Metastatic CRC Progressing on Multiple Therapies

October 2015

• A 64-year-old woman underwent left hemicolectomy for an obstructing mass at the rectosigmoid junction
  • CEA were elevated, 23.3 ng/mL
  • Pathology showed an undifferentiated adenocarcinoma, invading through the muscularis mucosae up to the pericolic fat; 14 nodes were biopsied, 10 of which were metastatic
  • Imaging with PET/CT showed several lung lesions, three measuring up to 3.0 cm in size
  • Mutational status was both RAS and BRAF wild-type
  • Microsatellite stable
  • Diagnosis; high grade colorectal adenocarcinoma, stage T4N2M1
• PMH includes arterial hypertension, well-controlled on an ACE inhibitor and coronary angioplasty with stent placement 4 years ago
• The patient received systemic therapy with FOLFIRI + cetuximab; grade 1 rash and grade 2 thrombocytopenia were managed with dose adjustment of FOLFIRI
• Follow-up imaging at 2 months and 4 months showed significant response in the lung lesions
• The patient was continued on maintenance therapy with cetuximab

August 2016

• The patient complains of weight loss, nausea and fatigue
• CT of the chest, abdomen, and pelvis showed marked progression in 2 of the lung lesions and development of new liver lesions
• The patient was switched to CAPEOX with bevacizumab. Her blood pressure was closely monitored and remained stable
• Follow up imaging at 2 months and at 4 months showed stable disease in the lung and liver lesions and improvement of her symptoms
• At 4 months, oxaliplatin was discontinued; maintenance therapy with capecitabine and bevacizumab was continued

January 2017

• At 5 months, the patient reports having reappearance of her symptoms, although she continues her normal physical activity
• CEA level is rising significantly
• Follow up CT showed further progressive disease in the lung and the appearance of several small boney lesions
• The patient is motivated to try another therapy and has opted for regorafenib