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

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Case 2: Opinions

Discussant: AXEL GROTHEY, MD

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Case Description:

A 59-year-old man diagnosed with a Stage II obstructing sigmoid tumor was deemed unresectable due to severe cardiovascular problems and had his primary tumor stented. Six weeks after bypass surgery, he underwent a laparoscopic left colectomy. At the time of resection, his tumor was staged as pT3 with N0 of 21 lymph nodes and was found to be K-ras wild type. He did not receive adjuvant therapy due to extensive comorbidities. After one year of observation, CT showed four hepatic metastasis and no extrahepatic disease. Twelve cycles of perioperative FOLFOX and cetuximab were recommended. He has completed two cycles thus far with no significant toxicities to report.

Case Discussion:

This 59-year-old man was diagnosed with a Stage II, obstructing sigmoid tumor. He had severe cardiovascular problems, including congestive heart failure, so he was not a candidate for colectomy. The cancer was stented endoscopically to gain some time and the patient had bypass surgery.

Six weeks later, he underwent a laparoscopic left colectomy. The tumor was pT3 and all 21 lymph nodes removed were negative. He received no adjuvant chemotherapy. Given his significant comorbidity, his recent bypass surgery and the fact that even 5-FU has some cardiac toxicity, we felt the risk-benefit ratio did not favor adjuvant therapy.

A little more than a year later, his CEA level rose and four hepatic metastases in the right lobe were identified on a CT scan. A PET scan did not reveal any extrahepatic disease. The metastases were potentially resectable, but I was concerned because they were scattered and they appeared simultaneously not long after his primary surgery. For those reasons, I felt we needed to treat him preoperatively to determine whether his disease would respond to therapy.

We questioned whether we should simply use chemotherapy or add another biologic to make it more active. I was concerned about using bevacizumab given his cardiovascular morbidity, so we tested the primary tumor for K-ras and found it to be wild type.

To date, he’s received two cycles of FOLFOX/cetuximab, which he is tolerating with only a mild rash. He lives in Minnesota and has experienced some cold sensitivity, which is an issue. Our plan is to evaluate response after three cycles and send him to surgery. If indeed he has a good response, he will receive an additional eight cycles after surgery. I expect that this tumor will respond to therapy.

The way we monitor these patients with Stage II disease is we begin with a baseline CT scan and measure the CEA level after surgery, then repeat both every six months. With Stage III disease, we obtain the baseline studies, repeat both every three to four months for the first two years and then every six months thereafter.


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