Expressing the Prochemotherapy Position on Treatment of Synchronous Colorectal Metastases in the Asymptomatic Patient

Team Strategy Optimization in Combined Resections for Synchronous Colorectal Liver Metastases. A Comparative Study with Bootstrapping Analysis

BACKGROUND

The aim of the study was to evaluate perioperative outcomes and to evaluate factors influencing rative morbidity and adoption of minimally invasive technique in 1-team (1-T) versus two teams (2-T) management of synchronous colorectal liver metastases.

METHODS

Within four referral centers, a group of 234 patients treated in 1-T centers was identified and compared with a group of 253 patients treated in 2-T. A nonparametric bootstrap process was applied to the original cohorts of 1-T group and 2-T group as a resampling method to obtain bootstrapped cohorts (155 patients per group).

RESULTS

33.5% of patients in 1-T boot group and 38.1% in the 2-T boot group were operated by laparoscopic approach. Multivariate analysis revealed that approach to primary tumor (laparoscopic or open) and intraoperative blood loss were independent prognostic factors for morbidity. Team approach did not show any significant correlation with incidence of postoperative complications nor with choice for laparoscopic approach.

CONCLUSION

The optimization of team strategy for patients with SCRLM is not solely based on the adoption of a 1-T or 2-T approach, but should instead be based on the implementation of a standard protocol for management of these patients.

Timing of Perioperative Chemotherapy Does Not Influence Long-Term Outcome of Patients Undergoing Combined Laparoscopic Colorectal and Liver Resection in Selected Upfront Resectable Synchronous Liver Metastases

BACKGROUND

The aim of this study was to compare patients undergoing combined colorectal and hepatic surgery with and without neoadjuvant chemotherapy to clarify the prognostic advantage of preoperative oncological treatment in a case-matched analysis using propensity scores and to identify factors predictive of good prognosis in a selected population of Synchronous ColoRectal Liver Metastases (SCRLM).

METHODS

A total of 73 patients who underwent upfront elective combined surgery without preoperative CT for SCRLM in two European tertiary referral centers were selected and constituted the study group (NoNACT group). The NoNACT group was matched (ratio 1:1) with patients who were operated after chemotherapy with neoadjuvant intent (NACT group, the control group). The matching was achieved based on six covariates representative of patients and disease characteristics.

RESULTS

While the characteristics of both colorectal and hepatic procedures were similar, the NoNACT group, as compared to the NACT group, had lower blood loss (200 mL vs. 550 mL). Postoperative stay (9 vs. 12 days) and morbidity rate (24.7% vs. 32.9%) were reduced in the NoNACT compared with the NACT group. Mid- and long-term outcomes were comparable. At multivariable analysis, predictors of long-term outcome were: right colonic neoplasms, RAS mutational status, CRS score ≥3 and the absence of perioperative chemotherapy.

CONCLUSION

Preoperative neoadjuvant chemotherapy in patients with colorectal cancer and synchronous resectable liver metastases does not influence the risk of recurrence in patients with favorable tumor biology, while it was associated with increased intraoperative blood loss and morbidity. There is no strong evidence to recommend upfront chemotherapy in the absence of negative prognostic factors.

Impact of primary tumour resection on survival of patients with colorectal cancer and synchronous metastases treated by chemotherapy: results from the multicenter, randomised trial Fédération Francophone de Cancérologie Digestive 9601

OBJECTIVE

To assess the impact of primary tumour resection on overall survival (OS) of patients diagnosed with stage IV colorectal cancer (CRC).

DESIGN

Among the 294 patients with non-resectable colorectal metastases enrolled in the Fédération Francophone de Cancérologie Digestive (FFCD) 9601 phase III trial, which compared different first-line single-agent chemotherapy regimens, 216 patients (73%) presented with synchronous metastases at study entry and constituted the present study population. Potential baseline prognostic variables including prior primary tumour resection were assessed by univariate and multivariate Cox analyses. Progression-free survival (PFS) and OS curves were compared with the logrank test.

RESULTS

Among the 216 patients with stage IV CRC (median follow-up, 33 months), 156 patients (72%) had undergone resection of their primary tumour prior to study entry. The resection and non-resection groups did not differ for baseline characteristics except for primary tumour location (rectum, 14% versus 35%; p=0.0006). In multivariate analysis, resection of the primary was the strongest independent prognostic factor for PFS (hazard ratio (HR), 0.5; 95% confidence interval [CI], 0.4-0.8; p=0.0002) and OS (HR, 0.4; CI, 0.3-0.6; p<0.0001). Both median PFS (5.1 [4.6-5.6] versus 2.9 [2.2-4.1] months; p=0.001) and OS (16.3 [13.7-19.2] versus 9.6 [7.4-12.5]; p<0.0001) were significantly higher in the resection group. These differences in patient survival were maintained after exclusion of patients with rectal primary (n=43).

CONCLUSION

Resection of the primary tumour may be associated with longer PFS and OS in patients with stage IV CRC starting first-line, single-agent chemotherapy.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Colorectal liver metastases

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

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

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

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

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

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

A critical appraisal: providing care for patients with solid tumors metastases--challenges across academic and community practice

Emerging therapies and the growing number of therapeutic options available for some of the solid cancers have led to a large number of patients eligible for metastasectomy and cytoreductive surgery. It is likely that within the current health care structure, academic tertiary referral centers alone are not going to be able to accommodate the growing number of patients that are potential beneficiaries. Community-based practices will have to develop strategies to meet the demand for appropriate multimodality treatment teams to address the needs of these patients.

Chemotherapy-induced suppression to adenoma or complete suppression of the primary in patients with stage IV colorectal cancer: report of four cases

BACKGROUND

Although modern chemotherapy of stage IV advanced colorectal cancer (CRC) has impressively improved overall survival, the response of the primary tumor has not been studied because surgical resection of the primary continues to be the standard procedure in stage IV CRC.

AIM

Long-term follow-up of the primary in patients with stage IV CRC under chemotherapy.

METHODS AND RESULTS

Here we report on the histological changes in the primary tumor in four patients suffering from stage IV CRC. Systemic chemotherapy was started immediately after endoscopic tumor debulking in three cases. In one case no endoscopic intervention was performed before chemotherapy. Neither macroscopic nor histological evidence for malignant tumor growth was found at the former site of the primary after 6, 23, 26 or 48 months, respectively. Two patients had a complete suppression of the primary, two patients had an adenoma at the former site of the primary. To date, three patients have died because of progression of liver metastases and one patient is still alive with no signs of tumor growth.

CONCLUSION

The four cases illustrate that today's chemotherapy may effectively induces suppression of the primary in CRC. The development of CRC may follow different pathways.