title: Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment.
abstract: OBJECTIVE
  The purpose of this study was to describe the frequency of interventions necessary to palliate the intact primary tumor in patients who present with synchronous, stage IV colorectal cancer (CRC) and who receive up-front modern combination chemotherapy without prophylactic surgery.
  
  
  METHODS
  By using a prospective institutional database, we identified 233 consecutive patients from 2000 through 2006 with synchronous metastatic CRC and an unresected primary tumor who received oxaliplatin- or irinotecan-based, triple-drug chemotherapy (infusional fluorouracil, leucovorin, and oxaliplatin; bolus fluorouracil, leucovorin, and irinotecan; or fluorouracil, leucovorin, and irinotecan) with or without bevacizumab as their initial treatment. The incidence of subsequent use of surgery, radiotherapy, and/or endoluminal stenting to manage primary tumor complications was recorded.
  
  
  RESULTS
  Of 233 patients, 217 (93%) never required surgical palliation of their primary tumor. Sixteen patients (7%) required emergent surgery for primary tumor obstruction or perforation, 10 patients (4%) required nonoperative intervention (ie, stent or radiotherapy), and 213 (89%) never required any direct symptomatic management for their intact primary tumor. Of those 213 patients, 47 patients (20%) ultimately underwent elective colon resection at the time of metastasectomy, and eight patients (3%) underwent this resection during laparotomy for hepatic artery infusion pump placement. Use of bevacizumab, location of the primary tumor in the rectum, and metastatic disease burden were not associated with increased intervention rate.
  
  
  CONCLUSIONS
  Most patients with synchronous, stage IV CRC who receive up-front modern combination chemotherapy never require palliative surgery for their intact primary tumor. These data support the use of chemotherapy, without routine prophylactic resection, as the appropriate standard practice for patients with neither obstructed nor hemorrhaging primary colorectal tumors in the setting of metastatic disease.
authors.affiliation: Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
authors.forename: George A
authors.initials: GA
authors.lastname: Poultsides
authors.forename: Elliot L
authors.initials: EL
authors.lastname: Servais
authors.forename: Leonard B
authors.initials: LB
authors.lastname: Saltz
authors.forename: Sujata
authors.initials: S
authors.lastname: Patil
authors.forename: Nancy E
authors.initials: NE
authors.lastname: Kemeny
authors.forename: Jose G
authors.initials: JG
authors.lastname: Guillem
authors.forename: Martin
authors.initials: M
authors.lastname: Weiser
authors.forename: Larissa K F
authors.initials: LK
authors.lastname: Temple
authors.forename: W Douglas
authors.initials: WD
authors.lastname: Wong
authors.forename: Phillip B
authors.initials: PB
authors.lastname: Paty
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery; D016208:Databases, Factual; D006801:Humans; D008875:Middle Aged; D009367:Neoplasm Staging; D010166:Palliative Care / Q000379:methods* / Q000706:statistics & numerical data; D016019:Survival Analysis; D016896:Treatment Outcome