A 54-year-old man initially presents with hemorrhoids and fatigue. Colonoscopy reveals a 5-cm mass in his midrectum. Poor-quality CT of the abdomen and pelvis is read as normal. He receives neoadjuvant chemoradiation therapy with and undergoes a low anterior resection of a Grade III adenocarcinoma. Seven of eight lymph nodes are positive, but surgical evaluation suggests the abdomen is otherwise normal. Follow-up CT obtained six weeks postoperatively shows a large mass occupying a substantial part of the peripheral right lobe of the liver. The mass was deemed resectable at presentation by right hepatectomy, but due to the short time since initial surgery, he was administered a preoperative course of FOLFOX and cetuximab (K-ras wild-type confirmed) for two cycles, which was switched to FOLFOX alone due to Grade III rash diarrhea. Despite no clinical response to chemotherapy, he proceeded to a right hepatectomy, where no intraoperative evidence of left liver lobe disease was found. Twenty-three separate nodules were discovered in the resected liver specimen. He is currently completing six cycles of postoperative FOLFIRI.
Case Discussion:
This was a 54-year-old man who initially presented for a routine check-up with hemorrhoids and complaints of some fatigue. After a routine colonoscopy, a 5-cm mass was discovered in the mid-rectum. Findings from a poor-quality contrast-enhanced CT scan of the abdomen and pelvis were said to be normal. He received neoadjuvant chemoradiation therapy with capecitabine as the radiation-sensitizing drug and subsequently underwent a low anterior resection of a Grade III ACA penetrating through the muscularis propria. Seven of eight lymph nodes showed evidence of metastatic disease. Upon surgical evaluation, the abdomen was considered otherwise normal. He developed pneumonia while still in the hospital recovering from surgery and presented six weeks after surgery. A postoperative CT scan showed a large mass in the right lobe of the liver, and he was referred to Mayo because his previous doctor thought the mass was unresectable.
One of our surgeons felt that the disease was technically resectable by doing a right hepatectomy, because no major vascular structure was involved and there would be enough preserved liver on the left side. However, because he’d just undergone the rectal surgery and was still recovering from this pneumonia, the concern was whether or not he could tolerate a second surgery at that point. The recommendation was to use chemotherapy initially.
In general, I favor using a perioperative approach for patients with large yet resectable disease. I am much more comfortable seeing some control of the disease, and particularly in this case, having some sense that the selected chemotherapy regimen is effective.
The patient had wild-type K-ras, and so we elected to use cetuximab with FOLFOX. He developed a Grade III rash and moderately severe diarrhea during the first two cycles. The concern was that he had some sort of infectious etiology for the diarrhea, and was being treated for possible Clostridium difficile-induced diarrhea. He returned to Mayo because of concerns that this wasn’t the right treatment regimen. At that point, I had recommended that he continue treatment with FOLFOX alone, and he received three additional cycles of FOLFOX without a lot of difficulty.
Findings from the preoperative scan showed that the mass looked slightly larger, although the radiologist felt that more necrotic tumor was present. He underwent a right hepatectomy, and no disease was found elsewhere, although he had 23 nodules in the resected right lobe of the liver all grouped together with a fair amount of what looked like viable tumor. Because there still appeared to be a high risk of recurrent disease, he was switched to FOLFIRI. We considered adding bevacizumab but decided against it because he developed a pulmonary embolism when hospitalized for severe diarrhea, he was receiving anticoagulant therapy, and he had a strong history of heart disease. Considering all of those factors, I felt that FOLFIRI alone would be enough. Because of the rash and the diarrhea, the patient refused to receive cetuximab again.
Several days ago, the patient was discharged from the hospital and is recovering from surgery. He will begin FOLFIRI shortly.
