Primary Tumor Resection in Patients with Incurable Localized or Metastatic Colorectal Cancer: A Systematic Review and Meta‐analysis

Abstract

Background To assess the impact of primary tumor resection (PTR) on survival and morbidity in incurable colorectal cancer. Methods Systematic literature review and meta-analysis to compare PTR versus primary tumor intact (PTI). Results Seventy-seven studies were included, reporting on 159,991 participants (94,745 PTR; 65,246 PTI). PTR improved overall survival (hazard ratio [HR] 0.59, P \ 0.0001; mean difference [MD] 7.27 months, P \ 0.0001), cancer-specific survival (HR 0.47, MD 10.80), and progression-free survival (HR 0.76, MD 1.67). Overall survival remained significantly improved during subgroup analysis of asymptomatic patients (HR 0.69, MD 3.86), elderly patients (HR 0.46, MD 7.71), patients diagnosed after 2000 (HR 0.62, MD 7.29), patients with colon (HR 0.58, MD 6.31) or rectal (HR 0.54, MD 6.88) primary tumor, patients undergoing resection of primary tumor versus nonresectional surgery (NRS) to treat primary tumor complications (HR 0.56, MD 8.72), and of studies with propensity score analysis (HR 0.65, MD 5.68). Overall survival per treatment strategy was: [PTI/chemotherapy] 14.30 months, [PTI/bevacizumab] 17.27 months, [PTR/chemotherapy] 21.52 months, [PTR/bevacizumab] 27.52 months. PTR resulted in 4.5% perioperative mortality and 22.4% morbidity (major adverse events 10.2%, minor 18.5%, reoperation 2.5%, intraabdominal collection/sepsis 2.2%). PTI had 21.7% morbidity (obstruction 14.4%, anemia 11.0%, hemorrhage 1.5%, perforation 0.6%, adverse events requiring surgery 15.8%). NRS resulted in 10.6% perioperative mortality and 21.7% morbidity (major 7.9%, minor 21.7%, reoperation 0.1%). Conclusions PTR in patients with incurable colorectal cancer results in a limited improvement of survival without a significant increase in morbidity. PTR should be considered by the multidisciplinary team on an individual patient basis.

Colorectal cancer survival among Ministry of National Guard-Health Affairs (MNG-HA) population 2009–2017: retrospective study

“…In multivariate analysis, we found that patients treated with surgery or chemotherapy, have significant lower risk of death than those who did not use treatment. Similar results have previously been described [29][30][31][32][33]. Prolonged survival outcomes have been shown among CRC patients who were treated with both surgery and chemotherapy [29,31].…”

Influence of the Primary Tumor Location on the Pattern of Synchronous Metastatic Spread in Patients with Stage IV Colorectal Carcinoma, According to the 8 th Edition of the AJCC Staging System

“…However, the magnitude of this selection bias would have been negligible because the policy of the center was to perform resection of the primary tumor even in patients with preoperatively known unresectable metastases. This strategy was based on the observation that primary tumor resection improves OS even in asymptomatic patients whose metastases were not resected [10,11]. The incidence of synchronous metastases reported by the current study (25.8%) was higher than those observed in autopsy or registry studies (16.3-21.3%) [7,14,26,27] suggesting that the proportion of patients with mCRC that were missed was insignificant.…”

“…It is worth mentioning that in our institution even patients with unresectable mCRC underwent surgery, either with the aim of primary tumor resection or with the goal of performing a stoma or by-pass for the primary tumor's complications. The decision to remove the primary tumor in patients with unresectable mCRC and uncomplicated primary tumors is based on the evidence (level B and C) which revealed that primary tumor resection improved overall survival in such patients [10,11].…”

Survival and relative dose intensity of 5-fluorouracil, oxaliplatin and irinotecan in real-life treatment of metastatic colorectal cancer

“…Our analysis identified the BRAF V600E mutation and colorectal surgery as independent factors for progression-free survival and overall survival. A recent meta-analysis of nearly 160,000 patients showed a significant effect on survival of primary tumor resection in patients with localized incurable or mCRC [ 21 ].…”