Ahead of our next Global Reach Webinar, ‘Translating Evidence into Practice’, Miguel Cunha and Nagendra Dudi-Venkata interview speaker Professor Surendra Mantoo about his talk, 'Resection of asymptomatic primary colorectal cancer in patients with unresectable synchronous metastases', which he will deliver on 19 March.


Miguel Cunha, Surendra Mantoo and Nagendra Dudi-Venkata


Surendra Mantoo graduated from NSCB, Medical College and obtained his Mastery in General Surgery from India. He completed his MRCS and FRCS with the Royal College of Surgeons, Edinburgh, UK. He was awarded an M.Med in Surgery by National University, Singapore. He received the HMDP award in 2011 and completed a fellowship in Anorectal and Pelvic Floor Surgery at University of Nantes, France.

With more than 20 years of experience, he is currently a Senior Consultant in the Colorectal Department of Khoo Teck Puat Hospital, Singapore. He is also the Endo-centre (Khoo Teck Puat Hospital) Chairman.

His areas of expertise include laparoscopic and robotic surgery for both cancer and benign disorders of the colon and rectum, proctology, advanced therapeutic endoscopy and functional bowel disorders. He is passionate about teaching, research, and an assiduous speaker at both national and international conferences. He is a reviewer and member of the editorial board for numerous journals. Finally, he has been awarded 'honorary fellow' by the International College of Laparoscopic Surgeons (FCLS) and 'exhibit of exceptional merit' by the American College of Surgeons.

Colorectal cancer (CRC) remains a burdensome global disease. Despite several improvements in systemic therapy and modern surgical strategies, most patients with stage IV disease have unresectable cancer, only amenable to palliative strategies. For patients with symptomatic primary colorectal cancer with unresectable synchronous metastases, the decision to resect the primary cancer can be straightforward. However, for those with asymptomatic primary cancer, surgery is controversial. There are 'pros and cons' for both resection vs no resection. The aim here is to present the current evidence on this topic and share the results of a web survey, on behalf of ESCP.

Miguel Cunha and Nagendra Dudi-Venkata: Firstly, we would like to thank you for sharing with us your experience and views on resection of asymptomatic primary colorectal cancer in patients with unresectable synchronous metastases.

One of the questions we would like you to share some insight on, is whether there is any difference in the management pathway for patients in this setting having a primary colon or rectal cancer?

Surendra Mantoo: Thank you for this important question. One of the principles of surgical resection in this group of patients is the avoidance of morbidity and a systemic therapy delay. Although there are no comparative studies between rectal and colonic resections, some studies have indicated that rectal resections comprise higher morbidity and that stomas are needed. Most investigators will avoid resection for asymptomatic rectal cancer with unresectable synchronous metastases. We are awaiting the results of GRECCAR 8 trial, which is specifically looking at the role of surgery in rectal primary tumours.

MC/NDV: Nowadays, we live in an era of constant scientific progression, where chemotherapy and radiotherapy are at the forefront of evolution. What is the role of these therapies in these patients? Regarding rectal cancer, has Total neoadjuvant treatment a role?

SM: Presently, systemic therapy remains the standard of care for this group of patients. The role of surgery is still under investigation. I am not aware of any study looking at the role of Total neoadjuvant treatment in patients with synchronous metastases.

MC/NDV: From a surgical point of view, do we have to change the technique of resection for these patients? Does the location of the metastasis change the approach? Do you have any tricks and tips for us that you can share before 19 March?

SM: The surgical technique and principles of surgery should remain unchanged for this group of patients. Minimally invasive surgery and enhanced recovery protocols can help improve surgical outcomes. There are a few retrospective studies which have suggested that location and volume of metastases influence survival. As an example, studies have shown that patients with only lung metastases have significantly better overall survival rates than those with liver metastases; while patients with peritoneal spread have the worst prognosis.

My tip will be to select your patient carefully, discuss the patient in a multi-disciplinary tumour board, avoid morbidity and involve the patient in decision making.

MC/NDV: Finally, what are the key take home points to know about this subject?

SM: This group of patients is highly heterogenous. A blanket palliative approach may not be justifiable for all. Role of surgery is under investigation. Systemic therapy still remains the standard of care especially after the recently published Japanese RCT results.

MC/NDV: Once again, thank you very much for sharing your knowledge with us. We are eagerly looking forward to hearing your talk at the ESCP Global Reach meeting. We will certainly be online on the 19th of March to learn more!

Professor Surendra Mantoo’s talk on the Resection of asymptomatic primary colorectal cancer in patients with unresectable synchronous metastases will take place on Friday, 19 March at ESCP’s Global Reach Webinar ‘Translating Evidence into Practice’.

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