Colorectal Cancer
Table 1: Study Results on Stage IV Colorectal Cancer and Unresectable Metastases, in which the Non-resection Arm Was Treated with Chemotherapy
Author Scoggins40 Tebbutt50 Konyalian58 Galizia62 Ruo51 Michel45 Sarela39 Benoist44 Karoui71 Aslam65 Bajwa66 Muratore43 Poultsides37 Seo70
#Konyalian58 ¶Galizia62 ¥Aslam65
Years of Study 1985–1997 1990–1999 1991–2002 1995–2005 1996–1999 1996–1999 1997–2000 1997–2002 1998–2007 1998–2007 1999–2005 2000–2004 2000–2006 2001–2008
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Resection Chemo
Number of Patients
66 23
280 82 62 47 42 23
127 103 31 23 -
24 32 27 85
123 366 281 -
67 -
35 -
233 144 83
not described; 12 patients with complications, mostly infectious. not described; 2 colon perforations, 1 intestinal haemorrhage, 1 bowel obstruction, 2 surgery owing to bowel perforation or stent dislocation. not described; 11 full-thickness wound dehiscence, 11 intra-abdominal collections, 11 anastomotic leak, 7 intra-abdominal sepsis, 5 haemorrhage, 4 post-operative ileus, 1 splenic tear, 1 inter-loop fistula.
capecitabine, or 5-fluorouracil (5-FU) with or without bevacizumab. In case of K-RAS wild-type tumours, anti-epidermal growth factor receptor (EGFR) antibodies, such as panitumumab and cetuximab, are being used.33
Resection of the Primary Tumour in Patients with Unresectable Synchronous Metastatic Colorectal Cancer
Traditional surgical teaching promotes resection of the primary tumour in patients with unresectable metastases, even if the primary tumour is asymptomatic. The rationale behind this strategy is that prophylactic surgery prevents future complications of intestinal obstruction, perforation and haemorrhage.34
However, resection does
not provide immediate palliative benefit in case of an asymptomatic primary tumour, and surgery is associated with high mortality (5–13 %) and morbidity (23–48 %) in patients with metastatic disease.16,34–37
Other studies have shown no association between the incidence of complications and the extent of metastatic disease.39,40
Received
Chemotherapy (%) 0
100 100 100 58 60
100 100 0
83 97
100 -
88 94
100 99
100 63 36 -
100 -
100 -
100 100 100
Secondary Palliative Surgical Intervention
2 (3 %) 2 (9 %)
14 (5 %) 8 (10 %) #
17 (36 %) 0
6 (26 %) 6 (5 %)
30 (29 %) 0
5 (22 %) -
6 (25 %) 0
4 (15 %) 27 (32 %) 15 (12 %) ¥
128 (46 %) -
27 (40 %) -
1 (3 %) -
16 (7 %) 22 (15 %) 4 (5 %)
Palliative Resection of Primary Tumour
-
0 -
1 (1 %) -
0 -
¶ -
0 -
3 (13 %) -
4 (17 %) -
3 (11 %) -
15 (12 %) -
0 -
25 (37 %) -
0 -
8 (3 %) -
1 (1 %)
Due to recent
advances in systemic chemotherapy, the risks and benefits of immediate or deferred surgical strategies are under debate.
Some clinicians in favour of the surgical approach argue that if the asymptomatic primary cancer is not resected, patients will develop disabling symptoms, such as weight loss and nutritional depletion (secondary to ‘near’ obstruction), and anaemia, due to bleeding of the primary tumour. Arguments supporting surgery include a lower reported operative mortality for elective surgery in patients with stage IV disease (3–6 %), compared with the more threatening operative mortality rates for non-elective resections in patients with advanced and symptomatic disease (20–40 %).34,41,42
Another argument
Some studies tried to selectively apply prophylactic surgery in patients with a low metastatic tumour burden, because these patients are presumed to be at risk of obstruction because of long survival. If the metastatic tumour burden is extensive, resection of the primary tumour is unlikely to benefit the patient and is associated with a high risk of post-operative complications. These patients are probably better served by focusing on the disseminated component of their disease and starting with systemic treatment early on in their course, reserving surgery for if and when symptoms from the primary tumour are substantial.35,38
28
supporting this concept is that pre-operative staging is sometimes unclear and that surgery is considered the last and most effective diagnostic tool for the correct staging of abdominal tumours before treatment.19
In addition, patients are provided with psychological comfort who feel that the ‘cancer’ has been removed.35
Chemotherapy First in Patients with Unresectable Synchronous Metastatic Colorectal Cancer
The advocates of a chemotherapy-first approach prefer to avoid complications, at least in asymptomatic patients. The argument of those who prefer ‘elective’ surgery, due to higher mortality if
EUROPEAN ONCOLOGY & HAEMATOLOGY
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77