Prognosis in patients with obstructing colorectal carcinoma

Prognosis in PatientsWith ObstructingColorectal Carcinoma

Ulf ahman, MD, Stockholm,Sweden

About 15 percent of patients with colorectal carcinoma present with obstruction of the large bowel. When carcinoma has proceeded to the stage of obstruction, the results of treatment are poor, both in terms of operative mortality and long-term survival [1,2]. Many factors have been incriminated for the poor outlook, including advanced age and deteriorated general condition of the patient, advanced stage of the tumor, and peristaltic bowel activity promoting dissemination of the tumor. This study was undertaken to analyze management and outcome in a group of patients with complete obstruction secondary to colorectal carcinoma, to elucidate the reason for the poor outlook in these patients, and to review the recent literature.

Material and Methods Over a 30 year interval from 1950 through 1979,1,072 patients with colorectal carcinoma were seen at the Department of Surgery, Karolinska Hospital. Complete clinical information including survival time was obtained for 1,061 patients. In this retrospective study, patients undergoing emergency surgery for obstruction were compared with those undergoing elective surgical treatment. The following variables were studied: age, sex, tumor location, curability rate, surgical management, tumor stage, and survival. Tumors were classified according to Dukes’ system [3,4], asfollows: Dukes’ A, tumor confined within the bowel walk Dukes’ B, tumor penetrating the muscularis propria; and Dukes’ C, tumor with regional lymph node metastases. Crude and uncorrected survival figures were utilized, that is, patients were considered survivors whether tumor was present or absent, and dead irrespective of the cause of death. The significance of differences between distributions was tested with chi-square analysis corrected for continuity according to Yates. From the

Depsrtment of Surgery, Karolinska Hospital, Stockholm, Sweden. Requests for reprints should be ackbsed to Ulf &msn, MD, Depaltment of Surgery, Karolinska Hospital, S-104 01 Stockholm, Sweden.

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Results Complete obstruction was encountered in 148 patients, 14 percent of the total series. Their mean age was 64.8 years, versus 63.5 years for nonobstrutted patients (Figure 1); 48 percent were male, versus 53 percent of those electively treated. The incidence of obstruction for each tumor location is shown in Figure 2; transverse and left colon tumors were more common and rectal cancers less common in patients with obstruction (Table I). The overall 5 year survival rate was 16 percent in patients with obstruction, less than half the rate for nonobstructed patients (Figure 3). The decrease in the survival rate was steep, irrespective of obstruction, in patients receiving palliative or no treatment (Figure 4). Half of the patients with obstruction were treated with the intention of cure, a significantly lower proportion than in elective patients; in patients treated for cure, those with obstruction had fewer stage A and more stage C lesions (Figure 5). The substantial difference in overall survival persisted into resection-for-cure groups; one third of patients with obstruction survived 5 years, versus half of those without obstruction (Figure 6). Survival within tumor stages, however, did not differ significantly between groups (Figure 7). Postoperative mortality was equal in the two series: 8 percent in curatively resected patients with obstruction and 7 percent in those electively treated. The subsequent difference in survival appeared over the first year and was significant throughout the 5 year interval (Figure 8). Tahle II lists treatment, tumor stage, and survival for each tumor location. One fourth of the patients treated for cure had immediate resections, with three postoperative fatalities. A 78 year old man died 10 days after emergency resection for obstructing cecal carcinoma

with gangrene

of the distal small bowel.

A 70 year old woman died from anastomotic

dehis-

The Amerken Journal ef Surgery

Obstructing Colorectal

cence 10 days after resection of a transverse colon carcinoma, and a 63 year old man died from bowel obstruction 4 days after emergency abdominoperineal excision of an obstructing rectal cancer. Three fourths of the patients treated for cure had staged treatment, with three deaths following the excisional stage. A 74 year old man and a 77 year old woman were treated with diverting colostomy and subsequent resection for obstructive sigmoid carcinomas; they died after 1 day and 1 week, respectively, from aortic stenosis and pulmonary embolism. A 59 year old woman had emergency diversion for obstruction caused by rectal cancer and died from cardiac failure and pulmonary edema 2 days after low anterior resection of the tumor. The surgical mortality rate in patients treated for cure was thus 14 percent for primary resections and

42 40

Carcinoma

5 percent for staged resections, for a total mortality of 8 percent. While survival for staged procedures was superior to that for primary resections over the first 3 years postoperatively, the significance did not persist into the fourth and fifth years (Figure 9). The

TABLE I

Distribution ot Tumors ( % ) in 148 Patients With ObstructingCotorectal Cancen and 913 Patients With NonobstructingLesions

Tumor Location Cecum and ascending colon Transverse colon and flexures Descending colon Sigmoid colon Rectosigmoid Rectum Multiple tumors

Obstruction

No Obstruction

15

18

NS

22

10

p <0.00003

9 39 5 8 1

3 19 7 41 2

p <0.0005 p <0.00001 NS p <0.00001 NS

Significance of Difference

NS = not significant.

I? 5 c

30

z 8

20

s 10

20

30

40

50 60 70 AGE, YEA!?S

80

90

100

F@re 1. Age distrbution for 148 patients with obstructingcob rectal carcboma.

I

YEARS

1 p<.m1

2

3

4

pc.ooool pc.ooool pdxm

5 p-=.oowl

Figure 3. Overall wrv/va/ rates ( cure andpalllatlon) tar patients w/th obstructiveand nonobstructivecohuectal carchroma.

YEARS

~2tm3&nceal~toreachtumorkcatknkr1,061 patients wfth cobrectal carcinoma.

Volume 143, June 1982

Figure 4. Suwlvalfor pat/antsreceivingpaNative treatmentor no treatment for obsttuctive and nonobstmct~vecobrectal carcinoma.

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ijhman

Prop. of Dukes’B

Prop. of Du kes’A

Resections for cure

Prop. of Dukes’ C

72%

obst

YEARS

nonobst 78 653 pc .CCQ8

n=148 91!I p-z.cc0ol

1 p405

78 653 p-=.01

78 653 N.S.

2

3

pe.01

p<.oo1

4 pc.001

5 p
Flgure 8. Survlval rate tar patients curatively resected for obstnrctive and nonobsbuctlve colorectal carcinoma.

Figure 5, CurabilIty rate In relathm to the presence of obstruct/on, and In curable cases tumor stag8 in relation to obstruction.

RES. FOR CURE

OVER-ALL

50 %

I 1

nonobstr n= 497 n=78 p< .003

nonobstr n=676

obstr n=l48

obstr

p’.oooo1

Figure 6, F/v8 year survival rate In patients w/th obsbuctive and

twm&structivecoWecta/ carcinoma,

overall and in patients re-

sected for cure.

3

2

4

5 YEARS

F&r8 #. Survivalrate after curative resection In 78 pattentswith obst~ctlve co&ectal carcinoma, divided Into those who had staged procedures and primary resectlons.

comparison is irrelevant, however, since patients were not randomly assigned to one treatment or the other. Comments

DUKES’A

obstr n=9 N.S.

DUKES’ B

DUKES’ C

igii

obstr

~~~{_,

obstr

zi:“t‘,

n=152

n=32 n=192 N.S.

n=37

n=153

N.S.

Figure 7. Five year survival rate within tumor sta#es for patieots with obsbuctlve awl nonobshuctlve coiorectal carcinoma.

744

Obstruction was the presenting complaint for 14 percent of patients with colorectal cancer. Table III lists the incidence of obstruction in previous reports; the incidence in the present series corresponds closely to the 15 percent rate in more than 23,000 patients. Age and sex distribution did not differ between obstructed and nonobstructed patients. Tumor distribution confirmed the classic observation that obstruction is mainly a feature of transverse and left colon carcinomas, whereas obstruction from rectal cancer is uncommon. Scrutiny of the literature reveals the following incidence of obstruction for different tumor locations: right colon, 12 percent; transverse and left colon, 25 percent; and rectum, 4 to 5 percent. Only 16 percent of the patients presenting with malignant obstruction survived 5 years. Two factors

The American Journal of Surgery

Obstructing Colorectal Carcinoma

TABLE II

Treatment, Tumor Stage and Survival for 78 Patients Curatively Treated for Colorectal Carcinoma With Obstruction

Tumor Location Cecum and ascending colon Transversecolon and flexures Descendingcolon Sigmoid Rectosigmoid Rectum Total

n

Resection(n) Primary staged

C

4

6

1

10

10

9

1

16

4

12

3

7

6

5

31

;A

1 5 ... 2

10 25 2 7

1 5 .

...

2 13 2 4

8 12 . 5

6 10 1 1

55 33 50 11

21

57

9

32

37

24

31

2 9 78

contributed to this distressingly poor outlook: only half of the patients were in a curable stage, and even within this curable group survival was markedly poorer than for elective patients. Previous studies of patients with obstructive carcinoma have documented a curability rate of about 50 percent and an overall 5 year survival rate of 8 to 23 percent [6,8,10,22,24,26,27,30]. Comparison with the corresponding rates for elective patients (Table IV) shows the prognosis for obstructed patients to be persistently worse than for those without obstruction, even in cases having treatment assumed to be curative. The present analysis clearly documents that the main reason for poor survival was more advanced disease in cases of obstruction. Stage A tumors were uncommon, although exceeding the 0 to 1 percent incidence sometimes reported [13,22,23,25,31,32]. Half of the obstructed and presumably curable patients had stage C lesions, versus one third of those without obstruction, distributions identical to those previously reported [9,25]. Patients with stage C and frankly incurable lesions constitute a group with a particularly poor outcome; 72 percent of obstructed patients were in this category, versus 51 percent of elective patients (p
Volume 143. June 1982

A

5 Year Survival n %

Dukes’ Lesions(n) B

results for primary tumor resection in this series were mainly the result of poor survival in 10 patients with right-sided colon cancer, 9 of whom underwent immediate resection with one postoperative fatality and a further seven deaths over the ensuing 3 years, leaving only 1 patient surviving beyond 5 years. Immediate resection was also performed in 10 patients with obstructing growths in the transverse or left colon. This somewhat unorthodox approach was,

TABLE III

Incidence of Obstruction In Patient8 With Colorectal Carcinoma

Authors Goligherand SmkMy [ 51, 1957 Chang and Burnett [ 61, 1962 Samenius [ 71, 1962 Loefler and Hafner [ 81, 1964 Minster [ 91, 1964 Hickey and Hyde [ IO], 1965 Peltokallio [ 7I], 1965 Floydand Cohn [ 721, 1967 Watters [ 73],1969 Balslev et al [ 741, 1971 Glennand k&Sherry [ 751, 1971 Raglandet al [ 761, 1971 Sanfelippoand Beahrs [ 771, 1972 Faltermanet al [ 781, 1974 Fieldingand Well8 [ 791, 1974 Welch and Donaldson[ 201, 1974 Howard et al [ 27],1975 Kronborget al [ 221, 1975 Duttonet al [ 231, 1976 Mzabi et al [ 241. 1976 Irvin and &eaney [ 251, 1977 Gennaroand Tyson [ 261, 1978 Nowotnyand Tautenhahn[ 271, 1978 Fieldinget al [ 281, 1979 Biilow [ 291, 1980 Ghman(presentseries) Total

n

With Obstruction n %

1,644 465 323 573 145 444 603 1,741 343 554 1,815 1,137 391 2,313 388 1,566 801 1,410 780 656 242 1,036 1,140

290

106 95 87 26 43 97 240 84 120 240 111 115 544 90 124 147 116 103 67 66 68 134

18 23 29 15 18 10 17 14 24 22 13 10 29 24 23 8 18 8 14 10 27 7 12

932 951 1,061 23.434

174 184 148 3.599

19 17 14 15

745

ohman

TABLE IV

Studies of Patients With Colorectal Carcinoma: Patients With and Without ObstructionCompared With Respect to Curability and Survlval Rates Curability Rate (%)

Authors Minster [ 91, 1964 Peltokallio [ 7I], 1965 Floyd and Cohn [ 12],1967 Balslev et al [ 141, 1971 Glenn and McSherry [ 751, 1971 Welch and Donaldson [ 201, 1974 Dutton et al [ 23],1976 Irvin and Greaney [ 251, 1977 Biilow [ 291. 1980 Ohman (present series)

Obstruction

No Obstruction

57 58 59 47 72 67 59 48 53

however, associated with only one postoperative fatality, and three patients survived 5 years. Appreciable mortality burdens emergency resection for left-sided obstructive colon cancer in several series [5,15,20,23,25,28]. Nevertheless, if immediate survival can be brought to an acceptable level, primary resection is a conceptually more attractive approach than staged surgery, irrespective of the location of the tumor in the large bowel [7,13,26,31,35-371. The surgical mortality for primary resection in this series, 14 percent, was not prohibitively high and should encourage continuing use of this strategy in carefully selected cases. Most patients with left-sided cancers in this series had staged treatment, however, in accordance with current teaching. The surgical mortality rate was 5 percent for staged resection with the intention of cure. The difference in mortality in favor of staged treatment, although not statistically significant, may be, at least in part, a reflection of the difference between the less than optimal conditions prevailing in the emergency setting and the elective situation created by a preliminary diverting procedure. The 5 year survival rate was 35 percent after staged treatment, seemingly superior to the 19 percent rate after one-stage resection. These results are not comparable, however, even if the two groups of patients had similarly staged disease, because the methods of treatment were not randomly allocated. This trend towards a more favorable outlook for patients having staged treatment than for those having emergency resection has been observed previously [12,20,23]. An increasing number of investigators, however, report opposing results [19,25,31,32] and therefore suggest a prospective clinical trial comparing primary with staged resection, the former with exteriorization rather than immediate anastomosis in cases of left colon obstruction. The dif-

740

59

... 3: 76 68 60 54 72

5 Year Survival Rate (%) Patients Resected All Patients No for Cure ObstrucObstrucElecObstruction tive tion tion 27 18 15 24 20 28 29 12 23 16

53 37 27 35 31 41 34 32 39 37

29 32 25 40 42 40 50 21 48 31

56 65 53 46 50 54 53 53 72 50

ficuhies associated with a multicenter trial have been well documented [38]. Results from a prospective study [28] demonstrate similar overall mortality for primary and staged resection, with a considerably shorter hospital stay for primarily resected patients. In that study it is concluded that patients with malignant obstruction should be treated by a fully trained surgeon and that immediate resection should be considered for every patient. Obstructing rectal cancer is uncommon; only nine patients in the present series were curatively treated for this serious disease. Two patients died postoperatively and only one survived 5 years, attesting to the poor outlook in this setting [26,39]. In conclusion, the present study demonstrates that patients with large bowel obstruction secondary to colorectal carcinoma have low curability and survival rates, primarily because of advanced disease at the time of diagnosis and treatment. Summary Over a 30 year interval (1950 to 1979), 1,061 patients with colorectal carcinoma were seen; 148 presented with bowel obstruction and in this retrospective study were compared with those having nonobstructive tumors. The age and sex distribution did not differ between the groups. The curability rate was 53 percent, versus 72 percent for nonobstructed patients; the 5 year survival rate was 16 percent overall and 31 percent in curable cases, versus 37 and 50 percent for elective patients, respectively. Survival within tumor stages did not differ between the groups; the difference in outcome was mainly a result of obstructed patients having fewer stage A and more stage C lesions. Most right-sided growths were primarily resected, while the left-sided growths were mainly treated with staged resection. Operative mortality for curable patients was 8 percent, not

The American Journal of Surgery

Obstructing Colorectal Carcinoma

different from the 7 percent rate in elective patients. The 5 year survival rate was 19 percent after primary and 35 percent after staged resection. It was concluded that patients with bowel obstruction secondary to colorectal carcinoma have low curability and survival rates, primarily because of advanced disease at the time of diagnosis and treatment.

19. Fielding LP, Wells BW. Survival after primary and after staged

20.

21. 22.

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