Primary Tumor Resection In Stage Research Articles

Updated evidence of primary tumor resection in stage IV breast cancer: a systematic review and meta-analysis

Background: In stage IV breast cancer, surgical resection of the primary tumor was traditionally performed solely to palliate symptoms such as bleeding, infection, or pain. The ongoing discussion has shown that there are many research gaps in the current literature and differences in clinical practice. Thus, this systematic review and meta-analysis was designed to evaluate how primary tumor resection (PTR) affects the overall survival (OS) of patients with stage IV breast cancer. Method: A thorough literature search was completed using different databases (PubMed, Google Scholar, Scopus, ScienceDirect, and Cochrane Library) to find papers contrasting PTR with no PTR. The quality of research articles was evaluated using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale (NOS). Review Manager 5.4 was used to determine how much demographic and clinical factors contribute to heterogeneity through subgroup and meta-regression analysis. Results: Data derived from 44 observational studies (OS) and four randomized controlled trials (RCTs) including 227,889 patients were analyzed. Of all cases, 150,239 patients were included in the non-PTR group, and 70,795 patients in the PTR group (37 observational studies and 4 randomized control trials). The pooled outcomes of four RCT studies (Hazard Ratio (HR) = 1.03, 95%CI: 0.67-1.58; I 2 = 88%; P < 0.0001; chi-square 24.57) favor non-PTR. While pooled outcomes of 43 observational studies showed PTR significantly improved OS (HR = 0.66, 95%CI: 0.61-0.71; I 2 = 87%; P < 0.00001; chi-square 359.12). Additionally, subgroup analysis that compared PTR with non-PTR in patients with stage IV breast cancer for progression free-survival (HR = 0.89, 95%CI: 0.62-1.28; P = 0.03; I 2 = 71%) and locoregional progression-free survival (LPFS) (HR = 0.33, 95%CI: 0.14-0.74; P = 0.0004; I 2 = 87%) was found to be significant favoring the PTR group. Distant progression-free survival (DPFS) had a non-significant relationship (HR = 0.42, 95%CI: 0.29-0.60; P = 0.12; I 2 = 53%), while overall, there was a significant relationship (HR = 0.49, 95%CI: 0.32-0.75; P < 0.00001; I 2 = 90%). Subgroup analysis revealed that PTR is beneficial in patients with bone metastasis (HR = 0.83, 95%CI: 0.68-1.01; P = 0.01; I 2 = 56%), with one metastatic site (HR = 0.75, 95%CI: 0.63-0.59; P = 0.006; I 2 = 62%), but not in patients with positive margins (HR = 0.84, 95%CI: 0.67-1.06; P = 0.07; I 2 = 61%), negative margins (HR = 0.61, 95%CI: 0.59-0.63, P = 1.00; I 2 = 0%). Most of the patients in PTR and non-PTR groups belonged to white compared to other ethnic groups. Overall, observational studies were of high quality, while RCTs were of low quality. Conclusion: The current research suggests that PTR may be discussed as a possible option.

The role of primary tumor resection in synchronous stage IV colorectal cancer: Subgroup analysis.

47 Background: The standard treatment for synchronous stage IV colorectal cancer (CRC) is systemic chemotherapy. There have been attempts to conduct elective primary tumor resection (PTR) as an upfront treatment to prevent complications in primary tumor sites, or improve prognosis. However, there are controversies about the role of PTR in stage IV CRC. We investigated the prognostic role of PTR and tried to find subgroups who might get benefit from upfront PTR in this population. Methods: Between 2010 and 2020, 330 patients diagnosed with synchronous stage IV CRC at St. Vincent Hospital in Korea were retrospectively reviewed. We excluded patients underwent PTR and metastasectomy at the same time, PTR for emergencies (perforation, acute bleeding with hemodynamic instability, fistula, and/or obstruction), or received chemoradiotherapy as an initial treatment. Overall survival (OS) was measured from the date of diagnosis until death resulting from any cause or the last censored date during follow-up. OS were calculated using the Kaplan-Meier method, and differences in survival between groups were compared by the log-rank test. Variables with p value <0.05 were included in the Cox regression multivariable model. Results: Total 223 patients were analyzed. Patients were divided into two groups; 45 patients receiving upfront elective PTR (PTR group), and the 178 patients receiving upfront systemic treatment (non-PTR group). Two groups were not different in terms of age ( p = 0.979), ECOG performance status ( p = 0.488), and serum CEA levels ( p = 0.252). However, the PTR group showed lesser number of metastatic organ compared to the non-PTR groups ( p = 0007). The PTR group survived longer than the non-PTR group ( p = 0.015). Multivariate analysis revealed that age≥60 (hazard ratio [HR], 1.55; 95% confidence interval [CI], 1.15-2.09; p = 0.004,), CEA≥30 ng/mL (HR, 1.32; 95% CI, 0.99-1.75, p = 0.061), PTR (HR, 0.66; 95% CI, 0.45-0.95; p =0.027), adding targeted agent (HR, 0.71; 95% CI, 0.53-0.96; p = 0.026), and ECOG≥3 (HR, 1.649; 95% CI, 1.15-2.37, p = 0.007) were associated with OS. Subgroup analysis showed that PTR might be beneficial in patients with low CEA (<30 ng/mL, p = 0.032), old age (≥60, p = 0.028), ECOG (≤2, p = 0.006), M1a stage ( p = 0.008), and receiving bevacizumab ( p = 0.016). Conclusions: Upfront PTR was conducted in selected patients with lower number of metastasis, but associated with OS after adjusting other prognostic factors. We suggested that PTR could be an option for patients with low CEA (<30 ng/mL), old age (≥60), ECOG (≤2), M1a stage, or receiving bevacizumab in this population.

The Prognostic Impact of Lymph Node Dissection on Primary Tumor Resection for Stage IV Non-Small Cell Lung Cancer: A Population-Based Study.

ObjectiveSelected patients with stage IV non–small cell lung cancer (NSCLC) who underwent primary tumor resection have witnessed a survival benefit. Whether additional lymph node dissection (LND) would result in a better effect remain unknown. We investigated the prognostic impact of LND on patients with stage IV NSCLC who received primary tumor resection (PTR).MethodsPatients with stage IV NSCLC who underwent PTR were identified from the Surveillance, Epidemiology, and End Results database from 2004 to 2016. Propensity-score matching was performed to minimize the confounding effect, and lung cancer-specific survival (CSS) and overall survival (OS) were compared after matching. Multivariable Cox regression was used to identify prognostic factors and to adjust for covariates in subgroup analysis. The effect of the number of lymph nodes examined on the CSS was evaluated by repeating the Cox analysis in a binary method.ResultsA total of 4,114 patients with stage IV NSCLC who receive surgery met our criteria, of which 2,622 (63.73%) underwent LND and 628 patients were identified 1:1 in LND and non-LND groups after matching. Compared with the non-LND group, the LND group had a longer CSS (median: 23 vs. 16 months, p < 0.001) and OS (median: 21 vs. 15 months, p < 0.001). Multivariable regression showed that LND was independently associated with favorable CCS [hazard ratio (HR) = 0.78, 95% confidence interval (CI) 0.69–0.89, P < 0.001] and OS (HR = 0.79, 95% CI 0.70–0.89, P < 0.001). Subgroup analysis suggested that LND is an independent favorable predictor to survival in the surgical patients who were older age (>60 years old), female, T3-4, N0, and M1a stage and those who underwent sublobar resection. In addition, a statistically significant CCS benefit was associated with an increasing number of lymph nodes examined through 25 lymph nodes.ConclusionsLND with a certain range of lymph nodes number examined was associated with improved survival for patients with stage IV NSCLC who received primary tumor resection. The results may have implications for guidelines on lymph nodes management in selective advanced NSCLC for surgery.

ASO Author Reflection: Primary Tumor Resection for Stage IV Lung Cancer after Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitor.

ASO Author Reflection: Primary Tumor Resection for Stage IV Lung Cancer after Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitor.

Primary Tumor Resection for Stage IV Non-small-cell Lung Cancer Without Progression After First-Line Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitor Treatment: A Retrospective Case-Control Study.

In studies of stage IV epidermal growth factor receptor (EGFR)-mutant nonsmall-cell lung cancer (NSCLC), <10% of patients underwent surgery; thus, the effect of surgery in these patients remains unclear. We investigated whether primary lung tumor resection could improve the survival of patients with stage IV EGFR-mutant NSCLC without progression after first-line EGFR-tyrosine kinase inhibitor (EGFR-TKI) treatment. This retrospective case-control study included patients treated with first-line EGFR-TKIs without progression on follow-up imaging. Patients in the surgery group (n = 56) underwent primary tumor resection, followed by TKI maintenance therapy. Patients in the control group (n = 224; matched for age, metastatic status, and Eastern Cooperative Oncology Group performance status) received only TKI maintenance therapy. Local ablative therapy for distant metastasis was allowed in both groups. The primary endpoint was progression-free survival. The secondary endpoints were overall survival, failure patterns, and complications/adverse events. The median time from TKI treatment to surgery was 5.1 months. For the surgery and control groups, the median follow-up periods were 34.0 and 38.5 months, respectively, with a median (95% confidence interval) progression-free survival of 29.6 (18.9-40.3) and 13.0 (11.8-14.2) months, respectively (P < 0.001). Progression occurred in 29/56 (51.8%) and 207/224 (92.4%) patients, respectively. The median overall survival in the surgery group was not reached. The rate of surgical complications of grade ≥2 was 12.5%; complications were treated conservatively. Primary tumor resection is feasible for patients with EGFR-mutant nonprogressed NSCLC during first-line EGFR-TKI treatment and may improve survival better than maintenance EGFR-TKI therapy alone.

Benefit of Primary Tumor Resection in Stage IV, Grade 1 and 2, Pancreatic Neuroendocrine Tumors: A Propensity-Score Matched Cohort Study.

To determine the association of primary tumor resection in stage IV pancreatic neuroendocrine tumors (Pan-NET) and survival in a propensity-score matched study. Pan-NET are often diagnosed with stage IV disease. The oncologic benefit from primary tumor resection in this scenario is debated and previous studies show contradictory results. Patients from 3 tertiary referral centers from January 1, 1985, through December 31, 2019: Uppsala University Hospital (Uppsala, Sweden), Sahlgrenska University Hospital (Gothenburg, Sweden), and Brigham and Women's Hospital/Dana-Farber Cancer Institute (Boston, USA) were assessed for eligibility. Patients with sporadic, grade 1 and 2, stage IV pan-NET, with baseline 2000-2019 were divided between those undergoing primary tumor resection combined with oncologic treatment (surgery group [SG]), and those who received oncologic treatment without primary tumor resection (non-SG). A propensity-score matching was performed to account for the variability in the extent of metastatic disease and comorbidity. Primary outcome was overall survival. Patients with stage IV Pan-NET (n = 733) were assessed for eligibility, 194 were included. Patients were divided into a SG (n = 65) and a non-SG (n = 129). Two isonumerical groups with 50 patients in each group remained after propensity-score matching. The 5-year survival was 65.4% (95% CI, 51.5-79.3) in the matched SG and 47.8% (95% CI, 30.6-65.0) in the matched non-SG (log-rank, P = 0.043). Resection of the primary tumor in patients with stage IV Pan-NET and G1/G2 grade was associated with prolonged overall survival compared to nonoperative management. A surgically aggressive regime should be considered where resection is not contraindicated.

Role of Primary Tumor Resection for Metastatic Small Bowel Neuroendocrine Tumors.

While small bowel resection is well established as standard of care for curative-intent management of localized and loco-regional small bowel neuroendocrine tumors (SB-NETs), resection of the primary tumor in the setting of metastatic disease is debated. This review addresses the role of primary tumor resection for stage IV well-differentiated grade 1 and 2 SB-NETs. While survival benefits have been reported for primary tumor resection in the setting of metastatic disease, these studies are limited by selection bias and thus controversial. The main clinical benefits of primary tumor resection for stage IV disease involve the prevention of potentially debilitating complications associated with mesenteric fibrosis, including intestinal obstruction, mesenteric ischemia and angina, venous congestion, malabsorption, and malnutrition. Patients with metastases undergoing initial resection of the primary SB-NETs appear to have fewer episodes of care and re-intervention for loco-regional complications than those who do not undergo resection. As recommended by the NANETS and ENETS guidelines, resection of the primary tumor for stage IV SB-NETs should be strongly considered to avoid future loco-regional complications and potentially to improve survival. All patients with stage IV SB-NETs should be assessed by a surgeon experienced in the management of NETs to consider surgical therapies, including resection of the primary tumor despite metastatic disease.

Comparative effectiveness of primary tumor resection in patients with stage III pancreatic adenocarcinoma

BackgroundPrevious studies comparing primary tumor resection (PTR) to palliative treatment for advanced-stage pancreatic ductal adenocarcinoma (PDA) were limited by strong selection bias. We used multiple methods to control for confounding and selection bias to estimate the effect of PTR on survival for late-stage PDA.MethodsSurveillance, Epidemiology, and End Results (SEER) 18 registry database for 2004 through 2014 was retrieved for the present study. A total of 4322 patients with stage III (AJCC, 6th) PDA were included in this study. Propensity score matching (PSM) was performed to eliminate possible bias. In addition, instrumental variable (IV) analysis was utilized to adjust for both measured and unmeasured confounders.ResultsA total of 4322 patients with stage III PDA including 552 (12.8%) who underwent PTR, 3770 (87.2%) without PTR, were identified. In the multivariable cohort, a clear prognostic advantage of PTR was observed in overall survival (OS) (P < 0.001) and disease-specific survival (DSS) (P < 0.001) compared to patients after non-surgery therapy. In the PSM cohort, patients in PTR group showed a better OS and DSS (both P values < 0.001) compared to patients in non-surgery group. The survival benefit of PTR for stage III PDA was not observed in the two-stage residual inclusion (2SRI) model. Estimates based on this instrument indicated that patients treated with PTR had similar OS (P = 0.448) and DSS (P = 0.719). In IV analyses stratified by chemotherapy and tumor location, patients undergoing PTR had similar OS and DSS compared to patients in non-surgery group across all subgroups.ConclusionsSurvival with PTR did not differ significantly from palliative treatment in marginal patients with stage III pancreatic adenocarcinoma. High-quality randomized trials are needed to validate these results.

Surgical resection of the primary tumor leads to prolonged survival in metastatic pancreatic neuroendocrine carcinoma

BackgroundPalliative resection of the primary tumor for metastatic pancreatic neuroendocrine carcinoma (pNEC) patients is not recommended because of the poor prognosis compared to that of patients with well-differentiated, lower grade tumors. However, the published data supporting this recommendation regarding pNEC are limited. In the present study, we assessed whether palliative primary tumor resection in stage IV pNEC patients affects survival and identified other factors that affect survival in these patients.MethodsWe collected data from stage IV pNEC patients registered in the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2014. Univariate and multivariate Cox regression analysis were used to compare overall survival (OS) and cancer-specific survival (CSS) of patients who did or did not undergo primary tumor resection.ResultsWe identified 350 patients with metastatic, poorly differentiated, and undifferentiated pNEC. A total of 14.3% (50/350) of patients underwent primary tumor resection. Multivariate Cox regression analysis showed that primary tumor resection provided a significant benefit for both OS and CSS in stage IV pNEC patients. Additionally, chemotherapy and the presence of the primary tumor in the pancreatic tail were independent positive prognostic factors for metastatic pNEC patients in the multivariate Cox regression analysis.ConclusionsThe present study suggests that chemotherapy, location of the primary tumor in the pancreatic tail, and, most importantly, surgical removal of the primary tumor are associated with prolonged survival in stage IV pNEC patients.

Primary Tumor Resection for Stage IV Colorectal Cancer in the Era of Targeted Chemotherapy

BackgroundIn the current era of targeted therapies, the benefits of resection of primary tumors in patients with unresectable stage IV colorectal cancer, specifically with regard to overall survival, are unknown. MethodsOur study population comprised 208 consecutive patients with unresectable stage IV colorectal cancer who received chemotherapy containing at least one molecular target agent, bevacizumab, cetuximab, and panitumumab, at the National Cancer Center Hospital from 2006 to 2013. To lessen the effects of confounding factors between two treatment groups (resection versus non-resection) such as performance status, presence of severe symptoms, M subcategories (M1a versus M1b, M1c) according to the TNM classification, primary tumor site, and CEA value, we conducted three different propensity score analyses (regression adjustment, stratification, and matching). ResultsOf the 208 patients, 108 (52%) underwent resection of the primary tumor, while 100 (48%) did not. Regression adjustment revealed that resection was not associated with longer overall survival (hazard ratio of 0.70 (95% CI [0.49–1.00]; p = 0.051)). Stratification analysis of five strata revealed inconsistent results (hazard ratios ranged from 0.50 to 1.58); specifically, resection was associated with longer overall survival in four strata, but with shorter survival in one stratum. The propensity score-matched cohort (64 matched pairs) yielded a hazard ratio of 0.76 (95% CI [0.51–1.15]; p = 0.197). ConclusionsAll three analyses revealed that, in the current era of chemotherapy with target agents, primary tumor resection was only marginally influential and did not significantly improve overall survival over chemotherapy alone.

A Novel Derivation Predicting Survival After Primary Tumor Resection in Stage IV Colorectal Cancer: Validation of a Prognostic Scoring Model and an Online Calculator to Provide Individualized Survival Estimation.

A prognostic scoring model has been devised previously to predict survival following primary tumor resection in patients with metastatic colorectal cancer and unresectable metastases. This has yet to be validated. The main objectives of this study are to validate the proposed prognostic scoring model and create an interactive online calculator to estimate an individual's survival after primary tumor resection. Clinical data and survival outcomes of patients were extracted from a prospectively maintained database. Patients were categorized into good, moderate, or poor survivor groups based on the previously proposed scoring algorithm. Discrimination was assessed and recalibration was performed, with the recalibrated model implemented as an interactive Web application to provide individualized survival probability. This study was conducted at a tertiary referral center. The study included 324 consecutive patients with metastatic colorectal carcinoma and unresectable metastases who underwent primary tumor resection between January 2008 and December 2013. The primary outcome measured was overall survival. Three hundred twenty-four patients were included in the study. Median survival in the good, moderate, and poor prognostic groups was 56.8, 25.7, and 19.9 months (log rank test, p = 0.003). The κ statistic was 0.638 and RD was 0.101. Significant differences in survival were found between the moderate and good prognostic groups (HR, 2.79; 95% CI, 1.51-5.15; p = 0.001) and between poor and good prognostic groups (HR, 4.12; 95% CI, 1.98-8.55; p < 0.001). The model was implemented as an interactive online calculator to provide individualized survival estimation after primary tumor resection (http://bit.ly/Stage4PrognosticScore). Selection bias and single-center data preclude the generalizability of the proposed model. Information regarding the severity or likelihood of developing symptoms from the primary tumor were also not accounted for in the prognostic scoring model proposed. The prognostic scoring model provides good prognostic stratification of survival after primary tumor resection and may be a useful tool to predict survival after primary tumor resection. See Video Abstract at http://links.lww.com/DCR/A330.

Meta-analysis of outcomes of patients with stage IV colorectal cancer managed with chemotherapy/radiochemotherapy with and without primary tumor resection.

BackgroundColorectal cancer is the third leading cause of death worldwide. Currently, novel chemotherapeutic agents are first-line therapy for unresectable stage IV colorectal cancer, while benefits of noncurative primary tumor resection in advanced disease remain debatable.ObjectiveThis meta-analysis evaluated outcomes of patients with unresectable stage IV colorectal cancer receiving systemic chemotherapy with or without primary tumor resection.Materials and methodsA database search of PubMed and Cochrane Library databases identified 167 studies that were screened for relevance. After 119 were excluded, 48 were assessed for eligibility and 26 were included for meta-analysis, including 24 retrospective studies, one prospective study, and one randomized, controlled trial. Extracted data included patient demographics (age, sex), clinical data (tumor stage, metastasis), targeted therapy agents, and surgical data (with/without tumor resection). Patients’ overall and progression-free survival was compared between groups with/without primary tumor resection.ResultsThe 26 studies included 43,903 patients with colorectal cancer, with 29,639 receiving chemotherapy/radiotherapy plus primary tumor resection, and 14,264 managed medically with chemotherapy/chemoradiotherapy alone without primary tumor resection. Patients receiving primary tumor resection plus chemotherapy/radiotherapy had longer overall survival (hazard ratio [HR 0.59], 95% confidence interval [CI] 0.51–0.68; P<0.001), with significant differences in overall survival between patients with and without primary tumor resection (HR 0.58, 95% CI 0.49–0.68; P<0.001). Longer overall survival was also found among patients receiving primary tumor resection who were treated with bevacizumab/cetuximab targeted therapy agents (HR 0.63, 95% CI 0.46–0.86; P=0.003). Patients from three studies who received primary tumor resection had longer progression-free survival (HR 0.73, 95% CI 0.58–0.91; P=0.005). Results are limited by retrospective data, inconsistent complications data, and publication bias.ConclusionStudy results support primary tumor resection in stage IV colorectal cancer, but significant biases in studies suggest that randomized trials are warranted to confirm findings.

Palliative resection of the primary tumor is associated with improved overall survival in incurable stage IV colorectal cancer: A nationwide population-based propensity-score adjusted study in the Netherlands.

As the value of palliative primary tumor resection in stage IV colorectal cancer (CRC) is still under debate, the purpose of this population-based study was to investigate if palliative primary tumor resection as the initial treatment after diagnosis was associated with improved overall survival. All patients with stage IV colorectal adenocarcinoma (2008-2011) were selected from the Netherlands Cancer Registry, and patients undergoing treatment with curative intent (i.e., metastasectomy, radiofrequency ablation and/or hyperthermic intraperitoneal chemotherapy), or best supportive care were excluded. After propensity score matching, a multivariable Cox proportional hazard model was performed to determine the association between treatment strategy and mortality. From a total group of 10,371 patients with stage IV CRC, 2,746 patients (26%) underwent an elective palliative resection of the primary tumor, whether or not followed by systemic therapy, and 3,345 patients (32%) were initially treated with palliative systemic therapy. After propensity score matching, median overall survival in these groups was 17.2 months (95% CI 16.3-18.1) and 11.5 months (95% CI 11.0-12.0), respectively. In Cox regression analysis, primary tumor resection was significantly associated with improved overall survival (hazard ratio of death=0.44 [95% CI 0.35-0.55], p<0.001). This large population-based study shows an overall survival benefit for patients with incurable stage IV CRC who underwent primary tumor resection as the initial treatment after diagnosis, compared to patients who started systemic therapy with the primary tumor in situ. This result is an argument in favor of resection of the primary tumor, even when patients have little to no symptoms.

Controversy of primary tumor resection for stage IV colorectal cancer

Primary tumor resection (PTR) is currently recommended for patients with unresectable stage IV colorectal cancer (CRC) who present symptoms related to their primary tumor (eg, obstruction, perforation, significant bleeding). The role of PTR in asymptomatic patients remains controversial. This article will review the role of PTR in incurable stage IV CRC, including the advantages and risks, with emphasis on identifying patients who may benefit from this palliative intervention.

Abstract P6-15-01: A comparative analysis of primary tumor resection in men and women with stage IV breast cancer

Abstract Background: Primary tumor resection (PTR) for metastatic female breast cancer continues to be debated. Given the rarity of male breast cancer, treatment paradigms for female breast cancer are extended to the management of male breast cancer. Whether the role of PTR in men with metastatic breast cancer is similar to that in women remains unclear. We sought to compare these two populations using a large, national database. Methods: All patients with Stage IV breast cancer between the years 1988-2011 in the SEER database were identified. Uni and multivariate descriptive and survival analyses were performed. Results: A total of 41,601 patients with stage IV breast cancer were identified; 98.9% (n=41,162) females, 1.1% (n=439) males. On average, female patients were younger (63 vs. 66y) and more often White (78 vs. 74%), p≤0.02. Tumors in male patients were more likely to be hormonally positive, with varying breakdown of T and N-stages and histologic subtypes as compared to tumors in females, p≤0.05. Males were more likely to undergo PTR (51 vs.40%, p&amp;lt;0.05), however both males and females had similar rates of radiotherapy (35 vs. 32%, p=0.35). Among male patients, those who received PTR were of similar age to those who did not receive PTR (p=0.64), but had a greater representation of White patients (p=0.04). There were differences in T-stage, N-stage and hormonal status between men who did and did not receive PTR, p≤0.05. Men receiving surgery were also more likely to receive radiation therapy (38 vs. 32%, p=0.003). In women, all demographic and tumor-related factors were significantly different between those who did and did not undergo PTR. On univariate analysis, surgery was associated with improved disease-specific median survival in both men (36 vs. 21 mths) and women (34 vs. 18 mths), p&amp;lt;0.05. Younger age, White race, lower T and N-stage, lower grade, hormonal positivity, mucinous histology, and radiation therapy were associated with improved disease specific survival (DSS) in females, while only lower T-stage, hormone positivity and mucinous histology were associated with improved DSS in men. On multivariate analysis, a lack of resection of the primary tumor remained independently associated with increased mortality in men (HR 1.91, p&amp;lt;0.05) and women (HR 1.6, p&amp;lt;0.05). Over the study period there was a decrease in the rate of surgery in both men and women, p≤0.0006, but only women were found to have a statistically significant improvement in DSS with surgery over time. Conclusion: Regardless of gender, patients with metastatic breast cancer who underwent primary tumor resection had a significant improvement in DSS. Factors associated with DSS varied between male and female patients, but the reasons for this difference are unclear. A well designed randomized trial including both genders will help determine the utility of PTR in stage IV breast cancer patients. Characteristics of Stage IV Breast Cancer in Males: Surgery vs. No surgery (S = ≤ p.05) Surgery (%)No surgery (%)P-valueWhite race78.468.7ST1 stage15.87.4SN1 stage27.538.6SER +72.557.6SPR +57.245.2SHer2 +1.43.70.25Grade II34.726.3SInfiltrating ductal carcinoma76.656.2SRadiation therapy37.832.3SYear of diagnosis 1988-19928.17.4S2008-201125.236.9S Citation Format: Nasreen A Vohra, Swapnil D Kachare, Timothy L Fitzgerald, Jan H Wong, Mahvish Muzaffar. A comparative analysis of primary tumor resection in men and women with stage IV breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-15-01.

Benefit of primary tumor resection in stage IV colorectal cancer with unresectable metastasis: a multicenter retrospective study using a propensity score analysis.

Retrospective studies have shown that primary tumor resection improves the prognosis of patients with colorectal cancer (CRC) with unresectable metastasis (mCRC). The aim of this study was to investigate the prognostic impact of primary tumor resection in various subgroups of mCRC patients. A total of 1982 patients with mCRC from January 1997 to December 2007 were retrospectively evaluated. The impact of primary tumor resection on cancer-specific survival (CSS) was analyzed using propensity score analysis to mitigate selection bias. Covariates in the models for propensity scores included treatment period, age, gender, tumor location, depth, lymph node metastasis, number of metastatic organs, and carcinoembryonic antigen (CEA) levels. Among the whole patient population, primary tumor resection significantly improved CSS [hazard ratio (HR) 0.46, 95% confidence interval (CI) 0.32-0.66, p < 0.01]. However, primary tumor resection did not significantly improve CSS in the following subgroups: patients treated in the first 5 years of the study (HR 0.56, 95% CI 0.28-1.13, p = 0.08), patients aged >65 years (HR 0.72, 95% CI 0.36-1.42, p = 0.31), female patients (HR 0.60, 95% CI 0.31-1.17, p = 0.13), patients with right-sided colon cancer (HR 0.68, 95% CI 0.39-1.20, p = 0.17), and patients without nodal involvement (HR 0.54, 95% CI 0.25-1.17, p = 0.09). Our study suggests that primary tumor resection improves the survival of patients with mCRC. However, the prognostic benefit is different among patient subpopulations.

Time trend analysis of primary tumor resection for stage IV colorectal cancer: less surgery, improved survival.

With the advent of effective modern chemotherapeutic and biologic agents, primary tumor resection for patients with stage IV colorectal cancer (CRC) may not be routinely necessary. To evaluate the secular patterns of primary tumor resection use in stage IV CRC in the United States. A retrospective cohort study using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results CRC registry. Demographic and clinical factors were compared for 64,157 patients diagnosed with stage IV colon or rectal cancer from January 1, 1988, through December 31, 2010, who had undergone primary tumor resection and those who had not. Rates of primary tumor resection and median relative survival were calculated for each year. Joinpoint regression analysis was used to determine when a significant change in trend in the primary tumor resection rate had occurred. Logistic regression analysis was used to assess factors associated with primary tumor resection. Difference in primary tumor resection rates over time. Of the 64,157 patients with stage IV CRC, 43,273 (67.4%) had undergone primary tumor resection. The annual rate of primary tumor resection decreased from 74.5% in 1988 to 57.4% in 2010 (P<.001), and a significant annual percentage change occurred between 1998-2001 and 2001-2010 (-0.41% vs -2.39%; P<.001). Factors associated with primary tumor resection were age younger than 50 years, female sex, being married, higher tumor grade, and presence of colon tumors. Median relative survival rate improved from 8.6% in 1988 to 17.8% in 2009 (P<.001); the annual percentage change was 2.18% in 1988-2001 and 5.43% in 1996-2009 (P<.001). The majority of patients with stage IV CRC had undergone primary tumor resection but, beginning in 2001, a trend toward fewer primary tumor resections was seen. Despite the decreasing primary tumor resection rate, patient survival rates improved. However, primary tumor resection may still be overused, and current treatment practices lag behind evidence-based treatment guidelines.

A meta-analysis to determine the effect of primary tumor resection for stage IV colorectal cancer with unresectable metastases on patient survival.

Approximately 20% of patients diagnosed with colorectal cancer will have distant metastases at first presentation (stage IV disease). The effect of removing the primary tumor on survival for patients with stage IV disease with unresectable metastases remains unclear. To address this a meta-analysis of all studies comparing primary tumor resection with chemotherapy alone in cases of stage IV colorectal cancer with unresectable metastases was performed. A comprehensive search for published studies examining the effect of primary tumor resection in the setting of colorectal cancer with unresectable metastases was performed. Each study was reviewed and data extracted. Random-effects methods were used to combine data. There were 21 studies including a total of 44,226 patients that met the inclusion criteria. Resection of the primary tumor in patients with unresectable metastases compared with chemotherapy alone was associated with a lower mortality risk (OR 0.28; 95% CI 0.165-0.474; P<0.001), translating into a difference in mean survival of 6.4months in favor of resection (95% CI 5.025-7.858, P<0.001). Patients who underwent resection of the primary tumor were more likely to have liver metastasis only (OR 1.551; 95% CI 1.247-1.929; P<0.001), were less likely to have ≥2 metastasis (OR 0.653; 95% CI 0.508-0.839; P=0.001), and were less likely to have rectal cancer (OR 0.495; 95% CI 0.390-0.629; P<0.001). There was significant cross-study heterogeneity. Resection of the primary tumor may confer a survival advantage in stage IV colorectal cancer with unresectable metastases but significant selection bias exists in current studies. Randomized controlled trials are essential to validate these findings.

Analysis of surgical complications of primary tumor resection after neoadjuvant treatment in stage IV colon cancer.

Assess the surgical complications of primary tumor resection in stage IV colon cancer patients previously treated with neoadjuvant chemotherapy. Between July 2001 and September 2010, 67 consecutive patients received preoperative chemotherapy. Clinical and surgical complications were obtained from the medical records. This study was retrospective in design. All patients were affected with liver metastasis, and 29.8% had metastasis in additional organs. Three different schemes of preoperative chemotherapy were employed, based on FOLFIRI, XELOXIRI or XELOX plus cetuximab. Eighteen patients (26.8%) reported some side effects to the chemotherapy, without contraindicating any intervention. All patients underwent colon surgery and within those, eight patients (11.9%), underwent liver surgery simultaneously. Median hospital admission was 8 [3-29] days. The perioperative complication rate was 16.2%, when the estimated physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) was 58.3%. There was not perioperative mortality, despite the mortality prediction for Portsmouth-POSSUM (P-POSSUM) being 5.07%. No differences were observed between the chemotherapy regimen (P=0.72) or the kind of the surgery-simple or combined (P=0.58). Neoadjuvant chemotherapy as a systemic treatment for stage IV colon cancer does not indicate surgery contraindication nor increases postoperative morbimortality by a significant amount.

Supporting Trials for Primary Tumor Resection in Stage IV Breast Cancer is Paramount

Supporting Trials for Primary Tumor Resection in Stage IV Breast Cancer is Paramount