Surgery of the Primary Tumour in Stage IV Colorectal Cancer with Unresectable Metastases

European Oncology & Haematology, 2011;8(1):27–31

Abstract:

Since patients with incurable metastatic colorectal cancer (CRC) only have a relatively limited life expectancy, and resection of the primary tumour is accompanied by both morbidity and mortality, it is under debate whether resection of the primary tumour has an effect on survival or quality of life. The rationale behind the resection strategy is that prophylactic surgery prevents future complications. With current new chemotherapy regimens, a relatively low number of patients with metastatic CRC require surgery for their primary tumour. Many studies concerning the management of incurable stage IV CRC have been performed and most studies suggest a survival benefit for patients undergoing surgical resection of the primary tumour compared with those who received palliative treatment. However, in stage IV CRC with unresectable metastases, the role of a palliative resection of the primary tumour has never been assessed properly. Because randomised clinical trials are lacking, it is difficult to draw conclusions from the present literature.
Keywords: Stage IV colorectal cancer, unresectable metastases, resection of the primary tumour, palliative chemotherapy
Disclosure: The authors have no conflicts of interest to declare.
Received: December 27, 2011 Accepted January 12, 2012 Citation European Oncology & Haematology, 2011;8(1):27–31
Correspondence: Cornelis Verhoef, Department of Surgical Oncology, Erasmus MC (Daniel den Hoed), Groene Hilledijk 301, 3075 EA Rotterdam, The Netherlands. E: c.verhoef@erasmusmc.nl

Colorectal cancer (CRC) is one of the two most commonly diagnosed cancers, with approximately 1.2 million new cases each year and more than 600,000 annual deaths estimated to occur worldwide.1 In addition, roughly one-fifth of patients present with incurable disseminated disease.2 In the last decade, the development of new chemotherapeutic biological agents has significantly improved overall survival (OS) of these patients.3–12
A palliative resection of the primary tumour is frequently performed13 and there is a clear indication for surgery when patients present with symptoms of the primary tumour. However, if patients present with absent or mild symptoms, the indication for resection is less obvious. Since patients with incurable metastatic CRC (mCRC) only have a relatively limited life expectancy, and resection of the primary tumour is accompanied by both morbidity and mortality,14–16 it is under debate whether resection of the primary tumour has an effect on survival or quality of life.17,18 Many studies concerning the management of incurable stage IV CRC have been performed; however, the advantage of a palliative resection of the primary tumour has never been assessed properly.19 Moreover, most studies do not even report whether a resection of the primary tumour has been performed.20
In this article we aim to evaluate the role of surgery of the primary tumour in stage IV CRC with unresectable metastases.
Treatment of Metastatic Colorectal Cancer
At diagnosis of CRC, approximately 20 % of patients present with synchronous mCRC, and the liver is the predilection site in half of these patients.21,22 The lungs represent the second most common site of metastases from CRC and, according to non-population-based studies, lung metastases are present in 10–15 % of patients with CRC.23,24
When metastases are limited, a possible curative treatment can be obtained by surgical resection; however, only 15–20 % of patients are resectable.25 Median five-year survival for patients undergoing an R0 resection of the metastases is approximately 30 % (range 15–67 %).26 Despite complete resection and neoadjuvant or adjuvant chemotherapy regimens, recurrences occur in 75 % of the patients.27
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Keywords: Stage IV colorectal cancer, unresectable metastases, resection of the primary tumour, palliative chemotherapy
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