Defining the Colorectal Surgeons role in patients with colorectal cancer and limited metastatic disease Jose G. Guillem, MD, MPH Department of Surgery Memorial Sloan Kettering Cancer Center Great Debates & Updates in GI Malignancies March 28-29, 2014
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Defining the Colorectal Surgeons role in patients with colorectal cancer and limited metastatic disease Jose G. Guillem, MD, MPH Department of Surgery.
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Defining the Colorectal Surgeons role in patients with colorectal cancer and
limited metastatic disease
Jose G. Guillem, MD, MPH
Department of Surgery
Memorial Sloan Kettering Cancer Center
Great Debates & Updates in GI Malignancies
March 28-29, 2014
Case
• 58M with 10lb weight loss, rectal pain/tenesmus, bleeding
• PMH: unremarkable
• DRE: palpable tethered mass with distal margin at 8cm from AV, 5cm above ring
• Flex sig: circumferential, ulcerated bulky near-obstructing mass
• CT scan: liver metastases
Stage IV Rectal Cancer
Stage IV Rectal Cancer
Management Options in Metastatic Rectal Ca
• Systemic Chemotherapy alone
• Stent and Chemotherapy
• Divert and Chemotherapy
• Resect and Chemotherapy
• Chemotherapy and Resect
• Chemotherapy, Chemoradiation and Resect
Central Issues
• Benefit of surgical resection over stent/diversion alone– Alleviation of bleeding, pain, tenesmus
• Morbidity and mortality of resection
• Delay in administering systemic chemo
Metastatic Rectal Cancer
• Bulky symptomatic primary with extensive liver mets
• Bulky symptomatic primary with limited liver metastases
• Non-bulky asymptomatic primary with extensive liver mets
• Non-bulky asymptomatic primary with limited liver mets
• 33 successful stents out of 34 pts (97%)
Palliation of malignant rectal obstruction with self-expanding metal stents
Hünerbein M et al. Surgery. 2005
Overall, 18% required surgery because of stent complications
Stent migration x 3Intractable pain x 2Incomplete stent expansion x 1Incontinence x 1
Rectovesical fistula x 1Incontinence x 1
Malignant rectal obstruction within 5cm of the anal verge: is there a role for
expandable metallic stent placement?• Group A: obstruction ≤ 5cm from AV• Group B: obstruction > 5cm from AV• Tx: PU or PTFE covered retrievable stents
Song HY et al. Gastrointest Endosc. 2008
Radical resection of rectal cancer primary tumor provides effective local therapy in patients with stage IV disease
• N=80 with rectal CA resection without radiotherapy