Should bypass or stoma creation be undertaken for unresectable stage IV colorectal carcinoma?

BACKGROUND

When patients with stage IV colorectal cancer are deemed to have an unresectable primary colorectal cancer or extensive metastases at surgery, bypass or stoma creation may be the only surgical options. Whether this surgical approach provides extra months of life or instead leads to prohibitive post-operative morbidity and mortality has not previously been well characterized. This study was conducted to evaluate early and long-term outcomes for stage IV colorectal cancer patients with unresectable primary tumour.

METHODS

Patients with unresectable colorectal cancer who underwent palliative bypass or stoma creation were identified from a prospective colorectal cancer database. Early and long-term outcomes were evaluated. Survival was determined using Kaplan-Meier survival curves.

RESULTS

From 1980 to 2008, 81 patients with stage IV colorectal cancer had an unresectable primary or extensive metastases and underwent palliative bypass or stoma creation. Mean age was 61.5 ± 13.9 years, 44 (54.3%) were male. Location of the colorectal cancer was left-sided in 82.7%. Of the patients, 38.3% had emergency or urgent surgery. Sixty-two (76.5%) patients underwent a diverting stoma, 15 (18.5%) underwent enteric bypass procedures and 4 (4.9%) had both a diverting stoma and proximal bypass created. Twenty-five complications occurred in 24 patients (29.6%) with 2 patients (2.5%) requiring further re-operation. There was no anastomotic leak. Mean length of hospital stay was 13.8 ± 11.2 days. Thirty-day mortality rate was 16%. The median overall survival was 4.7 months, while the overall survival at 1 year was 24.7%. At 2 years, 6.1% patients were alive, all with a stoma.

CONCLUSION

Palliative bypass or stoma creation is associated with survival for several months for a significant proportion of patients with stage IV colorectal cancers, who have unresectable primaries or extensive metastases. The findings of this study support the use of bypass or diversion when faced with an unresectable primary in patients with colorectal cancer with metastases.

An Australian translational study to evaluate the prognostic role of inflammatory markers in patients with metastatic ColorEctal caNcer Treated with bevacizumab (Avastin™) [ASCENT]

Background

The use of bevacizumab in combination with fluoropyrimidine-containing chemotherapy is a well-established first-line and second-line treatment for patients with metastatic colorectal cancer (mCRC). However, there remains a need for reproducible, validated, inexpensive and accessible prognostic markers to aid treatment selection. The optimal treatment duration and the role of bevacizumab in certain patient subgroups, considered at particular risk of bevacizumab-mediated toxicity, also require further investigation. The aim of the ASCENT study [an Australian translational Study to evaluate the prognostic role of inflammatory markers in patients with metastatic ColorEctal caNcer Treated with bevacizumab (Avastin™)] is to evaluate the relationship between the host inflammatory response as measured by neutrophil/lymphocyte ratio (NLR) and treatment outcomes in patients with previously untreated mCRC receiving bevacizumab-based first- and second-line treatment.

Methods/design

This open-label, prospective, single arm, phase IV, Australian multi-centre study evaluates the relationship between the host inflammatory response as measured by NLR and treatment outcomes in patients with previously untreated mCRC receiving bevacizumab-based first- and second-line treatment. 150 patients will be recruited from 16 centres around Australia. Patients will receive trial treatments in two phases: Phase A: XELOX or mFOLFOX6 plus bevacizumab administered from study start until first disease progression; and Phase B: FOLFIRI plus bevacizumab administered from first disease progression until second disease progression. The primary analysis will test the association between NLR and progression free survival using a proportional Hazards Model. Secondary analyses will investigate whether the relationship can be improved upon with other prognostic biomarkers, and further characterise the safety of bevacizumab following treatment initiation, and when continued after progression in combination with standard chemotherapy regimens (presented through summary statistics and Kaplan Meier curves).

Discussion

Quantifying the relationship between NLR and PFS will inform decision making on the extent to which this simple metric may be applied clinically.

Trial registration

ClinicalTrials.gov: NCT01588990

ESMO Consensus Guidelines for management of patients with colon and rectal cancer. a personalized approach to clinical decision making

Colorectal cancer (CRC) is the most common tumour type in both sexes combined in Western countries. Although screening programmes including the implementation of faecal occult blood test and colonoscopy might be able to reduce mortality by removing precursor lesions and by making diagnosis at an earlier stage, the burden of disease and mortality is still high. Improvement of diagnostic and treatment options increased staging accuracy, functional outcome for early stages as well as survival. Although high quality surgery is still the mainstay of curative treatment, the management of CRC must be a multi-modal approach performed by an experienced multi-disciplinary expert team. Optimal choice of the individual treatment modality according to disease localization and extent, tumour biology and patient factors is able to maintain quality of life, enables long-term survival and even cure in selected patients by a combination of chemotherapy and surgery. Treatment decisions must be based on the available evidence, which has been the basis for this consensus conference-based guideline delivering a clear proposal for diagnostic and treatment measures in each stage of rectal and colon cancer and the individual clinical situations. This ESMO guideline is recommended to be used as the basis for treatment and management decisions.

Clinical outcome of up-front surgery in patients with asymptomatic, incurable synchronous peritoneal carcinomatosis

PURPOSES

The purpose of this study was to show the clinical features of up-front surgery of the primary tumor in asymptomatic patients with incurable colorectal PC.

METHODS

Forty-six patients that were diagnosed between 1998 and 2007 with asymptomatic colorectal PC who could not be successfully cured by surgery were assessed retrospectively.

RESULTS

A univariate analysis revealed the presence of liver metastases, without the use of oxaliplatin (OX)/irinotecan (IRI) and without a primary tumor resection to be poor prognostic factors for survival (p = 0.044, p = 0.030, p < 0.001, respectively). According to a multivariate analysis, no use of OX/IRI and no primary tumor resection, were found to be independent poor prognostic factors for survival (HR 2.57; p = 0.047, HR 6.62; p = 0.003, respectively). The median survival time of patients treated with and without OX/IRI was 18 and 7 months, respectively. The median survival time of patients with and without primary tumor resection was 10 and 2 months, respectively. The number of patients needing surgical intervention for intestinal obstruction after surgery significantly increased in patients treated with OX/IRI (p = 0.001).

CONCLUSION

Improvement of survival may be related to widespread use of modern systemic chemotherapy and primary tumor resection. However, an increased number of patients that needed surgery for an intestinal obstruction were observed, even after up-front surgery, when patients were treated with modern systemic chemotherapy.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Non-resection versus resection for an asymptomatic primary tumour in patients with unresectable stage IV colorectal cancer

BACKGROUND

In a majority of patients with stage IV colorectal cancer, the metastatic disease is not resectable and the focus of management is on how best to palliate the patient. How to manage the primary tumour is an important part of palliation. A small proportion of these patients present with either obstructing or perforating cancers and require urgent surgical care. However, a majority are relatively asymptomatic from their primary cancer. Chemotherapy has been shown to prolong survival in this group of patients, and a majority of patients would be treated this way. Nonetheless, A recent meta-analysis (Stillwell 2010) suggests an improved overall survival and reduced requirement for emergency surgery in those patients who undergo primary tumour resection. This review was also able to quantify the mortality and morbidity associated with surgery to remove the primary.

OBJECTIVES

To determine if there is an improvement in overall survival following resection of the primary cancer in patients with unresectable stage IV colorectal cancer and an asymptomatic primary who are treated with chemo/radiotherapy.

SEARCH METHODS

In January 2012 we searched for published randomised and non-randomised controlled clinical trials without language restrictions using the following electronic databases: CENTRAL (the Cochrane Library (latest issue)), MEDLINE (1966 to date), EMBASE (1980 to date), Science Citation Index (1981 to date), ISI Proceedings (1990 to date), Current Controlled Trials MetaRegister (latest issue), Zetoc (latest issue) and CINAHL (1982 to date).

SELECTION CRITERIA

Randomised controlled trials and non-randomised controlled studies evaluating the influence on overall survival of primary tumour resection versus no resection in asymptomatic patients with unresectable stage IV colorectal cancer who are treated with palliative chemo/radiotherapy.

DATA COLLECTION AND ANALYSIS

We conducted the review according to the recommendations of The Cochrane Collaboration and the Cochrane Colorectal Group. "Review Manager 5" software was used.

MAIN RESULTS

A total of 798 studies were identified following the initial search. No published or unpublished randomised controlled trials comparing primary tumour resection versus no resection in asymptomatic patients with unresectable stage IV colorectal cancer who were treated with chemo/radiotherapy were identified. Seven non-randomised studies, potentially eligible for inclusion, were identified: 2 case-matched studies, 2 CCTs and 3 retrospective cohort studies. Overall, these trials included 1.086 patients (722 patients treated with primary tumour resection, and 364 patients managed first with chemotherapy and/or radiotherapy).

AUTHORS' CONCLUSIONS

Resection of the primary tumour in asymptomatic patients with unresectable stage IV colorectal cancer who are managed with chemo/radiotherapy is not associated with a consistent improvement in overall survival. In addition, resection does not significantly reduce the risk of complications from the primary tumour (i.e.  obstruction, perforation or bleeding). Yet there is enough doubt with regard to the published literature to justify further clinical trials in this area. The results from an ongoing high quality randomised controlled trial will help to answer this question.

Personalized treatment of colorectal cancer

In the last 15 years, significant progress in the management of colorectal cancer (CRC) has been achieved with several new agents licensed extending median overall survival for stage IV disease to about 2 years. Treatment of CRC is stage-specific, multidisciplinary, and based on patient and tumor characteristics. Although especially early stages (0-III, according to Union for International Cancer Control) are treated with curative intent, patients with limited stage IV disease (liver and/or lung or localized peritoneal metastases) might still be curable in a multimodality approach including surgery, perioperative chemotherapy and/or radiotherapy. Despite the broad variety of prognostic factors, treatment decisions and selection of drugs are mainly based on clinicopathologic variables for early stage CRC, extent of disease, potential resectability, patients' eligibility to receive aggressive treatments including chemotherapy, surgery, and very few molecular markers such as KRAS mutational status for advanced disease. However, a tailored approach for the treatment of CRC taking into account all mentioned factors is currently recommended by national and international guidelines and will be discussed in this review.

American Society of Clinical Oncology 2010 colorectal update

The 2010 American Society of Clinical Oncology (ASCO) Gastrointestinal (Colorectal) Cancer Track included several notable presentations. The addition of cetuximab to FOLFOX in stage III colon cancer did not improve disease-free survival, but increased toxicity. In the metastatic setting, cetuximab demonstrated benefit only in a small subset of patients (KRAS wild-type and limited metastatic disease). Bevacizumab monotherapy may be equivalent to combination chemotherapy in the maintenance phase of treatment in advanced disease, and in another study bevacizumab did not appear to incur excess morbidity in patients with an intact primary tumor. Alternate strategies for the treatment of stage II/III rectal cancer included short-course radiotherapy with adjuvant chemotherapy and neoadjuvant FOLFOX-bevacizumab without radiation, both demonstrating promising results.