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PRIMARY TUMOUR RESECTION CONFERS BENEFIT ON THE OVERALL SURVIVAL OF PATIENTS WITH METASTATIC COLORECTAL CANCER (MCRC) AND UNRESECTABLE METASTASES
Joel Wen Liang Lau1, Heidi S. Chang1, Kai Yin Lee*1, Wen Qiang S. Lee2, Choon Seng Chong1
1University Surgical Cluster, National University Healthcare System, Singapore, Singapore; 2Yong Loo Lin School of Medicine, National University Of Singapore, Singapore, Singapore
Background:
Patients with mCRC and unresectable metastases undergo surgery either emergently or semi-electively for symptomatic tumours, or tumour crisis. The role of primary tumour resection in these patients has gained interest in the literature, with evidence to suggest that reducing tumour burden may confer survival benefit. We aim to evaluate the impact of surgery, and in particular primary tumour resection on patients with mCRC and unresectable metastases.
Methods:
A retrospective review of all patients diagnosed with mCRC with unresectable metastases from January 2004 to December 2014 was performed. This includes a multivariate analysis to eliminate possible confounders. Patients with metastectomy and potentially resectable metastases were excluded. Patients with no follow-up after index presentation and those who elected for treatment with traditional medicine were also excluded.
Results:
436 patients were included over a median follow-up of 38 months. 52.7% (n = 230) underwent surgical intervention as their main treatment modality. 40.8% (n= 178) had upfront primary tumour resection while 11.9% (n =52) underwent the creation of a diverting stoma. 47.3% (n= 206) had no surgical intervention upfront, while 33.3% (n= 145) underwent palliative chemotherapy and 14.0% (n= 61) received best supportive care.
Univariate analysis showed that patients who underwent surgical intervention at any point in their management had longer overall survival (median 17.0 vs 5.4 months p<0.001) compared to patients who never received surgery. However, only primary tumour resection conferred a survival benefit compared to palliative chemotherapy (median 18.1 vs 13.4 months p< 0.001). Stoma creation did not benefit overall survival (median 5.1 months p< 0.001), while patients who received best supportive care had the worst overall survival (median 2.2 months). Among those who did undergo surgery, surgery in patients who received post-operative palliative chemotherapy conferred a survival benefit over those who received pre-operative chemotherapy before surgery (median 15.5 vs 8.8 p= 0.001).
Following multivariate analysis, predictors of poor overall survival were no primary tumour resection (HR 2.583 (1.721-3.875), p<0.001), no chemotherapy (HR 1.572 (1.159 - 2.132), p=0.004) and patients with other comorbidities (HR 2.522 (1.884 - 3.376), p<0.001).
Conclusions:
Primary tumour resection has a significant benefit on overall survival even in patients with mCRC and unresectable metastases. Our findings in this study seem to support the hypothesis that primary tumour resection contributes to a decrease in disease burden, which when supported with chemotherapy might have a superior outcome in terms of overall survival compared to palliative chemotherapy alone.
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