defining the colorectal surgeons role in patients with colorectal cancer and limited metastatic...
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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
Management Options in Metastatic Rectal Ca
• 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
• 33 successful stents out of 34 pts (97%)
Palliation of malignant rectal obstruction with self-expanding metal stents
Hünerbein M et al. Surgery. 2005
Overall, 18% required surgery because of stent complications
Stent migration x 3Intractable pain x 2Incomplete stent expansion x 1Incontinence x 1
Rectovesical fistula x 1Incontinence x 1
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.
• <50% liver replacement
• Complete or near complete response of primary to first chemo regimen
• Able to receive subsequent aggressive, post-operative chemo
Radical resection of primary in stage IV rectal cancer patients – who benefits?
Nash GM et al, Annals of Surg Oncol, 2002.
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
Poultsides et al. J Clin Oncol 2009
Rectal Primary(n=78)
No Emergent Intervention
85% (n=66)
Emergent Primary-Directed Intervention
15% (n=12)
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
Smith JD et al. Ann Surg Oncol. 2013
Overall leak rate 6.5%
3y OS 72%
3y OS 32%
Factors identified as significant in univariate analysis for Overall Survival (OS)
Multivariate analysis for overall survival
Treatment PathwayStage IV Rectal Cancer
with Synchronous Liver MetastasesObstructed Non-obstructed
Resect Stent Divert Extrahepatic Metastases
No Extrahepatic Metastases
ChemotherapyResectable Liver Metastases Nonresectable Liver Metastases
Isolated, Single, or Peripheral
Bilobar or Multiple
ChemotherapyResect Liver
Resectable Rectum Nonresectable Rectum
Chemoradiation TherapyResect Rectum
Resect metastases and rectumif possible
Treatment PathwayStage IV Rectal Cancer
with Synchronous Liver MetastasesObstructed Non-obstructed
Resect Stent Divert Extrahepatic Metastases
No Extrahepatic Metastases
ChemotherapyResectable Liver Metastases Nonresectable Liver Metastases
Isolated, Single, or Peripheral
Bilobar or Multiple
ChemotherapyResect Liver
Resectable Rectum Nonresectable Rectum
Chemoradiation TherapyResect Rectum
Resect metastases and rectumif possible
Synchronous vs. Staged
Systemic vs. HAI
Chemotherapy first, then radiation?Short-course vs. long-course?
When, and in what order?
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