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Locoregional methods for management and palliation in patients who present with stage IV colorectal cancer

Miguel A Rodriguez-Bigas, MD
Section Editor
Kenneth K Tanabe, MD
Deputy Editors
Diane MF Savarese, MD
Wenliang Chen, MD, PhD


In the United States, approximately 20 percent of patients with colorectal cancer (CRC) have metastatic (stage IV, (table 1)) disease at the time of diagnosis [1-3]. Although major advances in systemic chemotherapy have expanded the therapeutic options for these patients and improved median survival from less than one year to 20 months or longer, fewer than 10 percent of those treated with chemotherapy alone are still alive at five years [4]. (See "Systemic chemotherapy for metastatic colorectal cancer: General principles", section on 'Chemotherapy versus supportive care' and "Systemic chemotherapy for metastatic colorectal cancer: General principles".)

On the other hand, surgery provides a potentially curative option for selected patients with limited metastatic disease, especially if located in one organ system (such as liver or lung), isolated local recurrence, or limited intraabdominal disease. With aggressive management integrating chemotherapy and surgery, long-term survival can be achieved in as many as 50 percent of cases. In selected patients, even resection of metastases in more than one organ has been successful in achieving long-term survival [5]. Aggressive surgical cytoreduction with intraperitoneal chemotherapy has been applied to patients with isolated peritoneal carcinomatosis, but the benefits of this approach remain controversial. (See "Management of potentially resectable colorectal cancer liver metastases" and "Surgical resection of pulmonary metastases: Outcomes by histology" and "Surgical resection of pulmonary metastases: Benefits, indications, preoperative evaluation and techniques" and 'Aggressive cytoreduction and intraperitoneal chemotherapy for peritoneal carcinomatosis' below and "Treatment of locally recurrent rectal adenocarcinoma".)

Surgical resection may also provide the best option for palliation of symptoms of obstruction and bleeding from the primary tumor in patients who are not candidates for a curative resection. (See "Surgical resection of primary colon cancer", section on 'Complicated disease'.)

This topic will review the management of the primary tumor (surgical and nonsurgical options) in patients who present with stage IV CRC, and surgical cytoreduction and intraperitoneal chemotherapy for isolated peritoneal carcinomatosis. General surgical principles in patients with primary colon cancer, management of patients with isolated, potentially resectable liver metastases, surgical management of lung metastases, and posttreatment surveillance are discussed in detail elsewhere. (See appropriate topic reviews).


Surgery provides a potentially curative option for selected patients with limited metastatic disease. Long-term survival can be achieved with metastasectomy in as many as 50 percent of cases, and an aggressive surgical approach to both the primary and the metastatic sites is warranted in conjunction with systemic chemotherapy.


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Literature review current through: Sep 2016. | This topic last updated: Mar 21, 2016.
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