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Yang Y, Lam W, Lyu Z, Ouyang K, Chen R, Wang J, Wu D, Yang Z, Li Y. Predicting surgical benefit of primary tumor resection in patients with stage IV colorectal cancer. Asian J Surg 2024:S1015-9584(24)00606-7. [PMID: 38609833 DOI: 10.1016/j.asjsur.2024.03.179] [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: 11/28/2023] [Revised: 03/12/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND There exists continuous controversy regarding the benefit of primary tumor resection (PTR) for stage IV colorectal cancer (CRC) patients. Little is known about how to predict the patients' benefit from PTR. This study aimed to develop a tool for surgical benefit prediction. METHODS Stage IV CRC patients diagnosed between 2010 and 2015 from the Surveillance, Epidemiology and End Results database were included. Patients receiving PTR who survived longer than the median cancer-specific survival (CSS) time of those who did not undergo PTR were considered to benefit from surgery. Logistic regression analysis identified prognostic factors influencing surgical benefit, based on which a nomogram was constructed. The data of patients who underwent PTR from our institution was used for external validation. A user-friendly webserver was then built for convenient clinical use. RESULTS The median CSS of the PTR group was 23 months, significantly longer than that of the non-PTR group (7 months, P < 0.001). In the PTR group, 23.3% of patients did not benefit from surgery. Logistic regression analysis identified age, marital status, tumor location, CEA level, chemotherapy, metastasectomy, tumor size, tumor deposits, number of examined lymph nodes, N stage, histological grade and number of distant metastases as independently associated with surgical benefit. The established prognostic nomogram demonstrated satisfactory performance in both the internal and external validation. CONCLUSION PTR was associated with prolonged CSS in stage IV CRC. The proposed nomogram could be used as an evidenced-based platform for risk-to-benefit assessment to select appropriate patients for undergoing PTR.
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Affiliation(s)
- Yuesheng Yang
- Shantou University Medical College, Shantou, 515041, Guangdong Province, PR China; Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong Province, PR China
| | - Waiting Lam
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong Province, PR China; Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, 510080, Guangdong Province, PR China
| | - Zejian Lyu
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong Province, PR China
| | - Kaibo Ouyang
- Shantou University Medical College, Shantou, 515041, Guangdong Province, PR China; Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong Province, PR China
| | - Ruijain Chen
- Shantou University Medical College, Shantou, 515041, Guangdong Province, PR China; Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong Province, PR China
| | - Junjiang Wang
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong Province, PR China
| | - Deqing Wu
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong Province, PR China
| | - Zifeng Yang
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong Province, PR China.
| | - Yong Li
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong Province, PR China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong Province, PR China.
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Yang Y, Yang Z, Lyu Z, Wang J, Wu D, Li Y. Predicting Surgical Benefit for Primary Tumor Resection in Patients with Stage IV Colorectal Cancer.. [DOI: 10.21203/rs.3.rs-2031087/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Purpose
There exists continuous controversy regarding the effect of primary tumor resection (PTR) for stage IV colorectal cancer (CRC) patients. Little is known about how to predict the patients’ survival benefit from PTR. This study aimed to develop a tool for surgical benefit prediction.
Methods
Stage IV CRC patients diagnosed between 2010 and 2015 from the Surveillance, Epidemiology, and End Results database were included. After propensity score matching, patients receiving PTR that survived longer than the median cancer-specific survival (CSS) time of those who did not undergo PTR were considered to benefit from surgery. Logistic regression analysis identified prognostic factors influencing the surgical benefit, based on which a nomogram was constructed. A user-friendly webserver was then built for convenient clinical use. The predictive model was assessed using Harrell’s concordance index, calibration plot, receiver operative curve and decision curve analysis.
Results
The median CSS of the PTR group was 23 months, which was significantly longer than the non-PTR group (12 months, P < 0.001). In the PTR group, 32.9% of patients did not benefit from surgery. Logistic regression analysis identified age, tumor location, CEA level, histological grade, number of distant metastasis, and preoperative chemotherapy independently associated with surgical benefit. The established prognostic nomogram demonstrated satisfactory performance.
Conclusion
PTR was associated with prolonged survival in stage IV CRC. The proposed nomogram could be used as a risk-to-benefit assessment evidenced-based platform for selecting appropriate patients to undergo PTR.
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Affiliation(s)
| | | | | | | | - Deqing Wu
- Guangdong Provincial People's Hospital
| | - Yong Li
- Guangdong Provincial People's Hospital
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Cheng X, Li Y, Chen D, Xu X, Liu F, Zhao F. Primary Tumor Resection Provides Survival Benefits for Patients with Synchronous Brain Metastases from Colorectal Cancer. Diagnostics (Basel) 2022; 12:diagnostics12071586. [PMID: 35885491 PMCID: PMC9322496 DOI: 10.3390/diagnostics12071586] [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: 06/03/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Brain metastases (BMs), particularly synchronous brain metastases, in colorectal cancer (CRC) patients are uncommon. The survival benefit of primary tumor resection (PTR) in patients with metastatic colorectal cancer is controversial. Whether PTR can bring survival benefits to patients with BMs of CRC has not been reported. Methods: From 2010 to 2016, 581 CRC patients with BMs from the Surveillance, Epidemiology, and End Results (SEER) database were divided into PTR and non-PTR groups. The log-rank test was used to compare the survival distributions. The Kaplan-Meier method was used to estimate survival. By controlling additional prognostic factors, a Cox proportional multivariate regression analysis was used to estimate the survival benefit of PTR. Results: The median overall survival for CRC patients with synchronous BMs was 3 months, with a 1-year survival rate of 27.2% and a 2-year survival rate of 12.8%. The PTR group contained 171 patients (29.4%), whereas the non-PTR group had 410 patients (70.6%). Patients who underwent PTR had a 1-year survival rate of 40.2% compared to 21.7% in those who did not (p < 0.0001). Cox proportional analysis showed that patients ≥60 years (hazard ratio [HR] 1.718, 95% confidence interval [CI] 1.423−2.075, p < 0.0001) had a shorter OS than patients < 60 years of age. OS was better in CEA-negative than in CEA-positive patients (HR 0.652, 95% CI 0.472−0.899, p = 0.009). Patients in whom the primary tumor was removed had considerably improved prognoses (HR 0.654, 95% CI 0.531−0.805, p < 0.0001). Subgroup analysis revealed that the PTR group achieved a survival advantage except for patients with CEA negative. Conclusions: Patients with synchronous BMs from CRC may benefit from primary tumor resection (PTR). Age, CEA level, and PTR were independent prognostic risk factors for CRC patients with synchronous BMs.
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Affiliation(s)
- Xiaofei Cheng
- Department of Colorectal Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (X.C.); (D.C.); (X.X.)
| | - Yanqing Li
- Department of Pathology, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou 310009, China;
| | - Dong Chen
- Department of Colorectal Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (X.C.); (D.C.); (X.X.)
| | - Xiangming Xu
- Department of Colorectal Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (X.C.); (D.C.); (X.X.)
| | - Fanlong Liu
- Department of Colorectal Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; (X.C.); (D.C.); (X.X.)
- Correspondence: (F.L.); (F.Z.)
| | - Feng Zhao
- Department of Radiation Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- Correspondence: (F.L.); (F.Z.)
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Rasbach E, Birgin E, Betzler A, Rahbari NN, Reissfelder C. Therapiestrategien beim synchron metastasierten Kolonkarzinom. COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-022-00601-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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5
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Liang Z, Liu Z, Huang C, Chen X, Zhang Z, Xiang M, Hu W, Wang J, Feng X, Yao X. The role of upfront primary tumor resection in asymptomatic patients with unresectable stage IV colorectal cancer: A systematic review and meta-analysis. Front Surg 2022; 9:1047373. [PMID: 36684350 PMCID: PMC9857770 DOI: 10.3389/fsurg.2022.1047373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/01/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Controversy exists over the role of upfront primary tumor resection (PTR) in asymptomatic patients with unresectable stage IV colorectal cancer (CRC). The purpose of this study was to evaluate the effect of upfront PTR on survival outcomes and adverse outcomes. METHODS Searches were conducted on PubMed, EMBASE, Web of Science, and Cochrane Library from inception to August 2021. Studies comparing survival outcomes with or without adverse outcomes between PTR and non-PTR treatments were included. Review Manager 5.3 was applied for meta-analyses with a random-effects model whenever possible. RESULTS Overall, 20 studies with 3,088 patients were finally included in this systematic review. Compared with non-PTR, upfront PTR was associated with better 3-year (HR: 0.69, 95% CI, 0.57-0.83, P = 0.0001) and 5-year overall survival (OS) (HR: 0.77, 95% CI, 0.62-0.95, P = 0.01), while subgroup analysis indicated that there was no significant difference between upfront PTR and upfront chemotherapy (CT) group. In addition, grade 3 or higher adverse effects due to CT were more frequent in the PTR group with marginal significance (OR: 1.74, 95% CI, 0.99-3.06, P = 0.05), and other adverse outcomes were comparable. CONCLUSIONS PTR might be related to improved OS for asymptomatic patients with unresectable stage IV CRC, whereas receiving upfront CT is a rational alternative without detrimental influence on survival or adverse outcomes compared with upfront PTR. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272675.
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Affiliation(s)
- Zongyu Liang
- Department of Gastrointestinal Surgery, Second Department of General Surgery, The Sixth Affiliated Hospital, School of Medicine, South China University of Technology, Foshan, China
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
- Guangdong Provincial People’s Hospital Ganzhou Hospital (Ganzhou Municipal Hospital), Ganzhou, China
| | - Zhiyuan Liu
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
- Guangdong Provincial People’s Hospital Ganzhou Hospital (Ganzhou Municipal Hospital), Ganzhou, China
| | - Chengzhi Huang
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial People’s Hospital Ganzhou Hospital (Ganzhou Municipal Hospital), Ganzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Xin Chen
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
- Guangdong Provincial People’s Hospital Ganzhou Hospital (Ganzhou Municipal Hospital), Ganzhou, China
| | - Zhaojun Zhang
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial People’s Hospital Ganzhou Hospital (Ganzhou Municipal Hospital), Ganzhou, China
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Meijuan Xiang
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Guangdong Provincial People’s Hospital Ganzhou Hospital (Ganzhou Municipal Hospital), Ganzhou, China
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
| | - Weixian Hu
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Junjiang Wang
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
- School of Medicine, South China University of Technology, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Xingyu Feng
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Correspondence: Xingyu Feng ; Xueqing Yao
| | - Xueqing Yao
- Department of Gastrointestinal Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
- Guangdong Provincial People’s Hospital Ganzhou Hospital (Ganzhou Municipal Hospital), Ganzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Correspondence: Xingyu Feng ; Xueqing Yao
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Chen JN, Shoucair S, Wang Z, Habib JR, Zhao FQ, Yu J, Liu Z, Liu Q. Primary Tumor Resection for Rectal Cancer With Unresectable Liver Metastases: A Chance to Cut Is a Chance for Improved Survival. Front Oncol 2021; 11:628715. [PMID: 33791215 PMCID: PMC8006931 DOI: 10.3389/fonc.2021.628715] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/22/2021] [Indexed: 01/05/2023] Open
Abstract
Background: About half of the patients with rectal cancer will develop liver metastasis during the course of their illness. Unfortunately, a large proportion of these metastases are unresectable. Surgical resection of the primary tumor vs. palliative treatment in patients with unresectable synchronous liver metastases remains controversial. Methods: Patients with rectal cancer with surgically unresectable liver metastases were identified from the Surveillance, Epidemiology, and End Results (SEER) database from January 1, 2010, to December 31, 2015. According to different treatment modalities, patients were divided into a primary tumor resection group and a non-resection group. Rates of primary tumor resection and survival were calculated for each year. Kaplan–Meier methods and Cox regression models were used to assess long-term survival. Multivariable logistic regression models were used to evaluate factors potentially associated with primary tumor resection. Results: Among 1,957 patients, 494 (25.2%) had undergone primary tumor resection. Patients with primary tumor resection had significantly better 5-year survival rate (27.2 vs. 5.6%, P < 0.001) compared to the non-resection group. Chemoradiotherapy with primary site resection was associated with the longest mean and 5-year OS (44.7 months, 32.4%). The Cox regression analyses of the subgroup indicated that patients who underwent primary tumor resection had improved survival compared with those who did not undergo resection in all 25 subgroups. Factors associated with primary tumor resection were well or moderately differentiated tumor grade, undergoing radiation, and primary tumor size <5 cm. Conclusions: The majority of patients with rectal cancer with unresectable liver metastases did not undergo primary tumor resection. Our results indicate that resection of the primary tumor appears to offer the greatest chance of survival. Prospective studies are needed to confirm these results.
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Affiliation(s)
- Jia-Nan Chen
- Department of Colon and Rectal Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sami Shoucair
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Zheng Wang
- Department of Colon and Rectal Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Fu-Qiang Zhao
- Department of Colon and Rectal Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Zheng Liu
- Department of Colon and Rectal Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian Liu
- Department of Colon and Rectal Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kanemitsu Y, Shitara K, Mizusawa J, Hamaguchi T, Shida D, Komori K, Ikeda S, Ojima H, Ike H, Shiomi A, Watanabe J, Takii Y, Yamaguchi T, Katsumata K, Ito M, Okuda J, Hyakudomi R, Shimada Y, Katayama H, Fukuda H. Primary Tumor Resection Plus Chemotherapy Versus Chemotherapy Alone for Colorectal Cancer Patients With Asymptomatic, Synchronous Unresectable Metastases (JCOG1007; iPACS): A Randomized Clinical Trial. J Clin Oncol 2021; 39:1098-1107. [PMID: 33560877 PMCID: PMC8078424 DOI: 10.1200/jco.20.02447] [Citation(s) in RCA: 117] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
It remains controversial whether primary tumor resection (PTR) before chemotherapy improves survival in patients with colorectal cancer (CRC) with asymptomatic primary tumor and synchronous unresectable metastases.
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Affiliation(s)
| | - Kohei Shitara
- National Cancer Center Hospital East, Kashiwa, Japan
| | | | - Tetsuya Hamaguchi
- Saitama Medical University International Medical Center, Hidaka, Japan
| | - Dai Shida
- National Cancer Center Hospital, Tokyo, Japan
| | | | | | | | - Hideyuki Ike
- Saiseikai Yokohamashi Nanbu Hospital, Yokohama, Japan
| | - Akio Shiomi
- Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Jun Watanabe
- Yokohama City University Medical Center, Yokohama, Japan
| | | | | | | | - Masaaki Ito
- National Cancer Center Hospital East, Kashiwa, Japan
| | - Junji Okuda
- Osaka Medical College Hospital, Osaka, Japan
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Breugom A, Bastiaannet E, Guren M, Kørner H, Boelens P, Dekker F, Kapiteijn E, Gelderblom H, Larsen I, Liefers G, van de Velde C. Treatment strategies and overall survival for incurable metastatic colorectal cancer – A EURECCA international comparison including 21,196 patients from the Netherlands and Norway. Eur J Surg Oncol 2020; 46:1167-1173. [DOI: 10.1016/j.ejso.2020.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/15/2020] [Accepted: 02/10/2020] [Indexed: 12/26/2022] Open
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Moritani K, Kanemitsu Y, Shida D, Shitara K, Mizusawa J, Katayama H, Hamaguchi T, Shimada Y. A randomized controlled trial comparing primary tumour resection plus chemotherapy with chemotherapy alone in incurable stage IV colorectal cancer: JCOG1007 (iPACS study). Jpn J Clin Oncol 2020; 50:89-93. [PMID: 31829404 PMCID: PMC6978626 DOI: 10.1093/jjco/hyz173] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 02/07/2023] Open
Abstract
It is controversial whether chemotherapy with or without primary tumour resection is effective for the patients with incurable Stage IV colorectal cancer. A randomized controlled trial, initiated in Japan in 2012, is being conducted to evaluate the survival benefit and safety of primary tumour resection plus chemotherapy compared with chemotherapy alone in asymptomatic Stage IV colorectal cancer patients with unresectable metastatic disease. Patients are randomly assigned to either chemotherapy alone or primary tumour resection followed by chemotherapy. The primary endpoint is overall survival. Secondary endpoints are progression-free survival, incidence of adverse events, proportion of patients with R0 resection and proportion of palliative surgery for the chemotherapy-alone group. This trial was registered in June 2012 with the UMIN Clinical Trials Registry as UMIN000008147 [http://www.umin.ac.jp/ctr/index-j.htm]. In December 2017, the study protocol was amended for reducing sample size. A total of 280 patients will be enrolled over the course of 8.5 years.
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Affiliation(s)
- Konosuke Moritani
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Dai Shida
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Kohei Shitara
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Tokyo, Japan
| | - Junki Mizusawa
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Katayama
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Tetsuya Hamaguchi
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yasuhiro Shimada
- Clinical Oncology Division, Kochi Health Sciences Center, Kochi, Japan
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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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11
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Renz P, Wegner RE, Hasan S, Brookover R, Finley G, Monga D, Raj M, McCormick J, Kirichenko A. Survival Outcomes After Surgical Management of the Primary Tumor With and Without Radiotherapy for Metastatic Rectal Adenocarcinoma: A National Cancer Database (NCDB) Analysis. Clin Colorectal Cancer 2019; 18:e237-e243. [PMID: 30905549 DOI: 10.1016/j.clcc.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/21/2018] [Accepted: 12/24/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND With advances in systemic therapies, the role of primary tumor resection may be of increased importance in patients with metastatic rectal cancer. The role of combining pelvic radiotherapy with surgical resection in the metastatic setting is unknown. We utilized the National Cancer Database to examine outcomes in patients with metastatic rectal adenocarcinoma with primary tumor resection with and without pelvic radiotherapy. MATERIALS AND METHODS We queried the National Cancer Database from 2004 to 2014 for patients with stage IV rectal adenocarcinoma receiving chemotherapy. We identified 4051 patients in that group that had primary tumor resection. Patients were then stratified by receipt of pelvic radiotherapy (yes = 1882; no = 2169) Univariable and multivariable analyses identified characteristics predictive of overall survival. Propensity-adjusted Cox proportional hazard ratios for survival were used to account for indication bias. RESULTS The median patient age was 63 years (range, 18-90 years) with a median follow-up of 32.3 months (range, 3.02-151.29 months). There were proportionately more patients with T3/T4 disease or N1 disease in the surgery plus radiotherapy arm. The median survival was 46.3 months versus 35.3 months in favor of addition of radiotherapy (P < .001). The 2- and 5-year overall survival was 68.4% and 24.8% for surgical resection alone compared with 77.2% and 39.6% for surgery + radiotherapy. On propensity-adjusted multivariable analysis, radiotherapy was associated with a statistically significant reduction in risk of death (hazard ratio, 0.722; 95% confidence interval, 0.0665-0.784). CONCLUSION This analysis indicates that in patients with metastatic rectal adenocarcinoma receiving chemotherapy, pelvic radiotherapy in addition to primary tumor resection may be of significant benefit.
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Affiliation(s)
- Paul Renz
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA.
| | - Shaakir Hasan
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Robert Brookover
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Gene Finley
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Dulabh Monga
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Moses Raj
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - James McCormick
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Alexander Kirichenko
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
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12
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Lv X, Yu H, Gao P, Song Y, Sun J, Chen X, Wang Y, Wang Z. A nomogram for predicting bowel obstruction in preoperative colorectal cancer patients with clinical characteristics. World J Surg Oncol 2019; 17:21. [PMID: 30658652 PMCID: PMC6339443 DOI: 10.1186/s12957-019-1562-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/03/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Bowel obstruction (BO) is a complication that commonly affects patients with colorectal cancer (CRC). BO causes severe outcomes, and its treatment leads to a dilemma for many surgeons. Moreover, the factors correlated to BO in preoperative CRC patients remain unclear. The objectives of this study were to investigate the clinical characteristics of BO to identify risk predictors and to construct a BO prediction model with preoperative CRC patients. METHODS A large-scale, retrospective cohort, population-based study analyzed the data of 11,814 patients obtained from the Surveillance, Epidemiology, and End Results and Medicare claims-linked databases (SEER-M database). Patients aged ≥ 66 years and primarily diagnosed with CRC from 1992 to 2009 were divided into BO and non-BO groups. Cox proportional hazards regression models were used to determine predictors, and then, a nomogram was constructed by those predictors. RESULTS A total of 11,814 patients (5293 men and 6251 women) were identified. In multivariate analysis, 14 factors were found to be associated with BO including age, race, marital status, residence location, T category, M category, primary tumor site, histologic type, histologic grade, tumor size, history of alcoholism, chemotherapy, radiotherapy, abdominal pain, and anemia. A nomogram predicting the 90- and 180-day rates of BO was built for the preoperative CRC patients with a C-index of 0.795. CONCLUSIONS This study identified 14 BO-related factors, and a statistical model was constructed to predict the onset of BO in preoperative CRC patients. The obtained data may guide decision-making for the intervention of patients at risk for BO.
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Affiliation(s)
- Xinger Lv
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, People's Republic of China
| | - Hong Yu
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, People's Republic of China
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, People's Republic of China
| | - Yongxi Song
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, People's Republic of China
| | - Jingxu Sun
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, People's Republic of China
| | - Xiaowan Chen
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, People's Republic of China
| | - Yu Wang
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, People's Republic of China
| | - Zhenning Wang
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, People's Republic of China.
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13
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To resect or not to resect: The hamletic dilemma of primary tumor resection in patients with asymptomatic stage IV colorectal cancer. Crit Rev Oncol Hematol 2018; 132:154-160. [PMID: 30447921 DOI: 10.1016/j.critrevonc.2018.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/05/2018] [Indexed: 02/07/2023] Open
Abstract
Primary tumor resection (PTR) in advanced asymptomatic colorectal cancer (CRC) has been a matter of intense debate for long time. With the advances in systemic treatments, this practice has decreased over the years, although it remains still pervasive. Although the removal of primary tumor has been extensively interrogated both in retrospective and prospective studies, it still remains a clinical conundrum. There are many arguments for and against PTR in CRC both from the preclinical and the clinical point of view. Two scoring models have been published aiming at identifying patients who are suitable candidate for PTR, but they deserve further investigations in larger datasets. While awaiting the results of ongoing randomized clinical trials (RCTs) on this controversial topic, both upfront systemic treatment and PTR followed by chemotherapy should be considered valid options in patients with asymptomatic mCRC. Clinical selection and a shared-decision making approach are the keys to success.
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Thavanesan N, Abdalkoddus M, Yao C, Lai CW, Stubbs BM. Management of patients with incurable colorectal cancer: a retrospective audit. Colorectal Dis 2018; 20:864-872. [PMID: 29654629 DOI: 10.1111/codi.14116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 03/12/2018] [Indexed: 02/08/2023]
Abstract
AIM Counselling patients and their relatives about non-curative management options in colorectal cancer is difficult because of a paucity of published data. This study aims to determine outcomes in patients unsuitable for curative surgery and the rates of subsequent surgical intervention. METHOD This was an analysis of all colorectal cancers managed without curative surgery in a district general hospital from a prospectively maintained cancer registry between 2009 and 2016, as decided by a multidisciplinary team. Primary outcomes were overall survival and secondary outcomes were subsequent intervention rates and impact of tumour stage. RESULTS In all, 183 patients out of 976 patients (18.8%) were identified. The median age at diagnosis was 81 years [interquartile range (IQR) 71-87 years]. Overall median survival from diagnosis was 205 days (IQR 60-532 days). One-year mortality was 62.3%. Patients were classified into two groups depending on the reason for a non-curable approach: patient-related (PR) or disease-related (DR). The difference in survival between PR (median 277 days, IQR 70-593) and DR (median 179 days, IQR 51-450) was 98 days (P = 0.023). Twenty-four patients were alive at the end of the study period; 19 out of 91 cases in PR (20.8%) and five out of 92 cases in DR (5.4%). Overall intervention rates were 11.9%, with higher rates in the DR group (P = 0.005). Disease stage was not associated with subsequent surgical intervention between the two groups (P = 0.392). CONCLUSION Life expectancy for non-curatively managed patients within our unit was 6.8 months with one in nine patients requiring subsequent surgical admission for palliation. This information may be useful when counselling patients with incurable colorectal malignancy.
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Affiliation(s)
- N Thavanesan
- Department of General Surgery, Dorset County Hospital Foundation Trust, Dorchester, UK
| | - M Abdalkoddus
- Department of General Surgery, Dorset County Hospital Foundation Trust, Dorchester, UK
| | - C Yao
- Department of General Surgery, Dorset County Hospital Foundation Trust, Dorchester, UK
| | - C W Lai
- Department of General Surgery, Dorset County Hospital Foundation Trust, Dorchester, UK
| | - B M Stubbs
- Department of General Surgery, Dorset County Hospital Foundation Trust, Dorchester, UK
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15
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Feo L, Polcino M, Nash GM. Resection of the Primary Tumor in Stage IV Colorectal Cancer: When Is It Necessary? Surg Clin North Am 2017; 97:657-669. [PMID: 28501253 DOI: 10.1016/j.suc.2017.01.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Management of metastatic colorectal cancer requires accurate staging and multidisciplinary evaluation, leading to a consensus treatment plan with the ultimate goal of increasing survival and improving the quality of life, while taking into consideration the patient's performance status, disease burden, and goals of care. Since the introduction of multidrug chemotherapeutic regimens, survival of patients with metastatic colorectal cancer has improved. Many patients with unresectable disease are undergoing surgery for asymptomatic primary tumors despite evidence that it is usually a futile intervention. Palliative measures for local control of the primary tumor include colonic stents, laser therapy, and fulguration.
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Affiliation(s)
- Leandro Feo
- Colorectal Service, Department of Surgery, Catholic Medical Center, 100 McGregor Street, Suite 3100, Manchester, NH 03102, USA
| | - Michael Polcino
- Division of Colorectal Surgery, St. Barnabas Hospital, 4422 Third Avenue, Bronx, NY 10457, USA
| | - Garrett M Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1233 York Avenue, New York, NY 10065, USA.
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16
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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: 20] [Impact Index Per Article: 2.9] [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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Kim DH, Kim B, Choi JH, Park SJ, Hong SP, Cheon JH, Kim WH, Kim TI. Tumor characteristics associated with malignant large bowel obstruction in stage IV colorectal cancer patients undergoing chemotherapy. Int J Colorectal Dis 2016; 31:1767-1774. [PMID: 27613728 DOI: 10.1007/s00384-016-2638-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Little is known about predictable clinical factors associated with the occurrence of malignant large bowel obstruction (MLBO) in incurable stage IV colorectal cancer (CRC) patients undergoing medical treatment. This study investigates the clinical characteristics associated with MLBO that occurred while patients with stage IV CRC were receiving chemotherapy. METHODS A total of 216 patients who were diagnosed with stage IV CRC without bowel obstruction and who received chemotherapy between May 2005 and June 2012 were retrospectively included in this study. Patients were divided into an "obstruction group" and a "non-obstruction group" based on whether they did or did not develop MLBO during chemotherapy or follow-up, respectively. The initial endoscopic findings and clinical information were retrospectively reviewed and compared between the two groups. RESULTS Forty-six patients (21.3 %) developed MLBO during the treatment or follow-up periods. The mean duration between diagnosis and MLBO was 9.8 ± 9.3 months. After adjusting for clinically relevant factors, MLBO development was independently associated with the following factors: higher initial tumor-occupying circumference (HR 1.030 [95 % CI, 1.012-1.049], P = 0.001), longer initial horizontal tumor width (HR 1.035 [95 % CI, 1.011-1.059], P = 0.004), primary tumor location at a turning point in the colon (HR 2.404 [95 % CI, 1.185-4.877], P = 0.015), and the presence of primary tumor ulceration at presentation (HR 3.767 [95 % CI, 1.882-7.538], P < 0.001). MLBO development was not associated with tumor response to chemotherapy. CONCLUSION In patients with stage IV CRC, MLBO development during chemotherapy treatment is associated with tumor ulceration, location, circumference, and width at diagnosis.
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Affiliation(s)
- Duk Hwan Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Bun Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Jae Hyuk Choi
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Sung Pil Hong
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
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18
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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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19
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He WZ, Rong YM, Jiang C, Liao FX, Yin CX, Guo GF, Qiu HJ, Zhang B, Xia LP. Palliative primary tumor resection provides survival benefits for the patients with metastatic colorectal cancer and low circulating levels of dehydrogenase and carcinoembryonic antigen. CHINESE JOURNAL OF CANCER 2016; 35:58. [PMID: 27357402 PMCID: PMC4928252 DOI: 10.1186/s40880-016-0120-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 06/15/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND It remains controversial whether palliative primary tumor resection (PPTR) can provide survival benefits to the patients with metastatic colorectal cancer (mCRC) who have unresectable metastases. The aim of this study was to evaluate whether PPTR could improve the survival of patients with mCRC. METHODS We conducted a retrospective study on consecutive mCRC patients with unresectable metastases who were diagnosed at Sun Yat-sen University Cancer Center in Guangzhou, Guangdong, China, between January 2005 and December 2012. Overall survival (OS) and progression-free survival (PFS) after first-line chemotherapy failure were compared between the PPTR and non-PPTR patient groups. RESULTS A total of 387 patients were identified, including 254 who underwent PPTR and 133 who did not. The median OS of the PPTR and non-PPTR groups was 20.8 and 14.8 months (P < 0.001), respectively. The median PFS after first-line chemotherapy was 7.3 and 4.8 months (P < 0.001) in the PPTR and non-PPTR groups, respectively. A larger proportion of patients in the PPTR group (219 of 254, 86.2%) showed local progression compared with that of patients in the non-PPTR group (95 of 133, 71.4%; P < 0.001). Only patients with normal lactate dehydrogenase (LDH) levels and with carcinoembryonic antigen (CEA) levels <70 ng/mL benefited from PPTR (median OS, 22.2 months for the PPTR group and 16.2 months for the non-PPTR group; P < 0.001). CONCLUSIONS For mCRC patients with unresectable metastases, PPTR can improve OS and PFS after first-line chemotherapy and decrease the incidence of new organ involvement. However, PPTR should be recommended only for patients with normal LDH levels and with CEA levels <70 ng/mL.
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Affiliation(s)
- Wen-Zhuo He
- />State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
- />VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
| | - Yu-Ming Rong
- />State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
- />VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
| | - Chang Jiang
- />State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
- />VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
| | - Fang-Xin Liao
- />State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
- />VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
| | - Chen-Xi Yin
- />State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
- />VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
| | - Gui-Fang Guo
- />State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
- />VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
| | - Hui-Juan Qiu
- />State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
- />VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
| | - Bei Zhang
- />State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
- />VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
| | - Liang-Ping Xia
- />State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
- />VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, 510060 Guangdong P. R. China
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20
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Bethune R, Sbaih M, Brosnan C, Arulampalam T. What happens when we do not operate? Survival following conservative bowel cancer management. Ann R Coll Surg Engl 2016; 98:409-12. [PMID: 27055410 DOI: 10.1308/rcsann.2016.0146] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction While surgery is the cornerstone of bowel cancer treatment, it comes with significant risks. Among patients aged over 80 years, 30-day mortality is 13%-15%, and additionally 12% will not return home and go on to live in supportive care. The question for patients and clinicians is whether operative surgery benefits elderly, frail patients. Methods Multidisciplinary team outcomes between October 2010 and April 2012 were searched to conduct a retrospective analysis of patients with known localised colorectal cancer who did not undergo surgery due to being deemed unfit. Results Twenty six patients survived for more than a few weeks following surgery, of whom 20% survived for at least 36 months. The average life expectancy following diagnosis was 1 year and 176 days, with a mean age at diagnosis of 87 years (range 77-93 years). One patient survived for 3 years and 240 days after diagnosis. Conclusions Although surgeons are naturally focused on surgical outcomes, non-operative outcomes are equally as important for patients. Elderly, frail patients benefit less from surgery for bowel cancer and have higher risks than younger cohorts, and this needs to be carefully discussed when jointly making the decision whether or not to operate.
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Affiliation(s)
- R Bethune
- Colchester Hospital University NHS Trust , UK
| | - M Sbaih
- Colchester Hospital University NHS Trust , UK.,ICENI Centre for Surgical Education and Research , Colchester , UK
| | - C Brosnan
- Colchester Hospital University NHS Trust , UK
| | - T Arulampalam
- Colchester Hospital University NHS Trust , UK.,ICENI Centre for Surgical Education and Research , Colchester , UK
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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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22
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Feasibility of the liver-first approach for patients with initially unresectable and not optimally resectable synchronous colorectal liver metastases. Surg Today 2015; 46:721-8. [DOI: 10.1007/s00595-015-1242-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 07/21/2015] [Indexed: 02/07/2023]
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23
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Prognostic Relevance of Palliative Primary Tumor Removal in 37,793 Metastatic Colorectal Cancer Patients: A Population-Based, Propensity Score-Adjusted Trend Analysis. Ann Surg 2015; 262:112-20. [PMID: 25373464 DOI: 10.1097/sla.0000000000000860] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess whether palliative primary tumor resection in colorectal cancer patients with incurable stage IV disease is associated with improved survival. BACKGROUND There is a heated debate regarding whether or not an asymptomatic primary tumor should be removed in patients with incurable stage IV colorectal disease. METHODS Stage IV colorectal cancer patients were identified in the Surveillance, Epidemiology, and End Results database between 1998 and 2009. Patients undergoing surgery to metastatic sites were excluded. Overall survival and cancer-specific survival were compared between patients with and without palliative primary tumor resection using risk-adjusted Cox proportional hazard regression models and stratified propensity score methods. RESULTS Overall, 37,793 stage IV colorectal cancer patients were identified. Of those, 23,004 (60.9%) underwent palliative primary tumor resection. The rate of patients undergoing palliative primary cancer resection decreased from 68.4% in 1998 to 50.7% in 2009 (P < 0.001). In Cox regression analysis after propensity score matching primary cancer resection was associated with a significantly improved overall survival [hazard ratio (HR) of death = 0.40, 95% confidence interval (CI) = 0.39-0.42, P < 0.001] and cancer-specific survival (HR of death = 0.39, 95% CI = 0.38-0.40, P < 0.001). The benefit of palliative primary cancer resection persisted during the time period 1998 to 2009 with HRs equal to or less than 0.47 for both overall and cancer-specific survival. CONCLUSIONS On the basis of this population-based cohort of stage IV colorectal cancer patients, palliative primary tumor resection was associated with improved overall and cancer-specific survival. Therefore, the dogma that an asymptomatic primary tumor never should be resected in patients with unresectable colorectal cancer metastases must be questioned.
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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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Niitsu H, Hinoi T, Shimomura M, Egi H, Hattori M, Ishizaki Y, Adachi T, Saito Y, Miguchi M, Sawada H, Kochi M, Mukai S, Ohdan H. Up-front systemic chemotherapy is a feasible option compared to primary tumor resection followed by chemotherapy for colorectal cancer with unresectable synchronous metastases. World J Surg Oncol 2015; 13:162. [PMID: 25908502 PMCID: PMC4426172 DOI: 10.1186/s12957-015-0570-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 04/04/2015] [Indexed: 12/30/2022] Open
Abstract
Background In stage IV colorectal cancer (CRC) with unresectable metastases, whether or not resection of the primary tumor should be indicated remains controversial. We aim to determine the impact of primary tumor resection on the survival of stage IV CRC patients with unresectable metastases. Methods We retrospectively investigated 103 CRC patients with stage IV colorectal cancer with metastases, treated at Hiroshima University Hospital between 2007 and 2013. Of these, those who had resectable primary tumor but unresectable metastases and received any chemotherapy were included in the study. We analyzed the overall survival (OS) and short-term outcomes between the patients who received up-front systemic chemotherapy (USC group) and those who received primary tumor resection followed by chemotherapy (PTR group). Results Of the 57 included patients, 15 underwent USC and 42 PTR. The median survival times were 13.4 and 23.9 months in the USC and PTR groups, respectively (P = 0.093), but multivariate analysis for the overall survival showed no significant difference between the two groups (hazard ratio, 1.30; 95% confidence interval (CI), 0.60 to 2.73, P = 0.495). In the USC group, the disease control rate of primary tumor was observed in 12 patients (80.0%), but emergency laparotomy was required for 1 patient. Morbidity in the PTR group was observed in 18 cases (42.9%). Conclusions The overall survival did not differ significantly between the USC and PTR groups. USC may help avoid unnecessary resection and consequently the high morbidity rate associated with primary tumor resection for stage IV CRC with unresectable metastases.
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Affiliation(s)
- Hiroaki Niitsu
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Takao Hinoi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Manabu Shimomura
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Hiroyuki Egi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Minoru Hattori
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Yasuyo Ishizaki
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Tomohiro Adachi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Yasufumi Saito
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Masashi Miguchi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Hiroyuki Sawada
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Masatoshi Kochi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Shoichiro Mukai
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
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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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Manceau G, Dubreuil O, Karoui M. Forme métastatique non résécable : quid du primitif ? ONCOLOGIE 2014. [DOI: 10.1007/s10269-014-2470-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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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: 89] [Impact Index Per Article: 8.9] [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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't Lam-Boer J, Mol L, Verhoef C, de Haan AFJ, Yilmaz M, Punt CJA, de Wilt JHW, Koopman M. The CAIRO4 study: the role of surgery of the primary tumour with few or absent symptoms in patients with synchronous unresectable metastases of colorectal cancer--a randomized phase III study of the Dutch Colorectal Cancer Group (DCCG). BMC Cancer 2014; 14:741. [PMID: 25277170 PMCID: PMC4196118 DOI: 10.1186/1471-2407-14-741] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 09/23/2014] [Indexed: 12/16/2022] Open
Abstract
Background There is no consensus regarding resection of the primary tumour with few or absent symptoms in patients with synchronous unresectable metastatic colorectal cancer (CRC). A potential benefit of resection of the primary tumour is to prevent complications of the primary tumour in later stages of the disease. We here propose a randomized trial in order to demonstrate that resection of the primary tumour improves overall survival. Methods/design The CAIRO4 study is a multicentre, randomized, phase III study of the Dutch Colorectal Cancer Group (DCCG). Patients with synchronous unresectable metastases of CRC and few or absent symptoms of the primary tumour are randomized 1:1 between systemic therapy only, and resection of the primary tumour followed by systemic therapy. Systemic therapy will consist of fluoropyrimidine-based chemotherapy in combination with bevacizumab. The primary objective of this study is to determine the clinical benefit in terms of overall survival of initial resection of the primary tumour. Secondary endpoints include progression free survival, surgical morbidity, quality of life and the number of patients requiring resection of the primary tumour in the control arm. Discussion The CAIRO4 study is a multicentre, randomized, phase III study that will assess the benefit of resection of the primary tumour in patients with synchronous metastatic CRC. Trial registration The CAIRO4 study is registered at clinicaltrials.gov (NCT01606098)
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Affiliation(s)
- Jorine 't Lam-Boer
- Department of Surgery, Radboud university medical center, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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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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Miyamoto Y, Watanabe M, Sakamoto Y, Shigaki H, Murata A, Sugihara H, Etoh K, Ishimoto T, Iwatsuki M, Baba Y, Iwagami S, Yoshida N, Baba H. Evaluation of the necessity of primary tumor resection for synchronous metastatic colorectal cancer. Surg Today 2014; 44:2287-92. [DOI: 10.1007/s00595-014-0869-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 12/16/2013] [Indexed: 12/21/2022]
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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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Chen W, Tan XP, Ye JW, Liu Q, Zeng Q, Wang L, Wang JP. Effect of bowel obstruction on stage IV colorectal cancer. Mol Clin Oncol 2014; 2:308-312. [PMID: 24649353 DOI: 10.3892/mco.2014.240] [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: 10/14/2013] [Accepted: 12/19/2013] [Indexed: 01/12/2023] Open
Abstract
Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide, with a high mortality rate, particularly among patients with advanced-stage disease complicated by bowel obstruction. The present study aimed to investigate the value of different surgical procedures and potential predictors of survival for patients with stage IV CRC, with or without bowel obstruction. Between August, 1994 and December, 2005, a total of 2,950 CRC patients were diagnosed and treated at our hospital. Among these, 381 patients had stage IV disease and were divided into two groups according to the presence (n=295) or absence (n=86) of bowel obstruction. The clinical data of all the patients with stage IV CRC were retrospectively analyzed and all the patients were followed up. Our results demonstrated statistically significant differences in gender, radical resection, histological type, ascites, tumor location, peritoneal and liver metastases between the obstruction and non-obstruction groups. We also observed that hepatic metastases and radical resection were factors associated with prognosis according to the univariate and multivariate analyses. Furthermore, the mean/median survival time was 49.4/21.6 and 37.2/17.1 months in the non-obstruction and obstruction groups, respectively. In conclusion, obstruction was not found to be an independent indicator of survival for patients with stage IV CRC, with patients in the obstruction group exhibiting a worse overall survival compared to those in the non-obstruction group, whereas active radical surgery significantly improved the prognosis of patients with stage IV CRC.
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Affiliation(s)
- Wei Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510655, P.R. China
| | - Xiao-Ping Tan
- Emergency Department, The Fourth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510655, P.R. China
| | - Jun-Wen Ye
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510655, P.R. China
| | - Qin Liu
- Chongqing Hospital of Traditional Chinese Medicine, Jiangbei, Chongqing 400021, P.R. China ; Department of Pathophysiology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, Guangdong 510080, P.R. China
| | - Qingli Zeng
- Department of General Surgery, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi 330006, P.R. China
| | - Lei Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510655, P.R. China
| | - Jian-Ping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510655, P.R. China
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Cáceres M, Pascual M, Alonso S, Montagut C, Gallén M, Courtier R, Gil MJ, Grande L, Andreu M, Pera M. [Treatment of colorectal cancer with unresectable metastasis with chemotherapy without primary tumor resection: analysis of tumor-related complications]. Cir Esp 2013; 92:30-7. [PMID: 24176190 DOI: 10.1016/j.ciresp.2013.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 04/20/2013] [Accepted: 04/22/2013] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Although the conventional treatment of patients with stage iv colorectal cancer involves resection of the primary tumor followed by chemotherapy, several studies suggest that in patients with few symptoms the first and only treatment should be chemotherapy. The objective of this study is to analyze the complications related to the primary tumor in a series of patients with unresectable metastatic colorectal cancer treated with chemotherapy without surgery. MATERIAL AND METHODS Retrospective descriptive study. The study included all patients with unresectable metastatic colorectal cancer treated with chemotherapy without resection of the primary tumor (January 2007-February 2011). RESULTS The mean age of the 61 patients analyzed was 67±13 years and the performance status was 0-1 in 53 (87%). Twenty (33%) patients developed complications during follow-up. The most common complication was intestinal obstruction in 15 (25%) patients followed by perforation. Complications required surgery in 6 (10%) cases. We did not find differences in patient characteristics between those who had a complication and those without, although the complication rate in patients with a colonic stent (53%) was twice that of other patients (26%). CONCLUSIONS Chemotherapy without surgery is a good option in most patients with unresectable metastatic colorectal cancer. However, although the percentage of patients requiring surgery is low, the total number of complications related to the primary tumor is not negligible. Studies are needed to identify those patients in whom a prophylactic colectomy could be indicated.
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Affiliation(s)
- Marta Cáceres
- Unidad de Cirugía Colorrectal, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España
| | - Marta Pascual
- Unidad de Cirugía Colorrectal, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
| | - Sandra Alonso
- Unidad de Cirugía Colorrectal, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
| | - Clara Montagut
- Servicio de Oncología, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
| | - Manel Gallén
- Servicio de Oncología, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
| | - Ricard Courtier
- Unidad de Cirugía Colorrectal, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España
| | - M José Gil
- Unidad de Cirugía Colorrectal, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España
| | - Luis Grande
- Unidad de Cirugía Colorrectal, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
| | - Montserrat Andreu
- Servicio de Digestivo, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
| | - Miguel Pera
- Unidad de Cirugía Colorrectal, Unidad Funcional de Cáncer Colorrectal, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España.
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Ahmed S, Shahid R, Leis A, Haider K, Kanthan S, Reeder B, Pahwa P. Should noncurative resection of the primary tumour be performed in patients with stage iv colorectal cancer? A systematic review and meta-analysis. Curr Oncol 2013; 20:e420-41. [PMID: 24155639 PMCID: PMC3805411 DOI: 10.3747/co.20.1469] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Surgical resection of the primary tumour in patients with advanced colorectal cancer (crc) remains controversial. This review compares survival in patients with advanced crc who underwent surgical resection of the primary tumour with that in patients not undergoing resection, and determines rates of post-operative mortality and nonfatal complications, the primary tumour complication rate, the non-resection surgical procedures rate, and quality of life (qol). METHODS Reports in the central, medline, and embase databases were searched for relevant studies, which were selected using pre-specified eligibility criteria. The search was also restricted to publication dates from 1980 onward, the English language, and studies involving human subjects. Screening, evaluation of relevant articles, and data abstraction were performed in duplicate, and agreement between the abstractors was assessed. Articles that met the inclusion criteria were assessed for quality using the Newcastle-Ottawa Scale. Data were collected and synthesized per protocol. RESULTS From among the 3379 reports located, fifteen retrospective observational studies were selected. Of the 12,416 patients in the selected studies, 8620 (69%) underwent surgery. Median survival was 15.2 months (range: 10-30.7 months) in the resection group and 11.4 months (range: 3-22 months) in the non-resection group. Hazard ratio for survival was 0.69 [95% confidence interval (ci): 0.61 to 0.79] favouring surgical resection. Mean rates of postoperative mortality and nonfatal complications were 4.9% (95% ci: 0% to 9.7%) and 25.9% (95%ci: 20.1% to 31.6%) respectively. The mean primary tumour complication rate was 29.7% (95% ci: 18.5% to 41.0%), and the non-resection surgical procedures rate in the non-resection group was 27.6% (95 ci: 15.4% to 39.9%). No study provided qol data. CONCLUSIONS Although this review supports primary tumour resection in advanced crc, the results have significant biases. Randomized trials are warranted to confirm the findings.
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Affiliation(s)
- S. Ahmed
- Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, SK
- Department of Medicine, University of Saskatchewan, Saskatoon, SK
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK
| | - R.K. Shahid
- Department of Medicine, University of Saskatchewan, Saskatoon, SK
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK
| | - A. Leis
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK
| | - K. Haider
- Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, SK
- Department of Medicine, University of Saskatchewan, Saskatoon, SK
| | - S. Kanthan
- Department of Surgery, University of Saskatchewan, Saskatoon, SK
| | - B. Reeder
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK
| | - P. Pahwa
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK
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Polypurine reverse Hoogsteen hairpins as a gene therapy tool against survivin in human prostate cancer PC3 cells in vitro and in vivo. Biochem Pharmacol 2013; 86:1541-54. [PMID: 24070653 DOI: 10.1016/j.bcp.2013.09.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 09/12/2013] [Accepted: 09/12/2013] [Indexed: 11/22/2022]
Abstract
As a new approach for gene therapy, we recently developed a new type of molecule called polypurine reverse Hoogsteen hairpins (PPRHs). We decided to explore the in vitro and in vivo effect of PPRHs in cancer choosing survivin as a target since it is involved in apoptosis, mitosis and angiogenesis, and overexpressed in different tumors. We designed four PPRHs against the survivin gene, one of them directed against the template strand and three against different regions of the coding strand. These PPRHs were tested in PC3 prostate cancer cells in an in vitro screening of cell viability and apoptosis. PPRHs against the promoter sequence were the most effective and caused a decrease in survivin mRNA and protein levels. We confirmed the binding between the selected PPRHs and their target sequences in the survivin gene. In addition we determined that both the template- and the coding-PPRH targeting the survivin promoter were interfering with the binding of transcription factors Sp1 and GATA-3, respectively. Finally, we conducted two in vivo efficacy assays using the Coding-PPRH against the survivin promoter and performing two routes of administration, namely intratumoral and intravenous, in a subcutaneous xenograft tumor model of PC3 prostate cancer cells. The results showed that the chosen Coding-PPRH proved to be effective in decreasing tumor volume, and reduced the levels of survivin protein and the formation of blood vessels. These findings represent the preclinical proof of principle of PPRHs as a new silencing tool for cancer gene therapy.
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Biondo S, Frago R. [Value of tumour resection in colorectal cancer with unresectable metastases]. Cir Esp 2013; 91:349-51. [PMID: 23726476 DOI: 10.1016/j.ciresp.2013.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 05/08/2013] [Indexed: 11/26/2022]
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Multicenter study of short- and long-term outcomes of laparoscopic palliative resection for incurable, symptomatic stage IV colorectal cancer in Japan. J Gastrointest Surg 2013; 17:776-83. [PMID: 23435696 DOI: 10.1007/s11605-013-2173-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 02/13/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND This Japanese multicenter retrospective study evaluated short- and long-term outcomes of palliative laparoscopic procedures for symptomatic stage IV colorectal cancer compared with conventional open procedures. METHODS Of 968 eligible patients with stage IV colorectal cancer enrolled during January 2006-December 2007 from 41 participating surgical units (Japan Society of Laparoscopic Colorectal Surgery Group), we studied 409 patients who underwent palliative resection of symptomatic primary colorectal tumor. RESULTS Data from patients with laparoscopic resection (n = 98) and open colorectal resection (n = 311) were analyzed. Eleven (11.2 %) laparoscopic operations were converted to an open procedure. Fewer complications were reported for laparoscopic resections than for open procedures (13.3 vs. 26.7 %; p = 0.0042). Postoperative hospital stay was significantly shorter in the laparoscopic vs. open resection group (median, 14 vs. 17 days; p = 0.0242). Postoperative chemotherapy treatment was administered to 245 (78.9 %) patients in the open and 78 (79.6 %) patients in the laparoscopic resection group. Time from surgery to start of postoperative chemotherapy was significantly shorter in the laparoscopic vs. open resection group (median, 32 vs. 27 days; p = 0.0487). Median survival time between the two groups was not significantly different (22.0 vs. 22.2 months; p = 0.948). CONCLUSIONS Laparoscopic palliative resection results in reduced postoperative complications and earlier recovery with acceptable long-term outcomes comparable with open surgery. When performed by experienced surgeons in selected patients, it may be a safe and feasible option. Because of the potential of significant bias arising from the included studies, further randomized controlled trials should be undertaken to confirm this bias.
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Matsuda K, Hotta T, Takifuji K, Yokoyama S, Oku Y, Hashimoto T, Iwamoto H, Yamaue H. Clinical outcome of up-front surgery in patients with asymptomatic, incurable synchronous peritoneal carcinomatosis. Surg Today 2012; 43:984-9. [PMID: 23052739 DOI: 10.1007/s00595-012-0348-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 07/03/2012] [Indexed: 10/27/2022]
Abstract
PURPOSES The purpose of this study was to show the clinical features of up-front surgery of the primary tumor in asymptomatic patients with incurable colorectal PC. METHODS Forty-six patients that were diagnosed between 1998 and 2007 with asymptomatic colorectal PC who could not be successfully cured by surgery were assessed retrospectively. RESULTS A univariate analysis revealed the presence of liver metastases, without the use of oxaliplatin (OX)/irinotecan (IRI) and without a primary tumor resection to be poor prognostic factors for survival (p = 0.044, p = 0.030, p < 0.001, respectively). According to a multivariate analysis, no use of OX/IRI and no primary tumor resection, were found to be independent poor prognostic factors for survival (HR 2.57; p = 0.047, HR 6.62; p = 0.003, respectively). The median survival time of patients treated with and without OX/IRI was 18 and 7 months, respectively. The median survival time of patients with and without primary tumor resection was 10 and 2 months, respectively. The number of patients needing surgical intervention for intestinal obstruction after surgery significantly increased in patients treated with OX/IRI (p = 0.001). CONCLUSION Improvement of survival may be related to widespread use of modern systemic chemotherapy and primary tumor resection. However, an increased number of patients that needed surgery for an intestinal obstruction were observed, even after up-front surgery, when patients were treated with modern systemic chemotherapy.
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Affiliation(s)
- Kenji Matsuda
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama 641-8510, Japan
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Viganò L. Treatment strategy for colorectal cancer with resectable synchronous liver metastases: Is any evidence-based strategy possible? World J Hepatol 2012; 4:237-41. [PMID: 22993665 PMCID: PMC3443705 DOI: 10.4254/wjh.v4.i8.237] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Revised: 08/10/2012] [Accepted: 08/23/2012] [Indexed: 02/06/2023] Open
Abstract
Fifteen percent to twenty-five percent of patients affected by colorectal cancer presents with liver metastases at diagnosis. In resectable cases, surgery is the only potentially curative treatment and achieves survival rates up to 50% at 5 years. Management is complex, as colorectal resection, liver resection, chemotherapy, and, in locally advanced mid/low rectal tumors, radiotherapy have to be integrated. Modern medical practice usually relies on evidence-based protocols. Levels of evidence for synchronous metastases are poor: published studies include few recent prospective series and several retrospective analyses collecting a limited number of patients across long periods of time. Data are difficult to be generalized and are mainly representative of single centre's experience, biased by local recruitment, indications and surgical technique. In this context, surgeons have to renounce to "evidence-based medicine" and to adopt a sort of "experience-based medicine". Anyway, some suggestions are possible. Simultaneous colorectal and liver resection can be safely performed whenever minor hepatectomies are planned, while a case-by-case evaluation is mandatory in case of more complex procedures. Neoadjuvant chemotherapy is preferentially scheduled for patients with advanced metastatic tumors to assess disease biology and to control lesions. It can be safely performed with primary tumor in situ, even planning simultaneous resection at its end. Locally advanced mid/low rectal tumor represents a further indication to neoadjuvant therapies, even if treatment's schedule is not yet standardized. In summary, several issues have to be solved, but every single HPB centre should define its proper strategy to optimize patient's selection, disease control and safety and completeness of surgery.
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Affiliation(s)
- Luca Viganò
- Luca Viganò, Department of HPB and Digestive Surgery, Ospedale Mauriziano "Umberto I", Torino 10128, Italy
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Fahy BN, Fischer CP. Synchronous resection of colorectal primary and hepatic metastasis. J Gastrointest Oncol 2012; 3:48-58. [PMID: 22811869 DOI: 10.3978/j.issn.2078-6891.2012.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 01/13/2012] [Indexed: 12/14/2022] Open
Abstract
Up to 50% of the over 140,000 new colorectal cancer patients will present with synchronous colorectal cancer and liver metastasis. Surgical management of patients with resectable synchronous colorectal hepatic metastasis is complex and must consider multiple factors, including the presence of symptoms, location of primary tumor and liver metastases, extent of tumor (both primary and metastatic), patient performance status, and underlying comorbidities. Possible approaches to this select group of patients have included a synchronous resection of the colorectal primary and the hepatic metastases or a staged resection approach. The available literature regarding the safety of synchronous versus staged approaches confirms that a simultaneous resection may be performed in selected patients with acceptable morbidity and mortality. Perioperative mortality when minor hepatectomies are combined with colorectal resection is consistently ≤5%. Perioperative morbidity varies considerably following both synchronous and staged resections. However, the bulk of the existing literature confirms that simultaneous resections are both feasible and safe when hepatic resections are limited to <3 segments. Data regarding the oncologic outcomes following synchronous versus staged resections for Stage IV colorectal cancer are more limited than those available regarding postoperative morbidity and mortality. The available data suggest equivalent overall and disease-free survival regardless of timing of resection. Experience with minimally invasive combined colorectal and hepatic resections is extremely limited to date and consists exclusively of small single center series. The potential benefits of a minimally invasive approach will await the results of larger studies.
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Affiliation(s)
- Bridget N Fahy
- Weill Cornell Medical College, The Methodist Hospital, Houston, Texas, USA
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Takao M, Yamazaki K, Boku N, Ikehara H, Hamauchi S, Tsushima T, Taniguchi H, Todaka A, Machida N, Fukutomi A, Onozawa Y, Yasui H. Endoscopic evaluation of primary tumor response in patients with metastatic colorectal cancer treated by systemic chemotherapy. Int J Clin Oncol 2012; 18:864-8. [PMID: 22865286 DOI: 10.1007/s10147-012-0452-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 07/08/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND The number of cases of metastatic colorectal cancer treated by chemotherapy without primary tumor resection has recently increased. However, evaluation of primary tumor response by computed tomography is difficult in such cases. In this study, the usefulness of evaluation of primary tumor response to chemotherapy by endoscopy was investigated. METHODS This retrospective analysis was performed at the Shizuoka Cancer Center and included 31 patients (88 evaluations) with metastatic colorectal cancer. Computed tomography and endoscopy were performed concomitantly between September 2002 and June 2006. Patients were treated by systemic chemotherapy without prophylactic primary tumor resection. Definitions of primary tumor response were as follows: (1) complete response, confirmed by colorectal biopsy; (2) progressive disease, enlargement of at least one of five tumor parameters; and (3) neither (1) nor (2). Computed tomography was performed to evaluate primary tumor response according to the Response Evaluation Criteria in Solid Tumors and to identify colorectal stenosis secondary to primary tumors. RESULTS The rate of concordance between endoscopy and computed tomography for evaluation of primary tumor response was 75%. Colorectal stenosis was detected 14 times by endoscopy (9 cases) and 3 times by computed tomography (3 cases). Of the 7 patients in whom surgery was required, 6 exhibited stenotic symptoms before endoscopic detection. CONCLUSIONS With regard to primary tumor response evaluation, a high concordance rate was observed between endoscopy and computed tomography, although endoscopic evaluation appeared more sensitive in detecting colorectal stenosis requiring surgical treatment.
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Affiliation(s)
- Madoka Takao
- Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Suntougun, Shizuoka, 411-8777, Japan
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McCahill LE, Yothers G, Sharif S, Petrelli NJ, Lai LL, Bechar N, Giguere JK, Dakhil SR, Fehrenbacher L, Lopa SH, Wagman LD, O'Connell MJ, Wolmark N. Primary mFOLFOX6 plus bevacizumab without resection of the primary tumor for patients presenting with surgically unresectable metastatic colon cancer and an intact asymptomatic colon cancer: definitive analysis of NSABP trial C-10. J Clin Oncol 2012; 30:3223-8. [PMID: 22869888 DOI: 10.1200/jco.2012.42.4044] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Major concerns surround combining chemotherapy with bevacizumab in patients with colon cancer presenting with an asymptomatic intact primary tumor (IPT) and synchronous yet unresectable metastatic disease. Surgical resection of asymptomatic IPT is controversial. PATIENTS AND METHODS Eligibility for this prospective, multicenter phase II trial included Eastern Cooperative Oncology Group (ECOG) performance status 0 to 1, asymptomatic IPT, and unresectable metastases. All received infusional fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) combined with bevacizumab. The primary end point was major morbidity events, defined as surgical resection because of symptoms at or death related to the IPT. A 25% major morbidity rate was considered acceptable. Secondary end points included overall survival (OS) and minor morbidity related to IPT requiring hospitalization, transfusion, or nonsurgical intervention. RESULTS Ninety patients registered between March 2006 and June 2009: 86 were eligible with follow-up, median age was 58 years, and 52% were female. Median follow-up was 20.7 months. There were 12 patients (14%) with major morbidity related to IPT: 10 required surgery (eight, obstruction; one, perforation; and one, abdominal pain), and two patients died. The 24-month cumulative incidence of major morbidity was 16.3% (95% CI, 7.6% to 25.1%). Eleven IPTs were resected without a morbidity event: eight for attempted cure and three for other reasons. Two patients had minor morbidity events only: one hospitalization and one nonsurgical intervention. Median OS was 19.9 months (95% CI, 15.0 to 27.2 months). CONCLUSION This trial met its primary end point. Combining mFOLFOX6 with bevacizumab did not result in an unacceptable rate of obstruction, perforation, bleeding, or death related to IPT. Survival was not compromised. These patients can be spared initial noncurative resection of their asymptomatic IPT.
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Anwar S, Peter MB, Dent J, Scott NA. Palliative excisional surgery for primary colorectal cancer in patients with incurable metastatic disease. Is there a survival benefit? A systematic review. Colorectal Dis 2012; 14:920-30. [PMID: 21899714 DOI: 10.1111/j.1463-1318.2011.02817.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIM Patients with stage IV colorectal cancer with unresectable metastases can either receive chemotherapy or palliative resection of the primary lesion. In the absence of any randomized data the choice of initial treatment in stage IV colorectal cancer is not based on firm evidence. METHOD A search of MEDLINE, Pubmed, Embase and the Cochrane Library database was performed from 1980 to 2010 for studies comparing palliative resection in stage IV colorectal cancer with other treatment modalities. Audits and observational studies were excluded. Median survival was the primary outcome measure. The morbidity and mortality of surgical and nonsurgical treatments were compared. RESULTS Twenty-one studies (no randomized controlled trials) were identified. Most demonstrated a survival benefit for patients who underwent palliative resection. Multivariate analysis indicates that tumour burden and performance status are both major independent prognostic variables. Selection bias, incomplete follow up and nonstandardized reporting of complications make the data difficult to interpret. CONCLUSION The studies indicate that there may be a survival benefit for primary resection of colorectal cancer in stage IV disease. The findings suggest that resection of the primary tumour should be based on tumour burden and performance status rather than on the presence or absence of symptoms alone.
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Affiliation(s)
- S Anwar
- Department of Colorectal Surgery, Calderdale and Huddersfield NHS Trust, Huddersfield, UK.
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Treatment strategies for patients with stage IV rectal cancer: A report from the Swedish Rectal Cancer Registry. Eur J Cancer 2012; 48:1616-23. [DOI: 10.1016/j.ejca.2011.12.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 11/29/2011] [Accepted: 12/11/2011] [Indexed: 02/01/2023]
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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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50
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OCHIAI TAKUMI, NISHIMURA KAZUHIKO, WATANABE TOMOO, KITAJIMA MASAYUKI, NAKATANI AKINORI, INOU TAKASHI, WASHIO MARIE, SAKUYAMA NAOKI, SATO TSUYOSHI, KISHINE KENJI, OCHI TAKANORI, OOKUBO SATOSHI, FUTAGAWA SHUNJI, ORIKASA HIDEKI, MASHIKO SATOMI, NAGAOKA ISAO. Good response to leucovorin and fluorouracil plus oxaliplatin and cetuximab therapy in a patient with metastatic ascending colon cancer harboring a KRAS p.G13D mutation. Oncol Lett 2012; 3:269-272. [PMID: 22740893 PMCID: PMC3362562 DOI: 10.3892/ol.2011.503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2011] [Accepted: 11/07/2011] [Indexed: 11/05/2022] Open
Abstract
The effectiveness of cetuximab (Cmab) against KRAS p.G13D mutant-type tumors has been reported. In this study, we report a case of metastatic ascending colon cancer harboring a KRAS p.G13D mutation in a 65-year-old female. Considering the absence of symptoms and the post-operative risk of respiratory system complications due to multiple lung metastases, particularly at the entrance to the left main bronchus, anticancer drug therapy was selected as first-line therapy. With informed consent, FOLFOX4 [folinic acid (FOL), fluorouracil (F) plus oxaliplatin (OX)] + Cmab therapy was administered as preoperative chemotherapy. A good preoperative response was obtained to the chemotherapy, with a metastatic lesion disappearing from the entrance to the left main bronchus. Subsequent resection was performed successfully with no post-operative complications. Although a histopathological examination of the resected tissue specimen revealed residual cancer cells, it also showed the marked efficacy of the chemotherapy regimen used. In this study, we describe a case of metastatic ascending colon cancer harboring a KRAS p.G13D mutation in which the patient responded well to first-line therapy with FOLFOX4 + Cmab.
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Affiliation(s)
- TAKUMI OCHIAI
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - KAZUHIKO NISHIMURA
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - TOMOO WATANABE
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - MASAYUKI KITAJIMA
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - AKINORI NAKATANI
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - TAKASHI INOU
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - MARIE WASHIO
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - NAOKI SAKUYAMA
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - TSUYOSHI SATO
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - KENJI KISHINE
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - TAKANORI OCHI
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - SATOSHI OOKUBO
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - SHUNJI FUTAGAWA
- Department of Surgery, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - HIDEKI ORIKASA
- Department of Pathology, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - SATOMI MASHIKO
- Department of Pharmacy, Tobu Chiiki Hospital, Metropolitan Health and Medical Treatment Corporation, Tokyo 125-8512
| | - ISAO NAGAOKA
- Department of Host Defense and Biochemical Research, Juntendo University School of Medicine, Tokyo 113-8421, Japan
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