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

R 0 resection:

All tumour (primary + metastases) resected with microscopically clear margins

Should the primary tumour in stage IV be resected in patients who cannot be

cured?

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

To treat the most serious aspect of the disease first, without having to wait for

recovery after bowel surgery or complications, is appealing

however

to leave primary tumours with proven metastatic capacity may have

consequences

The scientific support for both strategies is weak.

Studies are retrospective and of different designs.

Palliative studies

Years R/Ch Survival mo Difference

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

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”

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

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.

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