No abstract

Death from colorectal cancer frequently results from manifestations of recurrent local or metastatic disease following initial 'curative' therapy. Presently, the attempted curative treatment of recurrent colorectal cancer lays in the hands of the surgeon. This paper reviews the natural history of surgically treated large bowel cancer and summarizes published and National Cancer Institute experience with the surgical therapy of recurrent disease. A schema with rationale is offered for follow-up of the patient following 'curative' bowel resection. The treatment of recurrent disease incorporating the use of CEA initiated second-look laparotomy is advocated. Hepatic and pulmonary resections for metastatic disease are accepted as important therapeutic endeavours, and are discussed in some detail. It is concluded that of all patients diagnosed as having large bowel cancer, roughly 70% are resectable for cure at time of presentation, and 45% will indeed be cured by primary resection. Of the 25% who fail primary therapy, approximately 20% (5% of all colorectal cancer patients) can be cured by local re-resection or hepatic or pulmonary resection.

This report analyzes an experience with 33 hepatic resections for metastatic colorectal cancer over a 7-year period and with intraperitoneal 5-FU administered as a postresection adjuvant in 21 of these patients. Particular emphasis is placed on the identification of clinical determinants of postresection survival. There was no operative mortality in this series. Postoperative complications occurred in 27% of patients, and the incidence of complications correlated with intraoperative blood loss (p = 0.002). Two- and 4-year estimated survivals were 72% and 53%, respectively. Patients with three or fewer metastases resected or with unilobar disease had improved survival when compared with patients having more than three metastases or bilobar disease, respectively (p less than 0.05). Disease-free survival was improved in patients with microscopically negative resection margins (p = 0.019). Dukes' stage of the primary lesion, interval between bowel resection and detection of hepatic metastases, method of detection of metastases, preoperative CEA level, and type of operation performed were not predictive of postresection survival. Intraperitoneal 5-FU was well tolerated. There was a trend toward improved survival in patients receiving adjuvant chemotherapy, but this was not statistically significant. It is concluded that the number of metastases resected, the distribution of the metastases, and the technical adequacy of the excision are all predictive of outcome following hepatic resection of colorectal metastases. Encouraging results with the use of intraperitoneal 5-FU as a postresection adjuvant have led to the initiation of a prospective randomized trial investigating this modality at the NCI.