Unresectable colorectal cancer synchronous metastases: How to manage the primary tumor

In patients with newly diagnosed colorectal cancer, a significant proportion of patients will present with disseminated disease. In the presence of a symptomatic primary tumor, resection may be required to alleviate the symptoms of obstruction, bleeding, or perforation. Historically, resection of the primary asymptomatic tumor was advocated because a large portion of patients eventually developed symptoms or complications related to their primary tumors. Resection was followed by adjuvant chemotherapy with 5FU and survival was modest. However, with the improved response rates to the newer cytotoxic systemic therapies the role of prophylactic resection of the primary tumor in unresectable stage IV colorectal cancer has been questioned. Newer data suggest that routine palliative resection of the synchronous primary lesion should not be performed in the absence of symptoms. Several questions remain and ongoing prospective randomized trials will likely address many of the limitations of currently available literature.