Against all odds: why surgeons need to be more aggressive in the era of the multidisciplinary team approach to colorectal cancer

Over the last 30+ years, during which I have been a colorectal surgeon, I have witnessed more dramatic advances in medical technology than ever before. Accordingly, the overall treatment outcomes for colorectal cancer have improved substantially. We now have a deeper understanding of the biology and behavior of colorectal cancer and have adopted more individual cancer-specific treatment protocols, despite the fact that development of new chemotherapeutic agents or regimens specifically effective for colorectal cancer is progressing very slowly. The multidisciplinary team (MDT) approach to colorectal cancer is now the standard approach to the management of colorectal cancer and has proven to be beneficial for patients. However, no matter what decision is made through MDT discussions, we should keep in mind that “a cure cannot be achieved without an aggressive and courageous surgical intervention.” A 36-year-old female patient presented with sigmoid cancer with obstruction symptoms. Her computed tomography (CT) scan showed cT4N+ sigmoid cancer with paraaortic and right external iliac lymph node metastasis confirmed on a positron emission tomography (PET) scan (Fig. 1). The liver and lungs were free from metastasis. Colonoscopy could be performed despite the obstructing lesion, and her biopsy findings were as follows: adenocarcinoma, moderately differentiated, RAS wild type, and low microsatellite instability. In the MDT discussion, since paraaortic lymph node (PALN) metastasis is regarded as M1 disease, neoadjuvant chemotherapy with possible consideration of a stent in case of obstruction was the primary treatment option. FOLFOX/FOLLFIRI+cetuximab was considered as the primary chemotherapy regimen. While this decision would be made by most MDTs, there are a few things to consider in this situation. First, we cannot be sure whether there will be a substantial response to chemotherapy. If there is a poor response to chemotherapy, the chance of curative treatment in this patient would be lost, with the subsequent development of probable unresectable metastases to other organs. Second, we have to consider the possible problems that may be caused by a primary sigmoid lesion. Whether or not a stent is placed over the lesion, and irrespective of the responsiveness, there is a high probability that a primary sigmoid lesion will cause problems, such as perforation or reobstruction, even after stent placement. An emergency situation during chemotherapy will increase the risk of perioperative complications, which in some cases, can be fatal. At our institution, we have a very aggressive approach to primary colorectal cancer lesions, even in unresectable stage IV situations. Although this remains controversial, we have reported survival benefits of palliative resection in metastatic colorectal cancer [1]. Accordingly, the patient underwent an operation first (Fig. 2). Complete dissection of the right external iliac lymph nodes, together with the paraaortic and aortocaval lymph nodes, was done in addition to anterior resection with modified total mesorectal excision. The pathologic report was T4aN2b, with metastasis in nine out of 18 paraaortic/aortocaval lymph nodes and two out of four external iliac lymph nodes. The patient recovered without any notable events and was discharged on postoperative day 4. After the operation, she underwent 12 cycles of FOLFIRI-cetuximab chemotherapy with monitoring for circulating tumor DNA [2], which turned negative at the end of the 12 cycles. No more chemotherapy was given. After 2 and half years of intensive follow-up, there is no evidence of recurrence. One has to wonder what would have happened if the chemotherapy-first approach had been applied. An aggressive surgical approach toward PALN metastasis has been my practice, and reviewing the results of PALN dissection for isolated PALN metastasis from colorectal cancer in our small Received: Oct 16, 2022 • Accepted: Nov 4, 2022 Correspondence to: Kyu Joo Park, M.D., Ph.D. Department of Surgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-2901, Fax: +82-2-766-3975 E-mail: kjparkmd@snu.ac.kr ORCID: https://orcid.org/0000-0002-9134-7426