Management of asymptomatic stage IV rectal cancer: should the primary tumor be resected?

• Main Authors: Faisal, Elagili, Stocchi, Luca, Kalady, Matthew F, Dietz, David
• Format: Article
• Language: English
• Published: Wiley-Blackwell 2014
• Subjects: RD Surgery
• Online Access: http://irep.iium.edu.my/69852/3/2014-Colorectal_Disease.pdf; http://irep.iium.edu.my/69852/; https://onlinelibrary.wiley.com/doi/epdf/10.1111/codi.12644_1
• Institution: Universiti Islam Antarabangsa Malaysia

Aim: The need for resection of the primary tumour in stage IV minimally symptomatic rectal cancer (RC) is controversial. Method: An IRB‐approved cancer database and billing records were queried to identify stage IV rectal cancer patients with a minimally‐symptomatic primary tumour (no obstruction, perforation, or massive bleeding) between 1980 and 2013. Patients who underwent initial resection of the primary tumour (Group I) were case‐matched with patients who underwent treatment without initial resection (Group II) according to age, sex, ASA classification, and number of organs involved with metastatic disease. Results: Ninety six patients were matched from a total cohort of 249 patients (215 Group I, 34 Group II) with stage IV RC. 54% were male and the mean age was 60.3 ± 11.2 years. Median survival times for Group I and Group II were 15 (range 11–20) and 20.5 (6–29) months respectively (P = 0.54). Within group I, 49 (73%) patients underwent anterior proctosigmoidectomy, 14 (21%) underwent abdominoperineal resection, 2 (3%) underwent Hartmann's procedure, and 2 (3%) underwent total proctocolectomy with end ileostomy. Treatment related mortality rate was 3% in Group I and 0% in Group II. In Group I, post operative morbidity rate was 48% (32 of 67 patients). In Group II, complications related to the unresected primary tumour occurred in 2 patients: acute bowel obstruction requiring endoscopic stenting (1) and rectovaginal fistula requiring stoma diversion (1). 4 patients in Group II required palliative radiotherapy during the course of treatment due to pelvic pain. The median number of in‐hospital days during the course of treatment was 10 (8–13) days in Group I and 1 (0–15) days in Group II (P < 0.001). Conclusion: In patients presenting with minimally symptomatic Stage IV RC, a treatment strategy of chemotherapy without resection of the primary tumour may minimize treatment‐related morbidity, mortality, and days spent in‐hospital without adversely affecting survival. This may have important implications for quality of life in these patients with limited life expectancy.