Nonoperative management of primary colorectal cancer in patients with stage IV disease

Background: Traditional teaching maintains that patients with primary color ectal adenocarcinoma require timely resection to prevent bleeding, perforat ion, or obstruction. The true benefits of primary tumor resection remain un documented for patients presenting with metastatic disease, however. We pos tulated that resection of primary colorectal tumors could be avoided safely in a select population of asymptomatic colorectal cancer patients presenti ng with incurable stage IV disease. Methods: A retrospective review of the Vanderbilt University Hospital tumor registry was performed for the years 1985 to 1997. During this period, 955 patients presented for management of primary colorectal cancer. From this group, all patients with stage TV disease at the time of diagnosis were ide ntified. Patients who initially underwent resection of their primary lesion were included in the resection group; those who underwent initial nonopera tive primary tumor management were included in the nonresection group. Data were obtained regarding age, extent of disease, nonsurgical therapy, tumor -specific complications, and palliative surgical procedures. Surgery-free s urvival and overall survival were analyzed using the Kaplan-Meier method. F or patients with liver metastases, hepatic tumor burden was defined as eith er H1 (<25% parenchymal replacement), H2 (25% to 50%), or H3 (>50%) disease . Results: Sixty-six patients were included in the resection group, and 23 pa tients with intact asymptomatic primary colorectal lesions were included in the nonresection group. Among patients with hepatic metastases, most of th e patients in both groups had H1 disease. Ten patients in the resection gro up and 3 patients in the nonresection group presented with exclusively extr ahepatic metastases. In the nonresection group, primary therapy included ch emotherapy in 13 patients, external beam radiation therapy in 1 patient, an d combination chemoradiation in 9 patients. The median survival in the nonr esection group was 16.6 months. The 2-year actuarial survival was 18%, and the surgery-free survival was 91.3%. Only 2 of 23 patients (8.7%) managed w ithout resection eventually developed obstruction at the primary tumor site requiring emergent diversion. There were no episodes of tumor-related hemo rrhage or perforation. For the resection group, the operative morbidity was 30.3%, and the perioperative mortality rate was 4.6%. The median survival in the resection group was 14.5 months (P = 0.59, log-rank test vs. nonrese ction group). Conclusions: Selected patients with asymptomatic primary colorectal tumors who present with incurable metastatic disease may safely avoid resection, o f their primary lesions, with an anticipated low rate of hemorrhage, perfor ation, or obstruction before death from systemic disease. Mo survival advan tage is gained by resection of an asymptomatic primary lesion in the settin g of incurable stage IV colorectal cancer.