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Treatment strategies for colon cancer at TNM stage IV

Treatment strategies for colon cancer at TNM stage IV. Gunnar Arbman Department of Surgery Norrköping, Sweden Bergen June 2011. Definitions. Stage IV colon cancer: Any T, any N, M1 (a + b) UICC: metastases diagnosed within 2 months from surgery are classified as synchronous

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Treatment strategies for colon cancer at TNM stage IV

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  1. Treatment strategies for colon cancer at TNM stage IV Gunnar Arbman Department of Surgery Norrköping, Sweden Bergen June 2011

  2. Definitions Stage IV colon cancer: Any T, any N, M1 (a + b) UICC: metastases diagnosed within 2 months from surgery are classified as synchronous R 0 resection: All tumour (primary + metastases) resected with microscopically clear margins

  3. Should the primary tumourin stage IV be resected in patients who cannot be cured?

  4. Treatment strategies Traditional strategy: Resect primary tumour and then start oncologic therapy Alternative strategy: Oncologic therapy directly, leave the primary tumour in place if possible

  5. To treat the most serious aspect of the disease first, without having to wait for recovery after bowel surgery or complications, is appealinghoweverto leave primary tumours with proven metastatic capacity may have consequences

  6. The scientific support for both strategies is weak.Studies are retrospective and of different designs.

  7. Palliative studies Years R/Ch Survival mo Difference Matheme et al 73-92 81/70 7,5/2,5 -5 Liu et al 86-91 57/11 11/3 -8 Scoggins et al 85-97 66/23 14,5/16,6 2 Cook et al 88-00 17656/9097 11-16/2-6 -9-10 Temple et al 91-99 6469/2542 10/3 -7 Terbutt et al 90-00 280/82 14/8,2 -6 Ahmed et al 92-00 594/219 9,7/3,3 -6 Konyalin et al 91-02 62/47 12,3/4,5 -8 Cummins et al 89-03 36/38 11,5/4,5 -7 Ruo et al 96-99 127/103 16/9 -7 Law et al 96-99 150/30 7/4 -3 Stelzner et al 95-01 128/58 11,4/4,6 -7 Michel et al 96-99 31/23 21/14 -7 Benoist et al 97-02 32/27 23/22 -1 Galizia et al 95-05 42/23 15,2/12,3 -3 Kaufman et al 98-03 115/21 22/15 -7 Bajwa et al 99-05 32/38 14/6 -8 Koopman et al 03-05 368/151 16,8/12,2 -4 Cellini et al 02-08 22/9 32/37 5

  8. Metaanalyses • Scheer et al 2008 7 studies ”primary resection provides minimal palliative benefit, risk for major morbidity/mortality and delays chemotherapy” • Eisenberg et al 2008 12 studies ”non-curative resection may prolong survival” • Stillwell et al 2010 8 studies ”primary resection improves survival and avoids the need for emergency surgery”

  9. Stent study Frago (2010): 52 patients with generalized left sided colon cancer and obstruction +/- perforation 12 patients resected because of perforation (6) or stent complications (6) 40 patients with primary tumour left i place with stents or stomas (5, due to stent complications) All had the same type of chemotherapy Median survival: Resected 24 months Not resected 4 months

  10. Conclusion There is not enough evidence to state if the primary tumour should be resected or not, but it may be that removing the primary tumour prolongs life in the palliative situation. Randomized studies are needed to clarify this.

  11. PGC-trial Swedish (Scandinavian) multicenter prospective randomized trial comparing the two strategies. Primary endpoint is median survival. www.clinicaltrials.gov Studies in GB and Australia/NZ as well

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