 311) were analyzed. Eleven (11.2 %) laparoscopic operations were converted to an open procedure. Fewer complications were reported for laparoscopic resections than for open procedures (13.3 vs. 26.7 %; p = 0.0042). Postoperative hospital stay was significantly shorter in the laparoscopic vs. open resection group (median, 14 vs. 17 days; p = 0.0242). Postoperative chemotherapy treatment was administered to 245 (78.9 %) patients in the open and 78 (79.6 %) patients in the laparoscopic resection group. Time from surgery to start of postoperative chemotherapy was significantly shorter in the laparoscopic vs. open resection group (median, 32 vs. 27 days; p = 0.0487). Median survival time between the two groups was not significantly different (22.0 vs. 22.2 months; p = 0.948).

CONCLUSIONS

Laparoscopic palliative resection results in reduced postoperative complications and earlier recovery with acceptable long-term outcomes comparable with open surgery. When performed by experienced surgeons in selected patients, it may be a safe and feasible option. Because of the potential of significant bias arising from the included studies, further randomized controlled trials should be undertaken to confirm this bias.

Surgery in asymptomatic patients with colorectal cancer and unresectable liver metastases: the authors' experience

PURPOSE

In asymptomatic patients with Stage IV colorectal cancer, the debate continues over the efficacy of primary resection compared to chemotherapy alone. The aim of this study was to define the optimal management for asymptomatic patients with colorectal cancer and unresectable liver metastases.

PATIENTS AND METHODS

Patients receiving elective surgery (n = 17) were compared to patients receiving chemotherapy only (n = 31). Data concerning patients' demographics, location of primary tumor, comorbidities, performance status, Child-Pugh score, extension of liver metastases, size of primary, and other secondary locations were collected.

RESULTS

Thirty-day mortality after chemotherapy was lower than that after surgical resection (19.3% versus 29.4%; not significant). In patients with >75% hepatic involvement, mortality at 1 month was higher after receiving surgical treatment than after chemotherapy alone (50% versus 25%). In patients with <75% hepatic involvement, 30-day mortality was similar in both groups (not significant). Thirty-day mortality in patients with Stage T3 was lower in those receiving chemotherapy (16.7% versus 30%; not significant). Overall survival was similar in both groups. The risk of all-cause death after elective surgery (2.1) was significantly higher than in patients receiving chemotherapy only (P = 0.035).

CONCLUSION

This study demonstrated that in palliative treatment of asymptomatic unresectable Stage IV colorectal cancer, the overall risk of death was significantly higher after elective surgery compared to patients receiving chemotherapy alone. However, in the literature, there is no substantial difference between these treatments. New studies are required to better evaluate outcomes.

Patterns of Practice in the Radiation Therapy Management of Rectal Cancer: Survey of the Interregional Group Piedmont, Valle d'Aosta and Liguria of the “Associazione Italiana di Radioterapia Oncologica (AIRO)”

Aims and background

To report the survey about the main aspects on the use of radiotherapy for the treatment of rectal cancer in Piedmont and Liguria.

Methods and study design

Sixteen centers (11 from Piedmont and 5 from Liguria) received and answered by email a questionnaire data base about clinical and technical aspects of the treatment of rectal cancer. All data were incorporated in a single data base and analyzed.

Results

Data regarding 593 patients who received radiotherapy for rectal cancer during the year 2009 were collected and analyzed. Staging consisted in colonoscopy, thoracic and abdominal CT, pelvic MRI and endoscopic ultrasound. PET/CT was employed to complete staging and in the treatment planning in 12/16 centers (75%). Neoadjuvant radiotherapy was employed more frequently than adjuvant radiotherapy (50% vs 36.4%), using typically a total dose of 45 Gy with 1.8 Gy/fraction. Concurrent chemoradiation with 5-fluorouracil or capecitabine was mainly employed in neoadjuvant and adjuvant settings, whereas oxaliplatin alone or in combination with 5-FU or capecitabine and leucovorin was commonly employed as the adjuvant agent. The median interval from neoadjuvant treatment to surgery was 7 weeks after long-course radiotherapy and 8 days after short-course radiotherapy. The pelvic total dose of 45 Gy in the adjuvant setting was the same in all the centers. Doses higher than 45 Gy were employed with a radical intent or in case of positive surgical margins. Hypofractionated regimens (2.5, 3 Gy to a total dose of 35–30 Gy) were used in the palliative setting. No relevant differences were observed in target volume definition and patient setup. Twenty-six patients (4.4%) developed grade 3 acute toxicity. Follow-up was scheduled in a similar way in all the centers.

Conclusions

No relevant differences were found among the centers involved in the survey. The approach can help clinicians to address important clinical questions and to improve consistency and homogeneity of treatments.

Non-resection versus resection for an asymptomatic primary tumour in patients with unresectable stage IV colorectal cancer

BACKGROUND

In a majority of patients with stage IV colorectal cancer, the metastatic disease is not resectable and the focus of management is on how best to palliate the patient. How to manage the primary tumour is an important part of palliation. A small proportion of these patients present with either obstructing or perforating cancers and require urgent surgical care. However, a majority are relatively asymptomatic from their primary cancer. Chemotherapy has been shown to prolong survival in this group of patients, and a majority of patients would be treated this way. Nonetheless, A recent meta-analysis (Stillwell 2010) suggests an improved overall survival and reduced requirement for emergency surgery in those patients who undergo primary tumour resection. This review was also able to quantify the mortality and morbidity associated with surgery to remove the primary.

OBJECTIVES

To determine if there is an improvement in overall survival following resection of the primary cancer in patients with unresectable stage IV colorectal cancer and an asymptomatic primary who are treated with chemo/radiotherapy.

SEARCH METHODS

In January 2012 we searched for published randomised and non-randomised controlled clinical trials without language restrictions using the following electronic databases: CENTRAL (the Cochrane Library (latest issue)), MEDLINE (1966 to date), EMBASE (1980 to date), Science Citation Index (1981 to date), ISI Proceedings (1990 to date), Current Controlled Trials MetaRegister (latest issue), Zetoc (latest issue) and CINAHL (1982 to date).

SELECTION CRITERIA

Randomised controlled trials and non-randomised controlled studies evaluating the influence on overall survival of primary tumour resection versus no resection in asymptomatic patients with unresectable stage IV colorectal cancer who are treated with palliative chemo/radiotherapy.

DATA COLLECTION AND ANALYSIS

We conducted the review according to the recommendations of The Cochrane Collaboration and the Cochrane Colorectal Group. "Review Manager 5" software was used.

MAIN RESULTS

A total of 798 studies were identified following the initial search. No published or unpublished randomised controlled trials comparing primary tumour resection versus no resection in asymptomatic patients with unresectable stage IV colorectal cancer who were treated with chemo/radiotherapy were identified. Seven non-randomised studies, potentially eligible for inclusion, were identified: 2 case-matched studies, 2 CCTs and 3 retrospective cohort studies. Overall, these trials included 1.086 patients (722 patients treated with primary tumour resection, and 364 patients managed first with chemotherapy and/or radiotherapy).

AUTHORS' CONCLUSIONS

Resection of the primary tumour in asymptomatic patients with unresectable stage IV colorectal cancer who are managed with chemo/radiotherapy is not associated with a consistent improvement in overall survival. In addition, resection does not significantly reduce the risk of complications from the primary tumour (i.e.  obstruction, perforation or bleeding). Yet there is enough doubt with regard to the published literature to justify further clinical trials in this area. The results from an ongoing high quality randomised controlled trial will help to answer this question.

Resection of the primary tumour versus no resection prior to systemic therapy in patients with colon cancer and synchronous unresectable metastases (UICC stage IV): SYNCHRONOUS--a randomised controlled multicentre trial (ISRCTN30964555)

Background

Currently, it remains unclear, if patients with colon cancer and synchronous unresectable metastases who present without severe symptoms should undergo resection of the primary tumour prior to systemic chemotherapy. Resection of the primary tumour may be associated with significant morbidity and delays the beginning of chemotherapy. However, it may prevent local symptoms and may, moreover, prolong survival as has been demonstrated in patients with metastatic renal cell carcinoma. It is the aim of the present randomised controlled trial to evaluate the efficacy of primary tumour resection prior to systemic chemotherapy to prolong survival in patients with newly diagnosed colon cancer who are not amenable to curative therapy.

Methods/design

The SYNCHRONOUS trial is a multicentre, randomised, controlled, superiority trial with a two-group parallel design. Colon cancer patients with synchronous unresectable metastases are eligible for inclusion. Exclusion criteria are primary tumour-related symptoms, inability to tolerate surgery and/or systemic chemotherapy and history of another primary cancer. Resection of the primary tumour as well as systemic chemotherapy is provided according to the standards of the participating institution. The primary endpoint is overall survival that is assessed with a minimum follow-up of 36 months. Furthermore, it is the objective of the trial to assess the safety of both treatment strategies as well as quality of life.

Discussion

The SYNCHRONOUS trial is a multicentre, randomised, controlled trial to assess the efficacy and safety of primary tumour resection before beginning of systemic chemotherapy in patients with metastatic colon cancer not amenable to curative therapy.

Trial registration

ISRCTN30964555

Laparoscopic versus open colorectal resections in patients with symptomatic stage IV colorectal cancer

BACKGROUND

The purpose of this study was to evaluate short-term and oncologic outcomes of laparoscopic resection (LR) for patients with symptomatic stage IV colorectal cancer compared with open resection (OR).

METHODS

This study is a retrospective analysis of a prospective database. Patients with a minimum follow-up of 12 months after LR or OR for metastatic colorectal cancer were included. All analyses were performed on an "intention-to-treat" basis.

RESULTS

A total of 162 consecutive patients submitted to LR and 127 submitted to OR were included. In the LR group, conversion rate was 26.5 %, mostly due to locally advanced disease (88.4 %). A greater risk of conversion was observed among patients with a tumor size greater than 5 cm regardless the tumor site (P = 0.07). Early postoperative outcome was significantly better for LR group, with a shorter hospital stay (P = 0.008), earlier onset of adjuvant treatment, and similar postoperative complications (P = 0.853) and mortality rates (P = 0.958). LR for rectal cancer was associated with a higher morbidity compared with colon cancer (P = 0.058). During a median follow-up time of 72 months, there was no significant difference in overall survival between the two groups (P = 0.622).

CONCLUSIONS

LR for symptomatic metastatic CRC is safe and, compared with OR, is associated with a shorter hospital stay and with similar survival rates. Concerns remain about LR of bulky tumors and rectal cancers due to the increased risk of conversion and postoperative complications.

Palliative resection of the primary tumour in stage IV rectal cancer

AIM

The aim of this study was to investigate the use of resection in a cohort of palliatively treated patients with stage IV rectal cancer. To avoid selection bias, particular attention was paid to correction for comorbidity and extent of disease.

METHOD

Patients with stage IV rectal cancer in two hospitals in Groningen were consecutively included over a 5-year period. Comorbidity was defined as major (dementia, cardiac failure or left ventricle ejection fraction <30%, or severe chronic obstructive pulmonary disease), minor (diabetes, hypertension, mild renal disease or mild pulmonary disease) or none. The effect of patient and disease characteristics on survival was assessed using Kaplan-Meier and Cox regression analyses.

RESULTS

Of 88 patients, 11 (13%) underwent elective surgical resection without chemotherapy, 15 (17%) received both elective resection and chemotherapy, 21 (24%) underwent palliative chemotherapy only and 41 (47%) had supportive care only. The extent of disease (P<0.01), hospital (P=0.02) and comorbidity (P=0.04) were correlated with worse survival. Patients treated surgically survived for longer than patients treated nonsurgically, when the data were corrected for age, comorbidity, extent of disease and hospital [hazard ratio (HR)=0.4 (95% CI=0.2-0.7)]. Perioperative morbidity was seen in 38% of the patients, and 30-day mortality was 0%.

CONCLUSION

In this retrospective cohort, resection was associated with longer survival independently of the extent of distant metastases, age and comorbidity.

Stage IV colorectal cancers: an analysis of factors predicting outcome and survival in 728 cases

INTRODUCTION

Stage IV colorectal cancer (CRC) is a heterogeneous disease with many treatment options. The optimum management algorithm is yet to be established. The aim of this study was to evaluate the prognostic factors of survival and to determine the operative benefit of resection of the primary tumour followed by chemotherapy.

METHODS

Seven hundred twenty-eight consecutive patients who presented with stage IV CRC from 1999 to 2007 were identified. The demographics and clinicopathological characteristics of these patients were reviewed. Survival curves were constructed using the Kaplan-Meier method. Multivariate analysis assessed independent prognostic factors.

RESULTS

In the surgical management of the primary, 79% (n = 572) were performed electively, 18% (n = 134) as an emergency procedure and 3% (n = 22) did not have any surgery. Twelve percent (n = 78) had a permanent stoma. Major morbidity was 4.3% (n = 31), and 30-day mortality was low at 6% (n = 46). Ten percent (n = 71) had a subsequent metasectomy. Patients who underwent curative resections tended to be female (p = 0.05), of a younger age group (age, ≤ 50; p = 0.005), as well as had better haemoglobin (p = 0.0001) and albumin levels (p = 0.0001). For the study cohort, the cancer-specific survival (CSS) at 1 year was 47.9% [95% confidence interval (CI), 44.2-51.6%], 3-year CSS was 10.8% (95% CI, 3.3-13.3%) and 5-year CSS was 7.0% (95% CI, 4.8-9.2%). CSS was significantly higher in patients that underwent colonic resection. In cases where resection of the primary was possible, multivariate analysis revealed that CEA value >40 ng/ml, low albumin levels ≤ 34 g/l, poorly differentiated tumours, advanced tumour stage (T3/T4), nodal disease (N1/N2) and presence of diffuse metastasis were all significant factors associated with poorer cancer-specific survival.

CONCLUSION

This study has shown a good survival benefit in stage IV CRC when an aggressive policy of primary resection is adopted. Resection of metastases with curative intent should be performed whenever possible.

Multivariate Analysis of the Survival Rate for Treatment Modalities in Incurable Stage IV Colorectal Cancer

PURPOSE

The aim of this study was to compare survival in patients that underwent palliative resection treatment versus non-resection for incurable colorectal cancer (ICRC).

METHODS

The case records of 201 patients with ICRC between January 2000 and December 2009 were reviewed. Demographics, American Society of Anesthesiologists (ASA) score, carcinoembryonic antigen (CEA) level, the location of the colon cancer, histology, metastasis, treatment options and median survival were analyzed retrospectively. We divided the patients into four groups according to the treatment modalities: resection alone, resection with post-operative chemotherapy, non-resection treatment by chemotherapy alone, and stent or bypass. Median survival times were compared according to each treatment option, and the survival rates were analyzed.

RESULTS

105 patients underwent palliative resection whereas 96 were treated with non-resection modalities. A palliative resection was performed in 44 cases for resection alone and in 61 cases for resection with post-operative chemotherapy. In patients treated with non-resection of the primary tumor, chemotherapy alone was done in 65 cases and stent or bypass in 31 cases. Multivariate analysis showed a median survival of 14 months in patients with palliative resections with post-operative chemotherapy, which was significantly higher than those for chemotherapy alone (8 months), primary tumor resection alone (5 months), and stent or bypass (5 months). Gender, age, ASA score, CEA level, the location of colon cancer, histology and the presence of multiple metastases were not independent factors in association with the median survival rate.

CONCLUSION

In the treatment of ICRC, palliative resection followed by post-operative chemotherapy shows the most favorable median survival compared to other treatment options.

Outcome and natural history of patients with stage IV colorectal cancer receiving chemotherapy without primary tumor resection

BACKGROUND

There is a trend toward nonsurgical management of patients with nonobstructing metastatic (stage IV) colorectal cancer (CRC), although some will eventually undergo surgery. We examined patients with metastatic CRC who were managed with an intact primary tumor.

METHODS

An institutional review board (IRB)-approved database was retrospectively reviewed. All patients presenting with stage IV CRC from 2000 to 2008 were identified and analyzed.

RESULTS

Among the 255 patients identified, 112 were taken directly to the operating room for either primary tumor resection or colostomy/bypass. Among the remaining 143 patients, 97 were managed without developing primary tumor-related symptoms, and 14 (9.8%) developed significant primary tumor-related symptoms necessitating operative or endoscopic management. Of the patients who developed symptoms, oxaliplatin and/or irinotecan was used among 71.4% of patients, and bevacizumab in 50%. Forty-two patients in the series underwent elective primary tumor resection after receiving chemotherapy. No independent predictors for development of primary tumor-related symptoms could be identified after controlling for age, gender, tumor location, number of metastatic sites, and type of chemotherapy. Median overall survival was 34 months for those who underwent elective primary tumor resection after chemotherapy, and 16 months for those who failed chemotherapy and developed symptoms.

CONCLUSIONS

Among patients with metastatic CRC without an initial indication for surgery, incidence of obstruction or perforation after initiating chemotherapy was low (9.8%). No predictors of primary tumor-related complications could be identified. Survival was favorable among the highly selected cohort of patients who underwent elective primary tumor resection after chemotherapy.

Expandable metal stents for malignant colorectal strictures

The surgical management of malignant colorectal obstruction is still controversial and has higher associated mortality and complication rates compared with elective surgery. Placement of self-expanding metallic stents (SEMS) has been proposed as an alternative therapeutic approach for colonic decompression of patients with acute malignant obstruction. SEMS placement may be used both as a bridge to surgery in patients who are good candidates for curative resection and for palliation of those patients presenting with advanced stage disease or with severe comorbid medical illnesses.

Systematic review of prognostic factors related to overall survival in patients with stage IV colorectal cancer and unresectable metastases

BACKGROUND

With the improvements in newer chemotherapeutic agents, the role of primary tumour resection in patients with stage IV colorectal cancer is controversial. In many cases primary tumour resection is still favoured as first-line management. However, a detailed understanding of independent prognostic factors related to survival is necessary before making this decision.

METHOD

A literature search was conducted using Medline and Embase. Studies that performed multivariate analysis on overall survival of patients with incurable stage IV colorectal cancer were included in this review.

RESULTS

Fourteen retrospective studies involving 3209 patients were included. Clinical variables analysed to consistently have independent prognostic significance for long-term survival included the patients' performance status (<2), volume of liver metastases (<50%), nodal stage (N0), disease-free resection margins, and treatment with chemotherapy and/or primary tumour resection. Cancer antigen (CA) 19-9, low albumin, elevated ALP levels, apical lymph node involvement, presence of ascites, and postoperative transfusion were each assessed by only one study and found to be independently associated with survival. Factors inconsistently reported to have independent prognostic significance were age, ASA score, preoperative CEA levels, primary tumour location, tumour size and differentiation, peritoneal dissemination, and extrahepatic metastases.

CONCLUSION

Each patient should be reviewed individually on the basis of the above independent prognostic factors before deciding to resect the primary tumour. Patients with a poor performance status, extensive hepatic metastases, and extensive nodal disease detected preoperatively are less likely to have a survival benefit. Nonsurgical approaches to manage these patients should be given careful consideration.

Pulmonary sclerosing hemangioma in a 21-year-old male with metastatic hereditary non-polyposis colorectal cancer: report of a case

Background

Pulmonary sclerosing hemangioma (SH) is a rare tumor of the lung predominantly affecting Asian women in their fifth decade of life. SH is thought to evolve from primitive respiratory epithelium and mostly shows benign biological behavior; however, cases of lymph node metastases, local recurrence and multiple lesions have been described.

Case Presentation

We report the case of a 21-year-old Caucasian male with a history of locally advanced and metastatic rectal carcinoma (UICC IV; pT4, pN1, M1(hep)) that was eventually identified as having hereditary non-polyposis colorectal cancer (HNPCC, Lynch syndrome). After neoadjuvant chemotherapy followed by low anterior resection, adjuvant chemotherapy and metachronous partial hepatectomy, he was admitted for treatment of newly diagnosed bilateral pulmonary metastases. Thoracic computed tomography showed a homogenous, sharply marked nodule in the left lower lobe. We decided in favor of atypical resection followed by systematic lymphadenectomy. Histopathological analysis revealed the diagnosis of SH.

Conclusions

Cases have been published with familial adenomatous polyposis (FAP) and simultaneous SH. FAP, Gardner syndrome and Li-Fraumeni syndrome, however, had been ruled out in the present case. To the best of our knowledge, this is the first report describing SH associated with Lynch syndrome.

Palliative radiotherapy in patients with a symptomatic pelvic mass of metastatic colorectal cancer

Background

To evaluate the palliative role of radiotherapy (RT) and define the effectiveness of chemotherapy combined with palliative RT (CCRT) in patients with a symptomatic pelvic mass of metastatic colorectal cancer.

Methods

From August 1995 to December 2007, 80 patients with a symptomatic pelvic mass of metastatic colorectal cancer were treated with palliative RT at Samsung Medical Center. Initial presenting symptoms were pain (68 cases), bleeding (18 cases), and obstruction (nine cases). The pelvic mass originated from rectal cancer in 58 patients (73%) and from colon cancer in 22 patients (27%). Initially 72 patients (90%) were treated with surgery, including 64 complete local excisions; 77% in colon cancer and 81% in rectal cancer. The total RT dose ranged 8-60 Gy (median: 36 Gy) with 1.8-8 Gy per fraction. When the α/β for the tumor was assumed to be 10 Gy for the biologically equivalent dose (BED), the median RT dose was 46.8 Gy₁₀ (14.4-78). Twenty one patients (26%) were treated with CCRT. Symptom palliation was assessed one month after the completion of RT.

Results

Symptom palliation was achieved in 80% of the cases. During the median follow-up period of five months (1-44 months), 45% of the cases experienced reappearance of symptoms; the median symptom control duration was five months. Median survival after RT was six months. On univariate analysis, the only significant prognostic factor for symptom control duration was BED ≥40 Gy₁₀ (p < 0.05), and CCRT was a marginally significant factor (p = 0.0644). On multivariate analysis, BED and CCRT were significant prognostic factors for symptom control duration (p < 0.05).

Conclusions

RT was an effective palliation method in patients with a symptomatic pelvic mass of metastatic colorectal cancer. For improvement of symptom control rate and duration, a BED ≥ 40 Gy₁₀ is recommended when possible. Considering the low morbidity and improved symptom palliation, CCRT might be considered in patients with good performance status.

Predictors of postoperative mortality, morbidity, and long-term survival after palliative resection in patients with colorectal cancer

BACKGROUND

Limited information is available on predictors of postoperative mortality, morbidity, and long-term survival in patients with stage IV colorectal cancer.

OBJECTIVE

This study aimed to identify independent predictors of postoperative mortality and morbidity as well as independent predictors of long-term survival.

DESIGN

This study was planned as a retrospective single-institution review.

SETTING

This study took place at the Department of Surgery, The Royal Brisbane and Women's Hospital, Australia, between 1984 and 2004.

PARTICIPANTS

Prospectively collected data were extracted from the records of 1867 patients undergoing treatment for colorectal cancer. The outcomes for 379 patients undergoing surgical resection of their primary colon or rectal tumor in the presence of unresectable synchronous metastases were analyzed.

MAIN OUTCOME MEASURES

Independent predictive factors for postoperative mortality and morbidity as well as long-term survival were assessed by use of logistic regression and Cox regression analysis.

RESULTS

Thirty-five (9.2%) patients died in the postoperative period and morbidity was 48.3%. Median survival was 11 months. Thirty-day postoperative mortality was independently associated with medical complications (P < .001), emergency operations (P = .001), female sex (P = .002), and age (≥ 70; P = .007) on regression analysis. Elderly (≥ 70) patients with either advanced local disease or extrahepatic metastases were at a particularly high risk. Preoperative predictors of surgical morbidity included male sex (P = .028) and advanced local disease (P = .036). Preoperative predictors of medical complications included repeat operations (P < .001), elevated urea levels (P = .017), and emergency operations (P = .003). Independent factors associated with poor overall survival included medical complications (P < .001), nodal stage (N2) (P = .004), poor tumor differentiation (P = .006), and apical lymph node involvement (P = .042). A subgroup of patients with advanced nodal disease (N2) and a poor tumor differentiation had a significantly poorer prognosis.

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSION

Elderly patients with advanced local disease or extrahepatic metastases are at high risk of 30-day postoperative mortality. Significant nodal disease and poor tumor differentiation are important predictors of long-term survival.

Outcomes in the management of obstructive unresectable stage IV colorectal cancer

AIM

To analyze short term results and to report survival rates in a series of patients after palliative emergency treatment for obstructive left sided colorectal cancer (CRC) with unresectable synchronous metastases.

PATIENTS AND METHODS

From 2004 to 2008, 55 patients were included. Palliative management consisted of stenting to recover bowel patency and starting chemotherapy. Indications for surgery were perforation or failure of stenting. Early failure occurred when decompression after insertion was unsuccessful and late failure when obstruction occurred after successful decompression. Morbidity and mortality were analyzed for stenting and surgery and survival for resected and non-resected patients.

RESULTS

Stenting was scheduled in 49 patients.Morbidity and mortality occurred in 5 and 3 patients respectively. Early failure occurred in 4 patients and late failure in 11 patients. Surgery was indicated in 6 patients for peritonitis at diagnosis and in 11 patients for complications (1 case) or stenting failure (10 cases). Of the 17 operated patients, 12 cases were resected and 5 cases were not. Mortality occurred in 1 case. Resected patients received first-line (12 cases) and second-line (5 cases) systemic chemotherapy based on FOLFIRI or FOLFOX while stented and non-resected patients were similarly treated in 37 cases and 12 cases respectively. Overall survival at 2 years was 39.3% in resected patients and 1% in stented and non-resected patients (p = 0.008).

CONCLUSION

Stenting in palliative stage IV obstructive CRC patients may be less successful as previously thought. Prospective studies are needed to define the role of palliative resection.

Laparoscopic resection of advanced colorectal cancer

Background

Palliative resection of the primary tumour in asymptomatic patients with stage IV colorectal cancer is associated with improved survival and fewer complications. Laparoscopic surgery is widely employed in the curative treatment of colorectal cancer, but its value in advanced colorectal cancer remains unclear.

Methods

All patients who underwent laparoscopic resection of primary colorectal cancer in this unit between June 1991 and Jan 2010 were entered into a prospective computerized database. Outcomes for patients with laparoscopic resection of stage IV colorectal cancer were compared with those of patients who had laparoscopic surgery for stage I disease.

Results

Some 185 patients with stage IV colorectal cancer who underwent laparoscopic resection were compared with 310 patients who had stage I colorectal cancer. Some 94·1 and 98·4 per cent of operations respectively were completed laparoscopically. Hospital stay was slightly longer in the group with stage IV disease (mean 6·2 versus 5·3 days; P = 0·091). The 30-day mortality rate was 2·7 per cent in patients with stage IV disease and 0·6 per cent in those with stage I tumours (P = 0·061). There was no difference in complications. One-year survival rates were 77·8 and 99·0 per cent respectively (P &lt; 0·001).

Conclusion

Short-term outcomes after laparoscopic surgery for stage IV colorectal cancer in selected patients are equivalent to those for stage I cancers.