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

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Case 34:

Discussant: ALAN VENOOK, MD

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Case Description:

A 38-year-old woman, postpartum, presents with rectal bleeding lasting a few months, and which was previously attributed to hemorrhoids. She is diagnosed with primary sigmoid cancer with a synchronous liver metastasis in the right lobe. Due to the central location of the liver lesion, she received FOLFOX and bevacizumab to facilitate resection. She experienced an allergic reaction to systemic therapy that did not respond to omission of oxaliplatin alone. She resumed FOLFOX without bevacizumab after a desensitization protocol for oxaliplatin and obtained a good response. Subsequent successful resection of the primary lesion and liver metastases was followed by a difficult postoperative course. Upon full recovery from surgery, FOLFOX was resumed with later reintroduction of bevacizumab. Despite tolerating treatment, she experienced peritoneal recurrence.

Case Discussion:

This was a 38-year-old woman, postpartum, who presented with rectal bleeding lasting a few months, previously attributed to hemorrhoids. After evaluation, she was diagnosed with a primary sigmoid cancer and synchronous centrally located liver metastases.

She was initially scheduled to undergo immediate liver resection, but we decided to administer chemotherapy first. We planned to administer four cycles of FOLFOX/bevacizumab because the lesions were in the central part of the liver and we wanted a little shrinkage, but she didn’t tolerate the chemotherapy — she had a hypersensitivity reaction. We did not know if her reaction was attributable to the oxaliplatin or the bevacizumab.

The patient developed a fever and pruritus after the first dose of FOLFOX/bevacizumab, and we assumed it was the oxaliplatin, so we treated with 5-FU and bevacizumab in the next cycle, but she had the same reaction. Consequently, we used a desensitization protocol for oxaliplatin to reinitiate the FOLFOX without bevacizumab, and she tolerated that fine.

She responded to chemotherapy, and we then resected the primary tumor and the liver metastases simultaneously. She had a difficult postoperative course. She had not received bevacizumab for about 10 weeks, so it may not have had anything to do with bevacizumab. She was in the community hospital ICU for about two months. Considering her postoperative course, her back-end chemotherapy was delayed for about three months. After she recovered fully, she was treated with FOLFOX postoperatively. Ultimately, we were able to reinitiate bevacizumab and she tolerated it fine, so we had no idea why she had an apparent reaction in the front-end.

She is now faring well, but has metastatic disease. She relapsed in the peritoneal cavity. She had been treated with irinotecan and elected not to take cetuximab. At this time, she is receiving complementary medicines and has low-volume disease.


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