Comprehensive Management of Disseminated Colorectal Cancer

Abstract

In 1977, Foster and Berman published a book showing surprising long-term benefits from the resection of liver tumors. Adson and colleagues from the Mayo Clinic in 1984 focused on the resection of isolated dissemination of colorectal cancer to the liver. Shortly thereafter, Hughes and colleagues reinforced these data by publishing a multiinstitutional registry of colorectal cancer metastases. This survey of 859 patients established a survival rate of approximately 30% in this large group of patients previously expected to have a 0% 5-year survival. Hughes and colleagues also established the pattern of failure to be expected after liver resection. Fernandez-Trigo and colleagues constructed a similar registry of repeat liver resections for colorectal cancer. They established that reoperation in this clinical setting was equally beneficial to the first resection. Numerous publications have established the prognostic indicators to be used to select these patients. However, no single clinical feature, such as multiple liver metastases, could be used as an absolute contraindication to liver resection. Even patients with concomitant liver metastases and other sites of disseminated disease could benefit from cancer resection. The single clinical requirement necessary for a potentially curative surgical intervention was complete resection of all sites of disease. As the requirement for complete resection of colorectal liver metastases was recognized as an absolute requirement of long-term benefit, Adam and colleagues developed treatment strategies to convert unresectable to resectable disease. Neoadjuvant chemotherapy with 5-fluorouracil and oxaliplatin will shrink the liver disease sufficiently in approximately 15% of patients so that a conversion of unresectable to resectable liver tumors occurs. The long-term survival of these patients in whom neoadjuvant chemotherapy made liver resection possible was similar to that in patients not requiring chemotherapy before liver resection. Although liver resection for colorectal metastatic disease is now considered the standard of care, no prospective randomized clinical trials have been published to support this surgical paradigm. Kaido, in his systematic review, concluded that no level 1 evidence supporting the superiority of surgical treatment of colorectal liver metastases over other treatments was available. Approximately a decade after the historically important contributions of Foster, Adson, and Hughes, new technologies emerged that allowed an evolution of surgical treatments of peritoneal dissemination of colorectal cancer. The surgical innovation was the peritonectomy procedure. The chemotherapeutic innovation was perioperative intraperitoneal chemotherapy. As clinical studies of this combined approach were published from many different institutions, the absolute necessity of a complete resection emerged, as was previously demonstrated for the surgical removal of liver metastases. A phase III study published by Zoetmulder and colleagues and a multi-institutional study published by Glehen and colleagues confirmed that cytoreductive surgery and perioperative intraperitoneal chemotherapy exist as a treatment option to be considered in all patients with peritoneal carcinomatosis from colorectal cancer. The remarkably similar benefits in survival achieved by radical resection of liver metastases and the complete resection of peritoneal carcinomatosis were first described by Gertsch in his historical perspective on these two clinical entities. Gertsch concluded that both the liver and peritoneum should be regarded as anatomic sites of locoregional spread of colorectal cancer and appropriate for surgical intervention. With liver metastases the comprehensive management includes systemic chemotherapy in an adjuvant or neoadjuvant setting, along with liver resection. With peritoneal Society of Surgical Oncology 2008

DOI: 10.1245/s10434-008-0173-y

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Cite this paper

@article{Sugarbaker2008ComprehensiveMO, title={Comprehensive Management of Disseminated Colorectal Cancer}, author={Paul H Sugarbaker}, journal={Annals of Surgical Oncology}, year={2008}, volume={15}, pages={3327-3330} }