Stage IV Rectal Cancer with Liver Metastases: Is There a Benefit to Resection of the Primary Tumor?

Predicting the surgical benefit of primary tumor resection in patients with stage IV colorectal cancer

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.

Multimodal treatment of rectal cancer with resectable synchronous liver metastases: A systematic review

BACKGROUND

Specific studies on stage IV rectal cancer are lacking. The aim of this study is to describe the current status of rectum-first approach (RFA), liver-first approach (LFA) and simultaneous approach (SA) in these patients.

METHODS

A systematic review was performed on PubMed, EMBASE and Cochrane including studies published from January 2005 to January 2021. Studies on colon cancer only, colon and rectal cancer without distinction, extrahepatic metastases at diagnosis, or case reports/letters were excluded. Main outcomes were 5-yr overall survival (OS) and treatment completion rates.

RESULTS

22 studies were included for a total of 1,653 patients. 77% of the studies were retrospective and mainly (59%) reported one treatment approach. The primary endpoint was declared in 27% of the studies. Irrespective of treatment approaches, the 5-yr OS rate was reported in 72% of the studies. The 5-yr OS rates ranged from 38.5% to 75% for LFA, from 28% and 80% for RFA and from 28.2% to 77.3% for SA. Treatment completion rates ranged from 50% to 100% for LFA, from 37% to 100% for RFA, and from 66% to 100% for SA.

CONCLUSION

The wide heterogeneity of the results reflects that the therapeutic strategy in this setting is a case-by-case multidisciplinary decision and depends on several patient-specific features.

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]

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.

The effect of primary tumor radiotherapy in patients with Unresectable stage IV Rectal or Rectosigmoid Cancer: a propensity score matching analysis for survival

BACKGROUND

To evaluate the impact of primary tumor radiotherapy on survival in patients with unresectable metastatic rectal or rectosigmoid cancer.

METHODS

From September 2008 to September 2017, 350 patients with unresectable metastatic rectal or rectosigmoid cancer were retrospectively reviewed in our center. All patients received at least 4 cycles of chemotherapy and were divided into two groups according to whether they received primary tumor radiotherapy. A total of 163 patients received primary tumor radiotherapy, and the median radiation dose was 56.69 Gy (50.4-60). Survival curves were estimated with the Kaplan-Meier method to roughly compare survival between the two groups. Subsequently, the 18-month survival rate was used as the outcome variable for this study. This study mainly evaluated the impact of primary tumor radiotherapy on the survival of these patients through a series of multivariate Cox regression analyses after propensity score matching (PSM).

RESULTS

The median follow-up time was 21 months. All 350 patients received a median of 7 cycles of chemotherapy (range 4-12), and 163 (46.67%) patients received primary tumor radiotherapy for local symptoms. The Kaplan-Meier survival curves showed that the primary tumor radiotherapy group had a significant overall survival (OS) advantage compared to the group without radiotherapy (20.07 vs 17.33 months; P = 0.002). In this study, the multivariate Cox regression analysis after adjusting for covariates, multivariate Cox regression analysis after PSM, inverse probability of treatment weighting (IPTW) analysis and propensity score (PS)-adjusted model analysis consistently showed that primary tumor radiotherapy could effectively reduce the risk of death for these patients at 18 months (HR: 0.62, 95% CI 0.40-0.98; HR: 0.79, 95% CI: 0.93-1.45; HR: 0.70, 95% CI 0.55-0.99 and HR: 0.74, 95% CI: 0.59-0.94).

CONCLUSION

Compared with patients with stage IV rectal or rectosigmoid cancer who did not receive primary tumor radiotherapy, those who received primary tumor radiotherapy had a lower risk of death. The prescription dose (59.4 Gy/33 fractions or 60 Gy/30 fractions) of radiation for primary tumors might be considered not only to relieve symptoms improve the survival of patients with inoperable metastatic rectal or rectosigmoid cancer.

Surgery on primary tumor shows survival benefit in selected stage IV colon cancer patients: A real-world study based on SEER database

Objectives: Most patients with stage IV colon cancer did not have the opportunity for curative surgery, only selected patients could benefit from surgery. This study aimed to determine whether surgery on the primary tumor (SPT) should be performed in patients with stage IV colon cancer and how to select patients for SPT.

Methods: This study included 48,933 patients with stage IV colon cancer who were identified in the Surveillance, Epidemiology and End Results (SEER) database between 1998 and 2015. Propensity score matching (PSM) analysis was adopted to balance baseline differences between SPT and non-surgery groups. Kaplan-Meier (K-M) curves were utilized to compare the overall survival (OS). Prognostic nomograms were generated to predict survival based on pre- and post-operative risk factors. Patients were divided into low, middle, and high mortality risk subsets for OS by X-tile analyses based on scores derived from above nomograms.

Results: Patients with SPT had a significantly longer OS than those without surgery, regardless of the metastatic sites and diagnostic years. Nomograms, according to the pre- and post-operative risk factors, showed moderate discrimination (all C-indexes above 0.7). Based on X-tile analyses, low mortality risk subset (post-operative score ≤ 22.3, preoperative score ≤ 9.7) recommended for SPT, and high mortality risk was not.

Conclusions: SPT led to prolonged survival in stage IV colon cancer. Our nomograms would help to select suitable patients for SPT.

Meta-analysis of outcomes following resection of the primary tumour in patients presenting with metastatic colorectal cancer

BACKGROUND

It is not clear whether resection of the primary tumour (when there are metastases) alters survival and/or whether resection is associated with increased morbidity. This systematic review and meta-analysis assessed the prognostic value of primary tumour resection in patients presenting with metastatic colorectal cancer.

METHODS

A systematic review of MEDLINE/PubMed was performed on 12 March 2016, with no language or date restrictions, for studies comparing primary tumour resection versus conservative treatment without primary tumour resection for metastatic colorectal cancer. The quality of the studies was assessed using the MINORS and STROBE criteria. Differences in survival, morbidity and mortality between groups were estimated using random-effects meta-analysis.

RESULTS

Of 37 412 initially screened articles, 56 retrospective studies with 148 151 patients met the inclusion criteria. Primary tumour resection led to an improvement in overall survival of 7·76 (95 per cent c.i. 5·96 to 9·56) months (risk ratio (RR) for overall survival 0·50, 95 per cent c.i. 0·47 to 0·53), but did not significantly reduce the risk of obstruction (RR 0·50, 95 per cent c.i. 0·16 to 1·53) or bleeding (RR 1·19, 0·48 to 2·97). Neither was the morbidity risk altered (RR 1·14, 0·77 to 1·68). Heterogeneity between the studies was high, with a calculated I² of more than 50 per cent for most outcomes.

CONCLUSION

Primary tumour resection may provide a modest survival advantage in patients presenting with metastatic colorectal cancer.

The influence of local therapy on the survival of patients with metastatic rectal cancer: a population-based, propensity-matched study

PURPOSE

This study was aimed to determine the effect of the local tumor therapy on patients' prognosis in the management of metastatic rectal cancer.

METHODS

Patients diagnosed with metastatic rectal cancer from 2004 to 2013 were selected from the SEER (Surveillance, Epidemiology, and End Results) database. Overall survival and cancer-specific survival were compared between the local treatment group and the nonlocal treatment group using Kaplan-Meier methods. Uni- and multivariate analyses were further performed to confirm or deny the results. The statistical approach of propensity score matching was conducted to avoid potential confounding factors.

RESULTS

Of 6867 patients included in this analysis, 3971 (57.8%) received local therapy to the primary tumor and 2896 (42.2%) did not receive. Both univariable and multivariable analysis showed local therapy continued to be associated with an improvement in OS (HR 0.532; 95% CI 0.503-0.563, p < 0.001 and HR 0.532; 95% CI 0.498-0.568, p < 0.001, respectively) and CSS (HR 0.527; 95% CI 0.497-0.559, p < 0.001 and HR 0.521; 95% CI 0.487-0.557, p < 0.001, respectively) in the unmatched cohorts. Further analysis showed patients underwent local tumor destruction or surgical resection had a better overall survival compared with those who did not undergo (p < 0.001). In the matched population, patients receiving local therapy had a better OS (HR 0.427; 95% CI 0.428-0.519, p < 0.001) and CSS (HR 0.462; 95% CI 0.418-0.511, p < 0.001) compared with those who did not receive.

CONCLUSIONS

Local therapy to the primary tumor may be associated with a better survival in patients with metastatic rectal cancer.

[How to manage a rectal cancer with synchronous liver metastases? A question of strategy]

The prognosis of patients with rectal cancer and synchronous liver metastasis has improved thanks to chemotherapy and rectal and liver surgery progresses. However, there is no consensus about optimal management and practices remain heterogeneous. A curative treatment may be considered for 20 to 30% of patients with complete resection of metastasis and primary tumor after induction chemotherapy. To this end, a primary optimal evaluation by a multidisciplinary board including hepatic and colorectal surgeons is crucial. The therapeutic strategy associates chemotherapy, radiotherapy, hepatic and rectal surgery. The most threatening site guides the sequence of treatments. If hepatic resectability is uncertain, a "liver first" strategy associating induction chemotherapy and hepatic surgery is preferred. In non-resectable metastatic cases, chemotherapies with targeted therapies might lead to secondary resection for 30% of patients (conversion). This has changed our practice and triggers reconsidering resectability after chemotherapy. When metastases remain non-resectable, additional treatment focusing on primary tumor should control pelvic symptoms otherwise hardly impacting quality of life. Rectal surgery, short-course radiotherapy (5×5Gy), conformational long-course chemoradiotherapy or intensity-modulated radiation therapy with dose escalation are options discussed in this review.

Short-Course Radiotherapy Followed by Neoadjuvant Bevacizumab, Capecitabine, and Oxaliplatin and Subsequent Radical Treatment in Primary Stage IV Rectal Cancer: Long-Term Results of a Phase II Study

Background

In a Dutch phase II trial conducted between 2006 and 2010, short-course radiotherapy followed by systemic therapy with capecitabine, oxaliplatin, and bevacizumab as neoadjuvant treatment and subsequent radical surgical treatment of primary tumor and metastatic sites was evaluated. In this study, we report the long-term results after a minimum follow-up of 6 years.

Methods

Patients with histologically confirmed rectal adenocarcinoma with potentially resectable or ablatable metastases in liver or lungs were eligible. Follow-up data were collected for all patients enrolled in the trial. Overall and recurrence-free survival were calculated using the Kaplan–Meier method.

Results

Follow-up data were available for all 50 patients. After a median follow-up time of 8.1 years (range 6.0–9.8), 16 patients (32.0%) were still alive and 14 (28%) were disease-free. The median overall survival was 3.8 years (range 0.5–9.4). From the 36 patients who received radical treatment, two (5.6%) had a local recurrence and 29 (80.6%) had a distant recurrence.

Conclusions

Long-term survival can be achieved in patients with primary metastatic rectal cancer after neoadjuvant radio- and chemotherapy. Despite a high number of recurrences, 32% of patients were alive after a median follow-up time of 8.1 years.

The Impact of Preoperative Radiation Therapy on Locoregional Recurrence in Patients with Stage IV Rectal Cancer Treated with Definitive Surgical Resection and Contemporary Chemotherapy

PURPOSE

Definitive resection of primary rectal cancers is frequently incorporated, with or without preoperative radiotherapy and perioperative chemotherapy, in the management of selected patients with metastatic rectal adenocarcinoma. This study reviews the impact of preoperative radiotherapy and perioperative chemotherapy on locoregional recurrence and overall survival in these patients.

METHODS AND MATERIALS

This retrospective study with an Institutional Review Board (IRB) waiver included 109 patients with metastatic rectal adenocarcinoma who underwent definitive primary resection between 1998 and 2011. In addition to resection, 64 patients were treated with preoperative radiotherapy and perioperative chemotherapy and 45 patients were treated with perioperative chemotherapy alone. Radiotherapy dose was typically 50.4 Gy. Baseline variables were compared using chi-square and unpaired t tests. Overall survival was calculated using Kaplan-Meier method. Univariate and multivariate analyses were performed using Cox proportional hazards regression.

RESULTS

There were no significant baseline differences between the two groups. There was no significant difference in locoregional recurrence (10.9 vs. 11.1%; p = 0.90) or overall survival (34.5 vs. 34.8 months; p = 0.89) for patients treated with preoperative radiotherapy compared to those treated with perioperative chemotherapy alone, respectively. Patients who underwent radiotherapy were less likely to have a positive margin (10.9 vs. 20.0%; p = 0.19), lymphovascular invasion (32.8 vs. 53.3%; p = 0.03), and pathologic stage N2 disease (25.0 vs. 42.2%; p = 0.02). Grade 2 postoperative complications were more common in the preoperative radiotherapy group (32.8 vs. 15.6%; p = 0.04). Multivariate analysis demonstrated that patients with poorly differentiated tumors (HR 2.19; p = 0.009) and those that did not undergo liver-directed therapy (HR 2.20; p = 0.005) had inferior survival.

CONCLUSIONS

Locoregional recurrence is modest in patients with metastatic rectal adenocarcinoma receiving definitive primary resection, irrespective of the use of radiotherapy. Preoperative radiotherapy may enhance pathologic downstaging at the expense of increased grade 2 postoperative complications. Its use should be reserved for patients at high risk for locoregional recurrence.

Comparative effectiveness in colon and rectal cancer

Treatment of colorectal cancer is becoming more uniform, with wider acceptance of standardized guidelines. However, areas of controversy exist where the appropriate treatment is not clear, including: should a segmental colectomy or a more extensive resection be performed in hereditary nonpolyposis colorectal cancer? should an asymptomatic primary cancer be resected in the presence of unresectable metastatic disease? what is the role of extended lymph node resection in colon and rectal cancer? are there clinically significant benefits for a robotic approach to colorectal resection versus a laparoscopic approach? This chapter will examine these issues and discuss how they may be resolved.

Rectal outcomes after a liver-first treatment of patients with stage IV rectal cancer

BACKGROUND

The treatment of patients with metastatic rectal cancer remains controversial. We developed a reverse strategy, the liver-first approach, to optimize the chance of a curative resection. The aim of this study was to assess rectal outcomes after reverse treatment of patients with metastatic rectal cancer.

METHODS

From May 2000 to November 2013, a total of 34 consecutive selected patients with histology-proven adenocarcinoma of the rectum and liver metastases were prospectively entered into a dedicated computerized database. All patients were treated via our reverse strategy. Rectal and overall survival outcomes were analyzed.

RESULTS

Most patients presented with advanced disease (median Fong clinical risk score of 3; range 2-5). One patient failed to complete the whole treatment (3%). Rectal surgery was performed after a median of 3.9 months (range 0.4-17.8 months). A total of 73.3% patients received preoperative radiotherapy. Perioperative mortality and morbidity rates were 0 and 27.3% after rectal surgery. Severe complications were reported in two patients (6.1%): one anastomotic leak and one systemic inflammatory response syndrome. The median hospital stay was 11 days (range 5-23 days). Complete local pathological response was observed in three patients (9.1%). The median number of lymph nodes collected was 14. The R0 rate was 93.9%. There was no positive circumferential margin. After a mean follow-up of 36 months after rectal surgery, 5-year overall survival was 52.5%. Five patients experienced pelvic recurrence.

CONCLUSIONS

In our cohort of selected patients with stage IV rectal cancer, the reverse strategy was not only safe and effective, but also oncologically promising, with a low morbidity rate and high long-term survival.

A meta-analysis to determine the effect of primary tumor resection for stage IV colorectal cancer with unresectable metastases on patient survival

BACKGROUND

Approximately 20 % of patients diagnosed with colorectal cancer will have distant metastases at first presentation (stage IV disease). The effect of removing the primary tumor on survival for patients with stage IV disease with unresectable metastases remains unclear. To address this a meta-analysis of all studies comparing primary tumor resection with chemotherapy alone in cases of stage IV colorectal cancer with unresectable metastases was performed.

METHODS

A comprehensive search for published studies examining the effect of primary tumor resection in the setting of colorectal cancer with unresectable metastases was performed. Each study was reviewed and data extracted. Random-effects methods were used to combine data.

RESULTS

There were 21 studies including a total of 44,226 patients that met the inclusion criteria. Resection of the primary tumor in patients with unresectable metastases compared with chemotherapy alone was associated with a lower mortality risk (OR 0.28; 95 % CI 0.165-0.474; P < 0.001), translating into a difference in mean survival of 6.4 months in favor of resection (95 % CI 5.025-7.858, P < 0.001). Patients who underwent resection of the primary tumor were more likely to have liver metastasis only (OR 1.551; 95 % CI 1.247-1.929; P < 0.001), were less likely to have ≥2 metastasis (OR 0.653; 95 % CI 0.508-0.839; P = 0.001), and were less likely to have rectal cancer (OR 0.495; 95 % CI 0.390-0.629; P < 0.001). There was significant cross-study heterogeneity.

CONCLUSIONS

Resection of the primary tumor may confer a survival advantage in stage IV colorectal cancer with unresectable metastases but significant selection bias exists in current studies. Randomized controlled trials are essential to validate these findings.

Treatment strategy for rectal cancer with synchronous metastasis: 65 consecutive Italian cases from the Bologna Multidisciplinary Rectal Cancer Group

BACKGROUND

Twenty percent of rectal cancer patients have synchronous distant metastasis at diagnosis. At present, the treatment strategy in this patient setting is not well defined. This study in one institution evaluates the treatment strategy of three different patient groups.

PATIENTS AND METHODS

Between January 2000 and July 2011, 65 patients with M1 rectal cancer were evaluated. Three different groups were defined: rectal cancer with resectable metastatic disease (group A); rectal cancer with potentially resectable metastatic disease (group B), and rectal cancer with unresectable metastatic disease (group C).

RESULTS

Group A included 11 patients (16.9%), group B 28 patients (43.1%) and group C 26 patients (40%). Forty-three (66.2%) patients underwent surgery for primary rectal cancer, and 30 (46.2%) patients for metastasis resection (23 liver, 4 lung and 3 ovary). Median overall survival (OS) by group was: 51 (5-86; group A), 32 (24-40; group B) and 16 (7-26; group C) months. Patients undergoing metastasis resection have higher median OS than unresected patients (44 vs. 15 months; p < 0.001).

CONCLUSIONS

The treatment strategy in synchronous metastatic rectal cancer must consider the possibility of distant metastasis resection. Long-term survival can be achieved using an integrated approach.

[Treatment of colorectal cancer with unresectable metastasis with chemotherapy without primary tumor resection: analysis of tumor-related complications]

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.

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.

Bevacizumab-containing chemotherapy is safe in patients with unresectable metastatic colorectal cancer and a synchronous asymptomatic primary tumor

OBJECTIVE

Surgical resection of asymptomatic primary colorectal cancer in patients presenting with synchronous unresectable metastatic disease is controversial. Concerns and controversies remain over combining cytotoxic chemotherapy with bevacizumab in this patient population.

METHODS

We identified medical records of 99 patients with synchronous metastatic primary colorectal cancer who received chemotherapy with bevacizumab as their initial treatment. The incidence of subsequent use of surgery and surgical outcomes were recorded. Patients were also assessed for overall survival.

RESULTS

Patients who received bevacizumab-containing chemotherapy for synchronous metastatic primary colorectal cancer were divided into the non-surgery and surgery groups according to the resection status of their asymptomatic primary tumor. In the non-surgery group, two patients (4.4%) underwent additional surgery, while three patients (5.7%) required surgery for rectovesical fistula in the surgery group. The median overall survival was 17 months for the non-surgery group (95% CI: 10.6-23.3 months) and 23 months for the surgery group (95% CI: 21.3-24.6 months; P = 0.322).

CONCLUSIONS

This study utilizing chemotherapy with bevacizumab did not result in an increased rate of morbidity related to the unresected primary tumor. Survival is not compromised by leaving the primary colon tumor intact.

Systematic review of prognostic factors related to overall survival in patients with stage IV colorectal cancer and unresectable metastases

BACKGROUND

With the improvements in newer chemotherapeutic agents, the role of primary tumour resection in patients with stage IV colorectal cancer is controversial. In many cases primary tumour resection is still favoured as first-line management. However, a detailed understanding of independent prognostic factors related to survival is necessary before making this decision.

METHOD

A literature search was conducted using Medline and Embase. Studies that performed multivariate analysis on overall survival of patients with incurable stage IV colorectal cancer were included in this review.

RESULTS

Fourteen retrospective studies involving 3209 patients were included. Clinical variables analysed to consistently have independent prognostic significance for long-term survival included the patients' performance status (<2), volume of liver metastases (<50%), nodal stage (N0), disease-free resection margins, and treatment with chemotherapy and/or primary tumour resection. Cancer antigen (CA) 19-9, low albumin, elevated ALP levels, apical lymph node involvement, presence of ascites, and postoperative transfusion were each assessed by only one study and found to be independently associated with survival. Factors inconsistently reported to have independent prognostic significance were age, ASA score, preoperative CEA levels, primary tumour location, tumour size and differentiation, peritoneal dissemination, and extrahepatic metastases.

CONCLUSION

Each patient should be reviewed individually on the basis of the above independent prognostic factors before deciding to resect the primary tumour. Patients with a poor performance status, extensive hepatic metastases, and extensive nodal disease detected preoperatively are less likely to have a survival benefit. Nonsurgical approaches to manage these patients should be given careful consideration.