Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment

Abstract

A B S T R A C T PurposeThe purpose of this study was to describe the frequency of interventions necessary to palliate the intact primary tumor in patients who present with synchronous, stage IV colorectal cancer (CRC) and who receive up-front modern combination chemotherapy without prophylactic surgery. Patients and MethodsBy using a prospective institutional database, we identified 233 consecutive patients from 2000 through 2006 with synchronous metastatic CRC and an unresected primary tumor who received oxaliplatin-or irinotecan-based, triple-drug chemotherapy (infusional fluorouracil, leucovorin, and oxaliplatin; bolus fluorouracil, leucovorin, and irinotecan; or fluorouracil, leucovorin, and irinotecan) with or without bevacizumab as their initial treatment. The incidence of subsequent use of surgery, radiotherapy, and/or endoluminal stenting to manage primary tumor complications was recorded. ResultsOf 233 patients, 217 (93%) never required surgical palliation of their primary tumor. Sixteen patients (7%) required emergent surgery for primary tumor obstruction or perforation, 10 patients (4%) required nonoperative intervention (ie, stent or radiotherapy), and 213 (89%) never required any direct symptomatic management for their intact primary tumor. Of those 213 patients, 47 patients (20%) ultimately underwent elective colon resection at the time of metastasectomy, and eight patients (3%) underwent this resection during laparotomy for hepatic artery infusion pump placement. Use of bevacizumab, location of the primary tumor in the rectum, and metastatic disease burden were not associated with increased intervention rate. ConclusionMost patients with synchronous, stage IV CRC who receive up-front modern combination chemotherapy never require palliative surgery for their intact primary tumor. These data support the use of chemotherapy, without routine prophylactic resection, as the appropriate standard practice for patients with neither obstructed nor hemorrhaging primary colorectal tumors in the setting of metastatic disease.

Review: Incidence and clinical significance of Bevacizumab-related non-surgical and surgical serious adverse events in metastatic colorectal cancer

“…Overall Survival, Progression-Free Survival and Response Rate [ Table 1] Table 1 gives an overview of data on overall survival (OS), progression-free survival (PFS) and response rate (RR) reported by 7 randomized controlled trials M A N U S C R I P T (RCTs) 19-25,31 , 4 prospective 8,26-28 and 3 retrospective studies 11,29,30 . A recent Cochrane Database systematic review by Wagner et al, including 5 randomized trials (>3000 patients) 19,22,23,25,31 , concluded BV prolongs both PFS and OS in patients with mCRC.…”

“…Two patients with primary tumor complications (<1%) died within 30 days of surgery. The authors didn't specify whether these patients were on BV-treatment, but they concluded that the risk of emergent intervention was not associated with the use of BV 30 . Of 529 patients under BV-based treatment in the ECOG study E3200 only 1 developed a grade 4 bleeding that required a hemostatic intervention and 6 events of bowel perforation were reported, 2 of which needed surgery and 2 cases were fatal 22 .…”

Surgical management of colorectal cancer: A review of the literature

“…Models of simultaneous colon and liver resection as well as resection of the primary followed by chemotherapy to stabilise the liver tumours with the intent to proceed to staged hepatectomy are being debated [26]. Studies have shown a survival benefi t to neoadjuvant chemotherapy and resection of liver metastases prior to the resection of the colon primary [26][27][28].…”

“…Poultsides et al retrospectively reviewed prospective data on 233 patients over a 6-year period with synchronous metastatic CRC and an unresected primary who received neoadjuvant chemotherapy [27]. Of this group, 93% never required any surgical intervention for palliation of the primary.…”

“…Ultimately, 20% of patients went on to surgical therapy with removal of the primary and metastasectomy. The authors concluded that the use of chemotherapy without prophylactic colectomy as initial treatment is appropriate for patients with asymptomatic disease [27].…”