International Journal of Surgery 49 (2018) 10–15

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International Journal of Surgery

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Prognostic factors predicting survival in incurable stage IV colorectal cancer T

patients who underwent palliative primary tumor resection. Retrospective
cohort study
Min Sung Kima, Eun Jung Parkb, Jeonghyun Kangb, Byung Soh Minb, Kang Young Leeb,
Nam Kyu Kimb, Seung Hyuk Baikb,∗
a
Department of Surgery, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Republic of Korea
b
Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University, College of Medicine, Seoul, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The aim of this study is to estimate prognostic factors predicting survival in patients with incurable
colorectal adenocarcinomas stage IV colorectal cancer (CRC), who underwent palliative primary tumor resection (PTR) with chemotherapy.
Neoplasm metastasis Materials and methods: We retrospectively performed an analysis using clinicopathological parameters of 103
Surgical treatment patients with incurable stage IV CRC, who underwent palliative PTR with chemotherapy between 2006 and
Survival
2010. Prognostic factors associated with overall survival (OS) were evaluated by univariate and multivariate
analyses.
Results: The median follow-up time was 17.5 months (range 2.4–60.5) for the total cohort (n = 103). There were
five independent factors related to OS in univariate analysis (body mass index, tumor differentiation, pT, pN
stage and local clearance of the primary tumor). A multivariate analysis revealed that pT, pN and local clearance
of the primary tumor were prognostic factors related to OS. Median survival months (95% CI) were pT1, 2, 3:
21.5 (16.23–26.77) months vs. pT4: 13.73 (9.94–17.53) months, pN-: 29.7 (22.55–35.99) months vs. pN+: 17.1
(15.0–19.41) months and R0: 18.57 (16.65–20.48) months vs. R1, 2: 12.43 (9.95–14.91) months.
Conclusion: Locally advanced primary tumor (high pT stage, positive regional lymph node, and local residual
primary tumor) was associated with poorer OS in incurable stage IV CRC patients, who underwent palliative PTR
with chemotherapy. The PTR appears to result in better OS in patients with a primary tumor that is not locally
advanced.

1. Introduction 12 years in a large cohort of CRC patients with incurable synchronous

Colorectal cancer (CRC) is one of the most common malignant
neoplasms worldwide. Each year about 20% of CRC diagnosed patients
have stage IV CRC. An estimated 75–90% of these patients has incur-
able synchronous metastases and requires palliative management [1].
Recent guidelines from the National Comprehensive Cancer Network
suggest that palliative primary tumor resection (PTR) should only be
considered if the patient has an unequivocal risk of obstruction or
significant bleeding [2]. In asymptomatic patients, considering PTR as
the preferred management is still controversial. Nevertheless, up to
75% of elderly CRC patients presenting with incurable synchronous
metastases still underwent palliative PTR in the US population [3].
Recently, a population-based study reported that a statistically sig-
nificant survival benefit was found in patients who underwent PTR over
metastases [4].
When 5-fluorouracil was the only active agent, chemotherapy was
considered generally ineffective in treating incurable stage IV CRC.
However, in the past decade with the development of modern che-
motherapy such as oxaliplatin, irinotecan, cetuximab and bevacizumab,
the overall survival (OS) with chemotherapy alone has improved to
almost 17–23 months for CRC patients with incurable synchronous
metastases in phase 3 trials [5–7].
Therefore, the role of palliative PTR may need to be re-evaluated in
the new era of chemotherapy. Although some studies [8–13] recently
have reported increased survival benefits with palliative PTR in the new
era of chemotherapy, no firm conclusions can be drawn with regard to
the role of PTR in patients with incurable synchronous metastases due
to a lack of data available from randomized studies. In this situation, it

∗
Corresponding author. Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of
Korea.
E-mail address: whitenoja@yuhs.ac (S.H. Baik).

https://doi.org/10.1016/j.ijsu.2017.11.038
Received 2 September 2017; Received in revised form 14 November 2017; Accepted 27 November 2017
Available online 01 December 2017
1743-9191/ © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
M.S. Kim et al. International Journal of Surgery 49 (2018) 10–15

can be difficult to decide whether to resect the primary tumor. Pallia- Table 1
tive PTR may not be the optimal treatment for all patients. Therefore, Patient and tumor characteristics.
before selecting PTR as treatment for CRC patients with incurable
Parameter No. of patients (%)
synchronous metastases, it is important to select the groups of patients
who had survival benefits with this procedure. Clearly, only patients n = 103
who can benefit from palliative PTR should be considered for this
Age
procedure.
Mean (range) 59.6 (25–85)
The aim of this study is to estimate prognostic factors predicting Sex
survival in patients with incurable stage IV CRC, who underwent pal- Male 58 (56.3%)
liative PTR with chemotherapy. Female 45 (43.7%)
BMI
Mean ( ± SD) 22.4 ( ± 3.4)
2. Methods CEAa levels at diagnosis(ng/ml)b
Median (range) 11.2 (0.83–7418)
Patients were retrospectively selected from the database at ASAc
Severance Hospital. A review of the cancer center and colorectal service 1 51 (49.5%)
2 49 (47.6%)
databases was performed between January 2006 and December 2010.
3 2 (1.9%)
Incurable stage IV CRC was defined as a stage impossible to undergo a 4 1 (1%)
complete resection of metastatic lesions. 485 patients were identified Comorbidityd
accordingly. From 485 patients, 382 patients were excluded sequen- No 61 (59.2%)
tially by the following criteria. Exclusion criteria included: 135 patients Yes 42 (40.8%)
Primary tumor location
who did not undergo chemotherapy (preoperative or postoperative) Colon 72 (69.9%)
due to poor performance status [Eastern Cooperative Oncology Group Rectum 28 (27.2%)
(ECOG) performance status > 2] or patients' refusal; 221 patients who Colon & Rectume 3 (2.9%)
did not receive palliative PTR; 6 patients who received a nonresective Liver metastasis
No 33 (32%)
procedure (stoma or bypass); 20 patients who eventually received
Yes 70 (68%)
curative resection or intervention for metastatic disease. The remaining Lung metastasis
eligible 103 patients with incurable stage IV CRC, who received both No 75 (72.8%)
palliative PTR and chemotherapy were retrospectively analyzed. Yes 28 (27.2%)
Patients and tumor characteristics included 22 clinicopathological Peritoneum metastasis
No 55 (53.4%)
parameters [age, sex, body mass index (BMI), performed procedure,
Yes 48 (46.6%)
carcinoembryonic antigen (CEA) at diagnosis, American Society of Bone metastasis
Anesthetists (ASA) score, comorbidity, mode of surgery, primary tumor No 94 (91.3%)
location (colon, rectum), site of metastases (liver, lung, peritoneum, Yes 9 (8.7%)
Other organ metastasisf
bone and other organs), number of distant metastatic organs, pre-
No 76 (73.8%)
operative chemotherapy, tumor differentiation, pathologic T stage (pT), Yes 27 (26.2%)
pathologic N stage (pN, regional lymph node), lymphovascular inva- No. of distant metastatic organs
sion, number of total retrieved lymph nodes and local clearance of 1 50 (48.5%)
primary tumor (R0, R1, R2)]. The seventh edition of the American Joint 2 33 (32%)
≥3 20 (19.5%)
Committee on Cancer (AJCC) TNM classification was used for staging of
Preoperative Chemotherapy
primary tumor. Two patients survived 30 days or less postoperatively. Nog 72 (70%)
These two patients received emergency PTR due to primary tumor Yes 31 (30%)
perforation during the period of preoperative chemotherapy and were Mode of surgery
Elective 65 (63.1%)
included in the statistical analysis. This study was approved by the
Emergency 38 (36.9%)
institutional review board of the Yonsei University College of Medicine. Performed Procedures
This study has been reported in line with the STROCCS criteria [14]. Colon 72
Right hemicolectomy 25
3. Statistical analysis Left hemicolectomy 9
Transverse colectomy 2
Anterior resection 22
Continuous parameters were presented as means ( ± SD). Hartmann's procedure 11
Categorical parameters were presented as the total number (percen- Near total colectomy 3
tage) in patient and tumor characteristics. OS was defined as the time Rectum 28
Abdomino-perineal resection 5
from initiation of treatment, either palliative chemotherapy or PTR, to
Low anterior resection 19
the time of death from any cause. All parameters were analyzed for OS Hartmann's procedure 4
using the Kaplan-Meier method and the log-rank test. Cox regression Colon & Rectum 3
analyses were used to discriminate independent prognostic factors for Total proctocolectomy 2
OS. The difference was statistically significant for p < 0.05. The sta- Low anterior resection & Rt. hemicolectomy 1
Primary tumor differentiation
tistical software package SPSS version 18 (SPSS, Chicago, IL) was used
Well 10 (9.7%)
for all analysis. Moderate 68 (66.0%)
Poor 12 (11.7%)
4. Results Othersh 13 (12.6%)
T stage
pT1 1 (1%)
4.1. Patient and tumor characteristics pT2 3 (2.9%)
pT3 50 (48.5%)
Table 1 shows 22 clinicopathological parameters of 103 patients. pT4 49 (64.6%)
The main organ of metastases was the liver (n = 70, 68%) followed by N stage
(continued on next page)
peritoneum (n = 48, 46.6%) and lung (n = 28, 27.2%). There was

11
M.S. Kim et al. International Journal of Surgery 49 (2018) 10–15

Table 1 (continued) Table 2

Overall survival of 103 patients who underwent primary tumor resection according to the
Parameter No. of patients (%) evaluated parameters.

n = 103 Parameter Number Median Survival (months) P value

pN (-) 23 (22.3%) n = 103 (95% CI)

pN (+) 80 (77.7%)
Lymphovascular invasion Age 0.496
No 36 (34.9%) < 60 46 17.97 (15.78–20.17)
Yes 67 (65.1%) ≥60 57 17.77 (15.22–20.32)
No. of total retrieved LNsi Sex 0.337
< 10 18 (17.5%) Male 58 17.2 (14.76–19.64)
≥10 85 (82.5%) Female 45 19.07 (13.02–25.12)
Local clearance of tumorj BMIa 0.034
R0 92 (89.3%) ≤25 82 15.93 (13.56–18.3)
R1 9 (8.7%) > 25 21 25.8 (22.63–28.97)
R2 2 (1.9%) Mode of surgery 0.969
Elective 67 17.77 (16.08–19.46)
a
CEA, carcinoembryonic antigen. Emergency 36 17.53 (11.6–23.47)
b
One missing data in the PTR group. CEAb 0.188
c
ASA, American Society of Anesthetists. ≤10 49 17.53 (13.11–21.95)
d
Cardiac disease: Coronary heart disease, history of myocardial infarction, valvular > 10 53 17.97 (16.17–19.77)
heart disease, congestive heart failure, cardiac arrhythmia, hypertension; Pulmonary ASAc 0.76
disease: Chronic obstructive pulmonary disease, emphysema, pulmonary hypertension; 1,2 100 17.77 (16.35–19.18)
3,4 3 14.6 (8.73–20.47)
Hepatic disease: Hepatitis, liver cirrhosis; Renal disease: Renal failure; Metabolic disease:
Comorbidity 0.11
Diabetes mellitus, hyperthyroidism, hyper-cholesterolemia.
e No 61 19.07 (13.42–24.71)
Double primary cancer in colon and rectum.
f Yes 42 17.07 (13.96–20.18)
Distant intraabdominal or retroperitoneal lymph nodes, brain, omentum, small
Liver metastasis 0.267
bowel, adrenal gland, mediastinum.
g
No 33 19.4 (12.6–26.2)
All patients of this group received postoperative chemotherapy after primary tumor Yes 70 17.53 (15.44–19.62)
resection. Lung metastasis 0.444
h
Undifferentiated adenocarcinoma, Mucinous adenocarcinoma, Signet ring cell. No 75 17.2 (15.69–18.71)
i
LN, lymph node. Yes 28 18.67 (16.88–20.46)
j
R0; microscopic negative resection margin, R1; microscopic positive resection Peritoneum metastasis 0.460
margin, R2; macro-scopic positive resection margin. No 55 17.53 (14.86–20.21)
Yes 48 19.07 (13.81–24.32)
more than one organ involved in 53 patients (51.5%). Among the 103 Bone metastasis 0.695
No 94 17.77 (15.81–19.72)
patients, 19 patients had primary tumor related complications at the Yes 9 21.5 (4.34–38.66)
time of diagnosis. 19 patients underwent emergency PTR and post- Other organ metastasis 0.355
operative chemotherapy. Among the 103 patients, 84 patients were No 76 17.77 (16.18–19.36)
asymptomatic at the time of diagnosis. Among the 84 patients, 53 pa- Yes 27 17.77 (12.71–22.83)
No. of metastatic organs 0.809
tients underwent preemptive PTR and postoperative chemotherapy.
One 50 17.53 (15.29–19.78)
Among the 84 patients, 31 patients underwent preoperative che- Multiple 53 17.97 (14.97–20.97)
motherapy. Undergoing preoperative chemotherapy, 12 patients un- Primary tumor location 0.8
derwent preemptive PTR and 19 patients underwent emergency PTR Colon 72 17.77 (15.52–20.02)
due to primary tumor related complication [intestinal obstruction Rectum 28 18.57 (14.22–22.91)
Multiple 3 8.1 (6.66–9.54)
(n = 8), perforation (n = 8), perforation with a rectovaginal fistula
Preoperative chemotherapy 0.801
(n = 1), intractable bleeding (n = 1) and severe pain at the site of the No 72 17.2 (14.93–19.47)
primary tumor (n = 1)]. All patients underwent palliative che- Yes 31 18.77 (13.47–24.07)
motherapy based on the inclusion criteria. 31 patients received pre- Tumor differentiation 0.043
WDd 10 28.8 (24.61–32.99)
operative chemotherapy. Palliative chemotherapy mainly consisted of
Others 93 17.2 (15.25–19.15)
oxaliplatin or irinotecan regimens in 97 patients (94.2%). Only 6 pa- pT 0.001
tients (5.8%) received TS-1 or Xeloda monotherapy for palliative che- pT1,2,3 54 21.5 (16.23–26.77)
motherapy. pT4 49 13.73 (9.94–17.53)
pN 0.001
pN (-) 22 29.27 (22.55–35.99)
pN (+) 81 17.2 (15.0–19.41)
4.2. Overall survival Lymphovascular invasion 0.236
No 36 21.5 (14.74–28.26)
Median follow-up time was 17.5 months (range 2.4–60.5) for the Yes 67 17.2 (14.88–19.52)
No. of total retrieved LNse 0.578
total number of patients (n = 103). Median OS period was 17.8 months
< 10 18 17.77 (13.19–22.34)
(95% CI, 16–19.5 months; range 2.4–60.5 months). Table 2 shows the ≥10 85 17.53 (14.79–20.27)
median OS of 103 patients according to the evaluated parameters. Five Local clearance of tumor < 0.001
parameters were associated with OS in the univariate analysis (Log- R0 92 18.57 (16.65–20.48)
rank test). In patients with high BMI (> 25), low grade of tumor dif- R1,2 11 12.43 (9.95–14.91)

ferentiation (well differentiation), low pT stage (pT1, 2, 3) and negative a

BMI, body mass index.
regional lymph node metastasis (pN-), the median OS periods were b
CEA, carcinoembryonic antigen.
longer than 20 months except patients with negative local resection c
ASA, American Society of Anesthetists.
margin (R0, median OS: 18.6 months). d
WD, well differentiation.
e
LN, lymph node.

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M.S. Kim et al. International Journal of Surgery 49 (2018) 10–15

Table 3 study was performed in a heterogeneous environment. To solve this

Prognostic factors related to overall survival in all patients (n = 103) (Cox's regression problem, several studies offered an opportunity to evaluate prognostic
model).
factors in a homogeneous class of PTR patients. Therefore, several
Parameter Univariate Multivariate studies have reported multivariate analysis of prognostic factors that
affect outcome after PTR in patients with incurable stage IV CRC
HR 95% CI P HR 95% CI P [19–25]. However, these studies showed that some of the patients were
a treated with chemotherapy and most of the patients only received 5-
BMI
> 25 1 fluorouracil based chemotherapy. Some studies did not include a de-
≤25 1.791 1.04–3.1 0.034 tailed description of chemotherapy use. These studies may not be
Tumor differentiation completely applicable to recent standard management of incurable
WDb 1 stage IV CRC. Otherwise, all patients underwent palliative PTR and
Others 2.309 1–5.31 0.049
pT
almost all patients (94.2%) received modern chemotherapy (such as
pT1,2,3 1 1 oxaliplatin or irinotecan containing regimens) in our study. In addition,
p4 1.993 1.29–3.07 0.002 1.645 1.04–2.59 0.032 the general condition of all patients was not poor (ECOG ≤ 2 by the
pN inclusion criteria). Our study is the first to report on homogeneous in-
pN (-) 1 1
curable stage IV CRC patients undergoing palliative PTR and che-
pN (+) 2.487 1.45–4.55 0.001 1.888 1.05–3.4 0.034
Local clearance of primary tumor motherapy with good performance status.
R0 1 1 In multivariate analysis, a high pT stage (T4) was independently
R1,2 2.821 1.46–5.43 0.002 2.74 1.41–2.31 0.003 associated with poor OS. Three studies reported that a T stage was in-
a
dependently associated with survival on multivariate analysis
BMI, body mass index.
b
[18,22,25]. Harris et al. [25] reported that T1 and T2 tumors were
WD, well differentiation.
associated with an improved survival compared with T3 and T4 tumors.
Stelzner et al. [18] found that T1, T2 and T3 tumors were associated
4.3. Prognostic factors of overall survival
with an improved survival compared with T4 tumors. Kleespies et al.
[22] also found the same results as Stelzner et al.
Table 3 shows prognostic factors affecting the OS. Based on uni-
We also found that metastasis to regional lymph nodes (LNs) was an
variate analysis, age, sex, mode of surgery, CEA, ASA score, co-
independent predictor of poor OS. Our study showed that patients with
morbidity, primary tumor location, site of metastases, number of dis-
pN (-) have a significantly better OS than those with pN (+) and the
tant metastatic organs, preoperative chemotherapy and number of total
proportion of pN (-) was 22.3% among the total patients.
retrieved lymph nodes significantly did not affect the OS. However, BMI
This result is consistent with the findings of other retrospective
(p = 0.034), tumor differentiation (p = 0.049), pT (p = 0.002), pN
studies. Eight studies report that nodal stage was independently asso-
(p = 0.001) and local clearance of primary tumor (p = 0.002) sig-
ciated with survival in patients with incurable stage IV CRC
nificantly affect the OS. When these factors were entered a multivariate
[16,19–22,24–26]. Stillwell et al. [19] reported that advanced nodal
analysis using a Cox regression model, it showed that pT, pN and local
metastasis (N2 or apical LNs involvement) was independently related to
clearance of the primary tumor were prognostic factors associated with
poor long-term survival. Costi et al. [20] showed that the percentage of
the OS (pT4, HR:2.24, 95% CI: 1.0–2.6, p = 0.032) (pN+, HR:1.89,
metastatic LNs (up to 25% and over) was very predictive of prognosis in
95% CI: 1.0–3.4, p = 0.034) (R1, 2, HR:2.74, 95% CI: 1.4–2.3,
incurable CRC. The other six studies showed that patients with N0 stage
p = 0.003).
had a significantly better survival than those with N1-N2 stage
Fig. 1A shows the OS curves for the total number of patients. The 1
[16,21,22,24–26]. These six studies uniformly reported the proportion
and 2-year OS rates were 76.7% and 35.7%, respectively. Fig. 1B shows
of pN (-) group was about 15–20% in incurable stage IV CRC patients
the comparison of the survival curves between pT1, 2 and 3 groups
who underwent PTR. In our study, the proportion of the pN (-) group
(n = 54) and pT4 group (n = 49). In pT1, 2 and 3 groups, the median
was 21% and is similar to the results of six previous studies. As afore-
OS was significantly longer than that of pT4 group (p = 0.001). The 1
mentioned, many studies reported that the majority (over 80%) of pa-
and 2-year OS rates were 87% and 43.4% in pT1, 2 and 3 groups. The 1
tients with incurable stage IV CRC had regional LN metastasis
and 2-year OS rates were 65.3% and 27.1% in pT4 group. Fig. 1C shows
[16,19,21,22,24,25].
the comparison of the survival curves between pN (-) group (n = 22)
Regional LN metastasis is considered one of the early signs of distant
and pN (+) group (n = 81). In pN (-) group, the median OS was sig-
metastasis. Therefore, it is somewhat paradoxical that there is no re-
nificantly longer than pN (+) group (p = 0.001). The 1 and 2-year OS
gional LN metastasis in CRC with incurable distant metastasis. Although
rates were 86.4% and 67.6% in pN (-) group. The 1 and 2-year OS rates
the mechanism of this observation is unclear, these results suggest that
were 74.1% and 26.7% in pN (+) group. Fig. 1D shows the comparison
the pN (-) group may have biologically less aggressive tumors than the
of the survival curves according to the local clearance of primary
pN (+) group. We can indirectly hypothesize that the pN (-) group may
tumor. In R0 group, the OS was significantly longer than that of R1, 2
have defects in cell-biological mediators related to lymphatic metas-
group (p = 0.001). The 1 and 2-year OS rates were 79.3% and 40.3% in
tasis. Relatively little is known about mediators related to the lym-
R0 group. The 1 and 2-year OS rates were 54.5% and 0% in R1, 2
phatic-specific metastasis in colorectal cancer. However, Kawada et al.
groups.
[27] recently demonstrated that the chemokine receptor CXCR3 is ex-
pressed in colon cancer cells and plays an important role in LN me-
5. Discussion tastasis of colon cancer cells preferentially. Patients with CXCR3-posi-
tive colon cancer also had a shorter survival than those without CXCR3.
We evaluated prognostic factors associated with survival benefits in If the pN (-) group does not have mediators (such as CXCR3) related to
incurable stage IV CRC patients who received palliative PTR with lymphatic-specific metastasis, this may result in less aggressive traits of
chemotherapy. The main result is that locally advanced primary tumor tumor with a favorable prognosis. We think that the pN (-) group
(high pT stage, positive regional lymph node, and local residual pri- among incurable stage IV CRC patients is especially worth noting and
mary tumor) is related to unfavorable oncologic outcomes. more research is needed.
Many studies conducted multivariate analysis to find prognostic Local clearance of primary tumor also proved to be an independent
factors associated with survival between PTR patients or no PTR in factor of overall survival in our study. Five previous studies have tried
patients with incurable stage IV CRC [8,9,11,15–18]. However, each to determine whether the presence of local residual tumor is an

13
M.S. Kim et al.
Fig. 1. Overall survival (OS) curves (Kaplan-Meier) among the 103 patients according to independent prognostic factors: (A) OS curves in 103 patients with palliative PTR. (B) OS curves
according to pT stage. (C) OS curves according to pN stage. (D) OS curves according to local clearance of primary tumor.
independent factor of overall survival in incurable stage IV CRC pa-
tients who underwent PTR [19,21,22,24,25]. Three of these studies
reported that the presence of local residual tumor is an independent
factor of poor survival [22,24,25]. Chafai et al. [24] demonstrated that
patients with local residual tumor did not survive more than 2 years
compared to the 2-year survival rate of 19.7% in those without local
residual tumor (p < 0.001). In our results, any patients with local
residual tumor did not survive more than 2 years compared to the 2-
year survival rate of 40.3% in those without local residual tumor
(p < 0.001). Kleespies et al. [22] demonstrated that patients without
local residual tumor showed a significantly better median OS compared
to those with local residual tumor (median OS 16.2 vs. 9.1 months;
p = 0.02). In our data, patients without local residual tumor showed a
significantly better median OS compared to those with local residual
tumor (median OS 18.57 vs. 12.43 months; p < 0.001). The results of
our study are similar to those of previous studies.
There are some limitations to our study. First, the retrospective
study design is a basic limit of the present study. Second, preoperative
imaging studies have a limitation to evaluate prognostic factors shown
in our study. Preoperative abdominal and pelvic computer tomography
(CT) scans can demonstrate regional tumor extension, regional nodal
involvement and distant metastases. However. The sensitivity of CT for
14
International Journal of Surgery 49 (2018) 10–15
detecting regional LN metastasis or the tumor depth is not high com-
pared to detecting distant metastases. The clinical nodal stage de-
termined by several imaging techniques may not be an important aid in
selecting PTR as treatment plan. Thus, parameters such as regional LN
metastasis may have a limited impact on the therapeutic strategy due to
these reasons.
Moreover, it is impossible to decide whether to perform PTR on the
basis of the postoperative pathologic results of the resected specimen
before surgery. However, recent advanced imaging tools may solve
these limitations with continuous technological advances.
6. Conclusions
Locally advanced primary tumor (high pT stage, positive regional
lymph node, and positive resection margins of primary tumor) was
associated with poorer OS in incurable stage IV CRC patients, who
underwent palliative PTR with modern chemotherapy. The PTR ap-
pears to result in better OS in patients with a primary tumor which is
not locally advanced. The results of this study may help clinicians to
select patients who may benefit from palliative PTR with chemotherapy
in terms of survival using preoperative imaging studies.
M.S. Kim et al.
Ethical approval
Not required/applicable.
Funding
This study was supported by the Korean National Cancer Control
Planning Board Study 2013 (no. 1320260), which is funded by the
Ministry of Health and Welfare and managed by the National Cancer
Center.
Author contribution
Min Sung Kim - conception, design, analysis and writing of paper.
Eun Jung Park - design, analysis.
Jeonghyun Kang - design, analysis.
Byung Soh Min - design, analysis.
Kang Young Lee - design, analysis.
Nam Kyu Kim - design, analysis.
Seung Hyuk Baik-conception, design, analysis and writing of paper.
Conflicts of interest
The authors declare that they have nothing to disclose.
Unique identifying number (UIN)
Researchregistry 3265.
Guarantor
Min Sung Kim, Eun Jung Park, Jeonghyun Kang, Byung Soh Min,
Kang Young Lee, Nam Kyu Kim, Seung Hyuk Baik.
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