An educational tool to assist in the management of hepatic metastases in patients with colorectal cancer

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Case 1:

Discussant: AXEL GROTHEY, MD

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Case Description:

A 50-year-old woman was previously treated with sigmoid resection for Stage III colon cancer followed by adjuvant FOLFOX and bevacizumab as a result of enrollment into the NSABP-C-08 clinical trial. She completed six cycles of chemotherapy and one year of bevacizumab. Shortly thereafter, a rapid rise in her CEA level during a three-month time frame led to an abdominal CT which showed a large, 8.4-cm mass in the right lobe of the liver. No radiographic evidence of extrahepatic disease was observed. She began preoperative systemic treatment with FOLFIRI and bevacizumab, experienced stable disease with some evidence of improvement in the delineation of tumor margins, followed by a right hepatectomy. Intraoperative evaluation of the porta hepatis revealed metastatic involvement in two of three dissected regional lymph nodes. Postoperative course was complicated by a pleural effusion of benign etiology, but the patient subsequently completed seven additional cycles of adjuvant FOLFIRI and bevacizumab. Six-month posthepatectomy imaging study showed no evidence of tumor recurrence or further metastases.

Case Discussion:

This 50-year-old woman originally presented 18 months ago with Stage III, N2 rectosigmoid cancer. Enrolled on the NSABP-C-08 trial, she received adjuvant FOLFOX and bevacizumab. She completed six cycles of chemotherapy and one year of bevacizumab.

Her CEA levels were monitored and rose from 3.7 ng/mL in December 2007 to 45 ng/mL in March 2008, at which time an abdominal CT revealed an 8.4-cm mass that was not well delineated in the right lobe of the liver. No other lesions were seen on the PET scan. A CT scan had not been performed after surgery, but the preoperative scan had shown no evidence of disease.

The patient was treated with FOLFIRI and bevacizumab. The idea was to change the chemotherapy backbone while continuing the anti-angiogenic agent to optimize therapy. At that time, K-ras testing was not performed, but if I saw this patient today, I would check the tumor’s Kras status to determine whether cetuximab was indicated.

After completing three cycles of FOLFIRI with bevacizumab and then two cycles without, her CEA level responded. No significant change was evident in the size of her liver metastasis, but it became much more circumscribed and some necrosis was identified. That’s a common finding in response to chemotherapy.

The patient underwent a right hepatectomy, during which involvement of the portal lymph nodes was identified. These had not been seen on the preoperative scans and not even in a later review. Pathology revealed that two of three nodes were positive for metastases and the liver mass measured 6.5 centimeters.

My treatment approach would have been the same with this patient, even if I had known about the metastatic involvement of the portal nodes prior to surgery. In a recent paper from René Adam’s group, they showed that cure was still possible despite positive portal lymph nodes. While their presence might influence prognosis, we believe they might be linked to the hepatic disease, unlike positive retroperitoneal nodes that indicate two different metastatic sites.

Postoperatively, she developed a right pleural effusion, which was nonmalignant. The patient continued her perioperative regimen, completing 12 cycles of systemic therapy. She was seen recently and had no radiographic or clinical evidence of early recurrence or metastasis. I would estimate that the median five-year tumor-free survival for a patient like this is probably in the 25 to 30-percent range and the overall survival is probably 40 percent.


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