Download The surgeon`s role in advanced CRC with limited metastatic disease

Defining the Colorectal Surgeons role
in patients with colorectal cancer and
limited metastatic disease
Jose G. Guillem, MD, MPH
Department of Surgery
Memorial Sloan Kettering Cancer Center
Great Debates & Updates in
GI Malignancies
March 28-29, 2014
Case
• 58M with 10lb weight loss, rectal
pain/tenesmus, bleeding
• PMH: unremarkable
• DRE: palpable tethered mass with distal
margin at 8cm from AV, 5cm above ring
• Flex sig: circumferential, ulcerated bulky
near-obstructing mass
• CT scan: liver metastases
Stage IV Rectal Cancer
Stage IV Rectal Cancer
Management Options in
Metastatic Rectal Ca
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•
•
•
•
•
Systemic Chemotherapy alone
Stent and Chemotherapy
Divert and Chemotherapy
Resect and Chemotherapy
Chemotherapy and Resect
Chemotherapy, Chemoradiation and
Resect
Central Issues
• Benefit of surgical resection over
stent/diversion alone
– Alleviation of bleeding, pain, tenesmus
• Morbidity and mortality of resection
• Delay in administering systemic chemo
Metastatic Rectal Cancer
• Bulky symptomatic primary with extensive
liver mets
• Bulky symptomatic primary with limited
liver metastases
• Non-bulky asymptomatic primary with
extensive liver mets
• Non-bulky asymptomatic primary with
limited liver mets
Palliation of malignant rectal obstruction
with self-expanding metal stents
• 33 successful stents out of 34 pts (97%)
Stent migration x 3
Intractable pain x 2
Incomplete stent expansion x 1
Incontinence x 1
Rectovesical fistula x 1
Incontinence x 1
Overall, 18% required surgery because of stent complications
Hünerbein M et al. Surgery. 2005
Malignant rectal obstruction within 5cm of
the anal verge: is there a role for
expandable metallic stent placement?
• Group A: obstruction ≤ 5cm from AV
• Group B: obstruction > 5cm from AV
• Tx: PU or PTFE covered retrievable stents
Song HY et al. Gastrointest Endosc. 2008
Radical resection of rectal cancer primary tumor provides
effective local therapy in patients with stage IV disease
• N=80 with rectal CA resection without radiotherapy
• 12 (15%) surgical complications
– 1 death
– 4 reoperations
• 15 (19%) required colostomy at initial resection
• 5 (6%) local recurrences
– Median time to local recurrence = 14 mos
• Median survival = 25 mos
– 11 patients died within 6 mos
Nash GM et al, Annals of Surg Oncol, 2002.
Radical resection of primary in stage IV rectal cancer
patients – who benefits?
• <50% liver replacement
• Complete or near complete response of primary
to first chemo regimen
• Able to receive subsequent aggressive, postoperative chemo
Nash GM et al, Annals of Surg Oncol, 2002.
Would modern, combination
chemotherapy obviate the need
for resection of the primary
rectal cancer?
Combination chemotherapy without
surgery as initial treatment
• 233 patients with synchronous metastatic
colorectal cancer
• 93% of patients who received upfront
chemotherapy never required palliative surgery
for primary tumor
• 89% required no direct symptomatic
management for intact primary tumor
Poultsides et al. J Clin Oncol 2009
Combination chemotherapy without
surgery as initial treatment
Rectal Primary
(n=78)
No Emergent
Intervention
85% (n=66)
Emergent PrimaryDirected Intervention
15% (n=12)
Poultsides et al. J Clin Oncol 2009
Would modern, combination chemotherapy
obviate the need for resection of the primary
rectal cancer?
In some, initially yes, but if combinational
chemotherapy converts unresectable liver
mets to resectable, in the long run we may
need to address the primary rectal cancer in
more.
Anastomotic leak following low anterior
resection in stage IV rectal cancer is associated
with poor survival
• N = 123 pts resected with curative intent
3y OS 72%
Multivariate analysis for overall survival
3y OS 32%
Overall leak rate 6.5%
Factors identified as significant in univariate
analysis for Overall Survival (OS)
Smith JD et al. Ann Surg Oncol. 2013
Management Dilemma
Morbidity
Efficacy
Treatment Pathway
Stage IV Rectal Cancer
with Synchronous
Liver Metastases
Obstructed
Resect
Stent
Divert
Resectable Liver Metastases
Isolated, Single,
or Peripheral
No Extrahepatic
Metastases
Extrahepatic
Metastases
Nonresectable
Liver Metastases
Chemotherapy
Bilobar or
Multiple
Resect Liver
Non-obstructed
Chemotherapy
Resectable Rectum
Nonresectable Rectum
Resect Rectum
Chemoradiation Therapy
Resect
metastases
and rectum
if possible
Treatment Pathway
Stage IV Rectal Cancer
with Synchronous
Liver Metastases
Obstructed
Resect
Stent
Divert
Resectable Liver Metastases
Isolated, Single,
or Peripheral
Resectable Rectum
No Extrahepatic
Metastases
Extrahepatic
Metastases
Nonresectable
Liver Metastases
Chemotherapy
Bilobar or
Multiple
Resect Liver
Non-obstructed
Systemic
Chemotherapy
vs. HAI
Nonresectable Rectum
Resect
metastases
and rectum
if possible
When, and in
what order?
Synchronous vs. Staged
Resect Rectum
Chemoradiation Therapy Chemotherapy first, then radiation?
Short-course vs. long-course?
Management Options in
Unresectable Metastatic Rectal Ca
• If symptoms of primary (bleeding, pain,
tenesmus) are formidable and volume of
liver mets limited (<50%) : Resect primary
• If patient cannot tolerate rectal resection:
Laparoscopic diversion
• Defer stenting rectal cancer as last resort
Metastatic Rectal CA – Chemotherapy,
Radiation, Divert, Stent or Resect First?
• Multidisciplinary approach throughout
• Colorectal surgeon:
Bulk/lumen of primary, CRM, sphincter
preservation, co-morbidities?
• Liver surgeon
Resectability of mets, status of liver
parenchyma, co-morbidities
• Medical/Radiation Oncologist
Co-morbidities, volume:primary vs mets
Metastatic Rectal Cancer – Chemotherapy,
Radiation, or Surgery First?
Individualize,
Individualize,
Individualize