Surgical resection of primary tumors in patients who present with stage IV colorectal cancer: an analysis of surveillance, epidemiology, and end results data, 1988 to 2000

The Role of Surgery for Asymptomatic Primary Tumors in Unresectable Stage IV Colorectal Cancer

There are still debates regarding the appropriate primary treatment policy for asymptomatic primary colorectal lesions in cases of unresectable metastatic colorectal cancer. Even though there are patients with asymptomatic primary tumors when starting chemotherapy, those patients may still undergo surgery due to complications related to primary tumors in the middle of chemotherapy; therefore, controversy exists regarding surgical resection of primary colorectal lesions in cases where symptoms are absent when making a diagnosis. Thus, based on the published literature, we discuss opinions that prefer first-line surgery for primary tumors as well as opinions favoring first-line chemotherapy for treating unresectable synchronous metastatic colorectal cancer. Although the upfront chemotherapy including targeted agents is suggested as an effective treatment in recent years, the first line surgery has been a preferred treatment for decades. The first line surgery is beneficial to prolong the survival duration given the retrospective analysis of randomized trial data. So far, no prospective comparison study has only focused on the first-line treatment modality; thus, future clinical studies focusing on the survival duration and the quality of life should be performed as soon as possible. Furthermore, at this point, multidisciplinary team approaches would be helpful in finding the appropriate therapy. Regardless of symptoms, the performance status and the tumor burden should be taken into consideration as well. In case of surgical resection, minimally invasive surgery, such as laparoscopic surgery, is recommended.

The Role of Surgery for Asymptomatic Primary Tumors in Unresectable Stage IV Colorectal Cancer

There are still debates regarding the appropriate primary treatment policy for asymptomatic primary colorectal lesions in cases of unresectable metastatic colorectal cancer. Even though there are patients with asymptomatic primary tumors when starting chemotherapy, those patients may still undergo surgery due to complications related to primary tumors in the middle of chemotherapy; therefore, controversy exists regarding surgical resection of primary colorectal lesions in cases where symptoms are absent when making a diagnosis. Thus, based on the published literature, we discuss opinions that prefer first-line surgery for primary tumors as well as opinions favoring first-line chemotherapy for treating unresectable synchronous metastatic colorectal cancer. Although the upfront chemotherapy including targeted agents is suggested as an effective treatment in recent years, the first line surgery has been a preferred treatment for decades. The first line surgery is beneficial to prolong the survival duration given the retrospective analysis of randomized trial data. So far, no prospective comparison study has only focused on the first-line treatment modality; thus, future clinical studies focusing on the survival duration and the quality of life should be performed as soon as possible. Furthermore, at this point, multidisciplinary team approaches would be helpful in finding the appropriate therapy. Regardless of symptoms, the performance status and the tumor burden should be taken into consideration as well. In case of surgical resection, minimally invasive surgery, such as laparoscopic surgery, is recommended.

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.

Racial disparities in advanced-stage colorectal cancer survival

PURPOSE

African-Americans (AA) have a higher incidence of and lower survival from colorectal cancer (CRC) compared with European Americans (EA). In the present study, statewide, population-based data from South Carolina Central Cancer Registry are used to investigate the relationship between race and age on advanced-stage CRC survival.

METHODS

The study population was comprised of 3,865 advanced pathologically documented colon and rectal adenocarcinoma cases diagnosed between 01 January 1996 and 31 December 2006: 2,673 (69 %) EA and 1,192 (31 %) AA. Kaplan-Meier methods were used to generate median survival time and corresponding 95 % confidence intervals (CI) by race, age, and gender. Factors associated with survival were evaluated by fitting Cox proportional hazards regression models to generate hazard ratios (HR) and 95 % CI.

RESULTS

We observed a significant interaction between race and age on CRC survival (p = 0.04). Among younger patients (<50 years), AA race was associated with a 1.34 times (95 % CI 1.06-1.71) higher risk of death compared with EA. Among older patients, we observed a modest increase in risk of death among AA men compared with EA [HR 1.16 (95 % CI 1.01-1.32)] but no difference by race between women [HR 0.94 (95 % CI 0.82-1.08)]. Moreover, we observed that the disparity in survival has worsened over the past 15 years.

CONCLUSIONS

Future studies that integrate clinical, molecular, and treatment-related data are needed for advancing understanding of the racial disparity in CRC survival, especially for those <50 years old.

Comparison of the feasibility of laparoscopic resection of the primary tumor in patients with stage IV colon cancer with early and advanced disease: the short- and long-term outcomes at a single institution

PURPOSE

The role of resection of the primary tumor in patients with stage IV colorectal cancer (CRC) remains controversial. Laparoscopic resection has become an accepted therapeutic option for treating early stage I-III CRC; however, it has not been evaluated for use in patients with advanced stage disease.

METHODS

We conducted a retrospective observational study to evaluate the feasibility of laparoscopic resection of the primary tumor exclusively in patients with stage IV colon cancer compared to open resection in patients with stage IV colon cancer and laparoscopic resection in patients with stage I-III colon cancer in terms of operative results and short- and long-term outcomes.

RESULTS

Laparoscopic resection was performed in 35 stage IV patients and open resection was performed in 40 stage IV patients. One hundred and eighteen stage I-III patients who underwent laparoscopic resection were evaluated. In the comparison between the laparoscopic group and the open group among patients with stage IV colon cancer, postoperative recovery appeared to be better in the laparoscopic group than in the open group, as reflected by shorter times to resumption of a regular diet (p = 0.049), shorter lengths of hospitalization (p = 0.083), increased feasibility of postoperative chemotherapy (p < 0.001), shorter time intervals from surgery to chemotherapy (p = 0.031) and longer median survival (p = 0.078) at the expense of longer operative times (p = 0.025). In the comparison between the laparoscopic resection in stage IV and stage I-III disease groups, no significant differences were observed in operative results and short- and long-term outcomes, except for the rate of ostomy creation (48.5 vs. 8.5%, p = 0.02).

CONCLUSION

Laparoscopic resection of the primary tumor in patients with stage IV colon cancer achieves equivalent results to that performed in patients with stage I-III disease and that performed in patients with stage IV disease using open resection. The use of a minimally invasive approach in the laparoscopic procedure is beneficial because it results in shorter times to resumption of a normal diet, shorter lengths of hospitalization, increased feasibility of postoperative chemotherapy and shorter time intervals from surgery to chemotherapy at the expense of longer operative times. We believe that patients undergoing laparoscopic resection can receive targeted chemotherapy earlier and more aggressively, which might provide a survival benefit.

Bevacizumab-containing chemotherapy is safe in patients with unresectable metastatic colorectal cancer and a synchronous asymptomatic primary tumor

OBJECTIVE

Surgical resection of asymptomatic primary colorectal cancer in patients presenting with synchronous unresectable metastatic disease is controversial. Concerns and controversies remain over combining cytotoxic chemotherapy with bevacizumab in this patient population.

METHODS

We identified medical records of 99 patients with synchronous metastatic primary colorectal cancer who received chemotherapy with bevacizumab as their initial treatment. The incidence of subsequent use of surgery and surgical outcomes were recorded. Patients were also assessed for overall survival.

RESULTS

Patients who received bevacizumab-containing chemotherapy for synchronous metastatic primary colorectal cancer were divided into the non-surgery and surgery groups according to the resection status of their asymptomatic primary tumor. In the non-surgery group, two patients (4.4%) underwent additional surgery, while three patients (5.7%) required surgery for rectovesical fistula in the surgery group. The median overall survival was 17 months for the non-surgery group (95% CI: 10.6-23.3 months) and 23 months for the surgery group (95% CI: 21.3-24.6 months; P = 0.322).

CONCLUSIONS

This study utilizing chemotherapy with bevacizumab did not result in an increased rate of morbidity related to the unresected primary tumor. Survival is not compromised by leaving the primary colon tumor intact.

Primary mFOLFOX6 plus bevacizumab without resection of the primary tumor for patients presenting with surgically unresectable metastatic colon cancer and an intact asymptomatic colon cancer: definitive analysis of NSABP trial C-10

PURPOSE

Major concerns surround combining chemotherapy with bevacizumab in patients with colon cancer presenting with an asymptomatic intact primary tumor (IPT) and synchronous yet unresectable metastatic disease. Surgical resection of asymptomatic IPT is controversial.

PATIENTS AND METHODS

Eligibility for this prospective, multicenter phase II trial included Eastern Cooperative Oncology Group (ECOG) performance status 0 to 1, asymptomatic IPT, and unresectable metastases. All received infusional fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) combined with bevacizumab. The primary end point was major morbidity events, defined as surgical resection because of symptoms at or death related to the IPT. A 25% major morbidity rate was considered acceptable. Secondary end points included overall survival (OS) and minor morbidity related to IPT requiring hospitalization, transfusion, or nonsurgical intervention.

RESULTS

Ninety patients registered between March 2006 and June 2009: 86 were eligible with follow-up, median age was 58 years, and 52% were female. Median follow-up was 20.7 months. There were 12 patients (14%) with major morbidity related to IPT: 10 required surgery (eight, obstruction; one, perforation; and one, abdominal pain), and two patients died. The 24-month cumulative incidence of major morbidity was 16.3% (95% CI, 7.6% to 25.1%). Eleven IPTs were resected without a morbidity event: eight for attempted cure and three for other reasons. Two patients had minor morbidity events only: one hospitalization and one nonsurgical intervention. Median OS was 19.9 months (95% CI, 15.0 to 27.2 months).

CONCLUSION

This trial met its primary end point. Combining mFOLFOX6 with bevacizumab did not result in an unacceptable rate of obstruction, perforation, bleeding, or death related to IPT. Survival was not compromised. These patients can be spared initial noncurative resection of their asymptomatic IPT.

Palliative excisional surgery for primary colorectal cancer in patients with incurable metastatic disease. Is there a survival benefit? A systematic review

AIM

Patients with stage IV colorectal cancer with unresectable metastases can either receive chemotherapy or palliative resection of the primary lesion. In the absence of any randomized data the choice of initial treatment in stage IV colorectal cancer is not based on firm evidence.

METHOD

A search of MEDLINE, Pubmed, Embase and the Cochrane Library database was performed from 1980 to 2010 for studies comparing palliative resection in stage IV colorectal cancer with other treatment modalities. Audits and observational studies were excluded. Median survival was the primary outcome measure. The morbidity and mortality of surgical and nonsurgical treatments were compared.

RESULTS

Twenty-one studies (no randomized controlled trials) were identified. Most demonstrated a survival benefit for patients who underwent palliative resection. Multivariate analysis indicates that tumour burden and performance status are both major independent prognostic variables. Selection bias, incomplete follow up and nonstandardized reporting of complications make the data difficult to interpret.

CONCLUSION

The studies indicate that there may be a survival benefit for primary resection of colorectal cancer in stage IV disease. The findings suggest that resection of the primary tumour should be based on tumour burden and performance status rather than on the presence or absence of symptoms alone.

Open versus laparoscopic resection of primary tumor for incurable stage IV colorectal cancer: a large multicenter consecutive patients cohort study

OBJECTIVE

To investigate the hypothesis that laparoscopic primary tumor resection is safe and effective when compared with the open approach for colorectal cancer patients with incurable metastases.

BACKGROUND

There are only a few reports with small numbers of patients on laparoscopic tumor resection for stage IV colorectal cancer.

METHODS

Data from consecutive patients who underwent palliative primary tumor resection for stage IV colorectal cancer between January 2006 and December 2007 were collected retrospectively from 41 institutions. Short- and long-term outcomes were compared between patients who underwent laparoscopic or open resection.

RESULTS

A total of 904 patients (laparoscopic group: 226, open group: 678) with a median age of 64 years (range: 22-95) were included in the analysis. Conversion was required in 28 patients (12.4%) and the most common reasons for conversion (23/28: 82%) were bulky or invasive tumors. There was no 30-day postoperative mortality in either group. The complication rate (NCI-CTCAE grade 2-4) after laparoscopic surgery (17%) was significantly lower than that after open surgery (24%) (P = 0.02), and the difference was greater (4% vs 12%; P < 0.001) when we limited the analysis to severe (≥grade 3) complications. The median length of postoperative hospital stay in the laparoscopic group was significantly shorter than that in the open group (14 vs 17 days; P = 0.002). In univariate analysis, overall survival for the laparoscopic group was significantly better than that for open surgery (median survival time: 25.9 vs 22.3 months, P = 0.04), although no difference was apparent in multivariate analysis.

CONCLUSIONS

Compared with open surgery, laparoscopic primary tumor resection has advantages in the short term and no disadvantages in the long term. It is a reasonable treatment option for certain stage IV colorectal cancer patients with incurable disease.

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

Simultaneous surgery for primary colorectal cancer and metastatic lesions?

Approximately 20-25% of patients with colorectal cancer present with liver metastases at the time of diagnosis. Traditionally, resection of the primary tumor has been advocated in order to prevent complications of the primary tumor colorectal cancer in patients with synchronous liver metastases. The published data concerning long-term prognosis in this group of patients are discordant. Although some of the reports show survival benefits from resection of the primary tumor, these studies are retrospective with small number of patients and using single drug chemotherapy. For patients with resectable liver metastases, new studies indicate that progression-free survival is best in patients receiving perioperative chemotherapy. In patients with synchronous nonresectable liver metastases and colorectal cancer, there is no published prospective randomized study comparing initial surgery of the primary tumor with neoadjuvant chemotherapy. However, recent publications show that in patients receiving chemotherapy based on oxaliplatin or irinotecan combined with targeted treatments, the complications associated with the primary tumor are less than 10%. The conclusion should be that today prophylactic surgery of asymptomatic primary colorectal cancer in patients with liver metastases cannot be recommended.

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.

Multi-modality treatment of colorectal liver metastases

Liver metastases synchronously or metachronously occur in approximately 50% of colorectal cancer patients. Multimodality comprehensive treatment is the best therapeutic strategy for these patients. However, the optimal pattern of multimodality therapy is still controversial, and it raises several significant concerns. Liver resection is the most important treatment for colorectal liver metastases. The definition of resectability has shifted to focus on the completion of R0 resection and normal liver function maintenance. The role of neoadjuvant and adjuvant chemotherapy still needs to be clarified. The management of either progression or complete remission during neoadjuvant chemotherapy is challenging. The optimal sequencing of surgery and chemotherapy in synchronous colorectal liver metastases patients is still unclear. Conversional chemotherapy, portal vein embolization, two-stage resection, and tumor ablation are effective approaches to improve resectability for initially unresectable patients. Several technical issues and concerns related to these methods need to be further explored. For patients with definitely unresectable liver disease, the necessity of resecting the primary tumor is still debatable, and evaluating and predicting the efficacy of targeted therapy deserve further investigation. This review discusses different patterns and important concerns of multidisciplinary treatment of colorectal liver metastases.

Trends in incidence, treatment and survival of patients with stage IV colorectal cancer: a population-based series

AIM

The incidence, patterns of care and survival were determined in patients with stage IV colorectal cancer (CRC) in a population-based series.

METHOD

Computer records for patients diagnosed with stage IV CRC diagnosed from 1 January 1995 to 31 December 2007 were retrieved from the Rotterdam Cancer Registry. Surgical resection of the primary tumour, chemotherapy use, hepatic surgery and survival were evaluated according to year of diagnosis, age, gender and primary tumour site.

RESULTS

In the southwestern part of the Netherlands, 19 014 new patients with CRC were diagnosed and synchronous metastatic disease was found in 3482 (18%). This proportion increased during the study period, from 16% to 21%. Surgical resection of the primary tumour was performed in approximately 50% of the patients and did not change over time. Postoperative 30-day mortality was 8%. Chemotherapy use increased from 18% in the first period to 56% in the latest period. Liver surgery increased from 4% in the first period to 10% in the latest period. Median survival increased from 7 months to 12 months and 2-year survival increased from 14% to 28%. Two-year survival declined with increasing age and was significantly worse for right-sided tumours (14%).

CONCLUSION

Survival of patients with stage IV CRC has improved over time and this is probably a result of the increased use of chemotherapy and the increased numbers of patients who underwent hepatic surgery.

Elective resection of rectal cancer primary tumor in patients with stage IV disease--own experiences

Optimal management of asymptomatic generalized rectal cancer is still the matter of debate. The aim of the study was to review stage IV rectal cancer patients who were treated in our clinic since 2000 till 2008 in order to evaluate the effectiveness of surgery.

MATERIAL AND METHODS

Fifty-two generalized rectal cancer patients treated with elective resection of primary tumor were identified. Patients' age, sex, duration of hospital stay, modality of surgery, complications, postoperative mortality rate and survival rate were assessed.

RESULTS

Median survival was 16.3 months. Postoperative complications occurred in 29% patients. Postoperative mortality rate was 1.9%.

CONCLUSIONS

In properly selected group of patients elective resection of primary tumor may cause low mortality rate and acceptable morbidity rate. This surgical modality allows to avoid potential complications of tumor local growth.

Surgery of the primary in stage IV colorectal cancer with unresectable metastases

Surgery plays an important role in the treatment of patients with limited metastatic disease of colorectal cancer (CRC). Long term survival and cure is reported in 20-50% of highly selected patients with oligometastatic disease who underwent surgery. This paper describes the role of surgery of the primary tumour in patients with unresectable stage IV colorectal cancer. Owing to the increased efficacy of chemotherapeutic regimens in stage IV colorectal cancer, complications from unresected primary tumours are relatively infrequent. The risk of emergency surgical intervention is less than 15% in patients with synchronous metastatic disease who are treated with chemotherapy. Therefore, there is a tendency among surgeons not to resect the primary tumour in case of unresectable metastases. However, it is suggested that resection of the primary tumour in case of unresectable metastatic disease might influence overall survival. All studies described in the literature (n = 24) are non-randomised and the majority is single-centre and retrospective of nature. Most studies are in favour of resection of the primary tumour in patients with symptomatic lesions. In asymptomatic patients the results are less clear, although median overall survival seems to be improved in resected patients in the majority of studies. The major drawback of all these studies is that primarily patients with a better performance status and better prognosis (less metastatic sites involved) are being operated on. Another limitation of these studies is that few if any data on the use of systemic therapy are presented, which makes it difficult to assess the relative contribution of resection on outcome. Prospective studies on this topic are warranted, and are currently being planned.

CONCLUSION

Surgery of the primary tumour in patients with synchronous metastasised CRC is controversial, although data from the literature suggest that resection might be a positive prognostic factor for survival. Therefore prospective studies on the value of resection in this setting are required.

Colorectal cancer with multiple metastases: is palliative surgery needed?

In patients with symptomatic incurable metastatic colorectal cancer (mCRC), the goal of resection of the primary lesion is to palliate cancer-related morbidity, including obstruction, bleeding, or perforation. In patients with asymptomatic primary tumors and incurable metastatic disease, however, the necessity of primary tumor resection is less clear. Although several retrospective analyses suggest survival benefit in patients who undergo resection of the primary tumor, applying this older evidence to modern patients is out of date for several reasons. Modern chemotherapy regimens incorporating the novel cytotoxic agents oxaliplatin and irinotecan, as well as the target agents bevacizumab and cetuximab, have improved median survival from less than 1 year with the only available single-agent 5-fluorouracil until the mid-1990s to over 2 years. In addition to significant prolongation of overall survival, combinations of novel chemotherapeutic and target agents have allowed improved local and distant tumor control, decreasing the likelihood of local tumor-related complications requiring surgical resection. Resection of an asymptomatic primary tumor risks surgical complications and may postpone the administration of chemotherapy that may offer both systemic and local control. In conclusion, the morbidity and the mortality of unnecessary surgery or surgery that does not improve quality of life or survival in patients with mCRC of a limited life expectancy should be carefully evaluated. With the availability of effective combinations of chemotherapy and target agents, systemic therapy for the treatment of life-threatening metastases would be a preferable treatment strategy for unresectable asymptomatic patients with mCRC.

Reassessing the need for primary tumor surgery in unresectable metastatic colorectal cancer: overview and perspective

In the absence of symptoms, primary tumor resection in patients who present with unresectable metastatic colorectal cancer is of uncertain benefit. Prophylactic surgery has been traditionally considered in this setting in order to prevent subsequent complications of perforation, obstruction, or bleeding later during the treatment course, which may require urgent surgery associated with higher mortality. However, recent data have called into question the efficacy of this upfront surgical strategy. We provide a brief overview of how current combinations of systemic chemotherapy including fluorouracil, oxaliplatin, irinotecan, and targeted biologic agents have allowed improved local (in addition to distant) tumor control, significantly decreasing the incidence of late primary-related complications requiring surgery from roughly 20% in the era of single-agent fluoropyrimidine chemotherapy to almost 7% in the era of modern triple-drug chemotherapy. In addition, we attempt to highlight those factors most associated with subsequent primary tumor-related complications in an effort to identify the subset of patients with synchronous metastatic colorectal cancer who might benefit from a surgery-first approach. Finally, we discuss modern nonsurgical options available for palliation of the primary colorectal tumor and review the outcome of patients for which emergent surgery is eventually required to address primary-related symptoms.

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.

Prognostic value of resection of primary tumor in patients with stage IV colorectal cancer: retrospective analysis of two randomized studies and a review of the literature

Background

In patients with metastatic colorectal cancer (mCRC) with an asymptomatic primary tumor, there is no consensus on the indication for resection of the primary tumor.

Methods

A retrospective analysis was performed on the outcome of stage IV colorectal cancer (CRC) patients with or without resection of the primary tumor treated in the phase III CAIRO and CAIRO2 studies. A review of the literature was performed.

Results

In the CAIRO and CAIRO2 studies, 258 and 289 patients had undergone a primary tumor resection and 141 and 159 patients had not, respectively. In the CAIRO study, a significantly better median overall survival and progression-free survival was observed for the resection compared to the nonresection group, with 16.7 vs. 11.4 months [P < 0.0001, hazard ratio (HR) 0.61], and 6.7 vs. 5.9 months (P = 0.004; HR 0.74), respectively. In the CAIRO2 study, median overall survival and progression-free survival were also significantly better for the resection compared to the nonresection group, with 20.7 vs. 13.4 months (P < 0.0001; HR 0.65) and 10.5 vs. 7.8 months (P = 0.014; HR 0.78), respectively. These differences remained significant in multivariate analyses. Our review identified 22 nonrandomized studies, most of which showed improved survival for mCRC patients who underwent resection of the primary tumor.

Conclusions

Our results as well as data from literature indicate that resection of the primary tumor is a prognostic factor for survival in stage IV CRC patients. The potential bias of these results warrants prospective studies on the value of resection of primary tumor in this setting; such studies are currently being planned.

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.

Colorectal liver metastases

The diagnosis and management of CRLM is complex and requires a multidisciplinary team approach for optimal outcomes. Over the past several decades, the 5-year survival following resection of CRLM has increased and the criteria for resection have broadened substantially. Even patients with multiple, bilateral CRLM, previously thought unresectable, may now be candidates for resection. Two-stage hepatectomy, repeat curative-intent hepatectomy, and even selected resection of extrahepatic metastases have further increased the number of patients who may be treated with curative intent. Multiple liver-directed therapies exist to treat unresectable, incurable patients with adequate survival benefit and morbidity rates.

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.

Elective palliative resection of incurable stage IV colorectal cancer: who really benefits from it?

PURPOSE

Despite the encouraging results of chemotherapy in patients affected by incurable colorectal cancer (CRC), surgical resection of a primitive tumor is still a common approach worldwide. The identification of prognostic factors related to short survival (<6 months) may allow excluding from resective surgery those who may not benefit from it.

METHODS

A retrospective analysis was performed of 15 variables in a population of 71 patients undergoing nonemergency palliative primary resections of incurable CRC, including patients' demographics and clinical/histopathological characteristics of the tumor.

RESULTS

No variables were related to perioperative mortality (8.5% overall). A multivariate analysis revealed that older age (≥80 years) and metastasis to more than 25% of the lymph nodes were associated with survival (4 and 6 months, respectively). Mucoid adenocarcinoma therefore tends to be associated with the prognosis (P = 0.070).

CONCLUSIONS

An elderly age tends to be a contraindication to an elective primary tumor resection in patients affected by incurable CRC. Massive lymph node involvement and mucoid adenocarcinoma should also be considered before planning major colonic surgery.

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.

Palliative endoscopic trans-anal resection of advanced rectosigmoid carcinoma

There is no consensus on optimal treatment of patients with rectosigmoid cancer and unresectable metastatic disease. This is a retrospective review of all patients who underwent palliative endoscopic trans-anal resection (ETAR) of rectosigmoid cancer over a 10-year period. Fourteen patients (11 male) with a mean age 69.7 years (range 51-86) underwent ETAR; 11 for rectal tumours and 3 for rectosigmoid tumours. Indications included tenesmus (5), troublesome bleeding (6), mucous discharge (1) and obstructed defaecation (8). The number of treatment episodes varied from 1 to 4 (median 1). The symptom-free interval was mean 6.25 months (range 2-15). Eight patients had lifelong relief of symptoms and four patients are currently symptom free. There were two short-term failures treated with stenting (1) and abdominoperineal resection (1). There were no immediate post-treatment complications. One patient developed increasing incontinence and another pelvic pain after ETAR attributable to local tumour infiltration. ETAR provides a convenient and safe method of palliation for patients with local symptoms of advanced rectosigmoid carcinoma.

Prognostic factors in survival of colorectal cancer patients with synchronous liver metastasis

AIM

To determine the factors affecting the survival in colorectal cancer patients with synchronous liver metastases.

METHOD

A total of 168 patients who had been treated colorectal cancer with synchronous liver metastases at Guangxi Medical University from January 2000 to December 2005 were identified. Criteria studied consisted of gender, age, time of symptoms, primary tumour location, primary tumour circumference, histological type, grade (tumour differentiation), T-status, N-status, large bowel obstruction, type of operation, primary tumour resection, ascities, location, number and diameter of liver lesions, preoperative CEA and chemotherapy. Survival curves were plotted using the Kaplan-Meier method. Multivariate analysis was conducted by Cox regression analysis.

RESULTS

The mean survival time for all patients was 18.71 (SEM = 1.59) months. The 1, 2, 3 and 5-year survival rates were 55.95%, 23.21%, 12.30%, 8.0% respectively. Univariate analysis share of grade (tumour differentiation), N-status, large bowel obstruction, operation, primary tumour resection, location, number and the most diameter of liver lesions, extrahepatic transfer, preoperative CEA level and chemotherapy to be predictors of survival. In the Cox regression analysis, the N-status, large bowel obstruction, operation, diameter of liver lesion and extrahepatic transfer were independent factors related to survival.

CONCLUSION

Tumour differentiation, N-status, bowel obstruction, operation, primary tumour resection, location of liver metastasis, number of liver metastasis, diameter of liver metastasis, extrahepatic transfer, preoperative CEA level and chemotherapy are related to the survival of patients with colorectal cancer and synchronous liver metastases.

Intestinal complications after palliative treatment for asymptomatic patients with unresectable stage IV colorectal cancer

BACKGROUND

The initial surgical management of asymptomatic patients with unresectable stage IV colorectal cancer (CRC) is still controversy. The aim of this study was to compare the incidence of major intestinal complications in asymptomatic patients who received palliative treatment for unresectable stage IV CRC, according to the type of treatment.

METHODS

Between March 2001 and January 2008, we retrospectively analyzed 227 asymptomatic patients who underwent first-line resection of the primary tumor followed by chemotherapy (144 patients, resection group) or those who underwent first-line chemotherapy (83 patients, chemotherapy group).

RESULTS

In the resection group, the incidences of intestinal obstruction, peritonitis, fistula, and intestinal hemorrhage were 14.6%, 0%, 0.7%, and 4.8%, respectively. In the chemotherapy group, these incidences were 15.2%, 1.2%, 0%, and 3.5%, respectively. There were no significant differences between the two groups in terms of intestinal complications. In multivariate analysis of overall survival, treatment type (resection group vs. chemotherapy group) was not a significant prognostic factor (P = 0.076).

CONCLUSIONS

In asymptomatic patients with unresectable stage IV CRC, first-line chemotherapy may be considered safe, with no increased risk of major intestinal complications compared with primary tumor resection plus chemotherapy.

Meta-analysis of survival of patients with stage IV colorectal cancer managed with surgical resection versus chemotherapy alone

BACKGROUND There is no consensus regarding the appropriate management of asymptomatic and minimally symptomatic patients with stage IV colorectal cancer and irresectable metastases. METHODS A literature search was conducted on Medline and Embase. Outcome measures included: survival; postoperative morbidity and mortality; complications from the primary tumor and the need for surgery to manage complications; the likelihood of curative surgery after initial response to primary therapy; and length of hospital stay. Quantitative meta-analysis was performed where appropriate. RESULTS Eight retrospective studies, including 1,062 patients, met the criteria for inclusion in this study. Meta-analysis has shown an improvement in the survival of patients managed with palliative resection of their primary tumor, with an estimated standardized median difference of 6.0 months (standardized difference, 0.55; 95% confidence interval (CI), 0.29, 0.82; p < 0.001). Patients managed with chemotherapy alone were 7.3 times more likely to have a complication from the primary tumor (95% CI, 1.7, 34.4; p = 0.008). There was no difference in the response rates to chemotherapy, making metastatic disease amendable to curative resection (0.85; 95% CI 0.40, 1.8; p = 0.662). CONCLUSIONS To date, only retrospective data are available, showing that palliative resection of the primary tumor in asymptomatic or minimally symptomatic patients with stage IV colorectal cancer is associated with longer survival. Resection of the primary tumor reduces the likelihood of complications from the primary tumor and avoids the need for emergency procedures.

Impact of palliative chemotherapy and surgery on management of stage IV incurable colorectal cancer

BACKGROUND

Recent trials proposed chemotherapy (CHT) as the treatment of choice for patients affected by incurable colorectal cancer (ICRC). Nevertheless, surgery is still commonly offered to these patients. On the other hand, CHT is offered to ICRC patients regardless of the pattern of spread of the disease, local or distant, despite some evidence suggesting that metastatic pattern may influence the response to treatment.

METHODS

A retrospective analysis was performed of 133 patients undergoing palliative treatment for ICRC from 1994 through 2007. Palliation consisted of surgery alone until 2002 and surgery with CHT (FOLFOX-FOLFIRI) thereafter. The impact of CHT and surgery was evaluated in the whole series as well as with respect to metastatic pattern (locally aggressive primary tumor and distant metastasis only), tumor site, and grading.

RESULTS

Chemotherapy prolonged survival by 9 months (p = 0.001). In patients undergoing CHT, resective surgery did not prolong survival (p = 0.931), whereas in patients not undergoing CHT, it improved prognosis by 5 months (p = 0.023). Considering patients with distant metastasis only, CHT significantly prolonged survival (p < 0.001), whereas it did not improve the prognosis of patients with a locally aggressive primary tumor (p = 0.943). No difference in CHT effectiveness with respect to tumor site and grading was recorded.

CONCLUSIONS

CHT should be the preferred option in patients undergoing elective treatment for ICRC, whereas surgery should be considered whenever CHT is not administered. CHT significantly increases survival of patients with unresectable distant metastasis only, whereas it seems to be useless in patients with locally aggressive primary tumors.

Outcomes of irinotecan-based chemotherapy regimens in elderly Medicare patients with metastatic colorectal cancer

BACKGROUND

Several population-based studies have confirmed the benefits of adjuvant chemotherapy with 5-fluorouracil/leucovorin for treatment of colorectal cancer. Few population-based studies have evaluated other chemotherapies that are now available for colorectal cancer management.

OBJECTIVE

This study primarily sought to evaluate the survival benefit of first-line irinotecan use in a group of Medicare patients with stage IV (metastatic) colorectal cancer.

METHODS

Data on chemotherapy users with a diagnosis of colorectal cancer reported between 1998 and 2002 were obtained from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Irinotecan, marketed in 1997, was one of the newer chemotherapy agents in the available data. Chemotherapy episodes, defined as periods of continuous chemotherapy treatment with no gaps >90 days between successive claims, were identified. The first chemotherapy episode after diagnosis was used to identify lines of treatment: patients may have initiated irinotecan therapy within 2 months (first-line), used irinotecan later in the first episode (second-line), or not used irinotecan at all. Descriptive statistics were generated and a multivariable Cox proportional hazards model was used to determine the survival benefit of irinotecan. Secondary analyses explored the survival benefit in specific patient subgroups. The impact of irinotecan use on health care utilization also was assessed.

RESULTS

Of 3327 chemotherapy users (mean/median age, 75 years), 842 (25.3%) initiated chemotherapy using irinotecan. No overall survival benefit for irinotecan was observed in the primary analysis comparing irinotecan initiators with all other chemotherapy users (including those who used irinotecan subsequently). Covariates that were negatively associated with survival included older age, presence of >1 comorbidity, a high tumor grade, lymph node involvement, and a primary tumor site in the colon. Surgery was positively associated with a lower hazard of death. In subgroup analyses that excluded subsequent irinotecan users, a survival benefit for irinotecan was observed but diminished over time. Irinotecan users had higher rates of hospitalizations possibly due to chemotherapy-related adverse effects. This retrospective claims study had limitations such as a lack of information on patient performance status, dosing, and the types of regimens used; hence, certain assumptions had to be made and selection bias may have been involved.

CONCLUSIONS

The definitive survival advantage of irinotecan observed in clinical trials was not reproducible in this population of elderly Medicare patients. The results emphasize the need for expansion of trials to include a more diverse patient group as well as continued evaluation of more recent chemotherapies in real-world settings.

Ten years experience of managing the primary tumours in patients with stage IV colorectal cancers

INTRODUCTION

Approximately 20% of patients with colorectal cancer have metastases at the time of presentation. Such patients are often offered systemic chemotherapy but debate continues as to whether these patients benefit from resection of the primary tumour. We describe our ten years experience of managing the primary tumours in patients with stage IV colorectal cancer. The aim of this study was to describe the overall survival of patients undergoing surgery in these circumstances and to determine whether any prognostic indicators could be identified.

PATIENTS & METHODS

920 consecutive patients presenting with stage IV colorectal cancer disease were identified from the Leicester Colorectal Cancer database. Patients undergoing resection of the primary tumour (Resection Group) with the residual metastatic disease were compared to those patients who had not their primary tumour excised (Non-Resection Group). Various different variables in two groups were compared by using Mann-Whitney U test. Kaplan-Meier survival analysis and log-rank test were used to compare the overall survivals. Univariate analysis was performed for each group to elicit the significant prognostic factors whereas Cox regression model was used to identify the independent predictors of overall survival.

RESULTS

The Kaplan-Meier survival analysis of two groups showed prolonged survival for Resection Group compared to the Non-Resection Group (median; 14.5 Vs 5.83 months, p = <0.005). The multivariate analysis of different survival predicting variables, revealed the resection of the primary tumour as an independent predictor of overall survival (p < 0.001). The univariate analysis of resection group identified age at presentation, tumour site, tumour stage (pT), lymph nodal stage (pN), complete histological resection, tumour fixity, ASA grade, mode of surgery, post-operative chemotherapy and sites of metastasis as significant factors (p < 0.05) for survival prediction. When these factors were used in Cox-Regression model, only the age at presentation (p = 0.001), tumour fixity (p = 0.012) and lymph nodal involvement (p = 0.042) were independent predictors for overall survival. Treatment with post-operative chemotherapy and a smaller volume of liver metastases were associated with prolonged survival (p < 0.05).

CONCLUSIONS

Surgical resection of primary tumour for stage IV colorectal cancers is associated with prolonged survival for selected patients. Age at presentation, extent of liver involvement, tumour fixity and ASA grade can help to decide the patients who will benefit from surgery.

Primary tumor resection in patients presenting with metastatic colorectal cancer: analysis of a provincial population-based cohort

PURPOSE

We conducted a Canadian population-based study to assess surgical practice patterns and outcomes among patients with metastatic colorectal cancer (mCRC) at diagnosis.

METHODS

We reviewed a provincial cancer registry for 2 years. Four hundred eleven patients presenting with mCRC were stratified by primary tumor resection status. Baseline characteristics, treatment modalities, and outcomes were assessed.

RESULTS

Seventy percent of patients underwent resection. Resected patients were less likely to have rectal primaries (16% vs. 42%, P < or = 0.001) and had more obstructive symptoms (47% vs. 31%, P < or = 0.001) or bleeding (26% vs. 6%, P < or = 0.001). They experienced fewer tumor-related complications (4% vs. 22%, P < or = 0.001). Use of first-line chemotherapy was similar (61% vs. 58%, P = 0.54), but the resection cohort was more likely to receive doublet chemotherapy (57% vs. 36%, P < or = 0.01) and metastatectomy (10% vs. 0%, P < or = 0.0001). Among patients with rectal tumors, radiation use was comparable (63% vs. 58%, P = 0.68). Median survival was longer in the resection group (14 vs. 6 months, P < or = 0.001).

CONCLUSIONS

Most patients presenting with mCRC underwent primary resection. Colonic tumors, obstruction, and bleeding were associated with resection. In situ primaries conferred more complications, despite similar use of radiation in cases of rectal cancer. Unresected patients were less likely to receive doublet chemotherapy or metastatectomy, and had inferior survival.

Surgical management of colorectal cancer: A review of the literature

BACKGROUND

Colon cancer management continues to evolve with significant advances in chemotherapy, surgical technique and palliative interventions. As the options of therapy have improved, so have the challenges of management of primary colon cancer.

REVIEW

A review of historical and up to date literature was undertaken utilising Medline/PubMed to examine relevant topics of interest-related to the surgical management. Enhanced knowledge of genetics associated with colon cancer has improved our care of patients with hereditary colon cancer syndromes. Additionally, traditional approaches to surgical intervention for primary colon cancer have been questioned and will be discussed in this review including the role of laparoscopy, use of mechanical bowel preparation, management of the primary tumour in the face of metastatic disease, as well as the role of palliative intervention in select patients.

CONCLUSION

Colon cancer has seen improvement and expansion of therapeutic approaches to primary colon cancer. Laparoscopy and palliative interventions have become widely accepted with level I evidence to demonstrate good patient outcomes. Traditional dogma with mechanical bowel preparation has been challenged and debunked with regards to the efficacious benefits previously accepted. The management of the primary tumour has now become increasingly complex as it appears to be a reasonable approach to manage the primary tumour non-operatively in select cases of extracolonic disease requiring management.

Laparoscopic surgery for stage IV colorectal cancer

BACKGROUND

The role of laparoscopic surgery in the management of stage IV colorectal cancer remains uncertain.

METHODS

Sixty-five patients with stage IV disease from among 578 colorectal cancer patients who underwent laparoscopic surgery since 2001 were compared with 513 patients who had stage 0-III disease. The criteria for excluding stage IV patients from laparoscopic surgery were huge tumors, low rectal cancer, massive ascites due to peritoneal seeding, bowel perforation and/or obstruction, and poor general condition and/or cachexia. Data were analyzed by chi-square test or Student's t-test, with P < 0.05 being considered significant.

RESULTS

The two groups of patients had similar demographic features. The open conversion rate was 4.6% (3/65 patients) in the stage IV group and 2.7% (14/513 patients) in the stage 0-III group, and the difference between the groups was not significant. In the stage IV group, depth of tumor invasion and tumor diameter were both significantly greater than in the stage 0-III group. However, operating time and blood loss were similar in the two groups (stage IV: 189.0 min and 95.0 g; stage 0-III: 182.5 min and 60.0 g), although blood loss was significantly greater in the stage IV group when patients undergoing rectal surgery were compared. The incidence of postoperative complications and the postoperative course of the two groups were similar.

CONCLUSIONS

Despite their larger and more invasive tumors, the short-term outcome of laparoscopic surgery in patients with stage IV colorectal cancer was similar to that for stage 0-III patients. This result indicates that laparoscopic surgery can be successfully performed in selected stage IV colorectal cancer patients.

Resection of the primary colorectal cancer is not necessary in nonobstructed patients with metastatic disease

Asymptomatic patients with metastatic colorectal cancer do not routinely need to undergo resection of the primary tumor. Although several retrospective analyses suggest that patients who undergo resection of the primary tumor live longer, most of these reviewed data prior to the advent of modern polychemotherapy and are subject to considerable bias, as patients who were considered able to undergo surgery likely had better overall prognoses than those who were not. In addition to significant prolongation of overall survival, current combinations of systemic chemotherapeutic agents and targeted agents have allowed improved local and distant tumor control, decreasing the likelihood of local tumor-related complications requiring colon resection.

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

PURPOSE

The benefit of elective primary tumor resection for non-curable stage IV colorectal cancer (CRC) remains largely undefined. We wanted to identify risk factors for postoperative complications and short survival.

METHODS

Using a prospective database, we analyzed potential risk factors in 233 patients, who were electively operated for non-curable stage IV CRC between 1996 and 2002. Patients with recurrent tumors, resectable metastases, emergency operations, and non-resective surgery were excluded. Risk factors for increased postoperative morbidity and limited postoperative survival were identified by multivariate analyses.

RESULTS

Patients with colon cancer (CC = 156) and rectal cancer (RC = 77) were comparable with regard to age, sex, comorbidity, American Society of Anesthesiologists score, carcinoembryonic antigen levels, hepatic spread, tumor grade, resection margins, 30-day mortality (CC 5.1%, RC 3.9%) and postoperative chemotherapy. pT4 tumors, carcinomatosis, and non-anatomical resections were more common in colon cancer patients, whereas enterostomies (CC 1.3%, RC 67.5%, p < 0.0001), anastomotic leaks (CC 7.7%, RC 24.2%, p = 0.002), and total surgical complications (CC 19.9%, RC 40.3%, p = 0.001) were more frequent after rectal surgery. Independent determinants of an increased postoperative morbidity were primary rectal cancer, hepatic tumor load >50%, and comorbidity >1 organ. Prognostic factors for limited postoperative survival were hepatic tumor load >50%, pT4 tumors, lymphatic spread, R1-2 resection, and lack of chemotherapy.

CONCLUSIONS

Palliative resection is associated with a particularly unfavorable outcome in rectal cancer patients presenting with a locally advanced tumor (pT4, expected R2 resection) or an extensive comorbidity, and in all CRC patients who show a hepatic tumor load >50%. For such patients, surgery might be contraindicated unless the tumor is immediately life-threatening.

Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment

PURPOSE

The purpose of this study was to describe the frequency of interventions necessary to palliate the intact primary tumor in patients who present with synchronous, stage IV colorectal cancer (CRC) and who receive up-front modern combination chemotherapy without prophylactic surgery.

PATIENTS AND METHODS

By using a prospective institutional database, we identified 233 consecutive patients from 2000 through 2006 with synchronous metastatic CRC and an unresected primary tumor who received oxaliplatin- or irinotecan-based, triple-drug chemotherapy (infusional fluorouracil, leucovorin, and oxaliplatin; bolus fluorouracil, leucovorin, and irinotecan; or fluorouracil, leucovorin, and irinotecan) with or without bevacizumab as their initial treatment. The incidence of subsequent use of surgery, radiotherapy, and/or endoluminal stenting to manage primary tumor complications was recorded.

RESULTS

Of 233 patients, 217 (93%) never required surgical palliation of their primary tumor. Sixteen patients (7%) required emergent surgery for primary tumor obstruction or perforation, 10 patients (4%) required nonoperative intervention (ie, stent or radiotherapy), and 213 (89%) never required any direct symptomatic management for their intact primary tumor. Of those 213 patients, 47 patients (20%) ultimately underwent elective colon resection at the time of metastasectomy, and eight patients (3%) underwent this resection during laparotomy for hepatic artery infusion pump placement. Use of bevacizumab, location of the primary tumor in the rectum, and metastatic disease burden were not associated with increased intervention rate.

CONCLUSION

Most patients with synchronous, stage IV CRC who receive up-front modern combination chemotherapy never require palliative surgery for their intact primary tumor. These data support the use of chemotherapy, without routine prophylactic resection, as the appropriate standard practice for patients with neither obstructed nor hemorrhaging primary colorectal tumors in the setting of metastatic disease.