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Meta-Analysis
. 2012 Aug 15;2012(8):CD008997.
doi: 10.1002/14651858.CD008997.pub2.

Non-resection versus resection for an asymptomatic primary tumour in patients with unresectable stage IV colorectal cancer

Roberto Cirocchi  1 , Stefano Trastulli, Iosief Abraha, Nereo Vettoretto, Carlo Boselli, Alessandro Montedori, Amilcare Parisi, Giuseppe Noya, Cameron Platell
Affiliations
Meta-Analysis

Non-resection versus resection for an asymptomatic primary tumour in patients with unresectable stage IV colorectal cancer

Roberto Cirocchi et al. Cochrane Database Syst Rev. .

Abstract

Background: In a majority of patients with stage IV colorectal cancer, the metastatic disease is not resectable and the focus of management is on how best to palliate the patient. How to manage the primary tumour is an important part of palliation. A small proportion of these patients present with either obstructing or perforating cancers and require urgent surgical care. However, a majority are relatively asymptomatic from their primary cancer. Chemotherapy has been shown to prolong survival in this group of patients, and a majority of patients would be treated this way. Nonetheless, A recent meta-analysis (Stillwell 2010) suggests an improved overall survival and reduced requirement for emergency surgery in those patients who undergo primary tumour resection. This review was also able to quantify the mortality and morbidity associated with surgery to remove the primary.

Objectives: To determine if there is an improvement in overall survival following resection of the primary cancer in patients with unresectable stage IV colorectal cancer and an asymptomatic primary who are treated with chemo/radiotherapy.

Search methods: In January 2012 we searched for published randomised and non-randomised controlled clinical trials without language restrictions using the following electronic databases: CENTRAL (the Cochrane Library (latest issue)), MEDLINE (1966 to date), EMBASE (1980 to date), Science Citation Index (1981 to date), ISI Proceedings (1990 to date), Current Controlled Trials MetaRegister (latest issue), Zetoc (latest issue) and CINAHL (1982 to date).

Selection criteria: Randomised controlled trials and non-randomised controlled studies evaluating the influence on overall survival of primary tumour resection versus no resection in asymptomatic patients with unresectable stage IV colorectal cancer who are treated with palliative chemo/radiotherapy.

Data collection and analysis: We conducted the review according to the recommendations of The Cochrane Collaboration and the Cochrane Colorectal Group. "Review Manager 5" software was used.

Main results: A total of 798 studies were identified following the initial search. No published or unpublished randomised controlled trials comparing primary tumour resection versus no resection in asymptomatic patients with unresectable stage IV colorectal cancer who were treated with chemo/radiotherapy were identified. Seven non-randomised studies, potentially eligible for inclusion, were identified: 2 case-matched studies, 2 CCTs and 3 retrospective cohort studies. Overall, these trials included 1.086 patients (722 patients treated with primary tumour resection, and 364 patients managed first with chemotherapy and/or radiotherapy).

Authors' conclusions: Resection of the primary tumour in asymptomatic patients with unresectable stage IV colorectal cancer who are managed with chemo/radiotherapy is not associated with a consistent improvement in overall survival. In addition, resection does not significantly reduce the risk of complications from the primary tumour (i.e. obstruction, perforation or bleeding). Yet there is enough doubt with regard to the published literature to justify further clinical trials in this area. The results from an ongoing high quality randomised controlled trial will help to answer this question.

PubMed Disclaimer

Conflict of interest statement

The authors state that none of the authors involved in the manuscript preparation have any conflicts of interest towards the manuscript itself, neither financial nor moral conflicts. Besides none of the authors receive support in the form of grants, equipment, and/or pharmaceutical items.

Figures

1
1
Study flow diagram.
1.1
1.1. Analysis
Comparison 1 Primary management of stage IV colorectal cancer, Outcome 1 2 years OS.
1.2
1.2. Analysis
Comparison 1 Primary management of stage IV colorectal cancer, Outcome 2 Death within 30 days from the first treatment.
1.3
1.3. Analysis
Comparison 1 Primary management of stage IV colorectal cancer, Outcome 3 Complications.
1.4
1.4. Analysis
Comparison 1 Primary management of stage IV colorectal cancer, Outcome 4 Complications requiring surgical treatment.
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  • doi: 10.1002/14651858.CD008997

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References

References to studies included in this review

Benoist 2005 {published data only}
    1. Benoist S, Pautrat K, Mitry E, Rougier P, Penna C, Nordlinger B. Treatment strategy for patients with colorectal cancer and synchronous irresectable liver metastases. The British Journal of Surgery 2005;92:1155‐60. - PubMed
Galizia 2008 {published data only}
    1. Galizia G, Lieto E, Orditura M, Castellano P, Imperatore V, Pinto M, et al. First‐line chemotherapy vs bowel tumor resection plus chemotherapy for patients with unresectable synchronous colorectal hepatic metastases. Archives of Surgery 2008;143:352‐8. - PubMed
Michel 2004 {published data only}
    1. Michel P, Roque I, Fiore F, Langlois S, Scotte M, Tenière P, et al. Colorectal cancer with non‐resectable synchronous metastases: should the primary tumor be resected?. Gastroentérologie Clinique et Biologique 2004;28:434‐7. - PubMed
Ruo 2003 {published data only}
    1. Ruo L, Gougoutas C, Paty PB, Guillem JG, Cohen AM, Wong WD. Elective bowel resection for incurable stage IV colorectal cancer: prognostic variables for asymptomatic patients. Journal of the American College of Surgeons 2003;196:722‐8. - PubMed
Scoggins 1999 {published data only}
    1. Scoggins CR, Meszoely IM, Blanke CD, Beauchamp RD, Leach SD. Non operative management of primary colorectal cancer in patients with stage IV disease. Annals of Surgical Oncology 1999;6:651‐7. - PubMed
Seo 2010 {published data only}
    1. Seo GJ, Park JW, Yoo SB, Kim SY, Choi HS, Chang HJ, et al. Intestinal complications after palliative treatment for asymptomatic patients with unresectable stage IV colorectal cancer. Journal of Surgical Oncology 2010;102:94‐9. - PubMed
Tebutt 2003 {published data only}
    1. Tebbutt NC, Norman AR, Cunningham D, Hill ME, Tait D, Oates J, et al. Intestinal complications after chemotherapy for patients with unresected primary colorectal cancer and synchronous metastases. Gut 2003;52:568‐73. - PMC - PubMed

References to studies excluded from this review

Aslam 2010 {published data only}
    1. Aslam MI, Kelkar A, Sharpe D, Jameson JS. Ten years experience of managing the primary tumours in patients with stage IV colorectal cancers. International Journal of Surgery 2010;8:305‐13. - PubMed
Bajwa 2009 {published data only}
    1. Bajwa A, Blunt N, Vyas S, Suliman I, Bridgewater J, Hochhauser D, et al. Primary tumour resection and survival in the palliative management of metastatic colorectal cancer. European Journal of Surgical Oncology 2009;35:164‐7. - PubMed
Costi 2010 {published data only}
    1. Costi R, Mauro D, Giordano P, Leonardi F, Veronesi L, Sarli L, et al. Impact of palliative chemotherapy and surgery on management of stage IV incurable colorectal cancer. Annals of Surgical Oncology 2010;17:432‐40. - PubMed
Costi 2011 {published data only}
    1. Costi R, Mauro D, Veronesi L, Ardizzoni A, Salcuni P, Roncoroni L, et al. Elective palliative resection of incurable stage IV colorectal cancer: Who really benefits from it?. Surgery Today 2011;41:222‐9. - PubMed
Eisenberger 2008 {published data only}
    1. Eisenberger A, Whelan RL, Neugut AI. Survival and symptomatic benefit from palliative primary tumor resection in patients with metastatic colorectal cancer: A review. International Journal of Colorectal Disease 2008;23:559‐68. - PubMed
Evans 2009 {published data only}
    1. Evans MD, Escofet X, Karandikar SS, Stamatakis JD. Outcomes of resection and non‐resection strategies in management of patients with advanced colorectal cancer. World Journal of Surgical oncology 2009;7:28. - PMC - PubMed
Kaufman 2008 {published data only}
    1. Kaufman MS, Radhakrishnan N, Roy R, Gecelter G, Tsang J, Thomas A, et al. Influence of palliative surgical resection on overall survival in patients with advanced colorectal cancer: a retrospective single institutional study. Colorectal Disease 2008;10:498‐502. - PubMed
Kleespies 2009 {published data only}
    1. Kleespies A, Fuessl KE, Seeliger H, Eichhorn ME, Muller MH, Rentsch M, et al. Determinants of morbidity and survival after elective non‐curative resection of stage IV colon and rectal cancer. International Journal of Colorectal Disease 2009;24:1097‐109. - PubMed
Law 2004 {published data only}
    1. Law WL, Chan WF, Lee YM, Chu KW. Non‐curative surgery for colorectal cancer: Critical appraisal of outcomes. International Journal of Colorectal Disease 2004;19:197‐202. - PubMed
Muratore 2006 {published data only}
    1. Muratore A, Zorzi D, Bouzari H, Amisano M, Massucco P, Sperti E, et al. Asymptomatic colorectal cancer with un‐resectable liver metastases: immediate colorectal resection or up‐front systemic chemotherapy?. Annals of Surgical Oncology 2006;14:766‐70. - PubMed
Nash 2002 {published data only}
    1. Nash GM, Saltz LB, Kemeny NE, Minsky B, Sharma S, Schwartz GK, Ilson DH, et al. Radical resection of rectal cancer primary tumor provides effective local therapy in patients with stage IV disease. Annals of Surgical Oncology 2002;9:954‐60. - PubMed
Platell 2011 {published data only}
    1. Platell C, Ng S, O'Bichere A, Tebbutt N. Changing management and survival in patients with stage IV colorectal cancer. Diseases of the Colon and Rectum 2011;54:214‐9. - PubMed
Poeze 1995 {published data only}
    1. Poeze M, Houbiers JG, Velde CJ, Wobbes T, Meyenfeldt M F. Radical resection of locally advanced colorectal cancer. The British journal of surgery 1995;82:1386‐90. - PubMed
Radu 2010 {published data only}
    1. Radu V, Ion D, Serban MB, Ciurea M. Locally aggressive colonic and rectal cancer‐clinical trial. Journal of Medicine & Life 2010;3:314‐9. - PMC - PubMed
Rodel 2010 {published data only}
    1. Rodel C, Arnold D, Becker H, Fietkau R, Ghadimi M, Graeven U, et al. Induction chemotherapy before chemoradiotherapy and surgery for locally advanced rectal cancer: Is it time for a randomised phase III trial?. Strahlentherapie und Onkologie 2010;186:658‐64. - PubMed
Stillwell 2010 {published data only}
    1. Stillwell AP, Buettner PG, Ho YH. Meta‐analysis of survival of patients with stage IV colorectal cancer managed with surgical resection versus chemotherapy alone. World Journal of Surgery 2010;34:797‐807. - PubMed
Temple 2004 {published data only}
    1. Temple LK, Hsieh L, Wong WD, Saltz L, Schrag D. Use of surgery among elderly patients with stage IV colorectal cancer. Journal of Clinical Oncology 2004;22:3475‐84. - PubMed
Venderbosch 2011 {published data only}
    1. Venderbosch S, Wilt JH, Teerenstra S, Loosveld OJ, Bochove A, Sinnige HA, et al. Prognostic Value of Resection of Primary Tumor in Patientswith Stage IV Colorectal Cancer: Retrospective Analysis of Two Randomized Studies and a Review of the Literature. Annals of Surgical Oncology 2011;18:3252‐60. - PMC - PubMed
Verhoef 2011 {published data only}
    1. Verhoef C, Wilt JH, Burger JW, Verheul HM, Koopman M. Surgery of the primary in stage IV colorectal cancer with unresectable metastases. European Journal of Cancer 2011;47(Suppl 3):S61‐6. - PubMed

References to ongoing studies

Obichere 2012 {published data only}
    1. Obichere A. Chemotherapy with or without surgery in treating patients With Metastatic Colorectal Cancer That Cannot Be Removed by Surgery. ClinicalTrials.gov study no. NCT01086618.
Platell 2012 {published data only}
    1. Platell 2012. A randomised phase III multicentre trial evaluating the role of palliative surgical resection of the primary tumour in patients with metastatic colorectal cancer. ACTRN12609000680268.
Rahbari 2012 {published data only}
    1. Rahbari N, Lordick F, Fink C, Bork U, Stange A, Jager D, et al. Resection of the primary tumour versus no resection prior to systemic therapy in patients with colon cancer and synchronous unresectable metastases (UICCstage IV): SYNCHRONOUS ‐ A randomised controlled multicentre trial (ISRCTN30964555). BMC Cancer 2012;12:142. - PMC - PubMed

Additional references

Ballian 2009
    1. Ballian N, Mahvi DM, Kennedy GD. Colonoscopic Findings and Tumor Site Do Not Predict BowelObstruction During Medical Treatment of Stage IV Colorectal Cancer. The Oncologist 2009;14:580‐5. - PubMed
Bokemeyer 2010
    1. Bokemeyer C, Kohne C, Rougier P, Stroh C, Schlichting M, Cutsem E. Cetuximab with chemotherapy (CT) as first‐line treatment for metastatic colorectal cancer (mCRC): analysis of the CRYSTAL and OPUS studies according to KRAS and BRAF mutation status. Journal of Clinical Oncology 2010;28(15.suppl (May 20 Supplement) 2010 ASCO Annual Meeting Proceedings):3506.
Capussotti 2007
    1. Capussotti L, Vigano' L, Ferrero A, Lo Tesoriere R, Ribero D, Polastri R. Timing of resection of liver metastases synchronous to colorectal tumor: proposal of prognosis‐based decisional model. Annals of Surgical Oncology 2007;14(3):1143‐50. - PubMed
Carrera 2011
    1. Carrera G, Garcia‐Albeniz X, Ayuso JR, Aparicio J, Castells A, Codony‐Servat J, et al. Design and endpoints of clinical and translational trials in advanced colorectal cancer. a proposal from GROUP Español Multidisciplinar en Cancer Digestivo (GEMCAD). Reviews on Recent Clinical Trials 2011;6:158‐70. - PubMed
Chen 2000
    1. Chen HS, Sheen‐Chen SM. Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends. Surgery 2000;127:370‐6. - PubMed
Chu 1989
    1. Chu DZ, Lang NP, Thomson C, Osteen PC, Westbrook KC. Peritoneal carcinomatosis in non gynecologic malignancy: a prospective study of prognostic factors. Cancer 1989;63:364‐7. - PubMed
Chung 2008
    1. Chung TS, Lim SB, Sohn DK, Hong CW, Han KS, Choi HS, et al. Feasibility of single‐stage laparoscopic resection after placement of a self‐expandable metallic stent for obstructive left colorectal cancer. World Journal of Surgery 2008;32:2275‐80. - PubMed
Cirocchi 1994
    1. Cirocchi R, Cagini L, Covarelli P, Mazieri M, Severini D, Rossi P, et al. Intestinal obstructions caused by colorectal carcinoma in the aged. Minerva Chirurgica 1994;49:247‐52. - PubMed
Damjanov 2009
    1. Damjanov N, Weiss J, Daniel G. Haller DG. Resection of the primary colorectal cancer is not necessary in nonobstructed patients with metastatic disease. The Oncologist 2009;14:963‐9. - PubMed
Dawson 1983
    1. Dawson LE, Russell AH, Tong D, Wisbeck WM. Adenocarcinoma of the sigmoid colon: sites of initial dissemination and clinical patterns of recurrence following surgery alone. Journal of Surgical Oncology 1983;22:92‐5. - PubMed
DerSimonian 1986
    1. DerSimonian R, Laird N. Meta‐analysis in clinical trials. Controlled Clinical Trials 1986;7:177‐88. - PubMed
Edwards 2010
    1. Edwards BK, Ward E, Kohler BA, Eheman C, Zauber AG, Anderson RN, et al. Annual report to the nation on the status of cancer, 1975‐2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 2010;116:544‐73. - PMC - PubMed
Engstrom 2009a
    1. Engstrom PF, Arnoletti JP, Benson AB 3rd, Chen YJ, Choti MA, Cooper HS, et al. NCCN Clinical Practice Guidelines in Oncology: rectal cancer. Journal of the National Comprehensive Cancer Network 2009;7:838‐81. - PubMed
Engstrom 2009b
    1. Engstrom PF, Arnoletti JP, Benson AB 3rd, Chen YJ, Choti MA, Cooper HS, et al. NCCN Clinical Practice Guidelines in Oncology: colon cancer. Journal of the National Comprehensive Cancer Network 2009;7:778‐831. - PubMed
Glehen 2004
    1. Glehen O, Kwiatkowski F, Sugarbaker PH, Elias D, Levine EA, Simone M, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi‐institutional study. Journal of Clinical Oncology 2004;22:3284‐92. - PubMed
GLOBOCAN 2002
    1. IARC, GLOBOCAN 2002. Cancer Incidence, Mortality and Prevalence Worldwide (2002 estimates). GLOBOCAN.
Greenland 1985
    1. Greenland S, Robins J. Estimation of a common effect parameter from sparse follow‐up data. Biometrics 1985;41:55‐68. - PubMed
Hassan 2010
    1. Hassan I, Advani V. Meta‐analysis of Survival of Patients with Stage 4 Colorectal Cancer Managed with Resection versus Chemotherapy Alone: Letter to the Editor. World Journal of Surgery 2010. - PubMed
Higgins 2009
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 www.cochrane‐handbook.org. The Cochrane Collaboration, 2009.
Inoue 2004
    1. Inoue M, Ohta M, Iuchi K, Matsumura A, Ideguchi K, Yasumitsu T, et al. Benefits of surgery for patients with pulmonary metastases from colorectal carcinoma. Annals of Thoracic Surgery 2004;78(1):238‐44. - PubMed
Iwasaki 2005
    1. Iwasaki A, Shirakusa T, Yamashita Y, Noritoni T, Maekawa T, Hamada T. Characteristic differences between patients who have undergone surgical treatment for lung metastasis or hepatic metastasis from colorectal cancer. The Thoracic and Cardiovascular Surgeon 2005;53(6):358‐64. - PubMed
Karoui 2010
    1. Karoui M, Soprani A, Charachon A, Delbaldo C, Vigano L, Luciani A, et al. Primary chemotherapy with or without colonic stent for management of irresectable stage IV colorectal cancer. European Journal of Surgical Oncology 2010;36:58‐64. - PubMed
Kjaergard 2001
    1. Kjaergard LL, Villumsen J, Gluud C. Reported methodological quality and discrepancies between large and small randomised trials in meta‐analyses. Annals of Internal Medicine 2001;135:982–9. - PubMed
Koopman 2007
    1. Koopman M, Antonini NF, Douma J, Wals J, Honkoop AH, Erdkamp FL, et al. Sequential versus combination chemotherapy with capecitabine, irinotecan, and oxaliplatin in advanced colorectal cancer (CAIRO): a phase III randomised controlled trial. Lancet 2007;370:135‐42. - PubMed
Lucena 2005
    1. Lucena JR. Reseccio´n de metastasis pulmonares en cancer colorectal. Cirugía Española 2005;78:362‐65. - PubMed
Manfredi 2006
    1. Manfredi S, Lepage C, Hatem C, Coatmeur O, Faivre J, Bouvier AM. Epidemiology and management of liver metastases from colorectal cancer. The American Surgeon 2006;244:254‐9. - PMC - PubMed
Mantel 1959
    1. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. Journal of the National Cancer Institute 1959;22:719‐48. - PubMed
McCahill 2010
    1. McCahill LE, Yothers GA, Sharif S, Petrelli NJ, Lopa S, O'Connell MJ, et al. A phase II trial of 5‐fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) chemotherapy plus bevacizumab (bev) for patients (pts) with unresectable stage IV colon cancer and a synchronous asymptomatic primary tumor: Results of NSABP C‐10. Journal of Clinical Oncology 2010;28(15.suppl (May 20 Supplement) 2010 ASCO Annual Meeting Proceedings):3527.
NCI 2006
    1. National Cancer Institute. Surveillance, Epidemiology and End Results (SEER). http://seer.cancer.gov/.
Ocvirk 2010
    1. Ocvirk J, Brodowicz T, Wrba F, Ciuleanu TE, Kurteva G, Beslija S, et al. Cetuximab plus FOLFOX6 or FOLFIRI in metastatic colorectal cancer: CECOG trial. World Journal of Gastroenterology 2010;7:3133‐43. - PMC - PubMed
Poultsides 2009
    1. Poultsides GA, Servais EL, Saltz LB, Patil S, Kemeny NE, Guillem, et al. Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment. Journal of Clinical Oncology 2009;27:3379‐84. - PMC - PubMed
Review Manager [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). The Cochrane Collaboration. Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008.
Simmonds 2006
    1. Simmonds PC, Primrose JN, Colquitt JL, Garden OJ, Poston GJ, Rees M. Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies. British Journal of Surgery 2006;94(7):982‐99. - PMC - PubMed
Stipa 2008
    1. Stipa F, Pigazzi A, Bascone B, Cimitan A, Villotti G, Burza A, et al. Management of obstructive colorectal cancer with endoscopic stenting followed by single‐stage surgery: open or laparoscopic resection?. Surgical Endoscopy 2008;22:1477‐81. - PubMed
Tol 2008
    1. Tol J, Koopman M, Rodenburg CJ, Cats A, Creemers GJ, Schrama JG, et al. A randomised phase IIIstudy on capecitabine, oxaliplatin and bevacizumab with or without cetuximab in first‐line advanced colorectal cancer: theCAIRO2 study of the Dutch Colorectal Cancer Group (DCCG).An interim analysis of toxicity. Annals of Oncology 2008;19:734‐8. - PubMed
Vandenbroucke 2007
    1. Vandenbroucke JP, Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Epidemiology 2007;18:805‐35. - PubMed

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