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Is there a role for surgery in metastatic colorectal cancer?

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Presentation on theme: "Is there a role for surgery in metastatic colorectal cancer?"— Presentation transcript:

1 Is there a role for surgery in metastatic colorectal cancer?
Alan E. Harzman, MD Assistant Professor - Clinical Set B1 – Title Slide

2 Yes. Large Projection – Content Slide Thank you for your time.

3 Outline Obstruction Overview of colorectal metastasis
Solid organ metastasis Peritoneal metastasis Set B1 – Content Slide

4 Obstruction Large Projection – Content Slide

5 Obstruction 8-29% of CRC patients at initial presentation
77% left-sided, 23% right-sided Set B1 – Content Slide

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 Set B1 – Content Slide

7 Overview Large Projection – Content Slide

8 Sites of Colorectal Metastasis
Peritoneum Liver Portal circulation Lung Ovary Bone Brain Incisions Spleen Other Set B1 – Content Slide

9 Sites of Possible Ectomies
Peritoneum Liver Lung Ovary Bone Brain Incisions Spleen Other Set B1 – Content Slide

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 can’t raise health like the government can raise taxes Set B1 – Content Slide

11 Lung as an example Large Projection – Content Slide

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 Set B1 – Content Slide

13 Survival After Lung Resection
Operative mortality – 3% 3-year survival – 45-78% 5-year survival – consistently around 30% Set B1 – Content Slide

14 Liver Large Projection – Content Slide

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 Set B1 – Content Slide

16 Surgical Options for Hepatic Metastasis
Hepatectomy Hepatic Artery Infusion Radio frequency ablation Cryoablation Set B1 – Content Slide

17 Hepatectomy Mortality – 5% or less Morbidity – 20-50%
5-year survival – 25-40% 10-year survival – 20-26% Median survival months Set B1 – Content Slide

18 Hepatectomy Not for Two-thirds will recur Extra-hepatic disease
Except maybe pulmonary or anastomotic Incomplete resectability Two-thirds will recur Set B1 – Content Slide

19 aka peritoneal carcinomatosis
Peritoneum aka peritoneal carcinomatosis Large Projection – Content Slide

20 'Omental cake' in a patient with peritoneal carcinomatosis arising from appendiceal cancer.
Glockzin et al. World Journal of Surgical Oncology :5   doi: /

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 Set B1 – Content Slide

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 Set B1 – Content Slide

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 Set B1 – Content Slide

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 Set B1 – Content Slide 25

26 Factors in Pseudomyxoma Peritonei
Tumor grade Extent of mesenteric invasion Liver metastasis Age Set B1 – Content Slide

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 Set B1 – Content Slide

28 Omphalectomy in a patient with umbilical tumor infiltration.
Glockzin et al. World Journal of Surgical Oncology :5   doi: /

29 (Cotte et al., 2009)

30 (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% Set B1 – Content Slide

32 Schematic diagram of HIPEC procedure.
Glockzin et al. World Journal of Surgical Oncology :5   doi: /

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 Set B1 – Content Slide

34 Survival With cytoreductive surgery and intraperitoneal hyperthermic chemotherapy Survival months 28-60 months with complete macroscopic cytoreduction With systemic chemotherapy alone (5-FU/leucovorin) 12-14 months Set B1 – Content Slide 34

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 Set B1 – Content Slide 35

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. Set B1 – Content Slide 36

37 References Berri, RN, & Abdalla EK. (2009). Curable metastatic colorectal cancer: recommended paradigms. Current Oncology Reports, 11, Cotte, E, Passot, G, Mohamed, F, Vaudoyer, D, & Glehen, O. (2009). Management of peritoneal carcinomatosis from colorectal cancer. The Cancer Journal, 15(3), 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, Wolff, BG, Fleshman, JW, Beck, DE, Pemberton, JH, & Wexner, SD. (2007). The ASCRS textbook of colon and rectal surgery. New York: Springer. Set B1 – Content Slide

38 Large Projection Closing Slide

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