Colorectal Cancer: Management of Stage IV Disease
Despite screening protocols, approximately 20 % of colorectal cancer patients present with established distant metastasis (Siegel et al. CA Cancer J Clin., 65(1), 5–29, 2015). Computed tomography (CT) scan or magnetic resonance imaging (MRI) generally det
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Key Concepts • Multidisciplinary evaluation is of paramount importance in the treatment of metastatic colorectal cancer. • Positron emission tomography (PET) scan should be used in the evaluation of metastatic disease prior to potentially curative surgical therapy, or in cases of equivocal disease, but not for routine detection of metastatic disease. • Patients with incurable metastatic disease and asymptomatic primary tumors should be considered for initial treatment with chemotherapy. • For metastatic colorectal liver lesions, synchronous resection, liver-first, or colon-first strategies are all acceptable means of surgical treatment. • Resection, ablation, or a combination of ablative and resection techniques can be used to minimize parenchymal liver resection and preserve function when treating metastatic colorectal metastases. • Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) may be considered in appropriately selected patients treated at specialized centers with expertise in this technique, although it has not been demonstrated to be superior to modern systemic chemotherapy. • Metastases to organs other than the liver, lung, ovary, or peritoneum are uncommon and commonly occur in conjunction with widely metastatic disease. Thus, resection rarely has an impact on overall survival and should only be undertaken in select circumstances after multidisciplinary evaluation. • Treatment of metastatic disease in the elderly requires consideration of the performance status, frailty, and impact of various treatments on quality of life.
Introduction Despite screening protocols, approximately 20% of colorectal cancer patients present with established distant metastasis [1]. Computed tomography (CT) scan or magnetic resonance
imaging (MRI) generally detects this metastasis at the time of the initial staging of the cancer. Once the diagnosis of stage IV disease is made, a multidisciplinary team should plan appropriate curative or palliative therapy. Unfortunately for the clinician, there is enormous heterogeneity with respect to sites of disease, extent of disease and symptoms, performance status, and comorbidities in these patients. Stage IV patients have a range of presentation from the asymptomatic patient with a single metastatic lesion to the rapidly deteriorating patient with colon obstruction and advanced multiorgan metastases. While treatment algorithms may exist for some forms of metastatic disease such as a solitary liver lesion, others, especially for those with multiple sites of metastases, are still being defined. This chapter aims to provide a reference source for colorectal surgeons managing patients who present with metastatic stage IV colorectal cancer. While there has been considerable progress in the treatment of advanced colorectal cancer, the vast majority of stage IV patients are unfortunately not curable by current treatment protocols. An evaluation of data from the SEER population-based database estimates that the 5-year survival rate for stage IV patients diagnosed between 1991 an
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