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Metastatic Colorectal Cancer: Goals of Resection

Panelists:Tanios Bekaii-Saab, MD, Ohio State University – James Cancer Hospital; Johanna Bendell, MD, Sarah Cannon Research Institute; Charles S. Fuchs, MD, Dana-Farber Cancer Institute; Richard Kim, MD, Moffitt Cancer Center; John L. Marshall, MD, Georgetown University Hospital
Published: Monday, Feb 22, 2016


Transcript:

John L. Marshall, MD:
Real quick, what do you all think about removing primaries when you can? Is this important when you have metastatic disease? So, Tony, what do you think? Is this something you’re going to want to do in the incurable metastatic patient or not?

Tanios Bekaii-Saab, MD: The clear answer to this right now is not present. But, for practical purposes, I would say not. The more recent data suggests that patients do as well whether you keep it in place or remove it, although there are some intriguing data that suggests that patients may do better if you do remove the primary. But I think since we have such effective first-line chemotherapeutic regimens and biologics, that the prior response, as well as the rest of the disease and there’s really at this point of time I think no role to remove the primary and keep it in place.

Charles S. Fuchs, MD, MPH: This is really confusing because we see a variety of studies saying that it’s not necessary to take out the primary and then other studies that say patients who have the primary removed may do better. But they’re all relatively flawed studies. The answer is going to come because there are two randomized trials conducted in Europe where they’re randomizing patients with metastatic disease to getting the primary out or not. So, until those studies come in, I don’t think we really know. But I agree with Tony. I wouldn’t ordinarily resect the primary unless it’s necessary.

John L. Marshall, MD: Yeah. Any differences? You all pro-resection, anti-resection?

Richard Kim, MD: I agree with Tony’s point that only patient that we would resect upfront is if they’re symptomatic, they’re bleeding, they’re near obstruction. They are the only patients we would take to the surgery. Otherwise, I agree, in an asymptomatic patient, the data is not out there so we will start with chemotherapy first and see what happens.

John L. Marshall, MD: What if it’s a near obstructing rectal, are you going to take it out? Are you going to divert? Are you going to cross your fingers that chemotherapy is going to work?

Johanna Bendell, MD: It depends how bad it is, and that’s the million dollar question. I think that it’s very reasonable to think of a diversion approach. It’s also very reasonable to think of a chemoradiation approach if you’ve got liver-only disease, too, because what even complicates this more is in a resectable patient who’s got liver-only metastases. And is this somebody where you’re going to take out the primary in a staged fashion or treat the primary in a staged fashion and then go over the metastatic disease.

John L. Marshall, MD: So, we talk a lot about liver resection. Of course, we’re all comfortable with the isolated or the very small oligometastatic stuff, but you know the bar is moving. What’s the wackiest thing you ever recommended being removed?

Tanios Bekaii-Saab, MD: So many things. I don’t know if we have enough time for that.

John L. Marshall, MD: We’ve had people do mediastinal lymph nodes because it’s isolated disease, and is that crazy or not?

Tanios Bekaii-Saab, MD: So we’ve removed isolated lymph nodes in the abdomen area. And actually it’s interesting. Once we establish an isolated area anywhere in the system, we’ve tended to remove it if it can be safely removed. Again, in the absence of randomization, we can’t really tell you that we change the biology of the disease or whether the biology was so indolent that it presents just in a single site. But we’ve done it, and we’ve been able to spare patients chemotherapy until recurrence. We don’t technically cure non-liver metastatic disease. It’s rare.

John L. Marshall, MD: So you don’t think maybe isolated lung? Or just liver-only biology?

Tanios Bekaii-Saab, MD: Again, if you hear experiences, patients with isolated lung metastases may actually have prolonged survival. But I think those patients do recur at some point, and most liver patients also do recur. You do provide them with an extended disease-free survival and likely a prolonged survival. But whether we’re truly curing most of these patients is unclear and questionable.

John L. Marshall, MD: Where are you all, Charlie?

Charles S. Fuchs, MD, MPH: There’s a subset here that we recognize, we don’t often discuss—those are the people we first see for whom we never even contemplate resection because of multiple metastases. And then they have a great response to therapy. And you’re asking the question, well, I know I saw multiple lung metastases, multiple liver metastases. I don’t see them anymore. Maybe I should ignore that first CT scan, look at today’s CT scan and send them to resection. And I suspect all of us are often referring those people to surgeons. I am, realizing I don’t think we ever contemplated we’d be doing that five years ago.

John L. Marshall, MD: I think, at least for me, the surgeons who work at our center are more comfortable, if you will, sort of pushing the surgical envelope. But I think a lot of community surgeons may be less comfortable. Is this a message we should be sending, that in the right patient to consider this kind of more aggressive surgical approach?

Johanna Bendell, MD: I think with the more aggressive surgical approach, it’s important to get a surgeon who’s used to doing these types of resections, a surgical oncologist or a surgeon who has a lot of experience doing these liver resections or these isolated resections. Because the last thing that you want to do is take somebody and send them to a surgery where they end up having a significant amount of morbidity and mortality that ends up costing the patient in the end. And I think Charlie makes a really good point. In the era where we’re sending more folks to potential surgery, knowing the biology of the disease really is something that you want to know.

So, giving those first few cycles of chemotherapy and seeing what kind of response the patient is going to have, you have that one isolated lesion that just sits there for a long period of time or they look disease-free for a while and then they have one isolated thing that pops up. That tells you a little bit more about how that patient is going to do if you take them to the operating room.
                                                                                                                                                                                                                                                                                                              
Transcript Edited for Clarity
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Transcript:

John L. Marshall, MD:
Real quick, what do you all think about removing primaries when you can? Is this important when you have metastatic disease? So, Tony, what do you think? Is this something you’re going to want to do in the incurable metastatic patient or not?

Tanios Bekaii-Saab, MD: The clear answer to this right now is not present. But, for practical purposes, I would say not. The more recent data suggests that patients do as well whether you keep it in place or remove it, although there are some intriguing data that suggests that patients may do better if you do remove the primary. But I think since we have such effective first-line chemotherapeutic regimens and biologics, that the prior response, as well as the rest of the disease and there’s really at this point of time I think no role to remove the primary and keep it in place.

Charles S. Fuchs, MD, MPH: This is really confusing because we see a variety of studies saying that it’s not necessary to take out the primary and then other studies that say patients who have the primary removed may do better. But they’re all relatively flawed studies. The answer is going to come because there are two randomized trials conducted in Europe where they’re randomizing patients with metastatic disease to getting the primary out or not. So, until those studies come in, I don’t think we really know. But I agree with Tony. I wouldn’t ordinarily resect the primary unless it’s necessary.

John L. Marshall, MD: Yeah. Any differences? You all pro-resection, anti-resection?

Richard Kim, MD: I agree with Tony’s point that only patient that we would resect upfront is if they’re symptomatic, they’re bleeding, they’re near obstruction. They are the only patients we would take to the surgery. Otherwise, I agree, in an asymptomatic patient, the data is not out there so we will start with chemotherapy first and see what happens.

John L. Marshall, MD: What if it’s a near obstructing rectal, are you going to take it out? Are you going to divert? Are you going to cross your fingers that chemotherapy is going to work?

Johanna Bendell, MD: It depends how bad it is, and that’s the million dollar question. I think that it’s very reasonable to think of a diversion approach. It’s also very reasonable to think of a chemoradiation approach if you’ve got liver-only disease, too, because what even complicates this more is in a resectable patient who’s got liver-only metastases. And is this somebody where you’re going to take out the primary in a staged fashion or treat the primary in a staged fashion and then go over the metastatic disease.

John L. Marshall, MD: So, we talk a lot about liver resection. Of course, we’re all comfortable with the isolated or the very small oligometastatic stuff, but you know the bar is moving. What’s the wackiest thing you ever recommended being removed?

Tanios Bekaii-Saab, MD: So many things. I don’t know if we have enough time for that.

John L. Marshall, MD: We’ve had people do mediastinal lymph nodes because it’s isolated disease, and is that crazy or not?

Tanios Bekaii-Saab, MD: So we’ve removed isolated lymph nodes in the abdomen area. And actually it’s interesting. Once we establish an isolated area anywhere in the system, we’ve tended to remove it if it can be safely removed. Again, in the absence of randomization, we can’t really tell you that we change the biology of the disease or whether the biology was so indolent that it presents just in a single site. But we’ve done it, and we’ve been able to spare patients chemotherapy until recurrence. We don’t technically cure non-liver metastatic disease. It’s rare.

John L. Marshall, MD: So you don’t think maybe isolated lung? Or just liver-only biology?

Tanios Bekaii-Saab, MD: Again, if you hear experiences, patients with isolated lung metastases may actually have prolonged survival. But I think those patients do recur at some point, and most liver patients also do recur. You do provide them with an extended disease-free survival and likely a prolonged survival. But whether we’re truly curing most of these patients is unclear and questionable.

John L. Marshall, MD: Where are you all, Charlie?

Charles S. Fuchs, MD, MPH: There’s a subset here that we recognize, we don’t often discuss—those are the people we first see for whom we never even contemplate resection because of multiple metastases. And then they have a great response to therapy. And you’re asking the question, well, I know I saw multiple lung metastases, multiple liver metastases. I don’t see them anymore. Maybe I should ignore that first CT scan, look at today’s CT scan and send them to resection. And I suspect all of us are often referring those people to surgeons. I am, realizing I don’t think we ever contemplated we’d be doing that five years ago.

John L. Marshall, MD: I think, at least for me, the surgeons who work at our center are more comfortable, if you will, sort of pushing the surgical envelope. But I think a lot of community surgeons may be less comfortable. Is this a message we should be sending, that in the right patient to consider this kind of more aggressive surgical approach?

Johanna Bendell, MD: I think with the more aggressive surgical approach, it’s important to get a surgeon who’s used to doing these types of resections, a surgical oncologist or a surgeon who has a lot of experience doing these liver resections or these isolated resections. Because the last thing that you want to do is take somebody and send them to a surgery where they end up having a significant amount of morbidity and mortality that ends up costing the patient in the end. And I think Charlie makes a really good point. In the era where we’re sending more folks to potential surgery, knowing the biology of the disease really is something that you want to know.

So, giving those first few cycles of chemotherapy and seeing what kind of response the patient is going to have, you have that one isolated lesion that just sits there for a long period of time or they look disease-free for a while and then they have one isolated thing that pops up. That tells you a little bit more about how that patient is going to do if you take them to the operating room.
                                                                                                                                                                                                                                                                                                              
Transcript Edited for Clarity
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