A 75-year-old woman with a history of Stage III colon cancer treated with resection and adjuvant FOLFOX now presents 18 months post initial diagnosis with rising CEA levels. A PET/CT scan indicates two liver metastases confined to the right lobe and two potentially resectable small metastases in the left lung. Recommended treatment includes preoperative chemotherapy followed by both liver and lung resection.
Case Discussion:
DR CHOTI: This was a 75-year-old woman with a history of colon cancer who presented with a rising CEA. PET scan findings showed two metastases in the liver and two small pulmonary nodules. Is that patient a candidate for surgery?
According to the data, if the extrahepatic disease is resectable, then we will often consider resecting both sites of metastasis. The procedures can be performed separately or at once, depending on the complexity of each surgery. The use of neoadjuvant chemotherapy for a patient with extrahepatic disease depends on other factors, such as the amount of time that has passed since they had colon cancer and whether they received prior chemotherapy. These patients may have a slightly worse prognosis than patients with liver-only or lung-only cancer. If the liver tumors are located in areas where the concern over potential growth is high and I want to avoid hepatotoxicity from the chemotherapy, I may use a staged-approach, and resect the liver first followed by chemotherapy and then operate on the lung. More prolonged chemotherapy can cause hepatotoxicity, although it does not cause lung toxicity. So if you’re going to proceed with staged procedures, then that’s a strategy that’s not a bad one.
All chemotherapy can cause toxicity. However, if the chemotherapy is administered carefully and not for a prolonged duration, either irinotecan or oxaliplatin can be administered safely without fear of liver toxicity. Some data suggest that the irinotecan-based therapies or 5-FU/leucovorin alone, particularly for a prolonged duration, cause fatty liver or steatosis. On the other hand, oxaliplatin-based therapy can sometimes result in the so-called blue liver or sinusoidal dilatation. Frankly, it depends a lot on the duration of therapy.
The MD Anderson study showed that patients who received irinotecan had a lot of steatohepatitis, but we find little steatohepatitis, as opposed to steatosis. Although the hepatotoxicity of irinotecan has been discussed frequently, I believe that if it is administered carefully and not for a prolonged duration, one can use irinotecan or oxaliplatin. I don’t feel strongly about one treatment versus the other. Frankly, the response rates seem to be higher with oxaliplatin. We generally use oxaliplatin in the adjuvant setting. Therefore, in the neoadjuvant setting, oxaliplatin-based regimens seem to be more desirable, but it’s not because of hepatotoxicity, in my opinion.
