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Is there a role for surgery in metastatic colorectal cancer? Alan E. Harzman, MD Assistant Professor - Clinical.

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Presentation on theme: "Is there a role for surgery in metastatic colorectal cancer? Alan E. Harzman, MD Assistant Professor - Clinical."— Presentation transcript:

1 Is there a role for surgery in metastatic colorectal cancer? Alan E. Harzman, MD Assistant Professor - Clinical

2 Yes. Thank you for your time.

3 Outline Obstruction Overview of colorectal metastasis Solid organ metastasis Peritoneal metastasis

4 Obstruction

5 8-29% of CRC patients at initial presentation 77% left-sided, 23% right-sided

6 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

7 Overview

8 Sites of Colorectal Metastasis Peritoneum Liver –Portal circulation Lung Ovary Bone Brain Incisions Spleen Other

9 Sites of Possible Ectomies Peritoneum Liver Lung Ovary Bone Brain Incisions Spleen Other

10 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 cant raise health like the government can raise taxes

11 Lung as an example

12 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

13 Survival After Lung Resection Operative mortality – 3% 3-year survival – 45-78% 5-year survival – consistently around 30%

14 Liver

15 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

16 Surgical Options for Hepatic Metastasis Hepatectomy Hepatic Artery Infusion Radio frequency ablation Cryoablation

17 Hepatectomy Mortality – 5% or less Morbidity – 20-50% 5-year survival – 25-40% 10-year survival – 20-26% Median survival 24-46 months

18 Hepatectomy Not for –Extra-hepatic disease Except maybe pulmonary or anastomotic –Incomplete resectability Two-thirds will recur

19 Peritoneum aka peritoneal carcinomatosis

20 '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

21 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

22 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

23 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

24 (Cotte et al., 2009)

25 Pseudomyxoma Peritonei Often diagnosed with acute appendicitis, abdominal swelling or ovarian mass Minimal operating should be done at the time of diagnosis Confusing pathology

26 Factors in Pseudomyxoma Peritonei Tumor grade Extent of mesenteric invasion Liver metastasis Age

27 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

28 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

29 (Cotte et al., 2009)


31 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%

32 Schematic diagram of HIPEC procedure. Glockzin et al. World Journal of Surgical Oncology 2009 7:5 doi:10.1186/1477-7819-7-5

33 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

34 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

35 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

36 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.

37 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.


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