36 years old male with advanced splenic flexure carcinoma with involvement of the anterior abdominal wall, stomach and small bowel. HPE revealed moderately differentiated (Greade 2 to 3) adenocarcinoma. pT4bN1bMx. Received 12 cycles of Folfurie with avastin. Now PET CT shows Hypermetabolic spots, one 1.4X1.6 cms at anastomotic site and another 1.4X1.5 at left hypochondrium region(Peritoneal deposits).
Difficult situation - was the first resection an R0? If so you can consider further chemo but unlikely to help. He had an anastomosis? Assume recurrence is at involved small bowel resection and anastomosis (and not ileorectal). Can be re-resected but unfortunately he is likely to have a poor outcome esp if he failed on Bevacizumab. I see he's already been on Irinotecan (FOLFIRI) - that could have been an option if not.
Good luck to you both! Tricky, but sadly not uncommon.
BW,
John
It sounds as if this patient has a peritoneal recurrence in the form of peritoneal metastases of his initial T4 tumour. If his recent PET-CT does not show any evidence of systemic metastases, and if the patient is in a good overall condition, I would definitely recommend referring him to a peritoneal malignancy centre to evaluate the option of cytoreductive surgery and HIPEC for him. There is quite some evidence, including a recent meta-analysis, supporting the use of
Sugarbaker for mCRC unfortunately not as good as for PMP I believe. Still an option for this chap esp given his age.
This patient had a liver metastasis, which resolved post chemotherapy. Is he still a candidate for cytoreduction surgery?
It depends on the interval: how much time has passed between his last chemotherapy and his most recent staging? Also: was a conscious decision made to not resect the liver metastasis but to treat it with chemotherapy?
first confirm by colonoscopic and percutaneous biopsy that PET CT hypermetabolic lesion is really recurrence.??
if its recurrence....n as being resectable 2 lesions.....it should be resected ...rest depend on further HPE.( if PS allows)which preferable in repeat chemo as he has shown good response for chemo......
aggressive management is needed considering his young age.
I agree that histological confirmation of actual metastatic disease is warranted; this could be achieved either by percutaneous biopsy or laparoscopic exploration. Laparoscopy would have the added benefit of establishing the extent of peritoneal disease and the possibility of a complete or near-complete cytoreduction. Also, colonoscopy should be done to rule out any metachronous colon lesions.
If and when peritoneal metastases are confirmed and you are certain that the liver remains clean, I would recommend proceeding with CRS-HIPEC. The question of whether he would require any additional systemic chemotherapy after his CRS-HIPEC depends on the success of the procedure. Good luck!