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Fanotto V, Salani F, Vivaldi C, Scartozzi M, Ribero D, Puzzoni M, Montagnani F, Leone F, Vasile E, Bencivenga M, De Manzoni G, Basile D, Fornaro L, Masi G, Aprile G. Primary Tumor Resection for Metastatic Colorectal, Gastric and Pancreatic Cancer Patients: In Search of Scientific Evidence to Inform Clinical Practice. Cancers (Basel) 2023; 15:cancers15030900. [PMID: 36765854 PMCID: PMC9913845 DOI: 10.3390/cancers15030900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/24/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023] Open
Abstract
The management of the primary tumor in metastatic colorectal, gastric and pancreatic cancer patients may be challenging. Indeed, primary tumor progression could be associated with severe symptoms, compromising the quality of life and the feasibility of effective systemic therapy, and might result in life-threatening complications. While retrospective series have suggested that surgery on the primary tumor may confer a survival advantage even in asymptomatic patients, randomized trials seem not to definitively support this hypothesis. We discuss the evidence for and against primary tumor resection for patients with metastatic gastrointestinal (colorectal, gastric and pancreatic) cancers treated with systemic therapies and put in context the pros and cons of the onco-surgical approach in the time of precision oncology. We also evaluate current ongoing trials on this topic, anticipating how these will influence both research and everyday practice.
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Affiliation(s)
- Valentina Fanotto
- Department of Oncology, Academic Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Piazzale Santa Maria della Misericordia, 33100 Udine, Italy
| | - Francesca Salani
- Unit of Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
- Institute of Interdisciplinary Research “Health Science”, Scuola Superiore Sant’Anna, Piazza Martiri della Libertà 33, 56124 Pisa, Italy
| | - Caterina Vivaldi
- Unit of Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Mario Scartozzi
- Unit of Medical Oncology, University Hospital, University of Cagliari, 09124 Cagliari, Italy
| | - Dario Ribero
- Division of General and Oncologic Surgery Multimedica, A.O. Santa Croce e Carle, 12100 Cuneo, Italy
| | - Marco Puzzoni
- Unit of Medical Oncology, University Hospital, University of Cagliari, 09124 Cagliari, Italy
| | - Francesco Montagnani
- Department of Oncology, Azienda Sanitaria Locale di Biella, 13900 Ponderano, Italy
| | - Francesco Leone
- Department of Oncology, Azienda Sanitaria Locale di Biella, 13900 Ponderano, Italy
| | - Enrico Vasile
- Unit of Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
| | - Maria Bencivenga
- General and Upper GI Surgery Division, Verona University (VR), 37134 Verona, Italy
| | - Giovanni De Manzoni
- General and Upper GI Surgery Division, Verona University (VR), 37134 Verona, Italy
| | - Debora Basile
- Department of Oncology, San Bortolo General Hospital, ULSS 8 Berica-Vicenza, 36100 Vicenza, Italy
| | - Lorenzo Fornaro
- Unit of Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
- Correspondence: ; Tel.: +39-050992466
| | - Gianluca Masi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Giuseppe Aprile
- Department of Oncology, San Bortolo General Hospital, ULSS 8 Berica-Vicenza, 36100 Vicenza, Italy
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2
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Colloca GA, Venturino A, Guarneri D. Primary tumor resection in patients with unresectable colorectal cancer with synchronous metastases could improve the activity of poly-chemotherapy: A trial-level meta-analysis. Surg Oncol 2022; 44:101820. [DOI: 10.1016/j.suronc.2022.101820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 06/12/2022] [Accepted: 07/11/2022] [Indexed: 12/24/2022]
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3
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Huang L, Wei G, Chen N, Liu J, Wang Z, Yu Y, Qiu M. Impact of Upfront Chemotherapy on the Effect of Primary Tumour Resection for Asymptomatic Synchronous Colorectal Cancer With Unresectable Metastases: A Propensity-Score-Matched Cohort Analysis. Clin Med Insights Oncol 2022; 16:11795549221085054. [PMID: 35355515 PMCID: PMC8958687 DOI: 10.1177/11795549221085054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/05/2022] [Indexed: 02/05/2023] Open
Abstract
Background: It is controversial whether primary tumour resection (PTR) and the sequencing of chemotherapy and PTR are associated with the survival of patients with incurable stage IV colorectal cancer. This study aimed to explore the effects of PTR and the sequencing of chemotherapy and PTR on asymptomatic colorectal cancer with synchronous unresectable metastases (asmCRC). Patients and Methods: Patients with asmCRC were retrospectively identified from a single centre and categorised into 3 groups: PTR followed by chemotherapy (POC), upfront chemotherapy followed by PTR (UFC), and palliative chemotherapy (PC). The primary end points included median overall survival (OS) and progression-free survival (PFS). Clinical features were analysed using χ2 test, while survival curves were generated using the Kaplan-Meier test. Propensity-score matching (PSM) was performed when comparing survival between POC and UFC groups. Results: From 2008 to 2014, 255 patients were identified and included into the POC (n = 101), UFC (n = 40), and PC (n = 114) groups. The UFC and POC groups had significantly better median OS compared with the PC group (40.7 vs 16.3 months, P < .0001; 39.7 vs 16.3 months, P < .0001). Before PSM, the UFC group had better median PFS than the POC and PC groups (18.5 vs 9.7 months, P = .038; 18.5 vs 6.1 months, P < .0001). After PSM, UFC has better PFS than POC (P = .038). And the UFC group did not have higher postoperative or preoperative morbidity compared with the POC group (P = .235). Conclusions: Primary tumour resection could improve the survival of patients with asmCRC. Compared with POC or PC, UFC was associated with a better median PFS without significantly increasing preoperative or postoperative morbidity.
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Affiliation(s)
- Lin Huang
- Lung Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Guixia Wei
- Department of Abdominal Cancer, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Nan Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jiewei Liu
- Lung Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yongyang Yu
- Department of Gastrointestinal Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Meng Qiu
- Department of Abdominal Cancer, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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4
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Colorectal cancer survival rates in Makassar, Eastern Indonesia: A retrospective Cohort Study. Ann Med Surg (Lond) 2022; 74:103211. [PMID: 35059192 PMCID: PMC8760491 DOI: 10.1016/j.amsu.2021.103211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 12/24/2022] Open
Abstract
Background Materials and methods Results Conclusion Colorectal cancer is relatively common in Indonesia, and its incidence is slowly increasing. Most Indonesian cases are detected at an advanced stage owing to educational, cultural, social, and economic factors. Histopathology, tumor stage and history of definitive surgery significantly affected recurrence-free survival. Chemotherapy and radiotherapy treatments had significantly different recurrence-free survival rates.
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5
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van de Geest T, van Amerongen M, Nierop P, Höppener D, Grünhagen D, Moelker A, Fütterer J, Verhoef C, de Wilt J. Propensity score matching demonstrates similar results for radiofrequency ablation compared to surgical resection in colorectal liver metastases. Eur J Surg Oncol 2022; 48:1368-1374. [DOI: 10.1016/j.ejso.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/20/2021] [Accepted: 01/06/2022] [Indexed: 02/07/2023] Open
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Haber Z, Lee EW, Price M, Wainberg Z, Hecht JR, Sayre J, Padia SA. Survival Advantage of Yttrium-90 Radioembolization to Systemic Therapy in Patients with Hepatic Metastases from Colorectal Cancer in the Salvage Setting: Results of a Matched Pair Study. Acad Radiol 2021; 28 Suppl 1:S210-S217. [PMID: 34099386 DOI: 10.1016/j.acra.2021.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/10/2021] [Accepted: 03/30/2021] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES Patients with hepatic metastases from colorectal cancer have a poor prognosis in the salvage setting. This study assessed the survival benefit of adding transarterial 90Y radioembolization in the salvage setting to systemic therapy. MATERIALS AND METHODS In this retrospective, matched-pair study, 21 patients who underwent radioembolization plus systemic therapy were matched with a cohort of 173 patients who received systemic chemotherapy alone in the salvage setting, defined as progression on at least two different regimens of systemic chemotherapy. Patients were matched one-to-one on Eastern Cooperative Oncology Group Performance Status, presence of extrahepatic disease, and presence of tumor KRAS mutation. Radioembolization patients underwent treatment using standard dosimetry to either a hepatic lobe or the whole liver. Survival data was analyzed using Kaplan-Meier analysis. RESULTS Patients who underwent radioembolization plus systemic therapy vs. those who had systemic therapy alone had similar demographics and exposure to prior systemic chemotherapies. Median survival from the date of primary diagnosis was 38 (95% CI 26 to 50) v 25 (95% CI 15 to 35) months in radioembolization with systemic therapy vs. systemic therapy alone (p = 0.17). Median survival from the date of hepatic metastases was 31 (95% CI 23.8 to 38.2) v 20 months (95% CI 10.2 to 29.8) in radioembolization with systemic therapy vs. systemic therapy alone (p = 0.03). CONCLUSION The addition of radioembolization to systemic therapy in patients with metastatic colorectal cancer to the liver may improve survival in the salvage setting.
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Affiliation(s)
- Zachary Haber
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at University of California, Los Angeles
| | - Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at University of California, Los Angeles
| | - Megan Price
- Division of Medical Oncology, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Zev Wainberg
- Division of Medical Oncology, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Joel Randolph Hecht
- Division of Medical Oncology, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - James Sayre
- Department of Radiology, David Geffen School of Medicine at University of California, Los Angeles
| | - Siddharth A Padia
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at University of California, Los Angeles.
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Sharma V, Sharma A, Raina V, Dabkara D, Mohanti BK, Shukla NK, Pathy S, Thulkar S, Deo SVS, Kumar S, Sahoo RK. Metastatic colo-rectal cancer: real life experience from an Indian tertiary care center. BMC Cancer 2021; 21:630. [PMID: 34049505 PMCID: PMC8164292 DOI: 10.1186/s12885-021-08398-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background No data exist for the long-term outcome of metastatic colorectal cancer (mCRC) from the Southern part of Asia. The primary objective of the study is to evaluate the survival outcome of mCRC from an Indian tertiary care center. The study also aims to highlight the treatment pattern practiced and the unique clinico-pathologic characteristics. Methods This is a single-center retrospective observational study done at a large referral tertiary care center in North India. All patients with synchronous or metachronous mCRC who received at least one dose of chemotherapy for metastatic disease, registered between 2003 to 2017 were included. Primary outcome measures were overall survival and progression-free survival and prognostic factors of overall survival. Descriptive analysis was done for the clinicopathological characteristics and treatment patterns. Kaplan Meier method for overall survival and progression-free survival. Cox regression analysis was performed for the determination of the prognostic factors for overall survival. Result Out of 377 eligible patients, 256 patients (68%) had de novo metastatic disease and the remaining 121 (32%) progressed to metastatic disease after initial treatment. The cohort was young (median age, 46 years) with the most common primary site being the rectum. A higher proportion of signet (9%) and mucinous histology (24%). The three common sites of metastasis were the liver, peritoneum, and lung. In the first line, most patients received oxaliplatin-based chemotherapy (70%). Only 12.5% of patients received biologicals in the first-line setting. The median follow-up and median overall survival of study cohort were 17 months and 18.5 months. The factors associated with poor outcome for overall survival on multivariate analysis were ECOG performance status of > 1, high CEA, low albumin, and the number of lines of chemotherapy received (< 2). Conclusion The outcome of mCRC is inferior to the published literature. We found a relatively higher proportion of patients with the following characteristics; younger, rectum as primary tumor location, the signet, and mucinous histology, higher incidence of peritoneum involvement. The routine use of targeted therapies is limited. Government schemes (inclusion of targeted therapies in the Ayushman scheme), NGO assistance, and availability of generic low-cost targeted drugs may increase the availability.
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Affiliation(s)
- Vinod Sharma
- Department of Medical Oncology, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Vinod Raina
- Department of Medical Oncology, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Deepak Dabkara
- Department of Medical Oncology, Tata Memorial Center, Kolkata, India
| | - Bidhu Kalyan Mohanti
- Department of Radiotherapy, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - N K Shukla
- Department of Surgical Oncology, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sushmita Pathy
- Department of Radiotherapy, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sanjay Thulkar
- Department of Radiodiagnosis, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - S V S Deo
- Department of Surgical Oncology, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sunil Kumar
- Department of Surgical Oncology, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ranjit Kumar Sahoo
- Department of Medical Oncology, Dr BRA IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Shuayb M, Mehedi Hasan M, Hoque MR, Mushtaq Hussain Q, Begum R, Reza MS. Survival and prognostic association in stage IV colorectal cancer patients treated with chemotherapy in Bangladesh. Jpn J Clin Oncol 2021; 51:552-559. [PMID: 33341898 DOI: 10.1093/jjco/hyaa228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/03/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Prognostic factors in colorectal cancer have lesser been evaluated in developing countries. This study aims to determine overall survival and prognostic factors for metastatic colorectal cancer patients who were non-operable and received chemotherapy. METHODS The study retrospectively investigated 67 inoperable metastatic colorectal cancer patients at Square Hospital, Bangladesh. The primary endpoint was overall survival, and the secondary endpoints were prognostic association with factors. Survival probabilities were calculated by non-parametric Kaplan-Meier method and compared by log-rank test. Univariate and multivariable Cox proportional hazard models were implemented to assess the prognostic association. RESULTS Median survival of the entire cohort was 14 months (95% confidence interval: 11-25). In multivariable analysis, two prognostic factors were independently associated with survival: Karnofsky performance status and carcinoembryonic antigen. Patients with Karnofsky performance status <70 had significant higher risk of death than those with Karnofsky performance status ≥70 (adjusted hazard ratio 4.25, 95% confidence interval: 2.15-8.39). Higher risk of death was found to be associated with higher carcinoembryonic antigen: adjusted hazard ratio was 1.72 (95% confidence interval: 0.81-3.68) and 2.96 (95% confidence interval: 1.25-7.01) for patients with carcinoembryonic antigen 10-100 and >100 ng/ml, respectively, while comparing with carcinoembryonic antigen <10 ng/ml. The presence of peritoneal metastasis and grade-III tumour significantly worsened the survival in univariate analysis (hazard ratio 2.46, 95% confidence interval: 1.32-4.57 and hazard ratio 1.74, 95% confidence interval: 1.01-3.03, respectively) but not in multivariable analysis (adjusted hazard ratio 1.92, 95% confidence interval: 0.88-4.18 and adjusted hazard ratio 1.25, 95% confidence interval: 0.66-2.36, respectively). CONCLUSION The study reported survival of stage IV colorectal cancer patients undergo chemotherapy and identified that Karnofsky performance status and carcinoembryonic antigen are the poor prognostic factors to this cohort adjusting for other factors.
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Affiliation(s)
- Md Shuayb
- Square Oncology & Radiotherapy Centre, Square Hospitals Ltd, Dhaka, Bangladesh.,Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Md Mehedi Hasan
- Square Oncology & Radiotherapy Centre, Square Hospitals Ltd, Dhaka, Bangladesh
| | - Md Rashedul Hoque
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | | | - Rabeya Begum
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Md Salim Reza
- Square Oncology & Radiotherapy Centre, Square Hospitals Ltd, Dhaka, Bangladesh
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Matsuda A, Yamada T, Matsumoto S, Shinji S, Ohta R, Sonoda H, Takahashi G, Iwai T, Takeda K, Sekiguchi K, Yoshida H. Systemic Chemotherapy is a Promising Treatment Option for Patients with Colonic Stents: A Review. J Anus Rectum Colon 2021; 5:1-10. [PMID: 33537495 PMCID: PMC7843144 DOI: 10.23922/jarc.2020-061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/15/2020] [Indexed: 02/08/2023] Open
Abstract
Approximately 10% of patients with colorectal cancer (CRC) develop malignant large bowel obstruction (MLBO) at diagnosis. Furthermore, for 35% of patients with MLBO, curative primary tumor resection is unfeasible because of locally advanced disease and comorbidities. The practice of placing a self-expandable metallic stent (SEMS) has dramatically increased as an effective palliative treatment. Recent advances in systemic chemotherapy for metastatic CRC have significantly contributed to prolonging patients' prognosis and expanding the indications. However, the safety and efficacy of systemic chemotherapy in patients with SEMS have not been established. This review outlines the current status of this relatively new therapeutic strategy and future perspectives. Some reports on this topic have demonstrated that 1) systemic chemotherapy and the addition of molecular targeted agents contribute to prolonged survival in patients with SEMS; 2) delayed SEMS-related complications are a major concern, and this requires strict patient monitoring; however, primary tumor control by chemotherapy might result in decreased complications, especially regarding re-obstruction; and 3) using bevacizumab could be a risk factor for SEMS-related perforation, which may be lethal. Although this relatively new approach for unresectable stage IV obstructive CRC requires a well-planned clinical trial, this therapy could be promising for patients who are unideal candidates for emergency surgery and require immediate systemic chemotherapy.
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Affiliation(s)
- Akihisa Matsuda
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takeshi Yamada
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Satoshi Matsumoto
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Kamagari, Inzai, Japan
| | - Seiichi Shinji
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Ryo Ohta
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiromichi Sonoda
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Goro Takahashi
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takuma Iwai
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kohki Takeda
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Kumiko Sekiguchi
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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Mukkamalla SKR, Somasundar P, Rathore B. Prognostic Impact of Tumor Status, Nodal Status and Tumor Sidedness in Metastatic Colon Cancer. Cureus 2020; 12:e11444. [PMID: 33329946 PMCID: PMC7734889 DOI: 10.7759/cureus.11444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Locally advanced primary tumors have been associated with poor overall survival (OS) in non-metastatic colon cancer. However, their impact on metastatic colon cancer (mCC) is not fully defined. The association between primary tumor location and prognosis in mCC is also evolving. Methods Using National Cancer Data Base, we identified a cohort of 25,377 patients diagnosed with mCC from 2004-2009. Chi-square test was used for descriptive analyses, while all potential prognostic factors were evaluated using Kaplan-Meier survival estimates and Cox proportional hazards regression modeling. Results The five-year OS for the entire study cohort was 12.3%. Factors associated with significant survival impact in multivariate analysis included age, gender, race, comorbidity index, academic level of treating institution, insurance status, income, year of diagnosis, primary tumor site, histologic differentiation, pathologic tumor stage (pT), pathologic nodal stage (pN), and modality of chemotherapy. pT1 lesions demonstrated poor prognosis in stage IV colon cancers, not statistically different when compared to survival outcomes observed in cases with pT4 lesions. Regional nodal involvement demonstrated poor OS in full cohort analysis and subgroup analysis independent of primary tumor location. Both right-sided and transverse colon tumors had similarly worse OS compared to left-sided tumors (right-sided: HR: 1.21, 95% CI: 1.17-1.25; transverse: HR: 1.21, 95% CI: 1.15-1.27). Conclusions T1 lesions arising from right-side or transverse colon portend a poor prognosis in mCC, while regional lymph node involvement by itself is an independent poor prognostic factor. Right-sided tumors are associated with poor outcomes than left-sided tumors, suggesting the role of underlying molecular or biologic variants.
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Affiliation(s)
- Shiva Kumar R Mukkamalla
- Hematology and Oncology, Ted and Margaret Jorgensen Cancer Center/Presbyterian Healthcare Services, Rio Rancho, USA
| | | | - Bharti Rathore
- Hematology and Medical Oncology, Roger Williams Medical Center, Providence, USA
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11
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Huang Y, Ge K, Fu G, Chu J, Wei W. Efficacy of Primary Tumor Resection in Metastatic Colorectal Cancer. Med Sci Monit 2020; 26:e923501. [PMID: 32859887 PMCID: PMC7477930 DOI: 10.12659/msm.923501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/11/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the survival benefit of palliative primary tumor resection in colorectal cancer (CRC) patients with unresectable metastases. MATERIAL AND METHODS Clinicopathological characteristics of eligible patients who underwent surgery to remove the primary tumor and those who did not between 2004 and 2013 were compared. We also evaluated the association between survival and different clinicopathologic characteristics in metastatic CRC. RESULTS The percentage of patients undergoing surgical resection of the primary tumor was higher during the earlier years and trended toward less use of surgery in later years. Palliative primary tumor resection was strongly associated with better cause-specific survival (hazard ratio=0.403, 95% confidence interval=0.389 to 0.417, P<0.001). CONCLUSIONS We added new strong evidence supporting the survival benefit of palliative resection, which should be confirmed in future randomized controlled trials.
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Affiliation(s)
- Yong Huang
- Department of General Surgery, Jiangdu People’s Hospital Affiliated to Medical College of Yangzhou University, Yangzhou, Jiangsu, P.R. China
| | - Kuanxue Ge
- Department of Gastroenterology, Jiangdu People’s Hospital Affiliated to Medical College of Yangzhou University, Yangzhou, Jiangsu, P.R. China
| | - Guangshun Fu
- Department of General Surgery, Jiangdu People’s Hospital Affiliated to Medical College of Yangzhou University, Yangzhou, Jiangsu, P.R. China
| | - Junfeng Chu
- Department of Radiotherapy, Jiangdu People’s Hospital Affiliated to Medical College of Yangzhou University, Yangzhou, Jiangsu, P.R. China
| | - Wei Wei
- Department of General Surgery, Jiangdu People’s Hospital Affiliated to Medical College of Yangzhou University, Yangzhou, Jiangsu, P.R. China
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12
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Ergun Y, Bal O, Dogan M, Ucar G, Dirikoc M, Acikgoz Y, Bacaksiz F, Uncu D. Does primary tumor resection contribute to overall survival in unresectable synchronous metastatic colorectal cancer? JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2020; 25:14. [PMID: 32174986 PMCID: PMC7053176 DOI: 10.4103/jrms.jrms_1056_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/15/2019] [Accepted: 11/22/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Primary tumor resection (PTR) in metastatic colorectal cancer (mCRC) has not been suggested by guidelines, since new systemic chemotherapy options have improved overall survival. However, the effect of PTR is still controversial in mCRC. In this study, we aimed to evaluate the effect of PTR on survival in unresectable mCRC. MATERIALS AND METHODS Two hundred and fifty-two patients with unresectable mCRC were screened retrospectively between January 2007 and December 2017 and a total of 147 patients who met inclusion criteria were included. The patients with emergency or elective PTR and the patients without surgery were compared for baseline features and overall survival. RESULTS The median follow-up time was 15.6 months (range; 1.2-78.9) in whole patients. There were 91 patients in nonsurgical (NS) group and 56 patients in PTR group. The median overall survival was significantly longer in PTR group compared NS group (21.8 vs. 17.0 months, P = 0.01), but it was not associated to better overall survival in multivariate Cox analysis (hazard ratio: 0.65, 95% confidence interval: 0.41-1.02, P = 0.06). There was no significant difference in overall survival between emergency and elective surgery subgroups (22.9 vs. 16.1 months, respectively, P = 0.9). CONCLUSION PTR did not offer an overall survival benefit in this study. Although it is debated, we think that it is better to start treatment with chemotherapy and biological agent combinations in patients with asymptomatic mCRC. Thus, the patients can be protected from the morbidity and mortality of the surgery.
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Affiliation(s)
- Yakup Ergun
- Department of Medical Oncology, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Oznur Bal
- Department of Medical Oncology, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Mutlu Dogan
- Department of Medical Oncology, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Gokhan Ucar
- Department of Medical Oncology, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Merve Dirikoc
- Department of Medical Oncology, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Yusuf Acikgoz
- Department of Medical Oncology, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Ferhat Bacaksiz
- Department of Gastroenterology, Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Dogan Uncu
- Department of Medical Oncology, Ankara Numune Training and Research Hospital, Ankara, Turkey
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13
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Han L, Mo S, Xiang W, Li Q, Wang R, Xu Y, Dai W, Cai G. Prognostic accuracy of different lymph node staging system in predicting overall survival in stage IV colon cancer. Int J Colorectal Dis 2020; 35:317-322. [PMID: 31858220 DOI: 10.1007/s00384-019-03486-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE With emphasis of surgical management, the lymph node (LN) status has been advocated to predict prognosis in colon cancer with distant metastatic. Therefore, we tend to compare the prognostic performance of American Joint Committee on Cancer (AJCC) N-staging relative to lymph node ratio (LNR), log odds of metastatic lymph nodes (LODDS), and N-score in stage IV colon cancer. METHODS About 20,961 patients who underwent primary surgical resection for stage IV colon cancer were extracted from Surveillance, Epidemiology, and End Results (SEER) Program database. Harrell's C statistic (C-index) and Akaike's Information Criterion (AIC) were used to distinguish the prognostic performance of the different LN-staging schemes. RESULTS Of the 20,961 patients, 17,043 (81.3%) had been with lymph node metastasis, and the median number of examined lymph nodes (ELNs) was 15. When assessed as continuous values, the LODDS shown as the best system with greatest discriminatory power (C-index, 0.6241; AIC, 29114.29) generally and each subgroups divided by ELNs. When modeled as categorical cutoff variables for further clinical usage, the 8th AJCC N-stage outperformed the other three schemes with either ELNs less than 12 (C-index, 0.5770; AIC, 8992.638), between 12 and 25 (C-index, 0.6084; AIC, 13905.72), or more than 25(C-index, 0.6192; AIC, 3138.018) with increasing C-index and less AIC value. CONCLUSIONS When assessed as categorical variables, N-stage performed superiorly regardless of ELNs. When assessed as a continuous variable, LODDS exhibited good discriminative ability and goodness of fit in predicting survival for colon cancer patients regardless of ELNs.
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Affiliation(s)
- Lingyu Han
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, 270 Dong'an Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Shaobo Mo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, 270 Dong'an Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Wenqiang Xiang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, 270 Dong'an Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Qingguo Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, 270 Dong'an Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Renjie Wang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, 270 Dong'an Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Ye Xu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, 270 Dong'an Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Weixing Dai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, 270 Dong'an Road, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
| | - Guoxiang Cai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, 270 Dong'an Road, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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14
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Yeom SS, Lee SY, Kwak HD, Kim CH, Kim YJ, Kim HR. The outcome of primary tumor resection in the unresectable stage IV colorectal cancer patients who received the bevacizumab-containing chemotherapy. Medicine (Baltimore) 2020; 99:e19258. [PMID: 32049866 PMCID: PMC7035101 DOI: 10.1097/md.0000000000019258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Primary tumor resection (PTR) for unresectable metastatic colorectal cancer (mCRC) patients has been documented to be associated with postoperative hyper-neovascularization and enhanced growth of metastases, which may be prevented by bevacizumab. This study aimed to investigate the survival outcome of PTR in patients who received palliative bevacizumab-containing chemotherapy (BCT).From January 2006 to December 2018, medical records of 240 mCRC patients who received palliative BCT at a single tertiary colorectal cancer center were retrospectively reviewed. Patients were classified into three groups: PTR-a (PTR before BCT, n = 60), PTR-b (PTR during BCT, n = 17), and BCT-only group (n = 163). Resectable mCRCs or recurrent diseases were excluded, and the end-point was overall survival (OS) rate.Three groups had similar age, cell differentiation, location of the primary tumor, and the number of metastatic organs. More than two-thirds of patients who received PTR experienced disease-progressions (PD) during their postoperative chemotherapy-free time (PTR-a vs PTR-b; 66.7% vs 76.5%, P = .170), but OS was not inferior to the BCT-only group (PTR-a vs BCT-only; HR 0.477 [95% CI 0.302-0.754], P = .002/PTR-b vs BCT-only; HR 0.77 [95% CI 0.406-1.462], P = .425). The postoperative chemotherapy-free time was similar between PTR-a and PTR-b (median 32.0 [14-98] days vs 41.0 [18-71] days, P = .142), but non-obstructive indications (perforation, bleeding, pain) were the more frequent in the PTR-b than PTR-a. Young age, the number of BCT, and PTR-a were the independent factors for OS.The efficacy of the PTR for unresectable mCRC has been controversial, but this study demonstrated that PTR should be considered for the unresectable mCRC patients regardless before and during BCT.
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15
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Hall C, Clarke L, Pal A, Buchwald P, Eglinton T, Wakeman C, Frizelle F. A Review of the Role of Carcinoembryonic Antigen in Clinical Practice. Ann Coloproctol 2019; 35:294-305. [PMID: 31937069 PMCID: PMC6968721 DOI: 10.3393/ac.2019.11.13] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/13/2019] [Indexed: 12/11/2022] Open
Abstract
Carcinoembryonic antigen (CEA) is not normally produced in significant quantities after birth but is elevated in colorectal cancer. The aim of this review was to define the current role of CEA and how best to investigate patients with elevated CEA levels. A systematic review of CEA was performed, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were identified from PubMed, Cochrane library, and controlled trials registers. We identified 2,712 papers of which 34 were relevant. Analysis of these papers found higher preoperative CEA levels were associated with advanced or metastatic disease and thus poorer prognosis. Postoperatively, failure of CEA to return to normal was found to be indicative of residual or recurrent disease. However, measurement of CEA levels alone was not sufficient to improve survival rates. Two algorithms are proposed to guide investigation of patients with elevated CEA: one for patients with elevated CEA after CRC resection, and another for patients with de novo elevated CEA. CEA measurement has an important role in the investigation, management and follow-up of patients with colorectal cancer.
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Affiliation(s)
- Claire Hall
- Colorectal Unit, Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Louise Clarke
- Colorectal Unit, Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Atanu Pal
- Colorectal Unit, Department of Surgery, University of Otago, Christchurch, New Zealand
- Norfolk & Norwich University Hospital, Norwich, UK
| | - Pamela Buchwald
- Colorectal Unit, Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Tim Eglinton
- Colorectal Unit, Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Chris Wakeman
- Colorectal Unit, Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Frank Frizelle
- Colorectal Unit, Department of Surgery, University of Otago, Christchurch, New Zealand
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16
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Stelzner S, Radulova-Mauersberger O, Zschuppe E, Kittner T, Abolmaali N, Puffer E, Zimmer J, Witzigmann H. Prognosis in patients with synchronous colorectal cancer metastases after complete resection of the primary tumor and the metastases. J Surg Oncol 2019; 120:438-445. [PMID: 31168858 DOI: 10.1002/jso.25578] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 05/02/2019] [Accepted: 05/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Synchronous metastases are considered a negative prognostic factor in patients with metastatic colorectal cancer (CRC). We investigated the outcomes of stage IV CRC patients undergoing complete gross resection (R0/1) of both the primary tumor and the metastases under the guidance of a multidisciplinary team (MDT). METHODS All CRC patients with synchronous metastases were retrieved from a prospective database. Patients treated from 2006 to 2017 who underwent complete resection were analyzed. Various factors, including multiple metastatic sites and complex procedures, were investigated. Univariate and multivariate overall survival (OS) calculations were performed. RESULTS Of 330 consecutive patients with synchronous metastases, 101 (30.6%) achieved an R0/1 status including 12 (11.9%) patients with multiple metastatic sites. Complex procedures were necessary in 45 (44.6%) patients. Five-year OS was 53.0% for the R0/1 patient group. Multivariate analysis could not detect factors associated with prognosis. CONCLUSIONS With modern treatment, the prognosis of patients with synchronous CRC metastases can be improved. Decisions made by a MDT offered one-third of patients a potentially curative approach to their stage IV disease. Despite the treatment of a high rate of patients with complex metastases necessitating complex procedures, we achieved a favorable 5-year OS rate.
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Affiliation(s)
- Sigmar Stelzner
- Department of General and Visceral Surgery, Stadtisches Klinikum Dresden, Teaching Hospital of the Technical University of Dresden, Dresden, Germany
| | - Olga Radulova-Mauersberger
- Department of General and Visceral Surgery, Stadtisches Klinikum Dresden, Teaching Hospital of the Technical University of Dresden, Dresden, Germany
| | - Ernst Zschuppe
- Department of Medical Oncology, Stadtisches Klinikum Dresden, Teaching Hospital of the Technical University of Dresden, Dresden, Germany
| | - Thomas Kittner
- Department of Radiology, Stadtisches Klinikum Dresden, Teaching Hospital of the Technical University of Dresden, Dresden, Germany
| | - Nasreddin Abolmaali
- Department of Radiology, Stadtisches Klinikum Dresden, Teaching Hospital of the Technical University of Dresden, Dresden, Germany
| | - Eric Puffer
- Department of Pathology, Stadtisches Klinikum Dresden, Teaching Hospital of the Technical University of Dresden, Dresden, Germany
| | - Joerg Zimmer
- Department of Radiation Therapy, Stadtisches Klinikum Dresden, Teaching Hospital of the Technical University of Dresden, Dresden, Germany
| | - Helmut Witzigmann
- Department of General and Visceral Surgery, Stadtisches Klinikum Dresden, Teaching Hospital of the Technical University of Dresden, Dresden, Germany
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17
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Lorimer PD, Motz BM, Kirks RC, Han Y, Symanowski JT, Hwang JJ, Salo JC, Hill JS. Frequency of unplanned surgery in patients with stage IV colorectal cancer receiving palliative chemotherapy with an intact primary: An analysis of SEER‐Medicare. J Surg Oncol 2019; 120:407-414. [DOI: 10.1002/jso.25508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/05/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Patrick D. Lorimer
- Department of Surgery, Carolinas Medical CenterLevine Cancer Institute Charlotte North Carolina
| | - Benjamin M. Motz
- Department of Surgery, Carolinas Medical CenterLevine Cancer Institute Charlotte North Carolina
| | - Russell C. Kirks
- Department of Surgery, Carolinas Medical CenterLevine Cancer Institute Charlotte North Carolina
| | - Yimei Han
- Department of Biostatistics, Carolinas Medical CenterLevine Cancer Institute Charlotte North Carolina
| | - James T. Symanowski
- Department of Biostatistics, Carolinas Medical CenterLevine Cancer Institute Charlotte North Carolina
| | - Jimmy J. Hwang
- Department of Surgery, Carolinas Medical CenterLevine Cancer Institute Charlotte North Carolina
| | - Jonathan C. Salo
- Department of Surgery, Carolinas Medical CenterLevine Cancer Institute Charlotte North Carolina
| | - Joshua S. Hill
- Department of Surgery, Carolinas Medical CenterLevine Cancer Institute Charlotte North Carolina
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18
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Simillis C, Kalakouti E, Afxentiou T, Kontovounisios C, Smith JJ, Cunningham D, Adamina M, Tekkis PP. Primary Tumor Resection in Patients with Incurable Localized or Metastatic Colorectal Cancer: A Systematic Review and Meta-analysis. World J Surg 2019; 43:1829-1840. [DOI: 10.1007/s00268-019-04984-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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19
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Ramphal W, Boeding JR, van Iwaarden M, Schreinemakers JM, Rutten HJ, Crolla RM, Gobardhan PD. Serum carcinoembryonic antigen to predict recurrence in the follow-up of patients with colorectal cancer. Int J Biol Markers 2019; 34:60-68. [DOI: 10.1177/1724600818820679] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: Serum carcinoembryonic (CEA) antigen is used as a diagnostic screening tool during follow-up in colorectal cancer patients. However, it remains unclear whether preoperative serum CEA is a reliable marker in the follow-up to predict recurrence. The aim of the study is to determine the value of elevated pre- and postoperative serum carcinoembryonic antigen levels (CEA > 5 µg/L) as an independent prognostic factor for locoregional and distant recurrence in patients who underwent curative surgery for colorectal cancer. Methods: This single center retrospective observational cohort study includes patients who underwent curative surgery for colorectal cancer between 2005 and 2015 and had pre- and postoperative serum CEA measurements. Five-year disease-free survival and multivariate Cox regression analyses were performed to adjust for confounding factors. Results: Preoperative serum CEA level was measured in 2093 patients with colorectal cancer. No significant association was found between an elevated preoperative serum CEA and locoregional recurrence (adjusted hazard ratio (HR) 1.29 (95% confidence interval (CI) 0.91, 1.84; P=0.26)). However, a significant association was found between an elevated preoperative serum CEA and systemic recurrence (adjusted HR 1.58 (95% CI 1.25, 2.00; P<0.01)]. The five-year disease-free survival was lower in patients with elevated preoperative serum CEA levels ( P<0.01). Postoperative serum CEA level was the most sensitive for hepatic metastases during follow-up (73.3%). Conclusions: The preoperative serum CEA level is an independent prognostic factor for systemic metastasis after curative surgery for colorectal cancer in patients with stage I–III disease. The level is the most sensitive for hepatic metastasis compared to metastasis to other anatomic sites.
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Affiliation(s)
- Winesh Ramphal
- Department of Surgery Amphia Hospital Breda, the Netherlands
| | | | | | | | - Harm J.T. Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
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20
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Harji DP, Vallance A, Selgimann J, Bach S, Mohamed F, Brown J, Fearnhead N. A systematic analysis highlighting deficiencies in reported outcomes for patients with stage IV colorectal cancer undergoing palliative resection of the primary tumour. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:1469-1478. [PMID: 30007475 DOI: 10.1016/j.ejso.2018.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/24/2018] [Accepted: 06/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Management of the primary tumour in the presence of unresectable metastatic colorectal cancer (mCRC) is controversial. The role of primary tumour resection (PTR) has been investigated by a number of retrospective cohort studies, with a number on going randomised controlled trials. The aim of this study was to identify the clinical and patient-reported outcomes currently reported in studies that evaluate the role of PTR in mCRC. METHODS Literature searches were performed in MEDLINE (via OvidSP) (1966-June 2017), EMBASE (via OvidSP) and the Cochrane Library using terms related to colorectal cancer and primary tumour resection. All studies documenting outcomes following palliative PTR were included. Eligible articles were assessed using the Risk of Bias In Non-Randomised Studies of Intervention (ROBINS-I) tool. RESULTS Of 11,209 studies screened, 59 non-randomised studies reporting outcomes on 331,157 patients were included. Patient characteristics regarding performance status and co-morbidity were recorded in 26 (44.1%) and 17 (28.8%) studies. The chemotherapy regime used was reported in 27 (45.8%) studies. The operative setting and the operative approach was reported in 42 (71%) and 14 (23.7%) studies. Post-operative mortality and morbidity were reported in 33 (55.9%) and 35 (59.3%) studies. Overall survival was reported in 49 (83.1%) studies, with 5 different definitions identified. Quality of life was only reported in 1 (1.7%) study. CONCLUSION This study demonstrates significant heterogeneity in the selection and definition of outcomes reported following PTR in mCRC. There is significant heterogeneity with a significant under-reporting of important outcomes such as treatment related adverse events and patient reported outcomes.
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Affiliation(s)
- Deena P Harji
- Newcastle Centre of Bowel Disease, Royal Victoria Infirmary, Newcastle upon Tyne, UK; Clinical Trials Research Unit, University of Leeds, UK.
| | - Abigail Vallance
- Clinical Effectiveness Unit, Royal College of Surgeons, London, UK
| | - Jenny Selgimann
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Simon Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Faheez Mohamed
- Peritoneal Malignancy Institute, North Hampshire Hospital, Hampshire Hospital Foundation Trust, Basingstoke, UK
| | - Julia Brown
- Clinical Trials Research Unit, University of Leeds, UK
| | - Nicola Fearnhead
- Department of Colorectal Surgery, Addenbrooke's Hospital, Cambridge, UK
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21
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Han EC, Kwon YH, Park KJ, Jeong SY, Kang SB, Oh JH, Heo SC. Significance of lymph node metastasis in the survival of stage IV colorectal cancer by hematogenous metastasis. Ann Surg Treat Res 2018; 95:201-212. [PMID: 30310803 PMCID: PMC6172352 DOI: 10.4174/astr.2018.95.4.201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/07/2018] [Indexed: 01/10/2023] Open
Abstract
Purpose Although lymph node (LN) metastasis is an important prognostic marker of colorectal cancer (CRC), the effect of LN metastasis on the survival of stage IV CRC is debated yet. Methods LN status and survivals as well as clinicopathological features of synchronous stage IV CRC patients, operated for 8 years, were analyzed. Patients with hematogenous metastases were included only but those with peritoneal seeding or preoperative adjuvant therapy were not included. Results Total 850 patients were enrolled and 77 (9.1%) were without LN metastases (N0M1). N0M1 patients were older and have favorable pathological features including lower CEA than patients with LN metastasis (N + M1). The pathologically poor features accumulated with N stage progression within N + M1. N0M1 had better 5-year overall survival (OS) and disease free survival than N + M1. And 5-year OS's within N + M1 group were stratified and different according to N stage progression, although the effect of N stage progression is different according to curative resection or not. When compared with stage III, 5-year OS of N0M1 with curative resection was comparable to that of anyTN2aM0 and was better than anyTN2bM1. Conclusion LN metastasis is a significant prognostic factor in stage IV by hematogenous metastasis, too. N stage progression accumulates pathologically poor prognostic factors. However, the effect on survival of each N stage progression differs depending on curative resection or not of the hematogenous metastases.
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Affiliation(s)
- Eon Chul Han
- Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Yoon-Hye Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Seung Chul Heo
- Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
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22
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Akagi T, Inomata M, Hasegawa S, Kinjo Y, Ito M, Fukunaga Y, Kanazawa A, Idani H, Yamamoto S, Otsuka K, Endo S, Watanabe M. Short- and long-term outcomes following laparoscopic palliative resection for patients with incurable, asymptomatic stage IV colorectal cancer: A multicenter study in Japan. JOURNAL OF THE ANUS RECTUM AND COLON 2018; 1:125-130. [PMID: 31583312 PMCID: PMC6768683 DOI: 10.23922/jarc.2017-012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/20/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This retrospective multicenter study compared short- and long-term results between Japanese patients with asymptomatic stage IV colorectal cancer who underwent palliative laparoscopic surgery (LS) versus those who underwent conventional open surgery (OS). METHODS Among 968 patients treated for stage IV colorectal cancer from January 2006 to December 2007 in 41 surgical units that were participating in the Japan Society of Laparoscopic Colorectal Surgery group, we studied 398 patients who received palliative resection of their asymptomatic primary colorectal tumor. RESULTS We analyzed data from patients undergoing LS (LS group, n=106) and OS (OS group, n=292). Fourteen (13.2%) LS group patients were converted to OS. Although the differences between groups for postoperative complications were not significant, the mean time to solid food intake and postoperative length of hospital stay for the LS group were significantly shorter than those for the OS group (2 vs. 3 days, p<0.0001; 13 vs. 16 days, p<0.0001, respectively). The LS group patients experienced a longer median survival time than that of the OS group (24.5 vs. 23.9 months, p=0.0357). CONCLUSIONS Laparoscopic palliative resection (LS) offers advantages for short-term outcomes and no disadvantages for long-term outcomes. The use of laparoscopic procedures to treat asymptomatic, incurable stage IV colorectal cancer appears to be acceptable.
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Affiliation(s)
- Tomonori Akagi
- Department of Gastroenterological & Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological & Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | | | - Yousuke Kinjo
- Department of Surgery, Kyoto University, Kyoto, Japan
| | - Masaaki Ito
- Department of Colorectal and Pelvic Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Yosuke Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, Japan
| | - Akiyoshi Kanazawa
- Department of Gastroenterology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hitoshi Idani
- Department of Surgery, Fukuyama City Hospital, Fukuyama, Japan
| | - Seiichiro Yamamoto
- Division of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University, Iwate, Japan
| | - Shungo Endo
- Department of Surgery, Showa University School of Medicine, Yokohama Northern Hospital, Yokohama, Japan
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23
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van Rooijen KL, Shi Q, Goey KKH, Meyers J, Heinemann V, Diaz-Rubio E, Aranda E, Falcone A, Green E, de Gramont A, Sargent DJ, Punt CJA, Koopman M. Prognostic value of primary tumour resection in synchronous metastatic colorectal cancer: Individual patient data analysis of first-line randomised trials from the ARCAD database. Eur J Cancer 2018; 91:99-106. [PMID: 29353165 DOI: 10.1016/j.ejca.2017.12.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/07/2017] [Indexed: 12/11/2022]
Abstract
Indication for primary tumour resection (PTR) in asymptomatic metastatic colorectal cancer (mCRC) patients is unclear. Previous retrospective analyses suggest a survival benefit for patients who underwent PTR. The aim was to evaluate the prognostic value of PTR in patients with synchronous mCRC by analysis of recent large RCTs including systemic therapy with modern targeted agents. Individual patient data (IPD) of 3423 patients enrolled into 8 randomised controlled trials (RCTs) with first-line systemic therapy in the ARCAD (Aide et Recherche en Cancérologie Digestive) database were analysed. The number of patients with unresected synchronous mCRC, resected synchronous mCRC and metachronous mCRC was 710 (21%), 1705 (50%) and 1008 (29%), respectively. Adjusting for age, gender, performance status (PS) and prior chemotherapy, the unresected group had a significantly worse median overall survival (16.4 m) compared with the synchronous resected (22.2 m; hazard ratio [HR] 1.60, 95% CI 1.43-1.78) and metachronous (22.4 m; HR 1.81, 95% CI 1.58-2.07) groups. Similarly, median progression-free survival was significantly worse for the unresected group compared with the synchronous resected (HR 1.31, 95% CI 1.19-1.44) and metachronous (HR 1.47, 95% CI 1.30-1.66) groups. In a multivariate analysis, the observed associations remained significant. This largest IPD analysis of mCRC trials to date demonstrates an improved survival in synchronous mCRC patients after PTR. These results may be subject to bias since reasons for (non)resection were not available. Until results of ongoing RCTs are available, both upfront PTR followed by systemic treatment and upfront systemic treatment are considered appropriate treatment strategies.
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Affiliation(s)
- K L van Rooijen
- Department of Medical Oncology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Q Shi
- Department of Health Science Research, Mayo Clinic, Rochester, USA
| | - K K H Goey
- Department of Medical Oncology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - J Meyers
- Department of Health Science Research, Mayo Clinic, Rochester, USA
| | - V Heinemann
- Department of Medical Oncology and Comprehensive Cancer Center, Munich, Germany
| | - E Diaz-Rubio
- Cancer Translational Unit, Hospital Clinico San Carlos, Universidad Complutense, Madrid, Spain
| | - E Aranda
- Department of Medical Oncology, UCO, Maimonides Institute of Biomedical Research (IMIBIC), CIBERONC, Instituto de Salud Carlos III, Córdoba, Spain
| | - A Falcone
- Department of Medical Oncology, University of Pisa, Pisa, Italy
| | - E Green
- Department of Health Science Research, Mayo Clinic, Rochester, USA
| | - A de Gramont
- Department of Medical Oncology, Franco-British Institute, Levallois-Perret, France
| | - D J Sargent
- Department of Health Science Research, Mayo Clinic, Rochester, USA
| | - C J A Punt
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M Koopman
- Department of Medical Oncology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands.
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Kim MS, Park EJ, Kang J, Min BS, Lee KY, Kim NK, Baik SH. Prognostic factors predicting survival in incurable stage IV colorectal cancer patients who underwent palliative primary tumor resection. Retrospective cohort study. Int J Surg 2018; 49:10-15. [DOI: 10.1016/j.ijsu.2017.11.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 11/14/2017] [Accepted: 11/27/2017] [Indexed: 02/02/2023]
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Nitsche U, Stöß C, Stecher L, Wilhelm D, Friess H, Ceyhan GO. Meta-analysis of outcomes following resection of the primary tumour in patients presenting with metastatic colorectal cancer. Br J Surg 2017; 105:784-796. [PMID: 29088493 DOI: 10.1002/bjs.10682] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/01/2017] [Accepted: 07/07/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is not clear whether resection of the primary tumour (when there are metastases) alters survival and/or whether resection is associated with increased morbidity. This systematic review and meta-analysis assessed the prognostic value of primary tumour resection in patients presenting with metastatic colorectal cancer. METHODS A systematic review of MEDLINE/PubMed was performed on 12 March 2016, with no language or date restrictions, for studies comparing primary tumour resection versus conservative treatment without primary tumour resection for metastatic colorectal cancer. The quality of the studies was assessed using the MINORS and STROBE criteria. Differences in survival, morbidity and mortality between groups were estimated using random-effects meta-analysis. RESULTS Of 37 412 initially screened articles, 56 retrospective studies with 148 151 patients met the inclusion criteria. Primary tumour resection led to an improvement in overall survival of 7·76 (95 per cent c.i. 5·96 to 9·56) months (risk ratio (RR) for overall survival 0·50, 95 per cent c.i. 0·47 to 0·53), but did not significantly reduce the risk of obstruction (RR 0·50, 95 per cent c.i. 0·16 to 1·53) or bleeding (RR 1·19, 0·48 to 2·97). Neither was the morbidity risk altered (RR 1·14, 0·77 to 1·68). Heterogeneity between the studies was high, with a calculated I2 of more than 50 per cent for most outcomes. CONCLUSION Primary tumour resection may provide a modest survival advantage in patients presenting with metastatic colorectal cancer.
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Affiliation(s)
- U Nitsche
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - C Stöß
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - L Stecher
- Institute of Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - D Wilhelm
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - H Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - G O Ceyhan
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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26
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Tong D, Liu F, Li W, Zhang W. The impacts of surgery of the primary cancer and radiotherapy on the survival of patients with metastatic rectal cancer. Oncotarget 2017; 8:89214-89227. [PMID: 29179513 PMCID: PMC5687683 DOI: 10.18632/oncotarget.19157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 06/28/2017] [Indexed: 12/24/2022] Open
Abstract
The role of surgery of the primary cancer and radiation in metastatic colorectal cancer (mCRC) is still controversial currently, and evidence implied that colon cancer (CC) and rectal cancer (RC) should be treated with difference. Hence we focused on metastatic rectal cancer (mRC) solely to compare the cancer cause-specific survival (CSS) of patients receiving varied treatments of the primary cancer: no treatment, surgery only, radiation only, and surgery plus radiation, based on the records of the Surveillance, Epidemiology, and End Results (SEER) database. A total of 8669 patients were included. Results demonstrated that the 2-year CSS was 28.1% for no treatment group, 30.7% for only radiation group, 50.2% for only surgery group, and 66.5% for surgery plus radiation group, reaching statistical difference (P < 0.001). Furthermore, the CSSs of mRC patients in the surgery group were similar regardless of resection ranges (P = 0.44). Besides, we analyzed the prognostic factors for mRC and found carcinoembryonic antigen (CEA) level, metastasis (M) stage, Tumor (T) stage, tumor size, differentiate grade, age and marital status should be taken into consideration when estimating the prognosis. Particularly, patients with normal CEA level or M1a stage showed a significant survival advantage. Overall, present study suggested that surgery of the primary cancer and radiation might help to improve the survival of mRC patients, especially when both treatments were conducted. Our results may assist clinicians to make better treatment strategy for patients with mRC.
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Affiliation(s)
- Duo Tong
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Fei Liu
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Wenhua Li
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Wen Zhang
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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Biondo S, Frago R, Kreisler E, Espin-Basany E. Impact of resection versus no resection of the primary tumor on survival in patients with colorectal cancer and synchronous unresectable metastases: protocol for a randomized multicenter study (CR4). Int J Colorectal Dis 2017; 32:1085-1090. [PMID: 28497402 DOI: 10.1007/s00384-017-2827-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to determine whether patients diagnosed with colorectal cancer and synchronous unresectable metastases (stage IV) can benefit from resection of the primary tumor in terms of an improvement in cancer-specific survival. METHODS Stage IV colorectal cancer patients are eligible for inclusion in a randomized multicenter study carried out in 22 hospitals throughout Spain. Exclusion criteria are rectal tumors below 12 cm from the anal verge or locally advanced tumors, multiple bone or central nervous system metastases, and history of another primary cancer. The parallel design of the trial includes an arm of systemic chemotherapy alone versus an arm of resection of the primary tumor plus systemic chemotherapy after surgery. The primary endpoint of the study is cancer-specific survival that is assessed with a minimum follow-up of 24 months. Secondary endpoints are postoperative morbidity and mortality associated with resection of the primary tumor, complications and need of surgery in patients treated with systemic chemotherapy only, safety of systemic chemotherapy in both treatment strategies, and quality of life. CONCLUSIONS Confirmation of a survival benefit of surgical resection of the primary tumor in stage IV colorectal cancer patients not amenable to curative therapy is very relevant from a clinical and societal perspective, particularly considering the increase in the incidence and prevalence of colorectal cancer in developed countries. ClinicalTrials.gov Identifier: NCT02015923.
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Affiliation(s)
- Sebastiano Biondo
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, C/ Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
| | - Ricardo Frago
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, C/ Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Esther Kreisler
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, C/ Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Eloy Espin-Basany
- Department of General and Digestive Surgery, Colorectal Unit, Vall d'Hebron University Hospital, Autonomic University of Barcelona, Barcelona, Spain
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Suárez J, Marín G, Vera R, Colibaseanu D, Vila JJ, Ciga MA, Oronoz B. Stent placement prior to initiation of chemotherapy in patients with obstructive, nonoperative left sided tumors is associated with fewer stomas. J Surg Oncol 2017; 115:856-863. [DOI: 10.1002/jso.24588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/07/2017] [Accepted: 02/02/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Javier Suárez
- Department of General Surgery; Coloproctology Unit, Complejo Hospitalario de Navarra; Pamplona Spain
| | - Gabriel Marín
- Department of General Surgery; Coloproctology Unit, Complejo Hospitalario de Navarra; Pamplona Spain
| | - Ruth Vera
- Department of Medical Oncology; Complejo Hospitalario de Navarra; Pamplona Spain
| | - Dorin Colibaseanu
- Department of Surgery; Section of Colon and Rectal Surgery, Mayo Clinic; Jacksonville Florida
| | - Juan J. Vila
- Department of Gastroenterology; Complejo Hospitalario de Navarra; Pamplona Spain
| | - Miguel A. Ciga
- Department of General Surgery; Coloproctology Unit, Complejo Hospitalario de Navarra; Pamplona Spain
| | - Begoña Oronoz
- Department of General Surgery; Coloproctology Unit, Complejo Hospitalario de Navarra; Pamplona Spain
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Jang HS, Ju JK, Kim CH, Lee SY, Kim HR, Kim YJ. Palliative resection of a primary tumor in patients with unresectable colorectal cancer: could resection type improve survival? Ann Surg Treat Res 2016; 91:172-177. [PMID: 27757394 PMCID: PMC5064227 DOI: 10.4174/astr.2016.91.4.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/09/2016] [Accepted: 06/02/2016] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate the impact of extended resection of primary tumor on survival outcome in unresectable colorectal cancer (UCRC). METHODS A retrospective analysis was conducted for 190 patients undergoing palliative surgery for UCRC between 1998 and 2007 at a single institution. Variables including demographics, histopathological characteristics of tumors, surgical procedures, and course of the disease were examined. RESULTS Kaplan-Meier survival curve indicated a significant increase in survival times in patients undergoing extended resection of the primary tumor (P < 0.001). Multivariate analysis showed that extra-abdominal metastasis (P = 0.03), minimal resection of the primary tumor (P = 0.034), and the absence of multimodality adjuvant therapy (P < 0.001) were significantly associated poor survival outcome. The histological characteristics were significantly associated with survival times. Patients with well to moderate differentiation tumors that were extensively resected had significantly increased survival time (P < 0.001), while those with poor differentiation tumors that were extensively resected did not have increase survival time (P = 0.786). CONCLUSION Extended resection of primary tumors significantly improved overall survival compared to minimal resection, especially in well to moderately differentiated tumors (survival time: extended resection, 27.8 ± 2.80 months; minimal resection, 16.5 ± 2.19 months; P = 0.002).
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Affiliation(s)
- Hyun Seok Jang
- Department of Surgery, Chonnam University Hospital, Gwangju, Korea
| | - Jae Kyun Ju
- Department of Surgery, Chonnam University Hospital, Gwangju, Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam University Hwasun Hospital, Gwangju, Korea
| | - Soo Young Lee
- Department of Surgery, Chonnam University Hwasun Hospital, Gwangju, Korea
| | - Hyeong Rok Kim
- Department of Surgery, Chonnam University Hwasun Hospital, Gwangju, Korea
| | - Young Jin Kim
- Department of Surgery, Chonnam University Hwasun Hospital, Gwangju, Korea
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30
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Kim BJ, Aloia TA. Cost-effectiveness of palliative surgery versus nonsurgical procedures in gastrointestinal cancer patients. J Surg Oncol 2016; 114:316-22. [PMID: 27132654 DOI: 10.1002/jso.24280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 04/13/2016] [Indexed: 01/04/2023]
Abstract
Palliative care is an essential component to multidisciplinary cancer care. Improved symptom control, quality of life (QOL), and survival have resulted from its utilization. Cost-effectiveness and utility analyses are significant variables that should be considered in comparing benefits and costs of medical interventions to determine if certain treatments are economically justified. This is a review on the cost-effectiveness of palliative surgery compared to other nonsurgical palliative procedures in patients with unresectable gastrointestinal cancers. J. Surg. Oncol. 2016;114:316-322. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Bradford J Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
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Chen D, Wen X, Song YS, Rhee YY, Lee TH, Cho NY, Han SW, Kim TY, Kang GH. Associations and prognostic implications of Eastern Cooperative Oncology Group performance status and tumoral LINE-1 methylation status in stage III colon cancer patients. Clin Epigenetics 2016; 8:36. [PMID: 27051466 PMCID: PMC4820986 DOI: 10.1186/s13148-016-0203-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/31/2016] [Indexed: 12/16/2022] Open
Abstract
Background Low methylation status of LINE-1 in tumors is associated with poor survival in patients with colon cancer. Eastern Cooperative Oncology Group performance status (ECOG-PS) is a method to assess the functional status of a patient. We retrospectively evaluated the relationship between ECOG-PS and LINE-1 methylation in colorectal cancers (CRCs) and their prognostic impact in CRC or colon cancer patients receiving adjuvant 5-fluorouracil/leucovorin/oxaliplatin (FOLFOX). Results LINE-1 methylation and microsatellite instability were analyzed in stage III or high-risk stage II CRCs (n = 336). LINE-1 methylation levels were correlated with clinicopathological features, including PS and recurrence-free survival (RFS). The association between the tumoral LINE-1 methylation level and PS was observed (OR = 2.56, P < 0.001). Differences in LINE-1 methylation levels in cancer tissue between the PS 0 and 1 groups were significant in patients older than 60 years (P = 0.001), the overweight body mass index group (P = 0.005), and the stage III disease group (P = 0.008). Prognostic significances of LINE-1 methylation status or combined PS and LINE-1 methylation statuses were identified in stage III colon cancers, not in stage III and high-risk stage II CRCs. Low LINE-1 methylation status was closely associated with a shorter RFS time. The difference between PS(0)/LINE-1(high) and PS(≥1)/LINE-1(low) was significant, which suggests that colon cancer patients with concurrent PS(≥1)/LINE-1 (low) have a higher recurrence rate. Conclusions PS was associated with LINE-1 methylation in CRC tissue. LINE-1 methylation was associated with RFS in stage III colon cancer patients who were treated with adjuvant FOLFOX chemotherapy. Combined PS and LINE-1 methylation status might serve as a useful predictor of cancer recurrence. Electronic supplementary material The online version of this article (doi:10.1186/s13148-016-0203-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Duo Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Cancer Epidemiology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Xianyu Wen
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Young Seok Song
- Laboratory of Epigenetics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ye-Young Rhee
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Hun Lee
- Laboratory of Epigenetics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Nam Yun Cho
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Sae-Won Han
- Division of Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-You Kim
- Division of Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Gyeong Hoon Kang
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
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Abstract
BACKGROUND The benefits of primary tumor resection in metastatic disease remains a matter of debate. Existing data are almost exclusively limited to results from retrospective analyses. Data from prospective, randomized trials are currently not available. AIM The results from two prospective observational studies involving gastric and rectal cancer patients are presented and discussed in the context of the available literature. METHOD Based on data collected within the prospective quality assurance studies on gastric and rectal cancer conducted by the Institute for Quality Assurance in Surgery at Otto von Guericke University, Magdeburg, Germany, the long-term outcome after palliative primary tumor resection in patients with International Union Against Cancer (UICC) stage IV rectal cancer (2005-2008, n = 2046) and metastatic gastric cancer (2007-2009, n = 687) was analyzed and compared to published data. RESULTS The median survival time following palliative primary tumor resection of UICC stage IV rectal cancer in the patients analyzed was 20 months. In patients with hepatic metastases undergoing metastasectomy the median survival was 38 months. This increased to 58 months for patients with lymph node negative primary tumors. In metastatic gastric cancer patients undergoing palliative (R2) gastric resection and also patients not undergoing surgery showed a prognostic benefit from palliative chemotherapy; however, the median survival time was significantly prolonged if palliative chemotherapy was preceded by resection of the primary tumor (11 versus 7 months, p < 0.001). DISCUSSION Together with previously published data, the results from the two observational studies on rectal and gastric cancer presented here suggest a prognostic benefit from palliative resection of the primary tumor in metastatic disease.
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Complications from the primary tumour are not related with survival in patients with synchronous stage IV colorectal cancer receiving chemotherapy without primary tumour resection. Int J Colorectal Dis 2015; 30:1357-63. [PMID: 26149942 DOI: 10.1007/s00384-015-2305-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the rate of complications from the primary tumour (CPT) requiring surgical or endoscopic intervention during chemotherapy treatment in patients with incurable synchronous stage IV colorectal cancer, the possibility of predicting such complications and their influence on survival. METHODS One hundred and twenty-five patients were initially treated with chemotherapy. Patients were grouped on the basis of appearance or not of CPT. We assessed the relation between age, gender, carcinoembryonic antigen (CEA) level, primary tumour location, alkaline phosphatase level, unilobar or bilobar liver involvement, presence of peritoneal carcinomatosis, the number of sites of metastatic disease, the addition of target therapies to chemotherapy, the ability to traverse the tumour with an endoscope and the appearance of complications due to the primary tumour and overall survival. RESULTS Mean age was 64.9 years, and 89 patients were men. Over a mean of 234 days, 25 patients (20 %) developed a CPT. Eighteen patients required surgery, and seven were treated exclusively by an endoscopic procedure. Mean survival was 15.8 months. We found a statistically relevant correlation between the inability to traverse the tumour with an endoscope and the occurrence of a CPT. There was no statistical differences in survival between both groups, but patients receiving target therapies had better survival. CONCLUSION Twenty percent of patients will suffer a CPT during chemotherapy treatment. The inability to pass the tumour with an endoscope can predict the CPT. Survival was only related to the addition of target therapies to chemotherapy.
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Shibata J, Kawai K, Nishikawa T, Tanaka T, Tanaka J, Kiyomatsu T, Hata K, Nozawa H, Kazama S, Yamaguchi H, Ishihara S, Sunami E, Kitayama J, Sugihara K, Watanabe T. Prognostic Impact of Histologic Type in Curatively Resected Stage IV Colorectal Cancer: A Japanese Multicenter Retrospective Study. Ann Surg Oncol 2015; 22 Suppl 3:S621-9. [DOI: 10.1245/s10434-015-4846-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Indexed: 12/21/2022]
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Dawood S, Sirohi B, Shrikhande SV, Toh HC, Eng C. Potential Prognostic Impact of Baseline CEA Level and Surgery of Primary Tumor Among Patients with Synchronous Stage IV Colorectal Cancer: A Large Population Based Study. Indian J Surg Oncol 2015; 6:198-206. [PMID: 27217664 DOI: 10.1007/s13193-015-0419-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 05/19/2015] [Indexed: 12/30/2022] Open
Abstract
Prognostic role of surgical resection of the primary tumor and baseline CEA among patients with synchronous stage IV colorectal cancer (CRC) remains an area of debate. The objective of this study was to determine the prognostic value of baseline CEA and surgical resection of the primary among patients with synchronous stage IV CRC in the era of modern chemotherapy and biologic therapy. The Surveillance, Epidemiology and End Results Registry was searched to identify patients with synchronous stage IV CRC diagnosed between 2004 and 2009. Colorectal-cancer-specific survival (CCS) was estimated using the Kaplan-Meier product limit method. Cox models were fitted to assess the multivariable relationship of various patient and tumor characteristics and CCS. Three hundred thirty-three thousand, three hundred ninety nine patients were identified in the SEER registry. Median CCS among patients with their primary tumor removed was 21 M vs. 7 M (primary intact) respectively (p < 0.001). Median CCS among patients who had an elevated vs. non-elevated baseline CEA level was 14 M vs. 24 M respectively (p < 0.0001). By multivariable analysis, patients with an elevated baseline CEA had a 56 % increased risk of death from CRC compared to those with a non-elevated CEA level (HR = 1.56, 95%CI 1.47-1.65, p < 0.0001). Similarly patients who underwent surgical resection of the primary tumor had a 33 % decreased risk of death from CRC compared to those who did not (HR = 0.61, 95%CI 0.54-0.69, p < 0.0001). In our review of this large population SEER based study, an elevated baseline CEA level and surgical resection of the primary tumor among patients with synchronous stage IV CRC appeared to impact survival outcomes. Prospective validation of these results in a surgically unresectable patient population will be required.
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Affiliation(s)
- Shaheenah Dawood
- Department of Medical Oncology, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Bhawna Sirohi
- Department of Medical Oncology, Mazumdar Shaw Cancer Centre, Narayana Health, Bangalore, India
| | | | - Han-Chong Toh
- Department of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Cathy Eng
- Department of GI Medical Oncology, MD Anderson Cancer Center, Houston, TX USA
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Benefit of primary tumor resection in stage IV colorectal cancer with unresectable metastasis: a multicenter retrospective study using a propensity score analysis. Int J Colorectal Dis 2015; 30:807-12. [PMID: 25922146 DOI: 10.1007/s00384-015-2228-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2015] [Indexed: 02/08/2023]
Abstract
PURPOSE Retrospective studies have shown that primary tumor resection improves the prognosis of patients with colorectal cancer (CRC) with unresectable metastasis (mCRC). The aim of this study was to investigate the prognostic impact of primary tumor resection in various subgroups of mCRC patients. METHODS A total of 1982 patients with mCRC from January 1997 to December 2007 were retrospectively evaluated. The impact of primary tumor resection on cancer-specific survival (CSS) was analyzed using propensity score analysis to mitigate selection bias. Covariates in the models for propensity scores included treatment period, age, gender, tumor location, depth, lymph node metastasis, number of metastatic organs, and carcinoembryonic antigen (CEA) levels. RESULTS Among the whole patient population, primary tumor resection significantly improved CSS [hazard ratio (HR) 0.46, 95% confidence interval (CI) 0.32-0.66, p < 0.01]. However, primary tumor resection did not significantly improve CSS in the following subgroups: patients treated in the first 5 years of the study (HR 0.56, 95% CI 0.28-1.13, p = 0.08), patients aged >65 years (HR 0.72, 95% CI 0.36-1.42, p = 0.31), female patients (HR 0.60, 95% CI 0.31-1.17, p = 0.13), patients with right-sided colon cancer (HR 0.68, 95% CI 0.39-1.20, p = 0.17), and patients without nodal involvement (HR 0.54, 95% CI 0.25-1.17, p = 0.09). CONCLUSIONS Our study suggests that primary tumor resection improves the survival of patients with mCRC. However, the prognostic benefit is different among patient subpopulations.
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Heedman PA, Canslätt E, Henriks G, Starkhammar H, Fomichov V, Sjödahl R. Variation at presentation among colon cancer patients with metastases: a population-based study. Colorectal Dis 2015; 17:403-8. [PMID: 25511984 DOI: 10.1111/codi.12864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 10/08/2014] [Indexed: 01/03/2023]
Abstract
AIM The study aimed to describe and follow a 2 year cohort of colon cancer patients with Stage IV disease from presentation to long-term outcome. METHOD The records of 177 colon cancer patients diagnosed in southeast Sweden during 2009-2010 with disseminated disease at presentation were reviewed retrospectively. RESULTS The patients were heterogeneous with respect to age, performance status and survival. Despite metastatic disease, local symptoms from the primary tumour dominated the initial clinical picture. Forty-one per cent had anaemia. The time from suspicion of colon cancer to established diagnosis of disseminated disease varied from 0 to 231 days (emergency cases included, median 12 days). The majority (77%) were diagnosed in hospital. In 53% the primary tumour and the metastases were not diagnosed on the same occasion which may increase the risk for misinformation or delays in the care process. The possibility of simultaneous diagnosis was doubled when the patient was investigated as an inpatient. Patients were seen by one to 12 physicians (median three) in the investigation phase, and one to 47 (median 11) from diagnosis until the last record in the hospital notes. The 1-year survival was 46%. CONCLUSION Patients with metastatic colon cancer at presentation are heterogeneous and warrant an adapted multidisciplinary approach to achieve the goal of individualized treatment for each patient in accordance with the Swedish national cancer strategy.
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Affiliation(s)
- P A Heedman
- Palliative Education and Research Center, Östergötland, Sweden; Regional Cancer Centre, Linköping, Sweden
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Ozaslan E, Duran AO, Bozkurt O, Inanc M, Ucar M, Berk V, Karaca H, Elmali F, Ozkan M. Analyses of Multiple Factors for Determination of "Selected Patients" Who Should Receive Rechallenge Treatment in Metastatic Colorectal Cancer: a Retrospective Study from Turkey. Asian Pac J Cancer Prev 2015; 16:2833-8. [DOI: 10.7314/apjcp.2015.16.7.2833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Cotte E, Villeneuve L, Passot G, Boschetti G, Bin-Dorel S, Francois Y, Glehen O. GRECCAR 8: impact on survival of the primary tumor resection in rectal cancer with unresectable synchronous metastasis: a randomized multicentre study. BMC Cancer 2015; 15:47. [PMID: 25849254 PMCID: PMC4327953 DOI: 10.1186/s12885-015-1060-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 01/29/2015] [Indexed: 12/15/2022] Open
Abstract
Background A majority of patients with rectal cancer and metastasis are not eligible to curative treatment because of an extensive and unresectable metastatic disease. Primary tumor resection is still debated in this situation. Rectal surgery treats or prevents the symptoms and avoids the risk of acute complications related to the primary tumor. Several studies on colorectal cancers seem to show interesting results in terms of survival in favor to the resection of the primary tumor. To date, no randomized trial or even a prospective study has assessed the impact of primary tumor resection on overall survival in patients with colorectal cancer with unresectable metastasis. All published studies were retrospective and included colon and rectal cancers. Rectal cancer is associated with specific problems related to the rectal surgery. Surgery is more complex, and may be source of more morbidity and postoperative functional dysfunctions (stoma, digestive, sexual, urinary) than colic surgery. On the other hand, symptoms related to the progression of rectal tumor are often very disabling: pain, rectal syndrome. Methods/Design GRECCAR 8 is a multicentre randomized open-label controlled trial aimed to evaluate the impact on survival of the primary tumor resection in rectal cancer with unresectable synchronous metastasis. Patients must undergo upfront systemic chemotherapy for at least 4 courses before inclusion. Patients with progressive metastatic disease during upfront chemotherapy will be excluded from the study. Patients will be randomly assigned in a 1:1 ratio to Arm A: primary tumor resection followed by systemic chemotherapy versus Arm B: systemic chemotherapy alone. Primary endpoint will be overall survival measured from the date of randomization to the date of death or to the end of follow-up (2 years). Secondary endpoints will include progression-free survival, quality of life, toxicity of chemotherapy, response of the primary tumor and metastatic disease to chemotherapy, postoperative morbidity and mortality, rate of patient not eligible for postoperative chemotherapy (arm A), primary tumor related complications and rate of emergency surgery (arm B). The number of patients needed is 290. Trial registration ClinicalTrial.gov: NCT02314182
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Abstract
Treatment of colorectal cancer is becoming more uniform, with wider acceptance of standardized guidelines. However, areas of controversy exist where the appropriate treatment is not clear, including: should a segmental colectomy or a more extensive resection be performed in hereditary nonpolyposis colorectal cancer? should an asymptomatic primary cancer be resected in the presence of unresectable metastatic disease? what is the role of extended lymph node resection in colon and rectal cancer? are there clinically significant benefits for a robotic approach to colorectal resection versus a laparoscopic approach? This chapter will examine these issues and discuss how they may be resolved.
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Faron M, Pignon JP, Malka D, Bourredjem A, Douillard JY, Adenis A, Elias D, Bouché O, Ducreux M. Is primary tumour resection associated with survival improvement in patients with colorectal cancer and unresectable synchronous metastases? A pooled analysis of individual data from four randomised trials. Eur J Cancer 2014; 51:166-76. [PMID: 25465185 DOI: 10.1016/j.ejca.2014.10.023] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 09/14/2014] [Accepted: 10/23/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the impact on survival of primary tumour resection in patients with unresectable synchronous metastases from colorectal cancer (CRC). SUMMARY BACKGROUND DATA Primary tumour resection in this setting remains controversial. PATIENTS AND METHODS We retrieved individual data of 1155 patients with metastatic CRC included in four first-line chemotherapy trials: Fédération Francophone de Cancérologie Digestive (FFCD)-9601, FFCD-2000-05, Actions Concertées dans les cancers COloRectaux et Digestifs (ACCORD)-13, and ML-16987. Patients with unresectable synchronous metastases were eligible for this study. We used univariate and multivariate analyses (Cox models stratified on the trial) to assess the impact of primary tumour resection and other potential prognostic variables on overall survival (OS) (the primary endpoint). RESULTS Amongst the 1155 patients, 810 patients met the inclusion criteria and 59% (n = 478) underwent resection of their primary tumour, prior to trial entry (resection group). Compared to patients in the non-resection group (n =3 32 [41%]), those in the resection group were more likely to have a colonic primary, lower baseline carcinoembryonic antigen (CEA) and alkaline phosphatase levels, and normal white-blood-cell count (p < 0.001 each). Primary tumour resection was independently associated to better OS in multivariate analysis (hazard ratio (HR), 0.63 [0.53-0.75]; p < 0.001, with a more favourable impact of resection on OS in case of rectal primary and low CEA level. Primary tumour resection was also independently associated to a better progression-free survival in multivariate analysis (HR, 0.82 [0.70-0.95]; p < 0.001). CONCLUSION Primary tumour resection was independently associated to a better OS in patients with CRC and unresectable synchronous metastases.
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Affiliation(s)
- Matthieu Faron
- Department of Biostatistics and Epidemiology, Gustave Roussy, Villejuif, France
| | - Jean-Pierre Pignon
- Department of Biostatistics and Epidemiology, Gustave Roussy, Villejuif, France.
| | - David Malka
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | | | - Jean-Yves Douillard
- Department of Medical and Translational Research, Centre René Gauducheau, Saint-Herblain, France
| | - Antoine Adenis
- Department of Urologic and Digestive Oncology, Centre Oscar Lambret, Lille, France
| | - Dominique Elias
- Department of Visceral Surgery, Gustave Roussy, Villejuif, France
| | - Olivier Bouché
- Department of Hepatogastroenterology and Digestive Oncology, Hôpital Robert Debré, Reims, France
| | - Michel Ducreux
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
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Ahn HJ, Oh HS, Ahn Y, Lee SJ, Kim HJ, Kim MH, Eom DW, Kwak JY, Han MS, Song JS. Prognostic Implications of Primary Tumor Resection in Stage IVB Colorectal Cancer in Elderly Patients. Ann Coloproctol 2014; 30:175-81. [PMID: 25210686 PMCID: PMC4155136 DOI: 10.3393/ac.2014.30.4.175] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 02/17/2014] [Indexed: 01/11/2023] Open
Abstract
PURPOSE The aim of this study was to identify prognostic factors in stage IVB colorectal cancer in elderly patients, focusing on the influence of treatment modalities, including palliative chemotherapy and primary tumor resection. METHODS A cohort of 64 patients aged over 65 years who presented with stage IVB colorectal cancer at the Gangneung Asan Hospital between July 1, 2001, and December 31, 2009, was analyzed. Demographics, tumor location, tumor grade, performance status, levels of carcinoembryonic antigen (CEA), level of aspartate aminotransferase (AST), and distant metastatic site at diagnosis were analyzed. Using the treatment histories, we analyzed the prognostic implications of palliative chemotherapy and surgical resection of the primary tumor retrospectively. RESULTS The cohort consisted of 30 male (46.9%) and 34 female patients (53.1%); the median age was 76.5 years. Primary tumor resection was done on 28 patients (43.8%); 36 patients (56.2%) were categorized in the nonresection group. The median survival times were 12.43 months in the resection group and 3.58 months in the nonresection group (P < 0.001). Gender, level of CEA, level of AST, Eastern Cooperative Oncology Group performance status, tumor location, and presence of liver metastasis also showed significant differences in overall survival. On multivariate analysis, male gender, higher level of CEA, higher AST level, and no primary tumor resection were independent poor prognostic factors. In particular, nonresection of the primary tumor was the most potent/poor prognostic factor in the elderly-patient study group (P = 0.001; 95% confidence interval, 2.33 to 21.99; hazard ratio, 7.16). CONCLUSION In stage IVB colorectal cancer in elderly patients, resection of the primary tumor may enhance survival.
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Affiliation(s)
- Heui-June Ahn
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Ho-Suk Oh
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Yongchel Ahn
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sang Jin Lee
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Hyun Joong Kim
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Moon Ho Kim
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Dae-Woon Eom
- Department of Pathology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jae Young Kwak
- Department of Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Myoung Sik Han
- Department of Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jae Seok Song
- Department of Preventive Medicine, Kwandong University College of Medicine, Gangneung, Korea
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Meisner S. Stent for palliation of advanced colorectal cancer. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Costi R, Leonardi F, Zanoni D, Violi V, Roncoroni L. Palliative care and end-stage colorectal cancer management: The surgeon meets the oncologist. World J Gastroenterol 2014; 20:7602-7621. [PMID: 24976699 PMCID: PMC4069290 DOI: 10.3748/wjg.v20.i24.7602] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 04/09/2014] [Indexed: 02/07/2023] Open
Abstract
Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.
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Mestier LD, Manceau G, Neuzillet C, Bachet JB, Spano JP, Kianmanesh R, Vaillant JC, Bouché O, Hannoun L, Karoui M. Primary tumor resection in colorectal cancer with unresectable synchronous metastases: A review. World J Gastrointest Oncol 2014; 6:156-69. [PMID: 24936226 PMCID: PMC4058723 DOI: 10.4251/wjgo.v6.i6.156] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 04/08/2014] [Accepted: 05/13/2014] [Indexed: 02/05/2023] Open
Abstract
At the time of diagnosis, 25% of patients with colorectal cancer (CRC) present with synchronous metastases, which are unresectable in the majority of patients. Whether primary tumor resection (PTR) followed by chemotherapy or immediate chemotherapy without PTR is the best therapeutic option in patients with asymptomatic CRC and unresectable metastases is a major issue, although unanswered to date. The aim of this study was to review all published data on whether PTR should be performed in patients with CRC and unresectable synchronous metastases. All aspects of the management of CRC were taken into account, especially prognostic factors in patients with CRC and unresectable metastases. The impact of PTR on survival and quality of life were reviewed, in addition to the characteristics of patients that could benefit from PTR and the possible underlying mechanisms. The risks of both approaches are reported. As no randomized study has been performed to date, we finally discussed how a therapeutic strategy's trial should be designed to provide answer to this issue.
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Aboziada M, Attia A, Alhamad A. Presentation and outcome of twenty patients with synchronous stage IV rectal carcinoma. INTERNATIONAL JOURNAL OF CANCER THERAPY AND ONCOLOGY 2014. [DOI: 10.14319/ijcto.0203.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Duraker N, Civelek Çaynak Z, Hot S. The impact of primary tumor resection on overall survival in patients with colorectal carcinoma and unresectable distant metastases: a prospective cohort study. Int J Surg 2014; 12:737-41. [PMID: 24802519 DOI: 10.1016/j.ijsu.2014.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/07/2014] [Accepted: 04/30/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND To compare the patients with primary colorectal carcinoma (CRC) and non-resectable distant metastases with or without primary colorectal tumor resection as a primary treatment in terms of postoperative mortality and overall survival (OS). PATIENTS AND METHODS The clinicopathological data of 188 CRC patients with non-resectable distant metastases was analyzed. All patient data were collected prospectively. Colorectal tumor was resected in 121 patients (64.3%). Kaplan-Meier method was used for calculation and plotting of the OS curves of the patient groups, and log-rank test was used for the comparison of the survival curves. The relative importance of the prognostic features was investigated using the Cox proportional hazards model. RESULTS In the whole series and in the patient group undergoing emergency surgical intervention, mortality rate was lower in patients having colorectal tumor resection compared with non-resected patients, with differences approaching the significance level (p = 0.072 and p = 0.076, respectively). Median OS time was significantly longer in resection group (11.0 months), compared with non-resection group (5.5 months) (p < 0.001); in the multivariate Cox analysis colorectal tumor resection had independent prognostic significance (p < 0.001). CONCLUSION Resection of colorectal tumor in primary CRC patients with non-resectable distant metastasis gives significant survival advantage without increasing postoperative mortality compared with non-resection.
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Affiliation(s)
- Nüvit Duraker
- Department of Surgery, SB Okmeydanı Training and Research Hospital, İstanbul, Turkey.
| | | | - Semih Hot
- Department of Surgery, SB Okmeydanı Training and Research Hospital, İstanbul, Turkey
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Ishihara S, Hayama T, Yamada H, Nozawa K, Matsuda K, Miyata H, Yoneyama S, Tanaka T, Tanaka J, Kiyomatsu T, Kawai K, Nozawa H, Kanazawa T, Kazama S, Yamaguchi H, Sunami E, Kitayama J, Hashiguchi Y, Sugihara K, Watanabe T. Prognostic impact of primary tumor resection and lymph node dissection in stage IV colorectal cancer with unresectable metastasis: a propensity score analysis in a multicenter retrospective study. Ann Surg Oncol 2014; 21:2949-55. [PMID: 24763981 DOI: 10.1245/s10434-014-3719-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Retrospective studies have shown that primary tumor resection improves the prognosis of patients with colorectal cancer with unresectable metastasis (mCRC). Prognostic significance of lymph node dissection (LND) in mCRC has not been examined previously. The aim of this study was to investigate the prognostic impact of primary tumor resection and LND in mCRC. METHODS A total of 1,982 patients with mCRC from January 1997 to December 2007 were retrospectively studied. The impact of primary tumor resection and LND on overall survival (OS) was analyzed using Cox proportional hazards model and propensity score analysis to mitigate the selection bias. Covariates in the models for propensity scores included treatment period, institution, age, sex, carcinoembryonic antigen, tumor location, histology, depth, lymph node metastasis, lymphovascular invasion, and number of metastatic organs. RESULTS In a multivariate analysis, primary tumor resection and treatment in the latter period were associated with an improved OS, and age over 70 years, female sex, lymph node metastasis, and multiple organ metastasis were associated with a decreased OS. In the propensity-matched cohort, patients treated with primary tumor resection showed a significantly better OS than those without tumor resection (median OS 13.8 vs. 6.3 months; p = 0.0001). Furthermore, among patients treated with primary tumor resection, patients treated with D3 LND showed a significantly better OS than those with less extensive LND (median OS 17.2 vs. 13.7 months; p < 0.0001). CONCLUSIONS It was suggested that primary tumor resection with D3 LND improves the survival of patients with mCRC.
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Affiliation(s)
- Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo Hospital, Tokyo, Japan
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de Mestier L, Neuzillet C, Pozet A, Desot E, Deguelte-Lardière S, Volet J, Karoui M, Kianmanesh R, Bonnetain F, Bouché O. Is primary tumor resection associated with a longer survival in colon cancer and unresectable synchronous metastases? A 4-year multicentre experience. Eur J Surg Oncol 2014; 40:685-91. [PMID: 24630774 DOI: 10.1016/j.ejso.2014.02.236] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 02/12/2014] [Accepted: 02/18/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To explore the survival impact of primary tumor resection (PTR) in patients with metastatic colon cancer (mCC) and unresectable metastases. METHODS We retrospectively studied a multicenter cohort of consecutive mCC patients with unresectable metastases receiving first-line chemotherapy. A weighted Cox proportional regression model was used to balance for clinical variables associated with the probability of undergoing PTR, using inverse probability of treatment weighting (IPTW) based on a propensity score. RESULTS Ninety-six patients were included. PTR was performed in 69 (72%). The rates of secondary resection of metastases (p = 0.02) and bevacizumab administration (p = 0.02) were higher in the PTR group. Raw median overall survival (OS) was 23.1 months (95%CI[14.6-27.8]) in the PTR group and 22.1 months (95%CI[12.3-23.7]) in the non-PTR group (p = 0.11). After adjustment on IPTW, OS was 23.1 months (95%CI[17.0-28.7]) in the PTR group and 17.2 months (95%CI[13.5-22.2]) in the non-PTR group (HR 0.68; 95%CI[0.50-0.93]; p = 0.016). This result remained significant on multivariate analysis (HR 0.71; 95%CI[0.50-1.00]; p = 0.05). CONCLUSION In mCC patients with unresectable metastases receiving chemotherapy, up-front PTR was independently associated with prolonged OS. Patients eligible for secondary metastases resection and/or bevacizumab may benefit the most from PTR. Randomized controlled trials are mandatory.
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Affiliation(s)
- L de Mestier
- Department of Hepato-Gastroenterology and Digestive Oncology, Robert-Debré University Hospital, Reims, France.
| | - C Neuzillet
- Department of Gastroenterology and Pancreatology, Beaujon University Hospital, Clichy, France
| | - A Pozet
- Unit of Methodology and Quality of Life in Oncology, EA 3181, Saint-Jacques University Hospital, Besançon, France
| | - E Desot
- Department of Hepato-Gastroenterology and Digestive Oncology, Robert-Debré University Hospital, Reims, France
| | - S Deguelte-Lardière
- Department of Digestive and Endocrine Surgery, Robert-Debré University Hospital, Reims, France
| | - J Volet
- Department of Hepato-Gastroenterology and Digestive Oncology, Robert-Debré University Hospital, Reims, France
| | - M Karoui
- Department of Digestive Surgery, Pitié-Salpetrière University Hospital, Assistance Publique Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France
| | - R Kianmanesh
- Department of Digestive and Endocrine Surgery, Robert-Debré University Hospital, Reims, France
| | - F Bonnetain
- Unit of Methodology and Quality of Life in Oncology, EA 3181, Saint-Jacques University Hospital, Besançon, France
| | - O Bouché
- Department of Hepato-Gastroenterology and Digestive Oncology, Robert-Debré University Hospital, Reims, France.
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Influence of primary tumor resection on survival in asymptomatic patients with incurable stage IV colorectal cancer. Int J Clin Oncol 2014; 19:1037-42. [DOI: 10.1007/s10147-014-0662-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 01/07/2014] [Indexed: 02/01/2023]
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