Treatment of a patient with colorectal cancer after kidney transplantation – case report
Patients after organ transplantation currently live to an older age thanks to advances in surgery and pharmacotherapy. However, the longer a person takes immunosuppressants, the more they are at risk of developing malignant disease. The case report of Hungarian doctors from the university hospital in Pécs illustrates what the treatment of metastatic colorectal cancer (mCRC) after kidney transplantation can look like.
Medical history and diagnostics
A 66-year-old man, who was being treated for type 2 diabetes, obesity, hypertension, and paroxysmal atrial fibrillation, underwent a kidney transplant in 2013 due to renal failure. Five years later, he was examined for abdominal discomfort. Endoscopic examination and computed tomography (CT) revealed a sigmoid tumor with minimal locoregional spread. Due to obstruction, an urgent Hartmann resection was performed. Histologically, it was a pT3 N1b (3/9+1TD), V1, Pn−, R0 adenocarcinoma with non-mutated KRAS and NRAS genes. Positron emission tomography (PET) with fluorodeoxyglucose revealed a 2.5 cm metastasis in the VII liver segment and in a paraaortic lymph node on the left.
The patient's pharmacological history included immunosuppressants tacrolimus, methylprednisolone, and mycophenolate mofetil, antihypertensives losartan and amlodipine in combination with furosemide, hypolipidemic atorvastatin, antidiabetics empagliflozin, dulaglutide, short-acting and long-acting insulin, as well as pantoprazole to prevent and treat corticosteroid gastrotoxicity and supplementation with potassium and vitamin D (calcitriol).
Treatment course and outcomes
In July 2018, palliative therapy for mCRC was initiated with the FOLFIRI regimen in combination with cetuximab. For the next cycle, cetuximab was replaced with panitumumab due to side effects (glycemic fluctuations, diarrhea, and hypomagnesemia). In August, PET/CT scan confirmed disease stabilization. However, due to severe side effects (diarrhea and consequent significant weight loss), the patient no longer wished to continue with the prescribed therapy.
Therefore, treatment continued with panitumumab alone, and the liver metastasis was treated with stereotactic radiotherapy (10× 5 Gy). In January 2019, the PET/CT scan showed regression of the liver metastasis but progression of the lymph node metastasis. This lesion was also subsequently treated with radiotherapy (5× 8 Gy), while the patient continued with panitumumab. During treatment, a rash appeared and hypomagnesemia persisted. The patient took immunosuppressants throughout the anticancer therapy. By June 2019, when complete remission was confirmed, he had undergone 16 cycles of targeted therapy with panitumumab.
In July 2019, the patient suffered a hemorrhagic stroke, which he did not survive. The attending doctors assessed that the stroke was not a result of the anticancer treatment.
Conclusion
Findings from various studies suggest that colorectal cancer screening should be part of the care for patients after organ transplantation. Attention should also be paid to optimizing anticancer therapy in transplant patients, which can be complicated by increased toxicity or drug interactions. The case report of a Hungarian patient with a transplanted kidney shows that even with limited use of chemotherapy, it is possible to achieve complete remission in mCRC with targeted anti-EGFR therapy with panitumumab.
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Source: Bellyei S., Boronkai Á., Pozsgai E. et al. Effective chemotherapy and targeted therapy supplemented with stereotactic radiotherapy of a patient with metastatic colon cancer following renal transplantation: a case report. J Med Case Rep 2021; 15 (1): 125, doi: 10.1186/s13256-021-02702-y.
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