Biochemotherapy of Aggressive Rectal Carcinoma – A Case Study from the Czech Republic
Colorectal cancer arises from a complex interplay of environmental and lifestyle factors complemented by hereditary factors. Nowadays, it represents not only a health concern but also a socioeconomic problem. It is the second most common malignant tumor in both sexes; fortunately, its incidence and mortality have been decreasing in recent years. Due to expanding and more accurately targeted treatment options and good patient care management, it is also possible to better manage more aggressive and previously difficult-to-treat forms of the disease, as demonstrated by the following case study from the Comprehensive Cancer Center of the University Hospital Hradec Králové.
Case History
This case study presents a patient (*1952) with a tumor at the junction of the lower and middle rectum. Notable medical history includes multiple internal comorbidities such as atrial fibrillation, ischemic heart disease with myocardial infarction (1996), stroke (2009), arterial hypertension, diabetes mellitus, and obesity. The patient smokes five cigarettes a day. There is no family history of cancer.
Initial Diagnosis
The patient was examined (4/2021) at a local internal medicine department for a two-month history of blood in the stool. During a colonoscopy, an adenoma was found in the colon transversum and a semicircular lesion in the rectum, which was highly suspicious for carcinoma. Histology confirmed a well-differentiated adenocarcinoma. An MRI of the rectum revealed that the tumor infiltrated the mesorectum over a length of 5 cm, with multiple lymph nodes involved. The disease was staged as T3N2M0.
(Neo)adjuvant Radio- and Chemotherapy, Surgery
The patient was indicated for neoadjuvant pelvic radiotherapy of 45 Gy/25 fractions, with a boost to the rectum up to 50 Gy/25 fractions, particularly due to his cardiac comorbidities, without chemotherapy. Radiotherapy was completed without major difficulties. Subsequently, a Miles resection of the rectum was performed (11/2021), complicated by intraoperative ureter injury requiring stent placement. Final histology of the resected specimen revealed a pT3 G2 adenocarcinoma with angioinvasion and two tumor satellites, and resection was R1. Due to these risk factors, 4 cycles of adjuvant chemotherapy with capecitabine were administered (until 5/2022).
Disease Generalization and Subsequent Biochemotherapy
After adjuvant treatment, restaging CT showed multiple new metastases in the liver, lungs, and left adrenal gland, so the patient was referred to our Comprehensive Cancer Center (CCC). Here, he was indicated for palliative biochemotherapy based on predictive marker results, which showed that the KRAS and NRAS oncogenes were wild-type (wt), and no BRAF mutation or microsatellite instability was present. Therefore, a combination of panitumumab/FOLFOX was initiated (from 7/2022).
Management of Treatment Complications
Immediately after the first application of this treatment, a whole-body papular rash appeared, treated with topical metronidazole ointment and a corticosteroid cream. Asymptomatic hypomagnesemia was also detected and managed with oral magnesium supplementation.
After the third cycle, the patient was briefly hospitalized for pneumonia at a local hospital. Overall, the treatment was managed without major difficulties. Before the sixth cycle, there was a worsening of the local reaction on the face with crusts and pustules, so he was examined in the dermatology clinic – assessed as a grade 2 reaction. Topical care was increased, using corticosteroid ointment and ichthammol paste for the face, and a chloramphenicol ointment and excipial for the trunk. Systemic antibiotics were not indicated, and the last cycle was recommended to be administered without panitumumab. In the interim between restaging CT and treatment, the patient had a scrotal abscess drained, which required antibiotics.
CT after 3 months of treatment (10/2022) showed partial regression of liver lesions. Therefore, continuation of palliative biochemotherapy is indicated, along with topical skin care and magnesium supplementation.
Conclusion
Overall, the patient feels well, and aside from skin issues, he is asymptomatic from his oncological disease. Given the aggressiveness of the initial disease and early generalization, partial regression is certainly a successful result. Despite numerous comorbidities and intercurrent complications (pneumonia, abscess), the patient is successfully managing the treatment and there has been no need to disrupt the treatment regimen.
Skin complications and hypomagnesemia are typical complications of panitumumab treatment. Management of these, in collaboration with a dermatologist, is already a routine part of daily practice. Although one cycle had to proceed without biological treatment, it did not significantly affect the overall course of treatment. On the contrary, evidence suggests that the severity of side effects correlates with the treatment response.
Dr. Libor Hruška
Clinic of Oncology and Radiotherapy, Faculty of Medicine, Charles University and University Hospital Hradec Králové
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