By Duke Medicine News and Communications

WASHINGTON, D.C. -- A single surgery to remove cancer from both the colon and the liver to which it has spread may be better in some cases than the current standard treatment of two separate surgeries with chemotherapy in between, according to a study led by Duke University Medical Center researchers.

Simultaneous surgeries on the colon and liver may reduce the length of a patient's stay in the hospital and potentially lessen the risk of surgical complications without compromising long-term survival, according to the study.

"In about a third of patients who are newly diagnosed with colorectal cancer, the cancer has already spread to the liver," said Bryan Clary, M.D., a surgical oncologist at Duke and senior investigator on the study. "The standard approach for these patients has been to remove the colorectal cancer and give them chemotherapy afterwards, waiting to remove liver tumors later if patients do not appear to be developing disease elsewhere in the body. These findings suggest there might be an alternative that is as safe and may even lead to better outcomes."

Colorectal cancer is the third most common cancer in both men and women in the United States, and it is the second-leading cause of cancer-related deaths in this country.

The researchers presented their findings on Saturday, March 17, in a plenary session at the annual meeting of the Society of Surgical Oncology in Washington, D.C. The study was funded by the National Institutes of Health and Duke's Department of Surgery.

The researchers looked at outcomes for 610 patients who had undergone either simultaneous or separate surgeries for removal of colorectal cancer from the colon or rectum and from the liver, where it had spread. The patients were treated at three academic medical centers -- Duke, the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University and the University of Texas M.D. Anderson Cancer Center -- between 1985 and 2006.

"We looked at factors including surgical complications and survival data among the groups and found that in certain patient groups, simultaneous surgery was as safe as separate surgeries, could shorten the length of hospital stay and might lead to fewer surgery-related complications," said Srinevas Reddy, M.D., a general surgery resident at Duke and the study's lead author.

Chemotherapy is used in addition to cancer surgery to kill cancer cells that may reside undetected in other parts of the body. Patients having separate surgeries commonly receive chemotherapy both after their initial colon surgery and then again after their liver surgery, Clary said. But the powerful drugs used in chemotherapy can have a toxic effect on other organs, including the liver, that may increase the risk of liver surgery, he said.

The researchers also discovered that chemotherapy administered after surgical removal of cancerous liver segments favorably affected survival rates, whether or not that surgery was done alone or in conjunction with colorectal surgery. Chemotherapy administered before liver surgery showed no benefits, Clary said.

The researchers found that simultaneous surgery was only as safe as standard treatment among patients who required a minimal amount of liver to be removed. But for those whose cancer was more extensive requiring larger amounts of liver to be removed, separate surgeries remain the better treatment choice.

"For patients who require a great deal of liver to be removed, the complication risks associated with such extensive surgery outweigh the benefits of doing it all at once," Clary said.

About half of patients with colorectal and liver tumors could be eligible for the simultaneous surgery, which could translate to about 25,000 patients per year, he said.

"This study is important because it shows that patients with liver metastases at the time of their original colorectal cancer diagnosis might benefit from evaluation at a multidisciplinary center that includes not only medical oncologists and surgical oncologists skilled in colorectal surgery, but also surgeons capable of performing liver surgery," Clary said.

Other Duke researchers involved in this study include Andrew Barbas, Kirk Ludwig, Michael Morse and Christopher Mantyh. Timothy Pawlik, Ana Gleisner, Lia Assumpcao and Michael Choti of Johns Hopkins and Dario Ribero, Daria Zorzi, Eddie Abdalla and Jean-Nicolas Vauthey of M.D. Anderson also participated in the research.