1. Is there a role for surgery in metastatic colorectal cancer?
Alan E. Harzman, MD
Assistant Professor - Clinical
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2. Yes.
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Thank you for your time.

3. Outline Obstruction Overview of colorectal metastasis
Solid organ metastasis
Peritoneal metastasis
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4. Obstruction
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5. Obstruction 8-29% of CRC patients at initial presentation
77% left-sided, 23% right-sided
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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
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7. Overview
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8. Sites of Colorectal Metastasis
Peritoneum
Liver
Portal circulation
Lung
Ovary
Bone
Brain
Incisions
Spleen
Other
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9. Sites of Possible Ectomies
Peritoneum
Liver
Lung
Ovary
Bone
Brain
Incisions
Spleen
Other
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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
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11. Lung
as an example
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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
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13. Survival After Lung Resection
Operative mortality – 3%
3-year survival – 45-78%
5-year survival – consistently around 30%
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14. Liver
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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
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16. Surgical Options for Hepatic Metastasis
Hepatectomy
Hepatic Artery Infusion
Radio frequency ablation
Cryoablation
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17. Hepatectomy Mortality – 5% or less Morbidity – 20-50%
5-year survival – 25-40%
10-year survival – 20-26%
Median survival months
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18. Hepatectomy Not for Two-thirds will recur Extra-hepatic disease
Except maybe pulmonary or anastomotic
Incomplete resectability
Two-thirds will recur
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19. aka peritoneal carcinomatosis
Peritoneum
aka peritoneal carcinomatosis
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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
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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
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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
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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
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26. Factors in Pseudomyxoma Peritonei
Tumor grade
Extent of mesenteric invasion
Liver metastasis
Age
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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
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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%
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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
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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
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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
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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.
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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.
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