Local Tumor Complications in Stage IV Colorectal Cancer

Despite modern colorectal cancer screening campaigns and efforts to increase patient access to screening resources, 19-26% of patients with colorectal cancer are found to have distant metastasis on initial presentation.1 Colorectal cancer metastasizes most often to lung, liver, and peritoneum, with less than 20% of metastatic cancers deemed to be resectable. While the five-year survival of stage IV colorectal cancer is only 14%, median overall survival has improved to two to three years with modern chemotherapy regimens.1,2 One third of emergency presentations of colorectal cancer are in patients with metastatic disease.3 Of these, obstruction, hemorrhage, and perforation are the primary concerns, which has led to some interest in palliative resection of primary colon cancer in the setting of metastatic disease. Current guidelines recommend initiation of systemic chemotherapy with or without targeted therapy (e.g., cetuximab, bevacizumab) for patients with asymptomatic stage IV disease.4,5 This is largely driven by observations that palliative resection of asymptomatic tumors exposes patients to increased potential morbidity and results in increased time to chemotherapy.6 Despite these recommendations (and likely driven by conflicting retrospective observational studies that have shown survival benefit for resection of primary tumors in stage IV disease), SEER data demonstrate that up to 58% of patients with stage IV colon cancer will undergo primary tumor resection, which suggests that improved education and compliance with guidelines is needed in this setting.7, 8, 9

For those that move on to systemic chemotherapy without primary tumor resection, or when a patient's initial presentation is due to local tumor complications, surgeons must be aware of the various treatment strategies available, as these patients will rarely follow a regimented treatment plan. Fortunately, the risk of development of local tumor complications during systemic treatment in patients that are initially asymptomatic is relatively low and has been reported in a multicenter prospective trial as occurring in 16.3% of cases.10

While many of these patients will have incurable metastatic disease, it is imperative to identify patients with potentially resectable/curable disease as this will certainly impact decision making and should prompt management according to oncologic principles whenever possible. In this review, we examine potential local complications stemming from stage IV colorectal cancer and the clinical approaches to each.

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