World Journal of Surgery

, Volume 34, Issue 4, pp 797–807 | Cite as

Meta-Analysis of Survival of Patients with Stage IV Colorectal Cancer Managed with Surgical Resection Versus Chemotherapy Alone

  • A. P. StillwellEmail author
  • P. G. Buettner
  • Y-H. Ho



There is no consensus regarding the appropriate management of asymptomatic and minimally symptomatic patients with stage IV colorectal cancer and irresectable metastases.


A literature search was conducted on Medline and Embase. Outcome measures included: survival; postoperative morbidity and mortality; complications from the primary tumor and the need for surgery to manage complications; the likelihood of curative surgery after initial response to primary therapy; and length of hospital stay. Quantitative meta-analysis was performed where appropriate.


Eight retrospective studies, including 1,062 patients, met the criteria for inclusion in this study. Meta-analysis has shown an improvement in the survival of patients managed with palliative resection of their primary tumor, with an estimated standardized median difference of 6.0 months (standardized difference, 0.55; 95% confidence interval (CI), 0.29, 0.82; p < 0.001). Patients managed with chemotherapy alone were 7.3 times more likely to have a complication from the primary tumor (95% CI, 1.7, 34.4; p = 0.008). There was no difference in the response rates to chemotherapy, making metastatic disease amendable to curative resection (0.85; 95% CI 0.40, 1.8; p = 0.662).


To date, only retrospective data are available, showing that palliative resection of the primary tumor in asymptomatic or minimally symptomatic patients with stage IV colorectal cancer is associated with longer survival. Resection of the primary tumor reduces the likelihood of complications from the primary tumor and avoids the need for emergency procedures.


Colorectal Cancer Primary Tumor Curative Resection Resection Group Chemotherapy Group 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Boyle P, Leon ME (2002) Epidemiology of colorectal cancer. Br Med Bull 64:1–25CrossRefPubMedGoogle Scholar
  2. 2.
    Cook AD, Single R, McCahill LE (2005) Surgical resection of primary tumors in patients who present with stage IV colorectal cancer: an analysis of surveillance, epidemiology, and end results data, 1988 to 2000. Ann Surg Oncol 12:637–645CrossRefPubMedGoogle Scholar
  3. 3.
    Temple LK, Hsieh L, Wong WD et al (2004) Use of surgery among elderly patients with stage IV colorectal cancer. J Clin Oncol 22:3475–3484CrossRefPubMedGoogle Scholar
  4. 4.
    Joffe J, Gordon PH (1981) Palliative resection for colorectal carcinoma. Dis Colon Rectum 24:355–360CrossRefPubMedGoogle Scholar
  5. 5.
    Makela J, Haukipuro K, Laitinen S et al (1990) Palliative operations for colorectal cancer. Dis Colon Rectum 33:846–850CrossRefPubMedGoogle Scholar
  6. 6.
    Galizia G, Lieto E, Orditura M et al (2008) First-line chemotherapy vs bowel tumor resection plus chemotherapy for patients with unresectable synchronous colorectal hepatic metastases. Arch Surg 143:352–358CrossRefPubMedGoogle Scholar
  7. 7.
    Law WL, Chan WF, Lee YM et al (2004) Non-curative surgery for colorectal cancer: critical appraisal of outcomes. Int J Colorectal Dis 19:197–202CrossRefPubMedGoogle Scholar
  8. 8.
    Michel P, Roque I, Di Fiore F et al (2004) Colorectal cancer with non-resectable synchronous metastases: should the primary tumor be resected? Gastroenterol Clin Biol 28:434–437PubMedCrossRefGoogle Scholar
  9. 9.
    Ruo L, Gougoutas C, Paty PB et al (2003) Elective bowel resection for incurable stage IV colorectal cancer: prognostic variables for asymptomatic patients. J Am Coll Surg 196:722–728CrossRefPubMedGoogle Scholar
  10. 10.
    Benoist S, Pautrat K, Mitry E et al (2005) Treatment strategy for patients with colorectal cancer and synchronous irresectable liver metastases. Br J Surg 92:1155–1160CrossRefPubMedGoogle Scholar
  11. 11.
    Muratore A, Zorzi D, Bouzari H et al (2007) Asymptomatic colorectal cancer with un-resectable liver metastases: immediate colorectal resection or up-front systemic chemotherapy? Ann Surg Oncol 14:766–770CrossRefPubMedGoogle Scholar
  12. 12.
    Sarela AI, Guthrie JA, Seymour MT et al (2001) Non-operative management of the primary tumour in patients with incurable stage IV colorectal cancer. Br J Surg 88:1352–1356CrossRefPubMedGoogle Scholar
  13. 13.
    Scoggins CR, Meszoely IM, Blanke CD et al (1999) Nonoperative management of primary colorectal cancer in patients with stage IV disease. Ann Surg Oncol 6:651–657CrossRefPubMedGoogle Scholar
  14. 14.
    Simmonds PC (2000) Palliative chemotherapy for advanced colorectal cancer: systematic review and meta-analysis, Colorectal Cancer Collaborative Group. BMJ 321:531–535CrossRefPubMedGoogle Scholar
  15. 15.
    Petrelli NJ (2006) Systemic chemotherapy should be the primary treatment of synchronous colorectal metastases in the asymptomatic patient. Ann Surg Oncol 13:137–139CrossRefPubMedGoogle Scholar
  16. 16.
    Tebbutt NC, Norman AR, Cunningham D et al (2003) Intestinal complications after chemotherapy for patients with unresected primary colorectal cancer and synchronous metastases. Gut 52:568–573CrossRefPubMedGoogle Scholar
  17. 17.
    Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 52:377–384CrossRefPubMedGoogle Scholar
  18. 18.
    Moher D, Cook DJ, Eastwood S et al (1999) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement, Quality of reporting of meta-analyses. Lancet 354:1896–1900CrossRefPubMedGoogle Scholar
  19. 19.
    Hintze J (2001) NCSS and PASS number cruncher statistical systems, Kaysville, UtahGoogle Scholar
  20. 20.
    Rosen SA, Buell JF, Yoshida A et al (2000) Initial presentation with stage IV colorectal cancer: how aggressive should we be? Arch Surg 135:530–534 discussion 534–535CrossRefPubMedGoogle Scholar
  21. 21.
    Stelzner S, Hellmich G, Koch R et al (2005) Factors predicting survival in stage IV colorectal carcinoma patients after palliative treatment: a multivariate analysis. J Surg Oncol 89:211–217CrossRefPubMedGoogle Scholar
  22. 22.
    Kaufman MS, Radhakrishnan N, Roy R et al (2008) Influence of palliative surgical resection on overall survival in patients with advanced colorectal cancer: a retrospective single institutional study. Colorectal Dis 10:498–502CrossRefPubMedGoogle Scholar
  23. 23.
    Bajwa A, Blunt N, Vyas S et al (2009) Primary tumour resection and survival in the palliative management of metastatic colorectal cancer. Eur J Surg Oncol 35:164–167PubMedGoogle Scholar
  24. 24.
    Cummins ER, Vick KD, Poole GV (2004) Incurable colorectal carcinoma: the role of surgical palliation. Am Surg 70:433–437PubMedGoogle Scholar
  25. 25.
    Konyalian VR, Rosing DK, Haukoos JS et al (2007) The role of primary tumour resection in patients with stage IV colorectal cancer. Colorectal Dis 9:430–437CrossRefPubMedGoogle Scholar
  26. 26.
    Van der Burg ME, Vergote I (2003) The role of interval debulking surgery in ovarian cancer. Curr Oncol Rep 5:473–481CrossRefPubMedGoogle Scholar
  27. 27.
    Flanigan RC, Salmon SE, Blumenstein BA et al (2001) Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med 345:1655–1659CrossRefPubMedGoogle Scholar
  28. 28.
    Adam R, Avisar E, Ariche A et al (2001) Five-year survival following hepatic resection after neoadjuvant therapy for nonresectable colorectal. Ann Surg Oncol 8:347–353CrossRefPubMedGoogle Scholar
  29. 29.
    Nash GM, Saltz LB, Kemeny NE et al (2020) Radical resection of rectal cancer primary tumor provides effective local therapy in patients with stage IV disease. Ann Surg Oncol 9:954–960CrossRefGoogle Scholar
  30. 30.
    Law WL, Chu KW (2006) Outcomes of resection of stage IV rectal cancer with mesorectal excision. J Surg Oncol 93:523–528CrossRefPubMedGoogle Scholar
  31. 31.
    Iversen LH, Bulow S, Christensen IJ et al (2008) Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer. Br J Surg 95:1012–1019CrossRefPubMedGoogle Scholar
  32. 32.
    Costi R, Mazzeo A, Di Mauro D et al (2007) Palliative resection of colorectal cancer: does it prolong survival? Ann Surg Oncol 14:2567–2576CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2010

Authors and Affiliations

  1. 1.Department of Surgery, School of Medicine and Dentistry and North Queensland Centre for Cancer ResearchJames Cook UniversityTownsvilleAustralia
  2. 2.School of Public Health and Tropical Medicine and North Queensland Centre for Cancer ResearchJames Cook UniversityTownsvilleAustralia

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