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Invited Critique |

First-Line Chemotherapy vs Bowel Tumor Resection Plus Chemotherapy for Patients With Unresectable Synchronous Colorectal Hepatic Metastases—Invited Critique

Gregory Kennedy, MD; Heidi Nelson, MD
Arch Surg. 2008;143(4):358. doi:10.1001/archsurg.143.4.358.
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The optimal management strategy for asymptomatic patients presenting with unresectable stage IV colorectal cancer remains controversial. Whether or not resection of the primary tumor provides a benefit to the patient of survival or prevention of secondary complications remains to be conclusively addressed. Many have devoted retrospective studies to this question,14 including the report by Galizia and colleagues, who make a compelling argument for proceeding with resection of the primary tumor before initiating chemotherapy. In their report, patients treated medically suffered a significant rate of secondary complications attributable to the primary tumor. Galizia et al ultimately concluded that resection of the primary tumor should be undertaken to reduce the risk of severe complications related to the unresected bowel tumor and to provide better median survival times. Although some authors such as Ruo et al1 report similar findings and support the surgery-first approach, others report that complication rates as low as 3% to 15% can be achieved without surgery first.24 Indeed, a review of the literature demonstrates that one can support surgery followed by chemotherapy or chemotherapy alone as treatment for this group of patients (ie, equipoise).

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