Colorectal Cancer with Multiple Metastases: Is Palliative Surgery Needed?

다국어 초록 (Multilingual Abstract)

In patients with symptomatic incurable metastatic colorectal cancer (mCRC), the goal of resection of the primary lesion is to palliate cancer-related morbidity, including obstruction, bleeding, or perforation. In patients with asymptomatic primary tumors and incurable metastatic disease, however, the necessity of primary tumor resection is less clear. Although several retrospective analyses suggest survival benefit in patients who undergo resection of the primary tumor, applying this older evidence to modern patients is out of date for several reasons. Modern chemotherapy regimens incorporating the novel cytotoxic agents oxaliplatin and irinotecan, as well as the target agents bevacizumab and cetuximab, have improved median survival from less than 1 year with the only available single-agent 5-fluorouracil until the mid-1990s to over 2 years. In addition to significant prolongation of overall survival, combinations of novel chemotherapeutic and target agents have allowed improved local and distant tumor control, decreasing the likelihood of local tumor-related complications requiring surgical resection. Resection of an asymptomatic primary tumor risks surgical complications and may postpone the administration of chemotherapy that may offer both systemic and local control. In conclusion, the morbidity and the mortality of unnecessary surgery or surgery that does not improve quality of life or survival in patients with mCRC of a limited life expectancy should be carefully evaluated. With the availability of effective combinations of chemotherapy and target agents,systemic therapy for the treatment of life-threatening metastases would be a preferable treatment strategy for unresectable asymptomatic patients with mCRC.

참고문헌 (Reference)

1 Benoist S, "Treatment strategy for patients with colorectal cancer and synchronous irresectable liver metastases" 92 : 1155-1160, 2005

2 Konyalian VR, "The role of primary tumour resection in patients with stage IV colorectal cancer" 9 : 430-437, 2007

3 Grothey A, "Survival of patients with advanced colorectal cancer improves with the availability of fluorouracil-leucovorin, irinotecan, and oxaliplatin in the course of treatment" 22 : 1209-1214, 2004

4 Cook AD, "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" 12 : 637-645, 2005

5 Ries LA, "SEER cancer statistics review, 1975-2005" National Cancer Institute

6 Mella J, "Population- based audit of colorectal cancer management in two UK health regions: Colorectal Cancer Working Group, Royal College of Surgeons of England Clinical Epidemiology and Audit Unit" 84 : 1731-1736, 1997

7 Falcone A, "Phase III trial of infusional fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI) compared with infusional fluorouracil, leucovorin, and irinotecan (FOLFIRI) as first-line treatment for metastatic colorectal cancer: the Gruppo Oncologico Nord Ovest" 25 : 1670-1676, 2007

8 Dohmoto M, "Palliative endoscopic therapy of rectal carcinoma" 32A : 25-29, 1996

9 Poultsides GA, "Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment" 27 : 3379-3384, 2009

10 Scoggins CR, "Nonoperative management of primary colorectal cancer in patients with stage IV disease" 6 : 651-657, 1999

11 Sarela AI, "Non-operative management of the primary tumour in patients with incurable stage IV colorectal cancer" 88 : 1352-1356, 2001

12 Chau I, "Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging-defined poor-risk rectal cancer" 24 : 668-674, 2006

13 National Comprehensive Cancer Network, "NCCN guidelines" National Comprehensive Cancer Network

14 Camunez F, "Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation" 216 : 492-497, 2000

15 de Gramont A, "Leucovorin and fluorouracil with or without oxaliplatin as first-line treatment in advanced colorectal cancer" 18 : 2938-2947, 2000

16 Tebbutt NC, "Intestinal complications after chemotherapy for patients with unresected primary colorectal cancer and synchronous metastases" 52 : 568-573, 2003

17 Rosen SA, "Initial presentation with stage IV colorectal cancer: how aggressive should we be" 135 : 530-534, 2000

18 Kuo LJ, "How aggressive should we be in patients with stage IV colorectal cancer" 46 : 1646-1652, 2003

19 Bokemeyer C, "Fluorouracil, leucovorin, and oxaliplatin with and without cetuximab in the first-line treatment of metastatic colorectal cancer" 27 : 663-671, 2009

20 Galizia G, "First-line chemotherapy vs bowel tumor resection plus chemotherapy for patients with unresectable synchronous colorectal hepatic metastases" 143 : 352-358, 2008

21 Tournigand C, "FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: a randomized GERCOR study" 22 : 229-237, 2004

22 Ruo L, "Elective bowel resection for incurable stage IV colorectal cancer: prognostic variables for asymptomatic patients" 196 : 722-728, 2003

23 Michel P, "Colorectal cancer with non-resectable synchronous metastases: should the primary tumor be resected" 28 : 434-437, 2004

24 Kozloff M, "Clinical outcomes associated with bevacizumab-containing treatment of metastatic colorectal cancer: the BRiTE observational cohort study" 14 : 862-870, 2009

25 노재경, "Cetuximab and chemotherapy as initial treatment for metastatic colorectal cancer" 360 (360): 1408-1417, 200904

26 National Cancer Information Center, "Cancer incidence rate 2008" National Cancer Information Center

27 Hurwitz H, "Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer" 350 : 2335-2342, 2004

28 Saltz LB, "Bevacizumab in combination with oxaliplatin-based chemotherapy as first-line therapy in metastatic colorectal cancer: a randomized phase III study" 26 : 2013-2019, 2008

29 Giantonio BJ, "Bevacizumab in combination with oxaliplatin, fluorouracil, and leucovorin (FOLFOX4) for previously treated metastatic colorectal cancer: results from the Eastern Cooperative Oncology Group Study E3200" 25 : 1539-1544, 2007

30 Grothey A, "Bevacizumab beyond first progression is associated with prolonged overall survival in metastatic colorectal cancer: results from a large observational cohort study (BRiTE)" 26 : 5326-5334, 2008