Author Wang Xi Cheng Wei Qing (Peking University Cancer Hospital,)In patients with advanced colorectal cancer who cannot be treated with rad
Author Wang Xi Cheng Wei Qing (Peking University Cancer Hospital,)
In patients with advanced colorectal cancer who cannot be treated with radical resection, should the primary site be resected if there is no risk of obstruction, bleeding or perforation, or associated symptoms? The author thinks that although there is no high level of evidence, and primary tumor resection do exist risks, but we should see the "removal of the primary tumor will bring prolonged survival and primary tumor related complications reduced in some patients benefit value, therefore should consider the" removal of the primary tumor the 5 factors "under the premise, to choose the most appropriate treatment.
For advanced colorectal cancer in the initial 10% to 20% of the patients can be directly metastasis and primary tumor resection; 15%~30% patients through conversion therapy has the potential to acceptable R0 radical resection may. However, there are still about 60% of patients with advanced colorectal cancer who do not have a chance to undergo radical surgery. In the NCCN guidelines, primary resection of primary colorectal cancer is not recommended if the primary site does not have the risk of obstruction, bleeding or perforation, or related symptoms.
The value of primary resection:
Primary resection may prolong the survival time of patients, and more than 10 years ago, it is one of the most important treatments for advanced colorectal cancer. However, because of the colorectal cancer drug only stay in the single phase of fluorouracil, the overall survival time is less than 1 years, the surgical resection of the primary tumor in the treatment of advanced colorectal cancer also occupy a dominant position. In recent years, there are still a number of studies and meta analysis showed that surgical resection of the primary tumor can prolong the survival time of 4 to 6 months. Unfortunately, many of the studies that show survival benefit are retrospective, single center studies, so that the primary resection may prolong the survival of patients, the argument is not fully convincing.
In colorectal cancer, there are two cases worth learning from. (1) localized peritoneal metastasis: multiple studies support that patients may benefit from peritoneal cytoreductive surgery. (2) the limitation of liver metastasis: the first is the non resectable liver metastasis, which can be converted to resectable liver metastasis. However, it is believed that even if there is a relapse, the patient has a survival benefit from surgical resection.
2 primary resection may improve the quality of life of patients
Although the quality of life of patients with advanced colorectal cancer has improved significantly with the progress of drug therapy, 10% to 20% of patients still need surgery or non-surgical intervention because of the complications associated with the primary tumor. It also suggests that if we do not remove the primary focus, we will be at risk for complications such as obstruction, perforation, bleeding, or abdominal infection at any time after the follow-up treatment. It is clear that the screening of the primary tumor in this population may improve the tolerance and improve the quality of life. I'm afraid it's hard to believe.
Factors to be considered in primary resection
1 primary obstruction, perforation or bleeding is greater risk
Generally, the ratio of left colon with right colon obstruction occurred and emergency operation was significantly higher than that of the right colon. A study shows that when the tumor is located in the rectum or tumor is greater than 5cm, prone to surgical or endoscopic intervention in the primary focus of the relevant complications. Another study suggests that when colonoscopy not by the tumor, with 1 years of domestic demand higher risk of surgical intervention. Therefore, left colon cancer, the tumor is greater than 5 cm and not through colonoscopy patients, all from the potential benefit of primary tumor resection in may. In addition, because of the risk of colorectal cancer surgery is higher than that of colon cancer, and there is still an important factor that can retain the anus, palliative radiotherapy is also an important means to remove the related complications of the primary tumor.
2 sensitive to systemic therapy
Disease progression is an important independent factor for poor prognosis during first-line therapy. Therefore, the primary resection should also try to choose the systemic treatment of sensitive people. A number of recent studies have suggested that, regardless of chemotherapy or chemotherapy combined with targeted therapy, left colon cancer. Therefore, it is more active for the patients who are sensitive to systemic therapy, especially the primary ones from the left colon.
3.RAS and BRAF gene were all wild type
CMS molecular typing of colorectal cancer showed that both RAS and BRAF genes belonged to second groups of molecular subtypes, and the longest survival time was found in this subgroup. We can consider the primary resection as a first-line treatment for extending the progression free time (PFS) beyond systemic therapy.
4 the timing of surgery is relatively small tumor load, the disease is relatively stable period
Learn from the experience of liver metastasis of colorectal cancer, most of the time the opportunity to choose the new adjuvant treatment. By analogy, when the system is effective, the tumor load is reduced, and the tumor cell multiplication is slow, the operation will reduce the risk of postoperative metastasis of rapid growth.
5 the patient's physical condition and accompanying disease does not affect postoperative recovery
For patients with advanced colorectal cancer, the surgery itself is palliative, so the goal is to achieve the minimum cost of primary resection.
Therefore, we should be alert to the selective removal of the primary tumor. Obviously, the above 5 factors if the answer is yes, the more, the more inclined to surgery.
Risk of primary resection
At the time of initial diagnosis for patients with advanced colorectal cancer who cannot be cured, the immediate risk of primary resection may be delayed or even lost. According to a 7 study Meta analysis suggested that for asymptomatic colorectal cancer metastasis, chemotherapy is relatively speaking, palliative resection can lead to more complications, the total incidence accounted for 11.8%, including obstruction, hemorrhage and sepsis, the main complications and delayed systemic chemotherapy, postoperative mortality rate of about 2.7%.
As a result of the initial diagnosis of colorectal cancer is usually given to patients with systemic chemotherapy combined with (or not combined) targeted therapy, so the timing of the primary resection is more choice after the end of treatment. However, because of the absence of significant tumor related symptoms, the risk of primary resection associated with peri operative risk and uncertain survival benefit is an important consideration. Patients with stage IV, especially those with stage IV chemotherapy, were less likely to have physical and nutritional status than patients with locally advanced disease, and the risk of postoperative complications and mortality increased. Therefore, the timing of primary resection should be carefully chosen.
To sum up, the incurable advanced colorectal cancer itself is a highly heterogeneous group, and the general principle of treatment should be individualized and comprehensive treatment in multidisciplinary discussions. Although there is no evidence of a high level of evidence-based medicine to guide the selection of a suitable population for primary resection, there are a number of risks associated with delayed systemic chemotherapy and surgical complications in primary resection. But we should also see that the primary resection will bring some patients to prolong survival and reduce the incidence of related complications. Therefore, we can consider the 5 factors of primary resection. In the future, we also look forward to more prospective studies to provide guidance on how to screen for people with the greatest benefit from primary resection.