Medical Oncology Follow-up

Identification

68 yo female with metastatic R-sided colon adenocarcinoma (pT3N1bM0 at initial diagnosis, MSS, KRAS G12D mutated, BRAF WT). Originally diagnosed 14/05/2021, s/p R hemicolectomy and 6 mos adjuvant FOLFOX, complicated by hepatic recurrence in 11/2023. Currently on 2nd-line FOLFIRI + bevacizumab with stable disease.

History

1. Presented 05/2021 with fatigue and IDA (Hb 82 g/L). Colonoscopy revealed a cecal mass; biopsy confirmed moderately differentiated adenocarcinoma. Underwent laparoscopic R hemicolectomy 12/06/2021 (pT3N1b, 2/18 LNs positive, margins negative). Completed 12 cycles of adjuvant mFOLFOX6 from 08/2021 to 02/2022, complicated by grade 2 peripheral neuropathy requiring oxaliplatin dose reduction for the final 3 cycles.

2. Routine surveillance CT on 15/11/2023 demonstrated 3 new bilobar hepatic lesions (largest 2.4 cm in segment VII), accompanied by a rising CEA to 18.4 ug/L. Patient was asymptomatic. Biopsy of segment VII lesion confirmed metastatic colon adenocarcinoma; NGS showed MSS, KRAS G12D mutation, NRAS/BRAF WT, HER2 negative. Initiated 1st-line FOLFIRI + bevacizumab on 04/12/2023.

3. Restaging CT after 6 cycles (03/2024) showed partial response with dominant liver lesion decreasing to 1.5 cm and CEA dropping to 6.2 ug/L. Treatment was modified at cycle 8 due to grade 2 diarrhea and neutropenia, reducing irinotecan dose by 20%. Tolerating reduced-dose regimen well with stable disease maintained on subsequent scans.

Current Treatment

Receiving palliative FOLFIRI (irinotecan 140 mg/m2 IV day 1, leucovorin 400 mg/m2 IV day 1, fluorouracil 400 mg/m2 IV bolus day 1 followed by 2,400 mg/m2 IV continuous infusion over 46 hours) plus bevacizumab (Avastin®) 5 mg/kg IV day 1 q14d, currently at Cycle 14.

Current Status

ECOG 1, feeling well overall with improved energy levels over the past month and able to perform all IADLs independently. Reports residual, stable grade 1 cold-induced neuropathy in fingertips/toes from prior oxaliplatin, and mild intermittent diarrhea well-controlled with loperamide (Imodium®) 2 mg PO PRN. Denies fever, chills, night sweats, weight loss, abdominal pain, or hematochezia.

Labs October 2024 show hemoglobin 114 g/L (stable, mild chronic anemia), WBC 4.8 x 10^9/L, ANC 2.4 x 10^9/L, and platelets 165 x 10^9/L, indicating adequate marrow recovery for chemotherapy. Creatinine is 72 umol/L, total bilirubin 11 umol/L, AST 28 U/L, ALT 31 U/L, and ALP 110 U/L, confirming preserved renal and hepatic function. CEA is 5.8 ug/L, stable compared to 6.2 ug/L in July 2024. Urine dipstick is negative for protein.

CT scan October 2024 shows stable bilobar hepatic metastases, with the index segment VII lesion measuring 1.4 cm (previously 1.5 cm), no new hepatic lesions, and no evidence of thoracic or extrahepatic abdominal/pelvic disease progression, consistent with RECIST stable disease.

Assessment / Plan

Metastatic KRAS-mutated colon adenocarcinoma with stable disease and preserved functional status on FOLFIRI + bevacizumab. Proceed with Cycle 15 of FOLFIRI + bevacizumab at current doses this week, maintaining routine pre-medications and PRN loperamide. Patient counselled to monitor for and immediately report fever > 38.0 °C, refractory diarrhea, significant bleeding, or new severe abdominal pain. Follow up in clinic in 4 weeks (prior to Cycle 17) with routine CBC, chemistry, urine protein/creatinine ratio, and CEA, with repeat restaging CT chest/abdomen/pelvis planned in 3 months; if progression occurs in the future, will consider 3rd-line trifluridine/tipiracil (Lonsurf®) + bevacizumab or regorafenib.

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