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Leijssen LGJ, Dinaux AM, Kunitake H, Bordeianou LG, Berger DL. The impact of postoperative morbidity on survival in patients with metastatic colon and rectal cancer. J Surg Oncol 2019; 120:460-472. [PMID: 31276213 DOI: 10.1002/jso.25610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 06/13/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Avoiding postoperative morbidity is essential in patients with advanced cancer. To further improve treatment in stage IV colorectal cancer, knowledge about risk factors which effect short- and long-term outcomes is important. METHODS All stage IV colon and rectal cancer who underwent elective surgery between 2004 and 2015 were included (n = 345). We compared resectable colon and rectal patients, and unresectable colon and rectal cancer patients. RESULTS Median follow-up duration was 22.2 (unresectable) and 56.7 months (resectable) with no difference in tumor location. Colon cancer patients were more often considered unresectable (P < .001). Rectal procedures were correlated with a higher morbidity rate and a longer surgical duration (P < .001). In the resectable cohort, obese patients, open procedures and prolonged surgery were independently associated with postoperative complications. Considering the palliative group, neoadjuvant treatment and age were correlated with worse outcomes. Morbidity was not associated with long-term outcomes in the resectable cohort. However, unresectable patients who developed respiratory (hazard ratio [HR]: 7.53) or cardiac (HR: 3.75) complications and patients with an American Society of Anesthesiologists-score III to IV (HR: 1.51) had an impaired survival. CONCLUSION Our results emphasize the need for an adequate preoperative assessment to identify patients at risk for postoperative complications and impaired survival.
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Affiliation(s)
- Lieve G J Leijssen
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anne M Dinaux
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hiroko Kunitake
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Liliane G Bordeianou
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David L Berger
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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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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Dorajoo SR, Tan WJH, Koo SX, Tan WS, Chew MH, Tang CL, Wee HL, Yap CW. A scoring model for predicting survival following primary tumour resection in stage IV colorectal cancer patients with unresectable metastasis. Int J Colorectal Dis 2016; 31:235-45. [PMID: 26490055 DOI: 10.1007/s00384-015-2419-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Stage IV colorectal cancer patients with unresectable metastasis who undergo elective primary tumour resection experience heterogeneous post-operative survival. We aimed to develop a scoring model for predicting post-operative survival using pre-operative variables to identify patients who are least likely to experience extended survival following the procedure. METHODS Survival data were collected from stage IV colorectal cancer patients who had undergone elective primary tumour resection between January 1999 and December 2007. Coefficients of significant covariates from the multivariate Cox regression model were used to compute individual survival scores to classify patients into three prognostic groups. A survival function was derived for each group via Kaplan-Meier estimation. Internal validation was performed. RESULTS Advanced age (hazard ratio, HR 1.43 (1.16-1.78)); poorly differentiated tumour (HR 2.72 (1.49-5.04)); metastasis to liver (HR 1.76 (1.33-2.33)), lung (HR 1.37 (1.10-1.71)) and bone (HR 2.08 ((1.16-3.71)); carcinomatosis (HR 1.68 (1.30-2.16)); hypoalbuminaemia (HR 1.30 (1.04-1.61) and elevated carcinoembryonic antigen levels (HR 1.89 (1.49-2.39)) significantly shorten post-operative survival. The scoring model separated patients into three prognostic groups with distinct median survival lengths of 4.8, 12.4 and 18.6 months (p < 0.0001). Internal validation revealed a concordance probability estimate of 0.65 and a time-dependent area under receiver operating curve of 0.75 at 6 months. Temporal split-sample validation implied good local generalizability to future patient populations (p < 0.0001). CONCLUSION Predicting survival following elective primary tumour resection using pre-operative variables has been demonstrated with the scoring model developed. Model-based survival prognostication can support clinical decisions on elective primary tumour resection eligibility.
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Pędziwiatr M, Pisarska M, Kisielewski M, Major P, Matłok M, Wierdak M, Natkaniec M, Budzyński A. Enhanced Recovery After Surgery (ERAS®) protocol in patients undergoing laparoscopic resection for stage IV colorectal cancer. World J Surg Oncol 2015; 13:330. [PMID: 26637203 PMCID: PMC4670520 DOI: 10.1186/s12957-015-0745-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/27/2015] [Indexed: 02/07/2023] Open
Abstract
Background There is strong evidence for the use of Enhanced Recovery After Surgery (ERAS) protocol with colorectal surgery. However, in most studies on ERAS, patients with stage IV colorectal cancer (CRC) are commonly excluded. It is not certain if the ERAS protocol combined with laparoscopy improves outcomes in this group of patients as well. The aim of the study is to assess the feasibility of the ERAS protocol implementation in patients operated laparoscopically due to stage IV CRC. Methods A prospective analysis of patients undergoing laparoscopic colorectal surgery was performed. Group 1 included patients with stages I–III, and group 2 included patients with stage IV CRC. Demographic, surgical factors, length of stay (LOS), complications, readmissions, ERAS implementation and early postoperative recovery were compared between the groups. Results Group 1 included 168 patients, and group 2 included 20 patients. There was no difference in the age, sex, BMI, ASA, cancer localisation or surgical parameters. No statistically significant difference was noted in complications (26.8 vs 20 %, p = 0.51344), LOS (4.7 vs 5.7 days, p = 0.28228) or readmissions (6 vs 10 %, p = 0.48392). The ERAS protocol compliance was 86.3 and 83.0 %, respectively (p = 0.17158). Conclusions Implementation of the ERAS protocol and laparoscopic surgery among patients with stage IV CRC is feasible and provides similar short-term clinical outcomes and recovery as with patients with stages I–III.
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Affiliation(s)
- Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.
| | - Michał Kisielewski
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.
| | - Maciej Matłok
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.
| | - Michał Natkaniec
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Jagiellonian University Medical College, Kopernika 21, 31-501, Kraków, Poland.
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Manyam BV, Mallick IH, Abdel-Wahab MM, Reddy CA, Remzi FH, Kalady MF, Lavery I, Koyfman SA. The Impact of Preoperative Radiation Therapy on Locoregional Recurrence in Patients with Stage IV Rectal Cancer Treated with Definitive Surgical Resection and Contemporary Chemotherapy. J Gastrointest Surg 2015; 19:1676-83. [PMID: 26014718 DOI: 10.1007/s11605-015-2861-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 05/12/2015] [Indexed: 01/31/2023]
Abstract
PURPOSE Definitive resection of primary rectal cancers is frequently incorporated, with or without preoperative radiotherapy and perioperative chemotherapy, in the management of selected patients with metastatic rectal adenocarcinoma. This study reviews the impact of preoperative radiotherapy and perioperative chemotherapy on locoregional recurrence and overall survival in these patients. METHODS AND MATERIALS This retrospective study with an Institutional Review Board (IRB) waiver included 109 patients with metastatic rectal adenocarcinoma who underwent definitive primary resection between 1998 and 2011. In addition to resection, 64 patients were treated with preoperative radiotherapy and perioperative chemotherapy and 45 patients were treated with perioperative chemotherapy alone. Radiotherapy dose was typically 50.4 Gy. Baseline variables were compared using chi-square and unpaired t tests. Overall survival was calculated using Kaplan-Meier method. Univariate and multivariate analyses were performed using Cox proportional hazards regression. RESULTS There were no significant baseline differences between the two groups. There was no significant difference in locoregional recurrence (10.9 vs. 11.1%; p = 0.90) or overall survival (34.5 vs. 34.8 months; p = 0.89) for patients treated with preoperative radiotherapy compared to those treated with perioperative chemotherapy alone, respectively. Patients who underwent radiotherapy were less likely to have a positive margin (10.9 vs. 20.0%; p = 0.19), lymphovascular invasion (32.8 vs. 53.3%; p = 0.03), and pathologic stage N2 disease (25.0 vs. 42.2%; p = 0.02). Grade 2 postoperative complications were more common in the preoperative radiotherapy group (32.8 vs. 15.6%; p = 0.04). Multivariate analysis demonstrated that patients with poorly differentiated tumors (HR 2.19; p = 0.009) and those that did not undergo liver-directed therapy (HR 2.20; p = 0.005) had inferior survival. CONCLUSIONS Locoregional recurrence is modest in patients with metastatic rectal adenocarcinoma receiving definitive primary resection, irrespective of the use of radiotherapy. Preoperative radiotherapy may enhance pathologic downstaging at the expense of increased grade 2 postoperative complications. Its use should be reserved for patients at high risk for locoregional recurrence.
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Affiliation(s)
- Bindu V Manyam
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave - Desk T28, Cleveland, OH, 44195, USA
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The role of palliative resection for asymptomatic primary tumor in patients with unresectable stage IV colorectal cancer. Dis Colon Rectum 2014; 57:1049-58. [PMID: 25101600 DOI: 10.1097/dcr.0000000000000193] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The prognostic role of surgical resection of primary tumors is not well established in patients with asymptomatic unresectable stage IV colorectal cancer. OBJECTIVE The aims of this study were to reveal the prognostic role of surgical resection of primary tumors and to define prognostic factors affecting long-term oncological outcomes in patients with asymptomatic unresectable synchronous metastases. DESIGN This study was a retrospective analysis of prospectively collected data. PATIENTS Between 2000 and 2008, a total of 416 patients with asymptomatic unresectable stage IV colorectal cancer were analyzed with propensity score matching. MAIN OUTCOME MEASURES Prematching baseline characteristics were compared by bivariate analysis, and 113 pairs were selected after 1:1 matching with propensity scores estimated from logistic regression. The primary end point was overall survival. RESULTS Among 416 patients, 218 (52.4%) underwent palliative resection of the primary tumor. Before propensity score matching, palliative resection resulted in a better survival rate than nonresection in univariate analysis (p < 0.001), but not in multivariate analysis (p = 0.08). After matching, the 5-year overall survival rate was significantly lower for patients with peritoneal metastasis and clinical M1b stage tumors in univariate analysis (p = 0.004 and p = 0.02). However, neither peritoneal metastasis nor clinical M1b stage showed any prognostic significance in multivariate analysis. The overall 5-year survival rate of the postmatching group was 4.9% and 3.5% in the palliative resection and nonresection groups. Consequently, palliative resection was not associated with a significant increase in survival compared with nonresection (p = 0.27). A subgroup analysis performed according to the site of metastasis also did not show any significant survival benefit of palliative resection after matching. LIMITATIONS Selection bias and potential confounders were limitations of this study. CONCLUSIONS Resection of the primary tumor in patients with asymptomatic unresectable stage IV colorectal cancer was not associated with an improvement in overall survival after propensity score matching.
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Liu YL, Xu HT, Jiang SX, Yang YM, Cui BB. Prognostic significance of lymph node status in patients with metastatic colorectal carcinoma treated with lymphadenectomy. J Surg Oncol 2014; 109:234-8. [PMID: 24449194 DOI: 10.1002/jso.23479] [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: 05/31/2013] [Accepted: 10/07/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES To test prognostic significance of lymph node status in patients with metastatic colorectal carcinoma (mCRC). METHODS Four hundred ninety six patients diagnosed with synchronous mCRC and treated with lymphadenectomy between 1995 and 2008 were identified and divided into groups pN0, pN1, and pN2 (140 (28.2%) in pN0, 223 (45.0%) in pN1, and 133 (26.8%) in pN2 group) according to their lymph node status. The Kaplan-Meier and Cox regression analyses were used to test associations and independent predictor status of lymph node involvement. RESULTS The Cox proportional hazards regression showed pN as significantly associated with disease-specific survival (DSS) both in univariate (HR = 1.609, 95% CI 1.411 to 1.835, P < 0.001) and multivariate (HR = 1.630, 95% CI 1.422 to 1.868, P < 0.001) analyses. The Kaplan-Meier analysis demonstrated that patients with pN2 and pN1 had a significantly worse DSS compared with patients with pN0 tumors (respectively, 17.273 ± 1.020 and 27.145 ± 1.715 vs. 34.992 ± 2.143 months; P < 0.001). In accuracy analyses based on AUC values, nodal status demonstrated the highest accuracy (65.1%) out of all the variables. CONCLUSIONS Our findings indicate that optimal TNM staging for mCRC should incorporate lymph node status to provide a more effective and predictive model.
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Affiliation(s)
- Yan-Long Liu
- Department of Colorectal Surgery, The Affiliated 3rd Hospital of Harbin Medical University, Harbin, PR China
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Kim YW, Kim IY. The Role of Surgery for Asymptomatic Primary Tumors in Unresectable Stage IV Colorectal Cancer. Ann Coloproctol 2013; 29:44-54. [PMID: 23700570 PMCID: PMC3659242 DOI: 10.3393/ac.2013.29.2.44] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 04/01/2013] [Indexed: 02/08/2023] Open
Abstract
There are still debates regarding the appropriate primary treatment policy for asymptomatic primary colorectal lesions in cases of unresectable metastatic colorectal cancer. Even though there are patients with asymptomatic primary tumors when starting chemotherapy, those patients may still undergo surgery due to complications related to primary tumors in the middle of chemotherapy; therefore, controversy exists regarding surgical resection of primary colorectal lesions in cases where symptoms are absent when making a diagnosis. Thus, based on the published literature, we discuss opinions that prefer first-line surgery for primary tumors as well as opinions favoring first-line chemotherapy for treating unresectable synchronous metastatic colorectal cancer. Although the upfront chemotherapy including targeted agents is suggested as an effective treatment in recent years, the first line surgery has been a preferred treatment for decades. The first line surgery is beneficial to prolong the survival duration given the retrospective analysis of randomized trial data. So far, no prospective comparison study has only focused on the first-line treatment modality; thus, future clinical studies focusing on the survival duration and the quality of life should be performed as soon as possible. Furthermore, at this point, multidisciplinary team approaches would be helpful in finding the appropriate therapy. Regardless of symptoms, the performance status and the tumor burden should be taken into consideration as well. In case of surgical resection, minimally invasive surgery, such as laparoscopic surgery, is recommended.
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Affiliation(s)
- Young Wan Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
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Kim YW, Kim IY. The Role of Surgery for Asymptomatic Primary Tumors in Unresectable Stage IV Colorectal Cancer. Ann Coloproctol 2013. [PMID: 23700570 DOI: 10.3393/ac.2013.3329.3392.3344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
There are still debates regarding the appropriate primary treatment policy for asymptomatic primary colorectal lesions in cases of unresectable metastatic colorectal cancer. Even though there are patients with asymptomatic primary tumors when starting chemotherapy, those patients may still undergo surgery due to complications related to primary tumors in the middle of chemotherapy; therefore, controversy exists regarding surgical resection of primary colorectal lesions in cases where symptoms are absent when making a diagnosis. Thus, based on the published literature, we discuss opinions that prefer first-line surgery for primary tumors as well as opinions favoring first-line chemotherapy for treating unresectable synchronous metastatic colorectal cancer. Although the upfront chemotherapy including targeted agents is suggested as an effective treatment in recent years, the first line surgery has been a preferred treatment for decades. The first line surgery is beneficial to prolong the survival duration given the retrospective analysis of randomized trial data. So far, no prospective comparison study has only focused on the first-line treatment modality; thus, future clinical studies focusing on the survival duration and the quality of life should be performed as soon as possible. Furthermore, at this point, multidisciplinary team approaches would be helpful in finding the appropriate therapy. Regardless of symptoms, the performance status and the tumor burden should be taken into consideration as well. In case of surgical resection, minimally invasive surgery, such as laparoscopic surgery, is recommended.
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Affiliation(s)
- Young Wan Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
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Smith JD, Butte JM, Weiser MR, D'Angelica MI, Paty PB, Temple LK, Guillem JG, Jarnagin WR, Nash GM. Anastomotic leak following low anterior resection in stage IV rectal cancer is associated with poor survival. Ann Surg Oncol 2013; 20:2641-6. [PMID: 23385965 DOI: 10.1245/s10434-012-2854-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Indexed: 01/15/2023]
Abstract
BACKGROUND Anastomotic leak is a serious complication of low anterior resection (LAR). The risk of leak in stage IV rectal cancer patients treated with synchronous or staged resection of the primary tumour and metastatic sites has not been reported. We measured the incidence of anastomotic leak and its association with clinical outcome. METHODS With institutional review board approval, patients undergoing LAR and resection of metastatic disease were analyzed from a prospectively collected colorectal database between 1992 and 2010. Data for use of ileostomy, clinical anastomotic leak, and clinical risk score (for liver metastases, n = 86) were collected. Categorical variables were compared with the χ(2) test. Estimated overall survival was compared using log-rank method and Cox regression analysis. RESULTS A total of 184 patients with LAR and stage IV disease were identified. Of those, 123 had curative resection for disease at distant sites. 72 % underwent simultaneous resection, 28 % staged resection. Median follow-up was 2.9 years for survivors. Anastomotic leak occurred in 6.5 %. There was one perioperative death (not attributable to leak). Overall 3-year survival following a leak was significantly worse compared with patients without a leak (35 vs. 73 %, P = 0.01). Clinical leak was associated with worse survival when controlled for use of diverting stoma, operative year, clinical risk score, and timing of resection of metastatic disease. CONCLUSIONS In this series of patients with stage IV rectal cancer, anastomotic leak was uncommon. However, patients who developed a clinical leak following surgery had worse survival. This finding was independent of use of diverting stoma or staged resection.
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Affiliation(s)
- James D Smith
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Allaix ME, Degiuli M, Giraudo G, Marano A, Morino M. Laparoscopic versus open colorectal resections in patients with symptomatic stage IV colorectal cancer. Surg Endosc 2012; 26:2609-16. [PMID: 22476839 DOI: 10.1007/s00464-012-2240-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 03/01/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate short-term and oncologic outcomes of laparoscopic resection (LR) for patients with symptomatic stage IV colorectal cancer compared with open resection (OR). METHODS This study is a retrospective analysis of a prospective database. Patients with a minimum follow-up of 12 months after LR or OR for metastatic colorectal cancer were included. All analyses were performed on an "intention-to-treat" basis. RESULTS A total of 162 consecutive patients submitted to LR and 127 submitted to OR were included. In the LR group, conversion rate was 26.5 %, mostly due to locally advanced disease (88.4 %). A greater risk of conversion was observed among patients with a tumor size greater than 5 cm regardless the tumor site (P = 0.07). Early postoperative outcome was significantly better for LR group, with a shorter hospital stay (P = 0.008), earlier onset of adjuvant treatment, and similar postoperative complications (P = 0.853) and mortality rates (P = 0.958). LR for rectal cancer was associated with a higher morbidity compared with colon cancer (P = 0.058). During a median follow-up time of 72 months, there was no significant difference in overall survival between the two groups (P = 0.622). CONCLUSIONS LR for symptomatic metastatic CRC is safe and, compared with OR, is associated with a shorter hospital stay and with similar survival rates. Concerns remain about LR of bulky tumors and rectal cancers due to the increased risk of conversion and postoperative complications.
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Affiliation(s)
- Marco Ettore Allaix
- Digestive and Colorectal Surgery and Centre for Minimal Invasive Surgery, University of Turin, Corso A. M. Dogliotti, 14, 10126 Turin, Italy
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Verberne CJ, de Bock GH, Pijl MEJ, Baas PC, Siesling S, Wiggers T. Palliative resection of the primary tumour in stage IV rectal cancer. Colorectal Dis 2012; 14:314-9. [PMID: 21689309 DOI: 10.1111/j.1463-1318.2011.02618.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
AIM The aim of this study was to investigate the use of resection in a cohort of palliatively treated patients with stage IV rectal cancer. To avoid selection bias, particular attention was paid to correction for comorbidity and extent of disease. METHOD Patients with stage IV rectal cancer in two hospitals in Groningen were consecutively included over a 5-year period. Comorbidity was defined as major (dementia, cardiac failure or left ventricle ejection fraction <30%, or severe chronic obstructive pulmonary disease), minor (diabetes, hypertension, mild renal disease or mild pulmonary disease) or none. The effect of patient and disease characteristics on survival was assessed using Kaplan-Meier and Cox regression analyses. RESULTS Of 88 patients, 11 (13%) underwent elective surgical resection without chemotherapy, 15 (17%) received both elective resection and chemotherapy, 21 (24%) underwent palliative chemotherapy only and 41 (47%) had supportive care only. The extent of disease (P<0.01), hospital (P=0.02) and comorbidity (P=0.04) were correlated with worse survival. Patients treated surgically survived for longer than patients treated nonsurgically, when the data were corrected for age, comorbidity, extent of disease and hospital [hazard ratio (HR)=0.4 (95% CI=0.2-0.7)]. Perioperative morbidity was seen in 38% of the patients, and 30-day mortality was 0%. CONCLUSION In this retrospective cohort, resection was associated with longer survival independently of the extent of distant metastases, age and comorbidity.
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Affiliation(s)
- C J Verberne
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands.
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Adjuvant chemotherapy with or without pelvic radiotherapy after simultaneous surgical resection of rectal cancer with liver metastases: analysis of prognosis and patterns of recurrence. Int J Radiat Oncol Biol Phys 2012; 84:73-80. [PMID: 22300562 DOI: 10.1016/j.ijrobp.2011.10.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 10/05/2011] [Accepted: 10/28/2011] [Indexed: 11/23/2022]
Abstract
PURPOSE To investigate the outcomes of adjuvant chemotherapy (CT) or chemoradiotherapy (CRT) after simultaneous surgical resection in rectal cancer patients with liver metastases (LM). MATERIALS AND METHODS One hundred and eight patients receiving total mesorectal excision for rectal cancer and surgical resection for LM were reviewed. Forty-eight patients received adjuvant CRT, and 60 were administered CT alone. Recurrence patterns and prognosis were analyzed. Disease-free survival (DFS) and overall survival (OS) rates were compared between the CRT and CT groups. The inverse probability of the treatment-weighted (IPTW) method based on the propensity score was used to adjust for selection bias between the two groups. RESULTS At a median follow-up period of 47.7 months, 77 (71.3%) patients had developed recurrences. The majority of recurrences (68.8%) occurred in distant organs. By contrast, the local recurrence rate was only 4.7%. Median DFS and OS were not significantly different between the CRT and CT groups. After applying the IPTW method, we observed no significant differences in terms of DFS (hazard ratio [HR], 1.347; 95% confidence interval [CI], 0.759-2.392; p = 0.309) and OS (HR, 1.413; CI, 0.752-2.653; p = 0.282). Multivariate analyses showed that unilobar distribution of LM and normal preoperative carcinoembryonic antigen level (<6 mg/mL) were significantly associated with longer DFS and OS. CONCLUSIONS The local recurrence rate after simultaneous resection of rectal cancer with LM was relatively low. DFS and OS rates were not different between the adjuvant CRT and CT groups. Adjuvant CRT may have a limited role in this setting. Further prospective randomized studies are required to evaluate optimal adjuvant treatment in these patients.
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Elective resection of rectal cancer primary tumor in patients with stage IV disease--own experiences. POLISH JOURNAL OF SURGERY 2011; 83:372-6. [PMID: 22166665 DOI: 10.2478/v10035-011-0059-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Optimal management of asymptomatic generalized rectal cancer is still the matter of debate. The aim of the study was to review stage IV rectal cancer patients who were treated in our clinic since 2000 till 2008 in order to evaluate the effectiveness of surgery. MATERIAL AND METHODS Fifty-two generalized rectal cancer patients treated with elective resection of primary tumor were identified. Patients' age, sex, duration of hospital stay, modality of surgery, complications, postoperative mortality rate and survival rate were assessed. RESULTS Median survival was 16.3 months. Postoperative complications occurred in 29% patients. Postoperative mortality rate was 1.9%. CONCLUSIONS In properly selected group of patients elective resection of primary tumor may cause low mortality rate and acceptable morbidity rate. This surgical modality allows to avoid potential complications of tumor local growth.
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Systematic review of prognostic factors related to overall survival in patients with stage IV colorectal cancer and unresectable metastases. World J Surg 2011; 35:684-92. [PMID: 21181473 DOI: 10.1007/s00268-010-0891-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND With the improvements in newer chemotherapeutic agents, the role of primary tumour resection in patients with stage IV colorectal cancer is controversial. In many cases primary tumour resection is still favoured as first-line management. However, a detailed understanding of independent prognostic factors related to survival is necessary before making this decision. METHOD A literature search was conducted using Medline and Embase. Studies that performed multivariate analysis on overall survival of patients with incurable stage IV colorectal cancer were included in this review. RESULTS Fourteen retrospective studies involving 3209 patients were included. Clinical variables analysed to consistently have independent prognostic significance for long-term survival included the patients' performance status (<2), volume of liver metastases (<50%), nodal stage (N0), disease-free resection margins, and treatment with chemotherapy and/or primary tumour resection. Cancer antigen (CA) 19-9, low albumin, elevated ALP levels, apical lymph node involvement, presence of ascites, and postoperative transfusion were each assessed by only one study and found to be independently associated with survival. Factors inconsistently reported to have independent prognostic significance were age, ASA score, preoperative CEA levels, primary tumour location, tumour size and differentiation, peritoneal dissemination, and extrahepatic metastases. CONCLUSION Each patient should be reviewed individually on the basis of the above independent prognostic factors before deciding to resect the primary tumour. Patients with a poor performance status, extensive hepatic metastases, and extensive nodal disease detected preoperatively are less likely to have a survival benefit. Nonsurgical approaches to manage these patients should be given careful consideration.
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Ronnekleiv-Kelly SM, Kennedy GD. Management of stage IV rectal cancer: Palliative options. World J Gastroenterol 2011; 17:835-47. [PMID: 21412493 PMCID: PMC3051134 DOI: 10.3748/wjg.v17.i7.835] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/04/2011] [Accepted: 01/11/2011] [Indexed: 02/06/2023] Open
Abstract
Approximately 30% of patients with rectal cancer present with metastatic disease. Many of these patients have symptoms of bleeding or obstruction. Several treatment options are available to deal with the various complications that may afflict these patients. Endorectal stenting, laser ablation, and operative resection are a few of the options available to the patient with a malignant large bowel obstruction. A thorough understanding of treatment options will ensure the patient is offered the most effective therapy with the least amount of associated morbidity. In this review, we describe various options for palliation of symptoms in patients with metastatic rectal cancer. Additionally, we briefly discuss treatment for asymptomatic patients with metastatic disease.
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17
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Seo GJ, Park JW, Yoo SB, Kim SY, Choi HS, Chang HJ, Shin A, Jeong SY, Kim DY, Oh JH. Intestinal complications after palliative treatment for asymptomatic patients with unresectable stage IV colorectal cancer. J Surg Oncol 2010; 102:94-9. [PMID: 20578086 DOI: 10.1002/jso.21577] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The initial surgical management of asymptomatic patients with unresectable stage IV colorectal cancer (CRC) is still controversy. The aim of this study was to compare the incidence of major intestinal complications in asymptomatic patients who received palliative treatment for unresectable stage IV CRC, according to the type of treatment. METHODS Between March 2001 and January 2008, we retrospectively analyzed 227 asymptomatic patients who underwent first-line resection of the primary tumor followed by chemotherapy (144 patients, resection group) or those who underwent first-line chemotherapy (83 patients, chemotherapy group). RESULTS In the resection group, the incidences of intestinal obstruction, peritonitis, fistula, and intestinal hemorrhage were 14.6%, 0%, 0.7%, and 4.8%, respectively. In the chemotherapy group, these incidences were 15.2%, 1.2%, 0%, and 3.5%, respectively. There were no significant differences between the two groups in terms of intestinal complications. In multivariate analysis of overall survival, treatment type (resection group vs. chemotherapy group) was not a significant prognostic factor (P = 0.076). CONCLUSIONS In asymptomatic patients with unresectable stage IV CRC, first-line chemotherapy may be considered safe, with no increased risk of major intestinal complications compared with primary tumor resection plus chemotherapy.
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Affiliation(s)
- Guh Jung Seo
- Center for Colorectal Cancer, Research Institute & Hospital, National Cancer Center, Goyang, Korea
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18
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Abstract
Metastatic colorectal cancer traditionally has been considered incurable. Over the past 3 decades, however, resection of low-volume hepatic disease has been recognized as beneficial in some cases. More recently, resection of isolated pulmonary metastases has been shown to offer long-term survival in carefully selected patients. Resection of metastases to more unusual sites (ovary, brain, peritoneal cavity) is more controversial; nevertheless, retrospective data suggest that a few patients may be cured with resection of these tumors. In this article, we review the history and current status of metastasectomy in stage IV colorectal cancer.
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Affiliation(s)
- Najjia Mahmoud
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Stillwell AP, Buettner PG, Ho YH. Meta-analysis of survival of patients with stage IV colorectal cancer managed with surgical resection versus chemotherapy alone. World J Surg 2010; 34:797-807. [PMID: 20054541 DOI: 10.1007/s00268-009-0366-y] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is no consensus regarding the appropriate management of asymptomatic and minimally symptomatic patients with stage IV colorectal cancer and irresectable metastases. METHODS A literature search was conducted on Medline and Embase. Outcome measures included: survival; postoperative morbidity and mortality; complications from the primary tumor and the need for surgery to manage complications; the likelihood of curative surgery after initial response to primary therapy; and length of hospital stay. Quantitative meta-analysis was performed where appropriate. RESULTS Eight retrospective studies, including 1,062 patients, met the criteria for inclusion in this study. Meta-analysis has shown an improvement in the survival of patients managed with palliative resection of their primary tumor, with an estimated standardized median difference of 6.0 months (standardized difference, 0.55; 95% confidence interval (CI), 0.29, 0.82; p < 0.001). Patients managed with chemotherapy alone were 7.3 times more likely to have a complication from the primary tumor (95% CI, 1.7, 34.4; p = 0.008). There was no difference in the response rates to chemotherapy, making metastatic disease amendable to curative resection (0.85; 95% CI 0.40, 1.8; p = 0.662). CONCLUSIONS To date, only retrospective data are available, showing that palliative resection of the primary tumor in asymptomatic or minimally symptomatic patients with stage IV colorectal cancer is associated with longer survival. Resection of the primary tumor reduces the likelihood of complications from the primary tumor and avoids the need for emergency procedures.
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Affiliation(s)
- A P Stillwell
- Department of Surgery, School of Medicine and Dentistry and North Queensland Centre for Cancer Research, James Cook University, Townsville, QLD, 4814, Australia.
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Aslam MI, Kelkar A, Sharpe D, Jameson JS. Ten years experience of managing the primary tumours in patients with stage IV colorectal cancers. Int J Surg 2010; 8:305-13. [PMID: 20380899 DOI: 10.1016/j.ijsu.2010.03.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 03/09/2010] [Accepted: 03/16/2010] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Approximately 20% of patients with colorectal cancer have metastases at the time of presentation. Such patients are often offered systemic chemotherapy but debate continues as to whether these patients benefit from resection of the primary tumour. We describe our ten years experience of managing the primary tumours in patients with stage IV colorectal cancer. The aim of this study was to describe the overall survival of patients undergoing surgery in these circumstances and to determine whether any prognostic indicators could be identified. PATIENTS & METHODS 920 consecutive patients presenting with stage IV colorectal cancer disease were identified from the Leicester Colorectal Cancer database. Patients undergoing resection of the primary tumour (Resection Group) with the residual metastatic disease were compared to those patients who had not their primary tumour excised (Non-Resection Group). Various different variables in two groups were compared by using Mann-Whitney U test. Kaplan-Meier survival analysis and log-rank test were used to compare the overall survivals. Univariate analysis was performed for each group to elicit the significant prognostic factors whereas Cox regression model was used to identify the independent predictors of overall survival. RESULTS The Kaplan-Meier survival analysis of two groups showed prolonged survival for Resection Group compared to the Non-Resection Group (median; 14.5 Vs 5.83 months, p = <0.005). The multivariate analysis of different survival predicting variables, revealed the resection of the primary tumour as an independent predictor of overall survival (p < 0.001). The univariate analysis of resection group identified age at presentation, tumour site, tumour stage (pT), lymph nodal stage (pN), complete histological resection, tumour fixity, ASA grade, mode of surgery, post-operative chemotherapy and sites of metastasis as significant factors (p < 0.05) for survival prediction. When these factors were used in Cox-Regression model, only the age at presentation (p = 0.001), tumour fixity (p = 0.012) and lymph nodal involvement (p = 0.042) were independent predictors for overall survival. Treatment with post-operative chemotherapy and a smaller volume of liver metastases were associated with prolonged survival (p < 0.05). CONCLUSIONS Surgical resection of primary tumour for stage IV colorectal cancers is associated with prolonged survival for selected patients. Age at presentation, extent of liver involvement, tumour fixity and ASA grade can help to decide the patients who will benefit from surgery.
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Affiliation(s)
- Muhammad Imran Aslam
- Department of Colorectal Surgery, Leicester General Hospital NHS Trust, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.
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Primary tumor resection in patients presenting with metastatic colorectal cancer: analysis of a provincial population-based cohort. Am J Clin Oncol 2010; 33:52-5. [PMID: 19704367 DOI: 10.1097/coc.0b013e31819e902d] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE We conducted a Canadian population-based study to assess surgical practice patterns and outcomes among patients with metastatic colorectal cancer (mCRC) at diagnosis. METHODS We reviewed a provincial cancer registry for 2 years. Four hundred eleven patients presenting with mCRC were stratified by primary tumor resection status. Baseline characteristics, treatment modalities, and outcomes were assessed. RESULTS Seventy percent of patients underwent resection. Resected patients were less likely to have rectal primaries (16% vs. 42%, P < or = 0.001) and had more obstructive symptoms (47% vs. 31%, P < or = 0.001) or bleeding (26% vs. 6%, P < or = 0.001). They experienced fewer tumor-related complications (4% vs. 22%, P < or = 0.001). Use of first-line chemotherapy was similar (61% vs. 58%, P = 0.54), but the resection cohort was more likely to receive doublet chemotherapy (57% vs. 36%, P < or = 0.01) and metastatectomy (10% vs. 0%, P < or = 0.0001). Among patients with rectal tumors, radiation use was comparable (63% vs. 58%, P = 0.68). Median survival was longer in the resection group (14 vs. 6 months, P < or = 0.001). CONCLUSIONS Most patients presenting with mCRC underwent primary resection. Colonic tumors, obstruction, and bleeding were associated with resection. In situ primaries conferred more complications, despite similar use of radiation in cases of rectal cancer. Unresected patients were less likely to receive doublet chemotherapy or metastatectomy, and had inferior survival.
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Cellini C, Hunt SR, Fleshman JW, Birnbaum EH, Bierhals AJ, Mutch MG. Stage IV Rectal Cancer with Liver Metastases: Is There a Benefit to Resection of the Primary Tumor? World J Surg 2010; 34:1102-8. [DOI: 10.1007/s00268-010-0483-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Kleespies A, Füessl KE, Seeliger H, Eichhorn ME, Müller MH, Rentsch M, Thasler WE, Angele MK, Kreis ME, Jauch KW. Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer. Int J Colorectal Dis 2009; 24:1097-109. [PMID: 19495779 DOI: 10.1007/s00384-009-0734-y] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE The benefit of elective primary tumor resection for non-curable stage IV colorectal cancer (CRC) remains largely undefined. We wanted to identify risk factors for postoperative complications and short survival. METHODS Using a prospective database, we analyzed potential risk factors in 233 patients, who were electively operated for non-curable stage IV CRC between 1996 and 2002. Patients with recurrent tumors, resectable metastases, emergency operations, and non-resective surgery were excluded. Risk factors for increased postoperative morbidity and limited postoperative survival were identified by multivariate analyses. RESULTS Patients with colon cancer (CC = 156) and rectal cancer (RC = 77) were comparable with regard to age, sex, comorbidity, American Society of Anesthesiologists score, carcinoembryonic antigen levels, hepatic spread, tumor grade, resection margins, 30-day mortality (CC 5.1%, RC 3.9%) and postoperative chemotherapy. pT4 tumors, carcinomatosis, and non-anatomical resections were more common in colon cancer patients, whereas enterostomies (CC 1.3%, RC 67.5%, p < 0.0001), anastomotic leaks (CC 7.7%, RC 24.2%, p = 0.002), and total surgical complications (CC 19.9%, RC 40.3%, p = 0.001) were more frequent after rectal surgery. Independent determinants of an increased postoperative morbidity were primary rectal cancer, hepatic tumor load >50%, and comorbidity >1 organ. Prognostic factors for limited postoperative survival were hepatic tumor load >50%, pT4 tumors, lymphatic spread, R1-2 resection, and lack of chemotherapy. CONCLUSIONS Palliative resection is associated with a particularly unfavorable outcome in rectal cancer patients presenting with a locally advanced tumor (pT4, expected R2 resection) or an extensive comorbidity, and in all CRC patients who show a hepatic tumor load >50%. For such patients, surgery might be contraindicated unless the tumor is immediately life-threatening.
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Affiliation(s)
- Axel Kleespies
- Department of Surgery, Klinikum Grosshadern, University of Munich (LMU), Marchioninistrasse 15, 81377 Munich, Germany.
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Survival and symptomatic benefit from palliative primary tumor resection in patients with metastatic colorectal cancer: a review. Int J Colorectal Dis 2008; 23:559-68. [PMID: 18330581 DOI: 10.1007/s00384-008-0456-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Patients with metastatic colorectal cancer have a limited life expectancy and are at risk for life-threatening tumor-related obstruction, perforation, and hemorrhage. Though surgical resection is performed frequently in this setting, its true benefit is not well-established. MATERIALS AND METHODS We reviewed the medical literature from 1996-2006 using the search terms metastatic colorectal cancer and primary resection to find studies that evaluated the management of primary tumors in metastatic colorectal cancer. All search results were included in our analysis and were assessed on the basis of methodologic quality. RESULTS/FINDINGS Twelve relevant studies were identified; ten were single-institution retrospective reviews and two were population-based studies using National Cancer Institute's Surveillance, Epidemiology, and End-Results database. No prospective or randomized studies were identified. Approximately 70% of patients diagnosed with metastatic colorectal cancer in the USA undergo primary tumor resection; only a minority have this done for tumor-related symptoms or as part of potentially curative resection. The postoperative mortality ranged from 9.0-11.2% in large cancer registries but was often lower in major cancer centers. Resection of asymptomatic primary tumors was frequently associated with prolonged survival but was not found to reduce significantly the incidence of life-threatening tumor-related complications. INTERPRETATION/CONCLUSION Retrospective data suggest that non-curative resection of asymptomatic colorectal primary tumors may prolong survival; however, selection bias and unaccounted clinical factors may explain this observation. Prospective, randomized surgical trials are needed to test the role of primary tumor resection in this setting, especially because of its current widespread use, and its associated cost, morbidity, and high postoperative mortality.
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Yun HR, Lee WY, Lee WS, Lee OS, Cho YB, Yun SH, Chun HK. The prognostic factors of stage IV colorectal cancer and assessment of proper treatment according to the patient's status. Int J Colorectal Dis 2007; 22:1301-10. [PMID: 17486358 DOI: 10.1007/s00384-007-0315-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Approximately 20% of patients with colorectal cancer are initially diagnosed with stage IV. The majority has non-curative metastases, and their chances of survival are pitiful. This study evaluated the prognostic factors of survival and the access to the effective treatment in accordance with patients. MATERIALS AND METHODS We retrospectively analyzed 503 patients for demographics, tumor characteristics, the treatment modality, and the survival outcome. Curative operation was performed in 127 patients and palliative operation in 376 patients. RESULTS For the curative operation group, the 5-year survival rate was 34.5%, and the prognostic factors of survival and recurrence were male gender (p = 0.003, 0.009), pathologic N stage (p < 0.001, p = 0.002), and perineural invasion (p = 0.003, p = 0.026), respectively. For the non-curative operation group, the 5-year survival rate was 0%, and the median survival duration was 16.5 months. The potential predictors of survival for the palliative operation group were carcinoembryonic antigen level (p = 0.013), differentiation of tumor (p = 0.011), resection of primary tumor (p < 0.001), and chemotherapy (p < 0.001). But for the 131 patients with asymptomatic incurable disease, only chemotherapy was related to survival (p < 0.001). CONCLUSIONS The potential predictors of survival for curative stage IV colorectal cancer were male gender, pathologic N stage, and perineural invasion. Resection of the primary tumor and chemotherapy showed benefit for the incurable patients. But for the asymptomatic incurable patients, only chemotherapy prolonged the survival.
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Affiliation(s)
- Hae Ran Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan [corrected] University School of Medicine, Seoul, South Korea
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Abstract
Patients with advanced incurable colorectal cancer (CRC) face a grim prognosis. The goal of palliative intervention is directed at alleviating disease-related symptoms and improving quality of life. The provision of optimal palliative care for these patients is a compound and demanding process. This dilemma becomes more challenging when patients with advanced metastatic colorectal disease present with an incurable and asymptomatic primary lesion. Treatment options are numerous and include a variety of surgical and nonsurgical interventions. Most data regarding the role of surgery in palliation of CRC are from retrospective, nonrandomized case series. Surgical resection may provide good palliation of symptoms and prevent future tumor-related complications. Metal stents are also able to provide good palliative relief of obstruction and should be used when appropriate. The best palliative care will often require a multidisciplinary approach that involves input from surgical and nonsurgical teams, where treatment plans will be made in accordance with the wishes of the patient and family with a goal of decreasing morbidity and a focus on quality of life.
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Affiliation(s)
- Nir Wasserberg
- Department of Surgery B, Rabin Medical Center, Petah Tiqwa, Israel
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