How aggressive should we be in patients with stage IV colorectal cancer?

A prognostic score predicting survival following emergency surgery in patients with metastatic colorectal cancer

BACKGROUND

Survival of patients with metastatic colorectal cancer (mCRC) varies. We aim to develop a prognostic score for mCRC after emergency surgery to guide treatment decisions.

METHODS

Newly diagnosed mCRC patients who presented with primary tumor-related complications and underwent emergency surgery between January 1999 and December 2013 were included. Univariate and multivariate Cox regression analyses were performed to identify covariates significantly associated with the time to death following surgery. A survival score was derived using the Cox regression equation.

RESULTS

The study cohort comprised 248 patients. Median patient age was 66 ± 13 years. Primary tumor was located in the left colon and rectum in 211 patients (85.1%) while 37 patients (14.9%) had primaries in the right colon. Liver, lung, and peritoneal metastases occurred in 161 patients (64.9%), 59 patients (23.8%), and 96 patients (38.7%), respectively. Majority of patients presented with either obstruction (174 patients, 70.1%) or perforation (52 patients, 21%). On multivariate analysis, age of 60 years or older (p = 0.007), carcinoembryonic antigen levels greater than 45 ng/ml (p = 0.022), presence of liver metastases (p = 0.024), and peritoneal carcinomatosis (p < 0.001) were found to be significantly associated with overall survival. A simplified score was derived with good survivors (score 0-2), moderate survivors (score 3-4), and poor survivors (score 5 and above) experiencing median survival of 7, 14, and 23 months, respectively (p < 0.001).

CONCLUSION

The management of mCRC presenting with an emergency is challenging. A prognostic score that estimates survival after emergency surgery may aid clinical decision-making.

Primary tumor sidedness is an independent prognostic marker for survival in metastatic colorectal cancer: Results from a large retrospective cohort with mutational analysis

Recent reports demonstrate inferior outcomes associated with primary right‐sided vs left‐sided colorectal tumors in patients with metastatic colorectal cancer (mCRC). We sought to describe our experience with mCRC patients on whom we have molecular data to determine whether primary tumor sidedness was an independent prognostic marker for overall survival (OS). mCRC patients with documented primary tumor sidedness who received mutational profiling between 2009 and 2014 were identified (n = 367, median follow‐up 30.4 months). Mutational profiling for >150 mutations across commonly mutated cancer genes including RAS, PIK3CA, BRAF, and PTEN as well as treatment data, including receipt of a biologic agent, were collected. Univariable/multivariable models were used to analyze relationships between collected data and OS. Among 367 patients, sidedness breakdown was as follows: 234 left (64%), 133 right (36%). 56% were male, with a median age at diagnosis of 57 (range 24‐89). A total of 143 patients had RAS mutations. Five‐year OS was 41%, median OS was 54 months (range 1‐149). Five‐year OS for left‐ vs right‐sided tumors was 46% vs 24% (P < .0001). On univariable analysis, among both RAS wildtype and mutant tumors, left‐sided tumors continued to have improved OS vs right‐sided tumors (HR: 0.49, 95% CI: 0.34‐0.69 RAS wildtype; HR: 0.61, 95% CI: 0.40‐0.95 RAS mutant). Left‐sidedness was an important prognostic factor for OS among RAS wildtype patients despite treatment with or without a biologic agent (P < .05). Left‐sidedness remained significant for improved OS on multivariable analysis (P < .0001). Left‐sided primary tumor remained most important prognostic factor for OS, even when adjusting for mutational status and receipt of biologic agent.

A scoring model for predicting survival following primary tumour resection in stage IV colorectal cancer patients with unresectable metastasis

BACKGROUND

Stage IV colorectal cancer patients with unresectable metastasis who undergo elective primary tumour resection experience heterogeneous post-operative survival. We aimed to develop a scoring model for predicting post-operative survival using pre-operative variables to identify patients who are least likely to experience extended survival following the procedure.

METHODS

Survival data were collected from stage IV colorectal cancer patients who had undergone elective primary tumour resection between January 1999 and December 2007. Coefficients of significant covariates from the multivariate Cox regression model were used to compute individual survival scores to classify patients into three prognostic groups. A survival function was derived for each group via Kaplan-Meier estimation. Internal validation was performed.

RESULTS

Advanced age (hazard ratio, HR 1.43 (1.16-1.78)); poorly differentiated tumour (HR 2.72 (1.49-5.04)); metastasis to liver (HR 1.76 (1.33-2.33)), lung (HR 1.37 (1.10-1.71)) and bone (HR 2.08 ((1.16-3.71)); carcinomatosis (HR 1.68 (1.30-2.16)); hypoalbuminaemia (HR 1.30 (1.04-1.61) and elevated carcinoembryonic antigen levels (HR 1.89 (1.49-2.39)) significantly shorten post-operative survival. The scoring model separated patients into three prognostic groups with distinct median survival lengths of 4.8, 12.4 and 18.6 months (p < 0.0001). Internal validation revealed a concordance probability estimate of 0.65 and a time-dependent area under receiver operating curve of 0.75 at 6 months. Temporal split-sample validation implied good local generalizability to future patient populations (p < 0.0001).

CONCLUSION

Predicting survival following elective primary tumour resection using pre-operative variables has been demonstrated with the scoring model developed. Model-based survival prognostication can support clinical decisions on elective primary tumour resection eligibility.

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)

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)

Prognostic factors associated with primary cancer in curatively resected stage IV colorectal cancer

PURPOSE

The aim of this study is to evaluate the prognostic factors associated with primary cancer in patients with curatively resected stage IV colorectal cancer, based on lymph node status.

METHODS

A total of 468 consecutive patients with curatively resected stage IV colorectal cancer from October 1994 to December 2010 were prospectively enrolled. Survival curves were constructed using the Kaplan-Meier method, and multivariate analysis assessed independent prognostic factors.

RESULTS

During the median follow-up period of this study, which was 37 months (range 1-177), the 3- and 5-year overall survival rates were 66.5 and 52.1%, respectively, and the 3- and 5-year disease-free survival rates were 43.0 and 38.2%, respectively. According to multivariate analysis, adjuvant chemotherapy and the preoperative serum carcinoembryonic antigen (CEA) level were independent prognostic factors for overall survival, and primary tumor location and preoperative serum CEA level were independent variables for disease-free survival. For the patients with N0 and N1 tumors, the overall survival curves in the preoperative CEA groups differed significantly (P = 0.046 and P < 0.013, respectively). However, for patients with pN2 tumors, the overall survival did not differ significantly according to the preoperative CEA (P = 0.948).

CONCLUSION

The preoperative serum CEA level is a reliable predictor of recurrence and survival after curative surgery in patients with metastatic colorectal cancer. A multidisciplinary approach that combines both complete resection and adjuvant chemotherapy may achieve improved overall survival in these patients.

Should noncurative resection of the primary tumour be performed in patients with stage iv colorectal cancer? A systematic review and meta-analysis

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.

Data on the characteristics and the survival of korean patients with colorectal cancer from the Korea central cancer registry

Purpose

The incidence rates of colorectal cancer (CRC) in Korea have been increasing during the past decade. Therefore, it is important to understand the characteristics, including survival, of Korean CRC patients. The aim of this study was to use the nationwide cancer registry to evaluate the characteristics of Korean CRC, focusing on the survival, according to tumor location, sex, and specific age groups.

Methods

Using the Korea Central Cancer Registry (KCCR), we analyzed a total of 226,352 CRC cases diagnosed from 1993 to 2010. The five-year relative survivals were compared for the proximal colon, the distal colon, and the rectum. Survival rates were compared between men and women and between patients of young age (less than 40 years old) and patients of advanced age (70 years old or older).

Results

The 5-year survival rates were improved in all subsites between 1993 and 2010. Distal colon cancer showed favorable survival compared to proximal colon or rectal cancer. Females demonstrated worse survival for local or regional cancers, and this difference was significant in for patients in their seventies. Young patients (<40 years old) showed better survival rates for overall and proximal colon cancer comparable to those for older patients (≥40 years old), but advanced age patients (≥70 years old) had worse survivals for all tumor subsites compared to their younger counterparts (<70 years old). These trends were similar in distant CRC.

Conclusion

Korean CRC has certain distinct characteristics of survival according to tumor location, sex, and age. Despite the limitations of available data, this study contributes to a better understanding of survival differences in Korean CRC.

Management of colorectal cancer patients after resection of liver metastases: can we offer a tailored treatment?

Surgical resection remains the only option of cure for patients with colorectal liver metastases, and no patient should be precluded from surgery. There is much controversy not only regarding the most appropriate therapeutic approach in the neoadjuvant setting but also after surgery is performed. Many patients will experience early relapses but others will be long survivors. We need to establish reliable prognostic and predictive factors to offer a tailored treatment. Several prognostic factors after metastasectomy have been identified: high C-reactive protein levels, a high neutrophil-lymphocyte ratio, elevated neutrophil count and low serum albumin are related to a worst outcome. Elevated CEA and Ki 67 levels, intrahepatic and perihepatic lymph node invasion are also some of the markers related to a worst outcome. In contrast, the administration of preoperative chemotherapy has been associated with a better prognosis after hepatectomy. The administration of adjuvant chemotherapy should be done taking in consideration these factors. Regarding predictive factors, determination of ERCC1, TS, TP and DPD and UGT1 polymorphisms assessment could be considered prior to chemotherapy administration. This would avoid treatment related toxicities and increase this population quality of life.

Palliative excisional surgery for primary colorectal cancer in patients with incurable metastatic disease. Is there a survival benefit? A systematic review

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.

Laparoscopic versus open colorectal resections in patients with symptomatic stage IV colorectal cancer

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.

Elective resection of rectal cancer primary tumor in patients with stage IV disease--own experiences

Optimal management of asymptomatic generalized rectal cancer is still the matter of debate. The aim of the study was to review stage IV rectal cancer patients who were treated in our clinic since 2000 till 2008 in order to evaluate the effectiveness of surgery.

MATERIAL AND METHODS

Fifty-two generalized rectal cancer patients treated with elective resection of primary tumor were identified. Patients' age, sex, duration of hospital stay, modality of surgery, complications, postoperative mortality rate and survival rate were assessed.

RESULTS

Median survival was 16.3 months. Postoperative complications occurred in 29% patients. Postoperative mortality rate was 1.9%.

CONCLUSIONS

In properly selected group of patients elective resection of primary tumor may cause low mortality rate and acceptable morbidity rate. This surgical modality allows to avoid potential complications of tumor local growth.

Colorectal cancer with multiple metastases: is palliative surgery needed?

In patients with symptomatic incurable metastatic colorectal cancer (mCRC), the goal of resection of the primary lesion is to palliate cancer-related morbidity, including obstruction, bleeding, or perforation. In patients with asymptomatic primary tumors and incurable metastatic disease, however, the necessity of primary tumor resection is less clear. Although several retrospective analyses suggest survival benefit in patients who undergo resection of the primary tumor, applying this older evidence to modern patients is out of date for several reasons. Modern chemotherapy regimens incorporating the novel cytotoxic agents oxaliplatin and irinotecan, as well as the target agents bevacizumab and cetuximab, have improved median survival from less than 1 year with the only available single-agent 5-fluorouracil until the mid-1990s to over 2 years. In addition to significant prolongation of overall survival, combinations of novel chemotherapeutic and target agents have allowed improved local and distant tumor control, decreasing the likelihood of local tumor-related complications requiring surgical resection. Resection of an asymptomatic primary tumor risks surgical complications and may postpone the administration of chemotherapy that may offer both systemic and local control. In conclusion, the morbidity and the mortality of unnecessary surgery or surgery that does not improve quality of life or survival in patients with mCRC of a limited life expectancy should be carefully evaluated. With the availability of effective combinations of chemotherapy and target agents, systemic therapy for the treatment of life-threatening metastases would be a preferable treatment strategy for unresectable asymptomatic patients with mCRC.

Isolated splenic metastasis from rectal carcinoma: a rare occurrence

The presence of isolated splenic metastasis in rectal carcinoma is uncommon and usually presents as an asymptomatic mass, noted incidentally on imaging. Splenectomy is usually performed with the goal of curing metastatic disease. It is unclear if adjuvant chemotherapy affords any benefit, and the prognosis is unknown. The case of a young woman is reported, in whom an isolated metastatic lesion in the spleen was discovered 9 months after adjuvant chemotherapy for stage III rectal adenocarcinoma. The patient has remained disease-free for nearly 5 years following splenectomy and chemotherapy. To our knowledge, this is the fourth reported case in the English literature of an isolated splenic metastatic lesion from rectal cancer. We discuss the unique presentation, the importance of post-treatment surveillance, and the implementation of multi-modality treatment strategies in this young patient.

Prognostic value of resection of primary tumor in patients with stage IV colorectal cancer: retrospective analysis of two randomized studies and a review of the literature

Background

In patients with metastatic colorectal cancer (mCRC) with an asymptomatic primary tumor, there is no consensus on the indication for resection of the primary tumor.

Methods

A retrospective analysis was performed on the outcome of stage IV colorectal cancer (CRC) patients with or without resection of the primary tumor treated in the phase III CAIRO and CAIRO2 studies. A review of the literature was performed.

Results

In the CAIRO and CAIRO2 studies, 258 and 289 patients had undergone a primary tumor resection and 141 and 159 patients had not, respectively. In the CAIRO study, a significantly better median overall survival and progression-free survival was observed for the resection compared to the nonresection group, with 16.7 vs. 11.4 months [P < 0.0001, hazard ratio (HR) 0.61], and 6.7 vs. 5.9 months (P = 0.004; HR 0.74), respectively. In the CAIRO2 study, median overall survival and progression-free survival were also significantly better for the resection compared to the nonresection group, with 20.7 vs. 13.4 months (P < 0.0001; HR 0.65) and 10.5 vs. 7.8 months (P = 0.014; HR 0.78), respectively. These differences remained significant in multivariate analyses. Our review identified 22 nonrandomized studies, most of which showed improved survival for mCRC patients who underwent resection of the primary tumor.

Conclusions

Our results as well as data from literature indicate that resection of the primary tumor is a prognostic factor for survival in stage IV CRC patients. The potential bias of these results warrants prospective studies on the value of resection of primary tumor in this setting; such studies are currently being planned.

Primary colectomy in patients with stage IV colon cancer and unresectable distant metastases improves overall survival: results of a multicentric study

BACKGROUND

Whether patients with stage IV colon cancer and unresectable distant metastases should be managed by primary colectomy followed by chemotherapy or immediate chemotherapy without resection of the primary tumor is still controversial.

OBJECTIVE

This study aimed to evaluate predictive factors associated with survival in patients with stage IV colon cancer and unresectable distant metastases.

DESIGN

This large retrospective multicentric study included 6 academic hospitals.

SETTINGS

This study was conducted at 6 Paris University Hospitals (Assistance Publique-Hôpitaux de Paris; Saint Antoine, Henri Mondor, Ambroise Paré, Hôpital Europeen Gorges Pompidou, Bichat, and Avicenne).

PATIENTS

Between 1998 and 2007, 208 patients with good performance status and stage IV colon cancer with unresectable distant metastases received chemotherapy, either as initial management or after primary tumor resection.

MAIN OUTCOME MEASURES

Survival was estimated by use of the Kaplan-Meier method. Factors associated with survival were tested by means of a log-rank test. Results were expressed as median values with 95% confidence intervals. Factors independently related to survival were tested using a Cox regression model adjusted for a propensity score.

RESULTS

Of the 208 patients, 85 underwent colectomy before chemotherapy, whereas 123 were treated with use of primary chemotherapy with or without biotherapy. At univariate analysis, the following factors were significantly associated with survival: primary colectomy (P = .031), secondary curative surgery (P < .001), well-differentiated primary tumor (P < .001), exclusive liver metastases (P < .027), absence of need for colonic stent (P = .009), and addition of antiangiogenic (P = .001) or anti-epidermal growth factor receptor (P = .013) drugs to chemotherapy. After Cox multivariate analysis and after adjusting for the propensity score, all of these factors, with the exception of two, colonic stent and anti-epidermal growth factor receptor drug, were found to be independently associated with overall survival.

LIMITATION

This study was limited by its retrospective nature.

CONCLUSIONS

In a selected population of patients with colon cancer and unresectable synchronous distant metastases, immediate colectomy followed by chemotherapy in association with targeted therapy was associated with longer overall survival. This strategy appears to be the most appropriate, especially for those with good performance status, well-differentiated tumors, and synchronous liver metastases only.

Elective palliative resection of incurable stage IV colorectal cancer: who really benefits from it?

PURPOSE

Despite the encouraging results of chemotherapy in patients affected by incurable colorectal cancer (CRC), surgical resection of a primitive tumor is still a common approach worldwide. The identification of prognostic factors related to short survival (<6 months) may allow excluding from resective surgery those who may not benefit from it.

METHODS

A retrospective analysis was performed of 15 variables in a population of 71 patients undergoing nonemergency palliative primary resections of incurable CRC, including patients' demographics and clinical/histopathological characteristics of the tumor.

RESULTS

No variables were related to perioperative mortality (8.5% overall). A multivariate analysis revealed that older age (≥80 years) and metastasis to more than 25% of the lymph nodes were associated with survival (4 and 6 months, respectively). Mucoid adenocarcinoma therefore tends to be associated with the prognosis (P = 0.070).

CONCLUSIONS

An elderly age tends to be a contraindication to an elective primary tumor resection in patients affected by incurable CRC. Massive lymph node involvement and mucoid adenocarcinoma should also be considered before planning major colonic surgery.

Prognostic factors in survival of colorectal cancer patients with synchronous liver metastasis

AIM

To determine the factors affecting the survival in colorectal cancer patients with synchronous liver metastases.

METHOD

A total of 168 patients who had been treated colorectal cancer with synchronous liver metastases at Guangxi Medical University from January 2000 to December 2005 were identified. Criteria studied consisted of gender, age, time of symptoms, primary tumour location, primary tumour circumference, histological type, grade (tumour differentiation), T-status, N-status, large bowel obstruction, type of operation, primary tumour resection, ascities, location, number and diameter of liver lesions, preoperative CEA and chemotherapy. Survival curves were plotted using the Kaplan-Meier method. Multivariate analysis was conducted by Cox regression analysis.

RESULTS

The mean survival time for all patients was 18.71 (SEM = 1.59) months. The 1, 2, 3 and 5-year survival rates were 55.95%, 23.21%, 12.30%, 8.0% respectively. Univariate analysis share of grade (tumour differentiation), N-status, large bowel obstruction, operation, primary tumour resection, location, number and the most diameter of liver lesions, extrahepatic transfer, preoperative CEA level and chemotherapy to be predictors of survival. In the Cox regression analysis, the N-status, large bowel obstruction, operation, diameter of liver lesion and extrahepatic transfer were independent factors related to survival.

CONCLUSION

Tumour differentiation, N-status, bowel obstruction, operation, primary tumour resection, location of liver metastasis, number of liver metastasis, diameter of liver metastasis, extrahepatic transfer, preoperative CEA level and chemotherapy are related to the survival of patients with colorectal cancer and synchronous liver metastases.

Impact of resection for primary colorectal cancer on outcomes in patients with synchronous colorectal liver metastases

PURPOSE

This study was designed to evaluate the impact of resection for primary colorectal cancer on oncologic outcomes in patients with synchronous colorectal liver metastases.

METHODS

A retrospective analysis was performed on 91 consecutive patients with synchronous colorectal liver metastases who underwent resection of the primary colorectal cancer between December 1999 and December 2007. Of the 91 patients, 54 (59.3%) also underwent complete (R0) resection for liver metastases, and 84 (92.3%) received postoperative chemotherapy. The oncologic outcomes and prognostic factors were analyzed.

RESULTS

Operative mortality was 1.1%, and morbidity was 37.4%. The 3- and 5-year overall survival rates were 44.5% and 26.8%, respectively. A multivariate analysis revealed that residual disease after surgery (non-R0 resection; p = 0.003), lymph node metastasis of the primary tumor (p = 0.015), and no postoperative chemotherapy (p = 0.001) were independent prognostic factors for poor survival. Independent predictors of an inability to achieve a complete resection were the presence of three or more liver metastases and the presence of extrahepatic disease at exploration. Significant differences in survival existed among the three risk stratification groups (no-, low-, and high-risk groups; p < 0.001).

CONCLUSIONS

The inability to safely render the liver and colon microscopically free of disease should cause a surgeon to reconsider synchronous colectomy and hepatectomy. A multidisciplinary approach that combines both complete resection of synchronous colorectal liver metastases and postoperative chemotherapy may achieve improved survival in patients with synchronous colorectal liver metastases.

Intestinal complications after palliative treatment for asymptomatic patients with unresectable stage IV colorectal cancer

BACKGROUND

The initial surgical management of asymptomatic patients with unresectable stage IV colorectal cancer (CRC) is still controversy. The aim of this study was to compare the incidence of major intestinal complications in asymptomatic patients who received palliative treatment for unresectable stage IV CRC, according to the type of treatment.

METHODS

Between March 2001 and January 2008, we retrospectively analyzed 227 asymptomatic patients who underwent first-line resection of the primary tumor followed by chemotherapy (144 patients, resection group) or those who underwent first-line chemotherapy (83 patients, chemotherapy group).

RESULTS

In the resection group, the incidences of intestinal obstruction, peritonitis, fistula, and intestinal hemorrhage were 14.6%, 0%, 0.7%, and 4.8%, respectively. In the chemotherapy group, these incidences were 15.2%, 1.2%, 0%, and 3.5%, respectively. There were no significant differences between the two groups in terms of intestinal complications. In multivariate analysis of overall survival, treatment type (resection group vs. chemotherapy group) was not a significant prognostic factor (P = 0.076).

CONCLUSIONS

In asymptomatic patients with unresectable stage IV CRC, first-line chemotherapy may be considered safe, with no increased risk of major intestinal complications compared with primary tumor resection plus chemotherapy.

Metastasectomy for stage IV colorectal cancer

Metastatic colorectal cancer traditionally has been considered incurable. Over the past 3 decades, however, resection of low-volume hepatic disease has been recognized as beneficial in some cases. More recently, resection of isolated pulmonary metastases has been shown to offer long-term survival in carefully selected patients. Resection of metastases to more unusual sites (ovary, brain, peritoneal cavity) is more controversial; nevertheless, retrospective data suggest that a few patients may be cured with resection of these tumors. In this article, we review the history and current status of metastasectomy in stage IV colorectal cancer.

Impact of palliative chemotherapy and surgery on management of stage IV incurable colorectal cancer

BACKGROUND

Recent trials proposed chemotherapy (CHT) as the treatment of choice for patients affected by incurable colorectal cancer (ICRC). Nevertheless, surgery is still commonly offered to these patients. On the other hand, CHT is offered to ICRC patients regardless of the pattern of spread of the disease, local or distant, despite some evidence suggesting that metastatic pattern may influence the response to treatment.

METHODS

A retrospective analysis was performed of 133 patients undergoing palliative treatment for ICRC from 1994 through 2007. Palliation consisted of surgery alone until 2002 and surgery with CHT (FOLFOX-FOLFIRI) thereafter. The impact of CHT and surgery was evaluated in the whole series as well as with respect to metastatic pattern (locally aggressive primary tumor and distant metastasis only), tumor site, and grading.

RESULTS

Chemotherapy prolonged survival by 9 months (p = 0.001). In patients undergoing CHT, resective surgery did not prolong survival (p = 0.931), whereas in patients not undergoing CHT, it improved prognosis by 5 months (p = 0.023). Considering patients with distant metastasis only, CHT significantly prolonged survival (p < 0.001), whereas it did not improve the prognosis of patients with a locally aggressive primary tumor (p = 0.943). No difference in CHT effectiveness with respect to tumor site and grading was recorded.

CONCLUSIONS

CHT should be the preferred option in patients undergoing elective treatment for ICRC, whereas surgery should be considered whenever CHT is not administered. CHT significantly increases survival of patients with unresectable distant metastasis only, whereas it seems to be useless in patients with locally aggressive primary tumors.

Stent or surgery for incurable obstructive colorectal cancer: an individualized decision

INTRODUCTION

In the setting of stage-IV obstructive colorectal cancer, self-expanding metallic stents (SEMS) placement and palliative surgery may be appropriate options. The aim of the present study is to evaluate the long-term results of surgery compared with stent implantation and to identify patients in whom one of these options can provide more benefit.

MATERIALS AND METHODS

From November 2000 to November 2008, 98 patients with incurable stage-IV colorectal cancer were treated with palliative surgery (n=53) or SEMS (n=45). Data were recorded with respect to age, gender, tumor location, carcinoembryogenic antigen, ASAclass, presence of metastatic disease in one or multiple organs, volume of liver metastases, urgency of the procedure and treatment with chemotherapy. Comparison between surgery and stent placement was performed for all group and for patients who received and did not receive chemotherapy.

RESULTS

Both groups were comparable regarding age, ASA-class, chemotherapy treatment, tumor location and presence of metastatic disease in one or multiple organs but not in gender, rate of urgent procedures, abnormal CEA and of volume of liver metastases >25%. Survival in surgical group was significantly higher (11.9 vs 7.3 months; log-rank test, p = 0.002). SEMS group had lower early morbidity, hospital stay and stoma creation. For patients who received chemotherapy, surgery provided benefit in survival (6.8 vs 3.9 months; log-rank test, p = 0.101); in this subgroup, long-term complications from the primary tumour were more common in stented group, and time to chemotherapy was longer in the group of surgery. No differences in survival were shown in patients who did not receive chemotherapy.

CONCLUSION

Stent placement offers advantages regarding early morbidity, hospital stay and stoma creation. Surgery offers a benefit in survival in patients who receive chemotherapy but not in non-candidates to chemotherapy.

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.

Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer

PURPOSE

The benefit of elective primary tumor resection for non-curable stage IV colorectal cancer (CRC) remains largely undefined. We wanted to identify risk factors for postoperative complications and short survival.

METHODS

Using a prospective database, we analyzed potential risk factors in 233 patients, who were electively operated for non-curable stage IV CRC between 1996 and 2002. Patients with recurrent tumors, resectable metastases, emergency operations, and non-resective surgery were excluded. Risk factors for increased postoperative morbidity and limited postoperative survival were identified by multivariate analyses.

RESULTS

Patients with colon cancer (CC = 156) and rectal cancer (RC = 77) were comparable with regard to age, sex, comorbidity, American Society of Anesthesiologists score, carcinoembryonic antigen levels, hepatic spread, tumor grade, resection margins, 30-day mortality (CC 5.1%, RC 3.9%) and postoperative chemotherapy. pT4 tumors, carcinomatosis, and non-anatomical resections were more common in colon cancer patients, whereas enterostomies (CC 1.3%, RC 67.5%, p < 0.0001), anastomotic leaks (CC 7.7%, RC 24.2%, p = 0.002), and total surgical complications (CC 19.9%, RC 40.3%, p = 0.001) were more frequent after rectal surgery. Independent determinants of an increased postoperative morbidity were primary rectal cancer, hepatic tumor load >50%, and comorbidity >1 organ. Prognostic factors for limited postoperative survival were hepatic tumor load >50%, pT4 tumors, lymphatic spread, R1-2 resection, and lack of chemotherapy.

CONCLUSIONS

Palliative resection is associated with a particularly unfavorable outcome in rectal cancer patients presenting with a locally advanced tumor (pT4, expected R2 resection) or an extensive comorbidity, and in all CRC patients who show a hepatic tumor load >50%. For such patients, surgery might be contraindicated unless the tumor is immediately life-threatening.

Colonoscopic findings and tumor site do not predict bowel obstruction during medical treatment of stage IV colorectal cancer

BACKGROUND

In the absence of symptoms related to their primary tumor, patients with stage IV colorectal cancer can undergo medical treatment with their primary tumor in situ. In these patients, bowel obstruction is the most common primary tumor-related complication. We hypothesized that left-sided, circumferential, near-obstructing lesions and/or inability to advance the colonoscope beyond the primary tumor are associated with symptomatic bowel obstruction and are indications for prophylactic primary tumor resection (PTR) or colonic diversion.

PATIENTS AND METHODS

The medical oncology database of the University of Wisconsin Hospital was retrospectively reviewed. Inclusion criteria were presentation with stage IV colorectal cancer without previous treatment. Student's t-test and Fisher's exact test were used to compare continuous and noncontinuous variables, respectively.

RESULTS

Forty-nine patients met the inclusion criteria. None underwent colonic diversion or stenting during the course of their disease. At presentation, nine patients underwent PTR for obstructive symptoms. Forty percent of patients with high-risk colonoscopic lesions required PTR at presentation, compared with 3% of patients without high-risk findings. No patients with high-risk colonoscopic findings and/or left-sided lesions who did not undergo PTR at presentation developed symptoms of obstruction during medical therapy.

CONCLUSION

In stage IV colorectal cancer, circumferential, near-obstructing lesions and inability to advance the colonoscope beyond the primary tumor are common colonoscopic findings and are associated with obstructive symptoms at the time of diagnosis. Left-sided lesions and/or high-risk colonoscopic findings do not predict bowel obstruction during medical treatment and should not be indications for prophylactic PTR or colonic diversion in asymptomatic patients.

Prognosis analysis and treatment strategy for patients with Dukes D stage rectal cancer

AIM: To evaluate the metastasis distribution, prognosis and treatment strategy for patients with Dukes D stage rectal cancer.

METHODS: Clinical data, type distribution and prognosis of 301 cases with Dukes D stage rectal cancer who underwent surgery from May 1991 to August 2003 were retrospectively analyzed using Log-rank and Kapla-Meier test.

RESULTS: The patients with Dukes D stage were associated with a mean OS (overall survival) of 32.50 ± 3.22 months, and OS rate were 64.61% (1 year), 26.40% (3 years) and 15.15% (5 years), respectively. The prognosis was related to factors such as gross type, tumor differentiation, T stage and surgery type. 32.56% patients underwent side-side anastomosis and no primary-cancer-directed surgery, and 67.44% patients underwent primary-cancer-directed surgery. Patients had significantly benefited from palliative resection in terms of overall survival (P = 0.0158). The patients with Dukes D stage were 10.29% with peritoneal carcinomatosis, 32.55% with local infiltration, 40.53% with distant metastasis, and 16.61% with complex metastasis. The prognosis among metastasis type was not significantly different (P = 0.4122). Patients with synchronous liver metastases accounted for 51.4% of all cases, and 84.23% for distant metastasis, which had a mean OS of 32.50 ± 3.22 months and had relatively longer life expectancy.

CONCLUSION: Patients of Dukes D stage rectal cancer show no significant difference regardless of metastasis type, and primary-cancer-directed surgery should be actively performed and the postoperative OS rate and quality of life can be improved.

A study of lymph node ratio in stage IV colorectal cancer

BACKGROUND

The finding of metastasis in colorectal cancer, stage IV disease, has a major impact on prognosis and treatment strategy. Known important factors include the extent of the metastasis and the patients' performance status. The lymph node factors are of known importance in earlier cancer stages but less described in metastatic disease. The aim of the study was to evaluate lymph node status and ratio as prognostic markers in stage IV colorectal cancer.

METHODS

The study was retrospective and assessing all patients operated, with bowel resection, for an initial stage IV colorectal cancer during 1999-2003 (n = 136). Basic demographic data as well as given treatment was assessed. The Lymph node ratio (LNR), the quota between the number of lymph node metastasis and assessed lymph nodes, was calculated. LNR groups were created by ratio thirds, 3 equally sized groups. The analysis was made by LNR group and by eligibility for chemotherapy with cancer specific survival as outcome parameter.

RESULTS

The median survival (CSS) for the entire group was 431 days with great variability. For the patients eligible for chemotherapy it ranged from 791 days in LNR-group 1 to 433 days for the patients in group 3. For patients ineligible for chemotherapy the corresponding figures were 209 and 91 days. The eligibility for chemotherapy was a major prognostic factor which also takes co-morbidity, age and performance status into consideration. The LNR (p < 0.01) and the tumour differentiation grade were also significant (p < 0.05) factors regarding survival. The LNR group 3 was also associated with a higher frequency of multiple metastasis locations (p < 0.05) and of more side effects with chemotherapy and thus of reductions in dosage or pre-emptive treatment ending (p < 0.05).

CONCLUSION

Stage IV colorectal cancer is a heterogeneous group regarding the survival prognosis. The lymph node ratio was found to be a significant marker for the survival prognosis (p < 0.0049). High and low risk groups could be identified with a survival difference of up to one year. It could be of importance when planning a treatment strategy or evaluating clinical data materials. A pathology report should include a node assessment even at presence of synchronous metastasis.

Management of patients with asymptomatic colorectal cancer and synchronous irresectable metastases

BACKGROUND

In patients with asymptomatic colorectal cancer with irresectable metastatic disease, the optimal treatment strategy remains controversial. Resection of the primary tumor followed by chemotherapy when possible versus systemic chemotherapy followed by resection of the primary tumor when necessary are compared in this systematic review.

PATIENTS AND METHODS

Seven studies reported series of patients with asymptomatic stage IV colorectal cancer and compared first-line chemotherapy with surgery for the primary tumor (n = 850 patients). Primary outcome measure was the complication rate related to the primary tumor in situ in patients receiving first-line systemic chemotherapy.

RESULTS

When leaving the primary tumor in situ, the mean complications were intestinal obstruction in 13.9% [95% confidence interval (CI) 9.6% to 18.8%] and hemorrhage in only 3.0% (95% CI 0.95% to 6.0%) of the patients. After resection, the overall postoperative morbidity ranged from 18.8% to 47.0%.

CONCLUSIONS

For patients with stage IV colorectal cancer, resection of the asymptomatic primary tumor provides only minimal palliative benefit, can give rise to major morbidity and mortality and therefore potentially delays beneficial systemic chemotherapy. When presenting with asymptomatic disease, initial chemotherapy should be started and resection of the primary tumor should be reserved for the small portion of patients who develop major complications from the primary tumor.

Multivariate analysis of predictive factors for early postoperative death after colorectal surgery in patients with colorectal cancer and synchronous unresectable liver metastases

PURPOSE

Surgery of the primary tumor in patients with colorectal cancer and unresectable synchronous liver metastases remains controversial. This study was designed to evaluate predictive preoperative factors of early postoperative death (<3 months) in such patients.

METHODS

This study included 80 patients who underwent colorectal resection (n = 56) or diversion stoma (n = 24) for colorectal cancer with unresectable liver metastases. Twenty-two patients (28 percent) died during the first three months after surgery with two (2.5 percent) in-hospital postoperative deaths. Analysis of predictive preoperative factors for three-month postoperative death risk was performed.

RESULTS

In univariate analysis, age older than 75 years (P = 0.01), American Society of Anesthesiologists grade > II (P = 0.009), symptomatic patient (P = 0.01), bowel obstruction (P = 0.03), aspartate aminotransferase serum level >50 (1.5 N) IU/L (P = 0.008), and alkaline phosphatase >200 (2 N) IU/L (P = 0.02) were prognostic risk factors for three-month death after surgery. In multivariate analysis, age older than 75 years (relative risk = 7.9; P = 0.04) and aspartate aminotransferase serum level >50 IU/L (relative risk = 8.3; P = 0.03) were independent risk factors.

CONCLUSIONS

In patients with colorectal cancer and synchronous unresectable liver metastases, the three-month mortality rate was high (28 percent). Thus, better knowledge of risk factors could help select patients who could possibly benefit from surgery. The study suggested that age older than 75 years and liver cytolysis (>1.5 N) are associated with an increased three-month postoperative death risk. In these patients, surgery should be avoided.

Prognostic Value of Pre-operative Assesment of Serum Carcino-embryonic Antigen and Carbohydrate Antigen 19-9 Levels in Colorectal Carcinoma

Colorectal cancer (CRC) is one of the most frequent and aggressive neoplasms. It is the second leading cause of death from cancer in the United States and is a significant overall health problem. Tumor markers are substances synthesized and excreted by tumor tissues that can be detected in abnormal concentrations in serum, urine, and other body fluids. Two such markers, Carcinoembryonic antigen (CEA) and Carbohydrate antigen 19-9 (CA 19-9), are useful in the diagnosis, prognosis and management of colorectal carcinoma. This study attempted to evaluate the clinical and prognostic value of the two markers using forty patients with CRC and ten healthy persons as a control group. All patients with CRC showed highly significant increases in CEA and CA-19-9 compared to the control group (p <  0.001), and there was a highly significant increase in the level of CEA in more advanced tumor stages, (p <  0.01). Regression analysis showed a significant correlation between CEA and CA-19-9 (p <  0.05; r = 0.35) and significant increases in CEA in rectal tumors compared to those located in the colon; in males compared to females (p <  0.05); and also a highly significant increase in patients over 60 years of age (p < 0.01) but no relation between CA 19-9 level and age, sex, and site of tumor. These data suggest that serum levels of CEA and CA-19-9 can be clinically useful in the diagnosis and staging of colorectal carcinoma.

The role of primary tumour resection in patients with stage IV colorectal cancer

OBJECTIVE

The management of stage IV colorectal cancer is controversial. Resection of the primary tumour to prevent obstruction, bleeding or perforation is the traditional approach, although survival benefit is undetermined. Management consisting of diverting ostomy, enteric bypass, laser recanalization or endoscopic stenting is an alternative to radical resection. The purpose of this study was to determine the role of resection of the primary tumour in patients with stage IV colorectal cancer, with specific attention paid to survival benefit and safety.

METHOD

This was a retrospective review of all stage IV colon and rectal cancer patients in our tumour registry between 1991 and 2002. Data collected included patient demographics, presenting symptoms, detail from the hospital course including diagnostic data and operative management, complications and survival time (days). Survival analysis was performed to assess the effect of primary tumour resection on long-term survival.

RESULTS

109 patients were studied. Sixty-two (57%) patients (group I) underwent resection of the primary tumour, whereas 47 (43%) patients (group II) were managed without resection. Median survival times for groups I and II were 375 (IQR: 179-759) and 138 (IQR: 35-262) days respectively (P < 0.0001). After controlling for age, sex, tumour location and level of liver involvement as well as liver function, patients who underwent resection still survived longer (HR = 0.34, 95% CI: 0.21-0.55).

CONCLUSION

Palliative resection of the primary tumour plays an essential role in the management of stage IV colorectal cancer. Resection can offer increased survival and is indicated in certain patients with incurable disease. Limited metastatic tumour burden of the liver was associated with better survival in such patients.

Palliative resection of colorectal cancer: does it prolong survival?

BACKGROUND

It is still a matter of debate as to whether resective surgery of the primary tumor may prolong the survival of patients affected by incurable colorectal cancer (CRC). The main goal of this retrospective study, carried out on patients not undergoing any therapy other than surgery, was to quantify the benefit of primary tumor removal in patients with differently presenting incurable CRC.

METHODS

One hundred and thirty consecutive patients were operated on for incurable CRC (83 undergoing resective and 47 non-resective procedures). With the purpose of comparing homogenous populations and of identifying patients who may benefit from primary tumor resection, the patients were classified according to classes of disease, based on the "metastatic pattern" and the "resectability of primary tumor."

RESULTS

In patients with "resectable" primary tumors, resective procedures are associated with longer median survival than after non-resective ones (9 months vs 3). Only patients with distant spread without neoplastic ascites/carcinosis benefit from primary tumor removal (median survival: 9 months vs 3). Morbidity and mortality of resective procedures is not significantly different from that of non-resective surgery, either in the population studied or in any of the groups considered.

CONCLUSIONS

Palliative resection of primary CRC should be pursued in patients with unresectable distant metastasis (without carcinomatosis), and, intraoperatively, whenever the primary tumor is technically resectable.

Metal stent placement in acute malignant colorectal obstruction

BACKGROUND

Obstruction is a common complication of advanced colorectal cancer. Stent insertion can reduce the need for emergency surgery and allows chemotherapy to begin immediately.

AIMS

To evaluate the technical and clinical success and long-term outcome of stent placement in the management of acute malignant colorectal obstruction.

METHODS

From July 2002 to April 2005, 29 self-expanding metal stents were placed in 24 patients (13 men, mean age 67 years, range 36-83). Stents were inserted under endoscopic and fluoroscopic control. Patients were clinically and endoscopically followed up.

RESULTS

Twenty-eight out of 29 stents were successfully placed (96.5%) in 23 out of 24 patients with 25 strictures. The clinical success rate was 95.8% (23/24). Two early stent migrations were observed in two patients (8.3%). Late complications developed in eight patients (33.3%) after a median of 3.8 months (range <1-8.6): two migrations and six occlusions. The median survival was 9.8 months (range <1-27). Eleven patients (45.8%) died from progressive disease without any clinical evidence of recurrent obstruction.

CONCLUSION

Stent placement is safe and effective. Stent complications are frequent but not life-threatening, and are easy to manage. An improvement in stent design and well-scheduled follow-up are needed in order to prevent such complications.

Treatment strategy for patients with colorectal cancer and synchronous irresectable liver metastases

BACKGROUND

The aim of this case-matched study was to determine the best treatment strategy for patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases.

METHODS

Between 1997 and 2002, 27 patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases were treated by chemotherapy without initial primary resection (chemotherapy group). These 27 patients were compared with 32 patients matched for age, sex, performance status, primary tumour location, number of liver metastases, nature of irresectable disease and type of chemotherapy, but who were treated initially by resection of primary tumour (resection group).

RESULTS

The 2-year actuarial survival rate was 41 per cent in the chemotherapy group and 44 per cent in the resection group (P = 0.753). In the latter group, the mortality and morbidity rates for primary resection were 0 and 19 per cent (six of 32 patients) respectively. In the chemotherapy group, intestinal obstruction related to the primary tumour occurred in four of 27 patients. The mean overall hospital stay was 11 days in the chemotherapy group and 22 days in the resection group (P = 0.003).

CONCLUSION

Systemic chemotherapy without resection of the bowel cancer is the option of choice because, for most patients, it is associated with a shorter hospital stay and avoids surgery without a detrimental effect on survival.

Evaluation of a pre-operative staging protocol in the management of colorectal carcinoma

OBJECTIVE

The optimum strategy for pre-operative staging of colorectal carcinoma (CRC) has yet to be defined. A protocol for staging CRC patients was set up in this hospital in 1998. The protocol included complete colonic visualization together with assessment of the liver and lung for potential metastatic disease. Pelvic imaging was required to assess the local spread of rectal tumours. Our aim was to evaluate prospectively this protocol.

PATIENTS AND METHODS

Data from all patients diagnosed with primary CRC between January 1999 and December 2002 were prospectively collected and analysed.

RESULTS

There were 295 patients; 56 (19%) patients presented as an emergency and were excluded. The study group consisted of 239 patients (206 had elective surgery and 33 had no resectional surgery). In the patients who presented electively; 88% had complete colonic imaging; 87% chest imaging; 90% had liver imaging; 91% of rectal tumours had pelvic imaging. Overall 75% of the elective patients completed the staging protocol. Reasons for incomplete staging were numerous and most were justifiable. Findings which influenced clinical management included alteration in surgical approach (14), lung metastases (7), primary lung cancers (2), definite liver metastases (25), possible liver metastases (8), neo-adjuvant radiotherapy required (27), advanced local disease (9) and other incidental findings (12).

CONCLUSION

Our protocol influenced further management decisions in 39% of patients. Better stratification of patient care is possible, with the ultimate aim to avoid unnecessary surgery. However, complete staging is not always possible to perform.