INCIDENCE OF COLORECTAL CANCER
Since 1985, the incidence and mortality of colorectal cancer in the United States have declined, but it remains the third most common cancer in men and women. In 1994, 160,000 new cases of colorectal cancer were diagnosed. Forty percent of the patients had distant metastatic disease at the time of presentation. About 60% of the patients had no evidence of metastatic disease at the time of presentation and underwent potentially "curative" resections. Twenty percent of those node-negative cancers and 40% of the node-positive cancers recur. Many of these cancers will be symptomatic at the time of their recurrence, whereas others will have recurrences identified prior to the onset of symptoms. This article reviews the role of surgical intervention in managing the patient with symptoms of recurrent and metastatic colorectal cancer.
MANAGEMENT OF THE PRIMARY CANCER IN PATIENTS PRESENTING WITH METASTATIC DISEASE
When the diagnosis of colorectal cancer is made, as many as 40% of the patients will already have metastatic disease. The overall median survival after palliative resection of the primary tumor is 10 to 12 months. ~ Nonetheless, palliative resection is warranted to relieve or prevent obstruction and bleeding. With modern anesthesia and surgical techniques, there are few reasons not to resect a primary colorectal cancer. Most patients will tolerate general anesthesia and a celiotomy. One exception to resection of the primary tumor is the rare patient presenting with malignant ascites and an asymptomatic primary colon cancer. The prognosis for these patients is measured in weeks, and obstructions are unlikely to occur during that time. Of those patients in whom a resection is attempted, most do not leave the hospital. Many authors have attempted to develop guidelines for identifying patients who may be treated expectantly without surgery. In two studies, age was a striking feature, with patients over 75 having an increased operative mortality rate> 2 Bath series are old and may not reflect results with modern surgery and anesthesia.
Rectal cancer presenting with metastatic disease offers a significant challenge to the oncologists. Fixed rectal tumors with metastatic 348