Prognostic Value of Resection of Primary Tumor in Patients with Stage IV Colorectal Cancer: Retrospective Analysis of Two Randomized Studies and a Review of the Literature

Abstract

BackgroundIn patients with metastatic colorectal cancer (mCRC) with an asymptomatic primary tumor, there is no consensus on the indication for resection of the primary tumor.MethodsA retrospective analysis was performed on the outcome of stage IV colorectal cancer (CRC) patients with or without resection of the primary tumor treated in the phase III CAIRO and CAIRO2 studies. A review of the literature was performed.ResultsIn the CAIRO and CAIRO2 studies, 258 and 289 patients had undergone a primary tumor resection and 141 and 159 patients had not, respectively. In the CAIRO study, a significantly better median overall survival and progression-free survival was observed for the resection compared to the nonresection group, with 16.7 vs. 11.4 months [P < 0.0001, hazard ratio (HR) 0.61], and 6.7 vs. 5.9 months (P = 0.004; HR 0.74), respectively. In the CAIRO2 study, median overall survival and progression-free survival were also significantly better for the resection compared to the nonresection group, with 20.7 vs. 13.4 months (P < 0.0001; HR 0.65) and 10.5 vs. 7.8 months (P = 0.014; HR 0.78), respectively. These differences remained significant in multivariate analyses. Our review identified 22 nonrandomized studies, most of which showed improved survival for mCRC patients who underwent resection of the primary tumor.ConclusionsOur results as well as data from literature indicate that resection of the primary tumor is a prognostic factor for survival in stage IV CRC patients. The potential bias of these results warrants prospective studies on the value of resection of primary tumor in this setting; such studies are currently being planned.

Complications from the primary tumour are not related with survival in patients with synchronous stage IV colorectal cancer receiving chemotherapy without primary tumour resection

“…A major draw-back of these studies was that patients with better prognosis at the moment of diagnosis were more likely to undergo surgery. An analysis of patients from CAIRO and CAIRO2 studies showed a benefit in overall survival and progression-free survival for patients in which the primary tumour resection was performed [12]. These data can be influenced by the criteria used for selecting patients and depend on the extent of the metastatic disease and the condition of the patients.…”

Primary Tumour Resection Could Improve the Survival of Unresectable Metastatic Colorectal Cancer Patients Receiving Bevacizumab-Containing Chemotherapy

“…However, the efficacy of initial primary tumour resection is uncertain. Recently, results from amount of studies and retrospective analyses have shown that the resection of the primary tumour provides some benefits to patients with unresectable colorectal metastases in terms of both the OS and PFS [11][12]. On the other hand, Poultsides George et al [13] reported based on a prospective institutional database that most patients with synchronous mCRC who have receive up-front modern combination chemotherapy never require palliative surgery for their intact primary tumour.…”

Current controversies in the management of metastatic colorectal cancer

“…The authors concluded that avoiding resection of the primary tumor was acceptable because, in a high proportion of patients, possible complications associated with the primary tumor did not compromise survival [13]. Nonetheless, some analysts suggest a benefit in survival associated with the resection of the primary tumor in patients with mCRC [14][15][16][17][18]. New prospective studies including CLIMAT-PRODIGE 30, CAIRO 4, and SYN-CHRONOUS are currently evaluating this question.…”

“…Also, age, PS, and comorbidities help to define the treatment strategy for many patients [7,9]. Regarding the question of carrying out surgery in the primary tumor, this procedure is not always required [13][14][15][16][17][18]. In addition, the location of the CRC may have prognostic and predictive implications on response to treatment or on treatment resistance [20,24,25].…”