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Letter to the Editor |
Peritoneal Surface Malignancy Program, St. Agnes Health Care, Baltimore, Maryland, E-mail: jesquive{at}stagnes.org
To the Editor:
Complete and adequate surgical resection remains the hallmark therapy for primary colorectal cancer. It allows the patients to become clinically disease free, provides proper staging, and determines who should receive adjuvant therapy. Traditionally, those patients who present with unresectable metastatic disease are referred to a medical oncologist for systemic chemotherapy, and surgical resections are performed only to alleviate symptoms of bleeding, obstruction, perforation, and/or intractable pain. For 40 years, we were unable to affect the 12-month median survival of these patients treated with 5-fluorouracil and levamisole/leucovorin. However, during this time, we were able to identify a subset of patients with resectable meta-static disease to the liver who benefited from a surgical resection followed by adjuvant systemic chemotherapy. In 2005, systemic chemotherapy with newer chemotherapeutic regimens in combination with targeted agents has increased the median survival of patients with unresectable metastatic colorectal cancer to more than 20 months.1 In addition, neoadjuvant protocols with combinations of different chemotherapeutic agents have allowed a subset of patients with unresectable liver metastases (approximately 15%) to become resectable and benefit from a very reasonable 40% 5-year survival.2 These data represent the benefits of a successful interaction between medical and surgical oncologists.
There have also been significant improvements in the surgical treatment of patients with metastatic colorectal cancer. For patients with colorectal cancer with extensive peritoneal dissemination and no evidence of hematogenous spread, the use of systematic cytoreductive surgery with newer surgical techniques that include peritonectomy procedures and intraperitoneal hyperthermic chemotherapy have resulted in a median survival of 42.9 months for patients who had a complete surgical removal of their peritoneal dissemination.3
The common national approach to the patient with colorectal cancer with peritoneal dissemination is to refer these patients to a medical oncologist for systemic chemotherapy, even though some of these patients have resectable metastatic disease and would probably benefit more if they had their disease removed, followed by systemic chemotherapy in an adjuvant setting. The lack of randomized trials in this country, the difficulty in objectively measuring peritoneal dissemination, and the fact that when first-line therapy for metastatic disease fails, patients can receive a second-line combination make it very difficult to really evaluate the benefits of a complete surgical resection in patients with peritoneal dissemination secondary to colorectal cancer. We, surgical oncologists, most often will see these patients after they have every possible regimen has failed. It is difficult to enter patients into randomized protocols that include extensive surgical resections and intraperitoneal chemotherapy because the patients by this time are not great surgical candidates and have a poor performance status, malnutrition, and usually intractable ascites.
Therefore, unless we have a much better interaction between medical and surgical oncologists, there will continue to be important clinical questions that cannot be answered, and there will be a subset of patients who are being denied a potential chance to a good long-term result with cytoreductive surgery followed by adjuvant systemic chemotherapy. Ideally, before patients with resectable peritoneal dissemination of colorectal origin are committed to a very expensive and potentially toxic systemic chemotherapeutic regimen, these patients need to be evaluated by both a medical oncologist and a surgical oncologist who is experienced in cytoreductive surgery and intraperitoneal chemotherapy. Also, we need to continue to improve the selection criteria for a surgical approach before systemic chemotherapy because we cannot ignore the fact that patients with peritoneal surface malignancies of colorectal origin who have an incomplete cytoreduction have an average of 6 months’ median survival.3,4 History repeats itself, and the story of colorectal liver metastases is being rewritten with a different title. We are at the end of the beginning of recognizing the surgical value in some patients with colon cancer with peritoneal dissemination, and only with a continued interaction between medical and surgical oncologists will we be able to find the answer.
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