Colorectal Cancer: Management of Stage IV Disease
Mohammad Ali Abbass
Bradley J. Champagne
Perioperative Considerations
Preoperative evaluation using computed tomography scan with intravenous contrast, magnetic resonance imaging, and positron emission tomography is crucial for diagnosis and determining the extent of disease.
Our approach for evaluating stage IV colorectal cancer patients and their operative planning, if feasible, depends on multiple factors:
Urgency of the procedure
Patient-related factors
Sites of metastatic disease
Survival benefit
When evaluating such patients, you have to first identify the presence of any life-threatening complications of the tumor (ie, bowel obstruction, perforation, bleeding).
Once ruled out, then the next step is to investigate the patient’s performance status and their comorbidities, thus deciding whether they are fit for surgery.
If the patient is stable and fit for surgery, the next step is to identify the burden of metastatic disease and isolate resectable cases versus widely metastatic disease, and based on the survival benefit of those cases, the treatment plan is customized.
Although decisions for treating these patients are made with the aid of a multidisciplinary tumor board, when operative plans are made, we also involve our urology and gynecology-oncology partners early on in the process.
Stage IV disease is a complicated entity; thus, the treatment plan is not always straightforward.
When thinking of operative management, the following algorithm is kept in mind to ease the process:
Surgical Approach to Distant Metastatic Disease
In patients with isolated lung metastasis, the primary lesion is always addressed first with an anatomic resection.
The decision to proceed with metastasectomy before or after adjuvant therapy is a decision made by multidisciplinary tumor board.
In patients with liver metastasis, there are multiple ways of approaching the pathology.
In patients with asymptomatic primary and liver metastasis >3 cm, liver-first approach is preferable.
Primary first is the preferable approach in patients with symptomatic tumor (ie, bleeding or near obstructing).
Combined approach is a feasible option when the liver resection is minor and not extending to more than a lobectomy.
Combined Liver Colon/Colon or Rectum Approach
The technical approach is similar to any approach for colon or rectal cancer, described in other chapters within the textbook; the only difference is the combined nature of this procedure.
Usually, the hepatic resection or the bowel resection can be done first, but the most important part of this approach is to leave the anastomosis to the final part of the procedure to avoid any hypotension or increased use of pressers that could affect the integrity of the anastomosis.
Surgical Approach to Local Metastatic Disease
Locally invading rectal cancer or recurrent rectal cancer can be an indication for pelvic exenteration in men when the tumor is invading the anterior pelvic compartment; in females most of the time, the invasion is through the vagina or the cervix, and thus a total mesorectal excision with total abdominal hysterectomy (TAH) and vaginectomy will be the operation of choice.
Approaching the rectum usually follows the same surgical principles as primary rectal cancer, following the total mesorectal excision, and the dissection extends anteriorly in the cases of prostate and bladder invasion and posteriorly in case of sacral invasion, as shown in Figure 42-1.
 FIGURE 42-1 ▪ The green plane including an anterior pelvic exenteration plan in males with anterior rectal tumors invading the prostate and/or the bladder. The red circle indicates the dissection plane in posterior rectal tumors that are invading the sacrum or the coccyx. The protection of sacral nerves in stage IV tumors is always secondary to achieving R0 resections. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.) |
Pelvic Exenteration in Men with Locally Invading Rectal Cancer
This will include a proctectomy combined either with local prostate resection, local bladder resection, or complete pelvic exenteration, which will end up with an end colostomy and neobladder and a urostomy (Figs. 42-2, 42-3, 42-4 and 42-5).
Total Mesorectal Excision with Total Abdominal Hysterectomy +/− Vaginectomy
This included a proctectomy with a TAH with or without a vaginectomy (see Chapter 33).
In some large tumors that are also invading the bladder, the patient might also end up with a neobladder and a urostomy.
 FIGURE 42-2 ▪ This is a sagittal image including the dissection plane of anterior tumors invading the bladder or the prostate. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.) |
 FIGURE 42-3 ▪ Picture of the mesorectal plane at the level of the sacral promontory in an open case for left lateral rectal cancer invading the prostate, bladder, pelvic wall, and external sphincter. The best approach starts with good exposure using a Bookwalter retractor and isolating the left and right ureters with vessel loops. |
 FIGURE 42-4 ▪ Picture of a pelvic exenteration in a male for low rectal cancer, left ureter isolated with vessel loop. |
 FIGURE 42-5 ▪ Picture of a pelvic exenteration in a male for low rectal cancer, right ureter is isolated with vessel loops. |
Posterior Pelvic Exenteration with Sacrectomy
Sacrectomy is done when the tumor is usually posterior and invading the coccyx or the sacrum, usually those cases include a proctectomy with sacral resection done but the spine surgery team (see Chapter 34). The resection plane is usually behind the holy plane and includes the sacrum to ensure R0 resections, as shown in Figure 42-5.
Sterile Surgical Equipment
Gastrointestinal (GI) open tray with pelvic retractors (add on for other specialties if further work is needed)
Knife handle
Adson forceps
Ochsner clamp
Allis clamp
Kelly clamp
Moynihan clamp (short and long)
Babcock clamp (short and long)
Kocher clamp
Tonsil tip
Dennis clamp
Suction tip
Metzenbaum scissors
Mayo scissors
Harrington scissors
Jones scissors
Needle holder
Monopolar cautery
Bonnie forceps
Appendiceal retractors
Bookwalter retractor
St. Mark retractor
Included in this tray also long instruments for the pelvic dissection
Additional instruments are usually needed dependent on the combined part with the proctectomy, gynecology tray, or urology or orthopedic specials.
Technique
Positioning and Preoperative Considerations
This is a multidisciplinary approach that includes multiple teams involved: colorectal, urology, orthopedic, and gynecology oncology.
The patient is usually in modified lithotomy position with both arms tucked to the side in anticipation of the pelvic dissection portion.
Foley catheter and orogastric tube are placed.
If able, a bowel preparation is utilized prior to surgery (not for obstructed lesions).Related posts:
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