Annals of Surgical Oncology, Vol 6, Issue 7 651-657, Copyright © 1999 by Society of Surgical Oncology

ARTICLES

Nonoperative management of primary colorectal cancer in patients with stage IV disease

C. R. Scoggins, I. M. Meszoely, C. D. Blanke, R. D. Beauchamp and S. D. Leach
Department of Surgery, The Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

BACKGROUND: Traditional teaching maintains that patients with primary colorectal adenocarcinoma require timely resection to prevent bleeding, perforation, or obstruction. The true benefits of primary tumor resection remain undocumented for patients presenting with metastatic disease, however. We postulated that resection of primary colorectal tumors could be avoided safely in a select population of asymptomatic colorectal cancer patients presenting with incurable stage IV disease. METHODS: A retrospective review of the Vanderbilt University Hospital tumor registry was performed for the years 1985 to 1997. During this period, 955 patients presented for management of primary colorectal cancer. From this group, all patients with stage IV disease at the time of diagnosis were identified. Patients who initially underwent resection of their primary lesion were included in the resection group; those who underwent initial nonoperative primary tumor management were included in the nonresection group. Data were obtained regarding age, extent of disease, nonsurgical therapy, tumor-specific complications, and palliative surgical procedures. Surgery-free survival and overall survival were analyzed using the Kaplan-Meier method. For patients with liver metastases, hepatic tumor burden was defined as either H1 (<25% parenchymal replacement), H2 (25% to 50%), or H3 (>50%) disease. RESULTS: Sixty-six patients were included in the resection group, and 23 patients with intact asymptomatic primary colorectal lesions were included in the nonresection group. Among patients with hepatic metastases, most of the patients in both groups had H1 disease. Ten patients in the resection group and 3 patients in the nonresection group presented with exclusively extrahepatic metastases. In the nonresection group, primary therapy included chemotherapy in 13 patients, external beam radiation therapy in 1 patient, and combination chemoradiation in 9 patients. The median survival in the nonresection group was 16.6 months. The 2-year actuarial survival was 18%, and the surgery-free survival was 91.3%. Only 2 of 23 patients (8.7%) managed without resection eventually developed obstruction at the primary tumor site requiring emergent diversion. There were no episodes of tumor-related hemorrhage or perforation. For the resection group, the operative morbidity was 30.3%, and the perioperative mortality rate was 4.6%. The median survival in the resection group was 14.5 months (P = 0.59, log-rank test vs. nonresection group). CONCLUSIONS: Selected patients with asymptomatic primary colorectal tumors who present with incurable metastatic disease may safely avoid resection of their primary lesions, with an anticipated low rate of hemorrhage, perforation, or obstruction before death from systemic disease. No survival advantage is gained by resection of an asymptomatic primary lesion in the setting of incurable stage IV colorectal cancer.

This article has been cited by other articles:

				M. G. W. Scheer, C. E. J. Sloots, G. J. van der Wilt, and T. J. M. Ruers Management of patients with asymptomatic colorectal cancer and synchronous irresectable metastases Ann. Onc., July 28, 2008; (2008) mdn398v1. [Abstract] [Full Text] [PDF]

				W. L. Law, J. K. M. Fan, J. T. C. Poon, H. K. Choi, and O. S. H. Lo Laparoscopic Bowel Resection in the Setting of Metastatic Colorectal Cancer Ann. Surg. Oncol., May 1, 2008; 15(5): 1424 - 1428. [Abstract] [Full Text] [PDF]

				G. Galizia, E. Lieto, M. Orditura, P. Castellano, V. Imperatore, M. Pinto, and A. Zamboli First-Line Chemotherapy vs Bowel Tumor Resection Plus Chemotherapy for Patients With Unresectable Synchronous Colorectal Hepatic Metastases Arch Surg, April 1, 2008; 143(4): 352 - 358. [Abstract] [Full Text] [PDF]

				G. Kennedy and H. Nelson First-Line Chemotherapy vs Bowel Tumor Resection Plus Chemotherapy for Patients With Unresectable Synchronous Colorectal Hepatic Metastases--Invited Critique Arch Surg, April 1, 2008; 143(4): 358 - 358. [Full Text] [PDF]

				R. Costi, A. Mazzeo, D. Di Mauro, L. Veronesi, G. Sansebastiano, V. Violi, L. Roncoroni, and L. Sarli Palliative Resection of Colorectal Cancer: Does It Prolong Survival? Ann. Surg. Oncol., September 1, 2007; 14(9): 2567 - 2576. [Abstract] [Full Text] [PDF]

				P. J. O'Dwyer, S. G. Eckhardt, D. G. Haller, J. Tepper, D. Ahnen, S. Hamilton, A. B. Benson III, M. Rothenberg, N. Petrelli, H.-J. Lenz, et al. Priorities in Colorectal Cancer Research: Recommendations From the Gastrointestinal Scientific Leadership Council of the Coalition of Cancer Cooperative Groups J. Clin. Oncol., June 1, 2007; 25(16): 2313 - 2321. [Abstract] [Full Text] [PDF]

				L. Capussotti, L. Vigano', A. Ferrero, R. L. Tesoriere, D. Ribero, and R. Polastri Timing of Resection of Liver Metastases Synchronous to Colorectal Tumor: Proposal of Prognosis-Based Decisional Model Ann. Surg. Oncol., March 1, 2007; 14(3): 1143 - 1150. [Abstract] [Full Text] [PDF]

				A. Muratore, D. Zorzi, H. Bouzari, M. Amisano, P. Massucco, E. Sperti, and L. Capussotti Asymptomatic Colorectal Cancer with Un-Resectable Liver Metastases: Immediate Colorectal Resection or Up-Front Systemic Chemotherapy? Ann. Surg. Oncol., February 1, 2007; 14(2): 766 - 770. [Abstract] [Full Text] [PDF]

				A. I. Sarela, S. Yelluri, and for the Leeds Upper Gastrointestinal Cancer Multid Gastric Adenocarcinoma With Distant Metastasis: Is Gastrectomy Necessary? Arch Surg, February 1, 2007; 142(2): 143 - 149. [Abstract] [Full Text] [PDF]

				N. J. Petrelli Expressing the Prochemotherapy Position on Treatment of Synchronous Colorectal Metastases in the Asymptomatic Patient Ann. Surg. Oncol., February 1, 2006; 13(2): 137 - 139. [Full Text] [PDF]

				A. D. Cook, R. Single, and L. E. McCahill Surgical Resection of Primary Tumors in Patients Who Present With Stage IV Colorectal Cancer: An Analysis of Surveillance, Epidemiology, and End Results Data, 1988 to 2000 Ann. Surg. Oncol., August 1, 2005; 12(8): 637 - 645. [Abstract] [Full Text] [PDF]

				L. K.F. Temple, L. Hsieh, W. D. Wong, L. Saltz, and D. Schrag Use of Surgery Among Elderly Patients With Stage IV Colorectal Cancer J. Clin. Oncol., September 1, 2004; 22(17): 3475 - 3484. [Abstract] [Full Text] [PDF]

				N C Tebbutt, A R Norman, D Cunningham, M E Hill, D Tait, J Oates, S Livingston, and J Andreyev Intestinal complications after chemotherapy for patients with unresected primary colorectal cancer and synchronous metastases Gut, April 1, 2003; 52(4): 568 - 573. [Abstract] [Full Text] [PDF]