Counting the cost of cancer surgery for advanced and metastatic disease

Is Surgery Warranted for Oligometastatic Disease?

The development of metastases after curative treatment can be seen as a failure. A common justification for the removal of metastases is that the knowledge that they are there may cause psychological distress, a real symptom that may be relieved by their removal. Although it is a commonly used justification for metastasectomy, the authors are unaware of any studies confirming or quantifying the health gain. This article strongly challenges the belief in clinical effectiveness and demonstrates that it is supported neither by a sound biological rationale nor by any good evidence. Reasons are suggested why this unfounded belief has become so prevalent.

Metastatic adenocarcinomas of the stomach or esophagogastric junction (UICC stage IV) are not always a palliative situation: a retrospective analysis

BACKGROUND

Gastric cancer is one of the most common cancers. Unfortunately, it is often diagnosed at the advanced stage International Union Against Cancer stage IV. This induced us to carry out an interdisciplinary analysis of this patient group with the Department of Internal Medicine 1. Our aim was to discuss cancers classified initially as unresectable in a meeting of the interdisciplinary tumor board after palliative chemotherapy, and to refer selected patients for surgery after establishing resectability. The outcome of the chemotherapy, operation method, complication rate, and long-term survival were analyzed.

METHODS

From 1999 to 2008, 76 patients with metastatic gastric cancer or carcinoma of the esophagogastric junction were discussed by the interdisciplinary tumor board of the University of Erlangen and classified initially as unresectable. The patients then received palliative chemotherapy according to the AIO regimen (weekly high-dose 5-fluorouracil/folinic acid [FU/FA] in a 24 h infusion), plus irinotecan. If the tumor was subsequently classified as resectable, the patient underwent either gastric resection or gastrectomy with DII-III dissection. Metastases were resected depending on their location (liver). Peritoneal carcinomatosis was treated additionally by HIPEC. Statistical analysis was with SPSSS version 20.

RESULTS

Surgical and general complications and hospital mortality were acceptable. There were no cases of anastomotic leak, but one patient died of fulminant pneumonia. The R0 resection rate was 69 %, and four patients had long-term survival of more than 60 months. There were significant survival advantages.

CONCLUSIONS

Metastatic gastric cancer or carcinoma of the esophagogastric junction can become resectable after downsizing the tumor with palliative chemotherapy. Long-term survival is achieved in some cases. Therefore, every patient with this type of cancer should be discussed by the interdisciplinary tumour board after palliative chemotherapy to provide him with a chance of cure after re-evaluation.

Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC International)

SUMMARY Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) is a randomized controlled trial. Patients with resected colorectal cancer found to have one or more pulmonary metastases are randomized to have a metastasectomy or not. Both arms include active monitoring. Patients considered possible candidates for pulmonary metastasectomy are asked to first give consent to be assessed according to protocol after which a decision to have or not have metastasectomy may be made. If there is uncertainty, patients are invited to consent to randomization, including minimization for known prognostic factors: the number of metastases, the interval since primary resection, carcinoembryonic antigen levels and the TNM stage of the primary cancer. The primary outcomes are survival and quality of life. The trial is open in England, and in Serbia and Italy as PulMiCC International.

Surgery in the treatment of malignant pleural mesothelioma: recruitment into trials should be the default position

BACKGROUND

Europe is at the peak of an epidemic of malignant pleural mesothelioma and the burden of disease is likely to continue rising in the large areas of the world where asbestos remains unregulated. Patients with mesothelioma present with thoracic symptoms and radiological changes so respiratory physicians take a leading role in diagnosis and management. Belief that the modest survival times reported after radical surgery, whether alone or as part of multimodal therapy, are longer than they it would have been without surgery relies on data from highly selected, uncontrolled, retrospectively analysed case series. The only randomised study, the Mesothelioma and Radical Surgery (MARS) trial showed no benefit. A simple modelling study of registry patients, described here, shows that an impression of longer survival is eroded when patients who were never candidates for operation on grounds of histology, performance status and age are sequentially excluded from the model.

CONCLUSION

Whenever the question arises `Might an operation help me?' there are two responses that can and should be given. The first is that there is doubt about whether there is any survival or symptomatic benefit from surgery but we know that there is harm. The second is that there are on-going studies, including two randomised trials, which patients should be informed about. The authors suggest that the default position for clinicians should be to encourage recruitment into these trials.

Survival benefit of palliative gastrectomy in gastric cancer patients with peritoneal metastasis

BACKGROUND

The survival benefit of palliative gastrectomy in patients with peritoneal metastasis as a single incurable factor remains unclear.

METHODS

A total of 148 gastric cancer patients with peritoneal metastasis underwent gastrectomy or chemotherapy at the Shizuoka Cancer Center between September 2002 and December 2008 and were included in this study. The effects of gastrectomy and chemotherapy on their long-term outcome were investigated. Multivariate analysis was also performed to identify independent prognostic factors.

RESULTS

Gastrectomy was performed in 82 patients and subsequent chemotherapy was administered to 55. Chemotherapy was selected as an initial treatment for 66 patients. Median survival time (MST) was identical between patients with and without gastrectomy (13.1 vs. 12.0 months; P = 0.410). Conversely, MST was significantly longer in patients who received chemotherapy (13.7 months) than those who did not (7.1 months; P = 0.048). According to the results of multivariate analysis, chemotherapy (hazards ratio [HR] = 0.476; 95 % CI = 0.288-0.787) was selected as an independent prognostic factor, while gastrectomy was not.

CONCLUSIONS

The results of the present study did not show a survival benefit of palliative gastrectomy in selected patients with peritoneal metastasis. Instead, chemotherapy has to be considered as an initial treatment for these patients.