A 62-year-old man presents with shortness of breath and fatigue. Upon further probing, the man reveals that he has been experiencing vague chest pains. An EKG reveals that he had had an anterior septal myocardial infarction. He was admitted to the hospital, during which a digital rectal exam was performed and found to be heme-positive. Upon his discharge from the hospital, a colonoscopy was performed and it was found that he has a rectosigmoid adenocarcinoma six centimeters from the anal verge. CT revealed two small, fairly peripheral liver metastases. Due to his recent MI, he was not considered a good candidate for surgery. As such, he underwent a FOLFOX-based neoadjuvant regimen. He exhibited reduction in his primary tumor and metastatic disease. Routine repeat stress tests and coronary angiograms were performed, and he was determined to be in good health. He proceeded with a low anterior resection and, after his anastomosis was completed, underwent resection of the two residual hepatic metastases. Final pathology confirmed a major response in metastatic disease, with 70 to 80 percent of the lesions necrotic or fibrotic. He completed an additional three months of chemotherapy and is faring well at two years out.
Case Discussion:
DR CURLEY: This was a 62-year-old man who presented with shortness of breath and fatigue. Upon further probing, the man revealed that he had been experiencing vague chest pains, and an EKG revealed that he had had an anterior septal myocardial infarction. After he was admitted to the hospital, he underwent an angiogram and a single coronary artery stent was placed. Subsequently, a digital rectal exam was performed and found to be heme-positive. Upon his discharge from the hospital, a colonoscopy was performed and he was found to have a rectosigmoid adenocarcinoma six centimeters from the anal verge. A CT scan revealed two small, fairly peripheral liver metastases.
Because he had recently experienced an acute myocardial infarction, we did not feel he was a good candidate for surgical treatment of his primary lesion or metastatic disease, so he underwent neoadjuvant chemotherapy with a FOLFOX-based regimen. He showed good response in both the primary tumor and the metastatic disease, with reduction in all. He underwent repeat stress tests and repeat coronary angiograms. The patient returned to work on his ranch and was working 12 to 14-hour days. He was totally asymptomatic from a cardiac point of view, and his performance status was excellent.
He then underwent a low anterior resection that went quite well, and at the same time, after his anastomosis was completed, he underwent resection of the residual two hepatic metastases. His final pathology confirmed a major response in all of his metastatic disease, with 70 and 80 percent of the lesions necrotic or fibrotic. He then received an additional three months of chemotherapy as an adjuvant and has been followed for almost two years out now since that time, with no evidence of recurrent or new metastatic disease.
Other than FOLFOX, we have also used CAPOX, particularly as a radiation sensitizer with great success. Initially, patients were treated with CAPOX as part of a chemoradiation therapy protocol for patients with T3 or T4 rectal tumors and either N0 or N1 by ultrasound. We were using the CAPOX initially to see if it improved the complete response rate in the primary tumor that was subsequently resected. We found that for patients who presented with synchronous disease, like this patient, CAPOX was adequate — it not only was a good radiation sensitizer, but it was adequate as chemotherapy to treat small-volume metastatic disease. We had a number of patients who showed response not only in the primary tumor that was receiving radiation therapy, but also some reduction occurred in the size of their metastatic lesions after being treated with CAPOX. The toxicity profile is obviously a little bit different. We have found that when we use full-dose capecitabine, the hand-foot syndrome and the neuropathy can be impressive. Some patients feel that the capecitabine makes the oxaliplatin-based neurotoxicity worse or that they have more trouble with it. So we are focused on that, and we follow up to make sure that if patients are experiencing neuropathy, we’ll go back to a FOLFOX-based regimen and the intravenous fluoropyrimidines.
