Originally published as JCO Early Release 10.1200/JCO.2008.17.6453 on August 18 2008

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Urgent Need for a New Staging System in Advanced Colorectal Cancer

Graeme J. Poston, Joan Figueras, Felice Giuliante, Gennaro Nuzzo, Alberto F. Sobrero, Jean-Francois Gigot, Bernard Nordlinger, Rene Adam, Thomas Gruenberger, Michael A. Choti, Anton J. Bilchik, Eric J.D. Van Cutsem, Jy-Ming Chiang, Michael I. D'Angelica

From the Department of Surgery, University Hospital Aintree, Liverpool, United Kingdom; Hospital Josep Trueta, Girona, Spain; Universita Cattolica del Sacro Cuore, Rome; Oncologia Medica, Ospedale San Martino, Genova, Italy; Saint-Luc, University Hospital, Brussels Digestive Oncology Unit, University Hospital, Gasthuisberg, Leuven, Belgium; Hôpital Ambroise Paré, Centre Hospitalier Universitaire Paris, Cedex; Hôpital Paul Brousse, Villejuif, France; University of Vienna, Vienna, Austria; Division of Surgical Oncology, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; California Oncology Research Institute and UCLA School of Medicine, Santa Monica, CA; Memorial Sloan-Kettering Cancer Center, New York, NY; and the Chang Gung Memorial Hospital, Kwei-Shan, Taoyuan, Taiwan

Corresponding author: Graeme J. Poston, FRCS, Department of Surgery, University Hospital Aintree, Liverpool, L9 7AL, United Kingdom; e-mail: graeme.poston{at}aintree.nhs.uk

Despite recent advances in the medical treatment of metastatic colorectal cancer (mCRC), which include irinotecan- and oxaliplatin-based first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the increasing use of targeted monoclonal antibodies, 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with CRC liver metastases, liver resection remains the only chance of cure, with 5-year survival rates ranging from 25% to 40%. However, 80% to 85% of patients with stage IV CRC have liver disease which is considered unresectable at presentation. The rapid expansion in the use of improved combination chemotherapy regimens plus or minus biologics, to render initially unresectable metastases resectable has increased the percentage of patients eligible for potentially curative surgery. However, the current staging criteria for CRC patients with metastatic disease do not reflect these recent changes or the fact that there is also a large variation in the survival of patients with stage IV CRC. For example the survival for a patient with a solitary, resectable liver metastasis is better than that for a patient with stage III disease. A new staging system is therefore needed that acknowledges both the improvements that have been made in surgical techniques for resectable metastases and the impact of modern chemotherapy on rendering initially unresectable CRC liver metastases resectable, while at the same time distinguishing between patients with a chance of cure at presentation and those for whom only palliative treatment is possible.

published online ahead of print at www.jco.org on August 18, 2008.

Presented in part at the First International Workshop on the Treatment of Hepatic and Lung Metastases of Colorectal Carcinoma, Barcelona, Spain, November 15-16, 2007.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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