Post on 26-Mar-2015
Is there a role for surgery in metastatic colorectal cancer?
Alan E. Harzman, MD
Assistant Professor - Clinical
Yes.
Thank you for your time.
Outline
• Obstruction
• Overview of colorectal metastasis
• Solid organ metastasis
• Peritoneal metastasis
Obstruction
Obstruction
• 8-29% of CRC patients at initial presentation
• 77% left-sided, 23% right-sided
Interventions
• Low-residue diet and start chemotherapy or radiation
• Laser therapy to open lumen (for distal lesions)
• Fulguration• Stent• Diverting stoma• Resection +/- anastomosis
– But not above another lesion
Overview
Sites of Colorectal Metastasis• Peritoneum• Liver
– Portal circulation
• Lung• Ovary• Bone• Brain• Incisions• Spleen• Other
Sites of Possible Ectomies• Peritoneum• Liver• Lung• Ovary• Bone• Brain• Incisions• Spleen• Other
Basic Elements of a Good Metastasectomy
• Long disease-free interval
• Slow-growing disease
• Good functional status
• Good exit strategy– This is not like a war. We can’t raise health
like the government can raise taxes
Lung
as an example
Factors in Lung Resection
• Ideally, a solitary metastasis. Possibly multiple nodules in one lung, or a single nodule in each.
• Primary site is controlled
• No other evidence of metastasis
• Patient can tolerate resection
Survival After Lung Resection
• Operative mortality – 3%
• 3-year survival – 45-78%
• 5-year survival – consistently around 30%
Liver
Liver Metastasis
• 60% of the 150,000 new US cases of CRC yearly will eventually develop liver metastasis.
• 10% of those people will be candidates for curative-intent hepatic surgery
• 5-10 month survival untreated
• 24-23% 3-year and 2-8% 5-year survival of people who might have been surgical candidates in retrospect
Surgical Options for Hepatic Metastasis
• Hepatectomy
• Hepatic Artery Infusion
• Radio frequency ablation
• Cryoablation
Hepatectomy
• Mortality – 5% or less
• Morbidity – 20-50%
• 5-year survival – 25-40%
• 10-year survival – 20-26%
• Median survival 24-46 months
Hepatectomy
• Not for– Extra-hepatic disease
• Except maybe pulmonary or anastomotic
– Incomplete resectability
• Two-thirds will recur
Peritoneum
aka peritoneal carcinomatosis
'Omental cake' in a patient with peritoneal carcinomatosis arising from appendiceal cancer.Glockzin et al. World Journal of Surgical Oncology 2009 7:5 doi:10.1186/1477-7819-7-5
Peritoneal Carcinomatosis - Mechanisms
• Seeding from T4 CRC
• Extravasation with perforation of the tumor
• Tumor perforation at operation
• Leakage of tumor cells from lymphatics or veins at time of operation
Peritoneal Carcinomatosis
• 10-15% of patients at CRC presentation
• 25-35% of CRC recurrences
• Survival 6-8 months without therapy
• Can lead to malignant ascites or malignant bowel obstruction
Peritoneal Surface Malignancy Group
• Increased probability of complete macroscopic cytoreduction in CRC– ECOG performance status <=2– No extra-abdominal disease– Up to three, small, resectable hepatic mets– No biliary obstruction– No ureteral obstruction– Small bowel – no gross mesenteric disease – Small-volume disease in gastro-hepatic ligament
(Cotte et al., 2009)
Pseudomyxoma Peritonei
• Often diagnosed with acute appendicitis, abdominal swelling or ovarian mass
• Minimal operating should be done at the time of diagnosis
• Confusing pathology
Factors in Pseudomyxoma Peritonei
• Tumor grade
• Extent of mesenteric invasion
• Liver metastasis
• Age
Cytoreductive Surgery
• Peritonectomy (parietal and visceral)• Greater omentectomy• Lesser omentectomy• Splenectomy• Cholecystectomy• Liver capsule resection• Small bowel resection• Large bowel/rectal resection• Hysterectomy• Oopherectomy• Cystectomy• Omphalectomy – for invasion of umbilicus
Omphalectomy in a patient with umbilical tumor infiltration.Glockzin et al. World Journal of Surgical Oncology 2009 7:5 doi:10.1186/1477-7819-7-5
(Cotte et al., 2009)
(Cotte et al., 2009)
Intraperitoneal Chemotherapy
• Mortality – 5%• Morbidity – 35%• Various agents, especially mitomycin C• Hyperthermia
– Increased chemotherapeutic activity– Direct effects – protein denaturation, induction of
apoptosis, inhibition of angiogenesis
• High local dose with less systemic toxicity• Complete gross resection is most important
– 5-year survival – 27-54%
Schematic diagram of HIPEC procedure.Glockzin et al. World Journal of Surgical Oncology 2009 7:5 doi:10.1186/1477-7819-7-5
Cytoreductive Surgery and IPHP
• Morbidity 25-41%– Surgical – Anastomotic leak, ileus, wound
infection, bleeding, thrombosis, embolism– Chemotherapeutic – Leukopenia, anemia,
thrombopenia, heart, liver, renal
• Mortality 0-8%
• Shows individual and institutional learning curves
Survival
• With cytoreductive surgery and intraperitoneal hyperthermic chemotherapy– Survival 15-32 months– 28-60 months with complete macroscopic
cytoreduction
• With systemic chemotherapy alone (5-FU/leucovorin)– 12-14 months
Quality of Life
• Acceptable functional status returns at 3-6 months
• 32% depressed at surgery, and 24% one year afterward
• Role and social functioning may remain impaired in long-term functioning
Summary• There are a wide variety of options for surgical
therapy in metastatic colorectal cancer. • Most are very invasive and somewhat risky. • However, they all extend meaningful life in
properly selected patients. • Those patients may be the minority of patients
with metastatic colorectal cancer, but with 150,000 new cases a year, there are many of them out there.
References• Berri, RN, & Abdalla EK. (2009). Curable metastatic colorectal cancer:
recommended paradigms. Current Oncology Reports, 11, 200-208. • Cotte, E, Passot, G, Mohamed, F, Vaudoyer, D, & Glehen, O. (2009).
Management of peritoneal carcinomatosis from colorectal cancer. The Cancer Journal, 15(3), 243-248.
• Glockzin, G. (2009). Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. World Journal of Surgical Oncology, 7(5).
• Gordon, PH, & Nivatvongs, S. (2007). Principles and practice of surgery for the colon, rectum, and anus. Third edition. New York: Informa Healthcare.
• Moran, B, Baratti, D, Yan, TD, Kusamura, S, & Deraco, M. (2008). Consensus statement on teh loco-regional treatment of appendiceal mucinous neoplasms with peritoneal dissemination (pseudomyxoma peritonei). Journal of Surgical Oncology, 98, 277-282.
• Wolff, BG, Fleshman, JW, Beck, DE, Pemberton, JH, & Wexner, SD. (2007). The ASCRS textbook of colon and rectal surgery. New York: Springer.