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

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Case 4:

Discussant: ALAN VENOOK, MD

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Case Description:

A 50-year-old man previously treated for Stage III primary CRC with adjuvant FOLFOX, presents three years after initial diagnosis with a 3-cm solitary lesion in the right lobe of the liver (segment VI). The patient underwent immediate resection of the lesion and refused postoperative adjuvant therapy due to residual neuropathy from prior FOLFOX treatment. Three months after resection of the metastasis, the patient presented with multiple, nonresectable pulmonary nodules.

Case Discussion:

This was a 50-year-old man previously treated with adjuvant FOLFOX for Stage III primary CRC. He now presents three years after initial diagnosis with a solitary metastasis in right liver lobe. The patient had a bit of peripheral neuropathy.

We performed an immediate hepatic resection and then debated about whether or not to treat with adjuvant chemotherapy but the patient refused. One of the reasons the patient refused is because no consensus was reached on the appropriate strategy. We had offered the patient capecitabine on the backend, but without much supporting knowledge.

The rationale to suggest adjuvant chemotherapy was that we estimated a 50 percent chance of cure three years later. Although no data support the use of adjuvant chemotherapy in this situation, we wanted to increase the odds of survival. Part of the issue for this patient was that he still had residual neuropathy, although it wasn’t substantial. In the absence of data, this patient ultimately opted not to receive adjuvant therapy.

Patients with a solitary metastasis that is metachronous in presentation — probably more than a couple of years out — have a 40 or 50 percent chance of being cured. Patients with recurrent disease after FOLFOX adjuvant have a poorer prognosis than patients who’ve not seen adjuvant with this scenario.

Three months later, the patient developed multiple pulmonary nodules. He elected not to receive chemotherapy. It is now approximately six months after treatment. If this patient had agreed to chemotherapy, I would probably have administered FOLFIRI/bevacizumab.


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