TIO may be associated with mesenchymal tumours which may be benign or malignant in rare cases. The clinical presentation of TIO includes bone fractures, bone and muscular pains, and sometimes height and weight loss. The epidemiology likewise aetiology is not known. Because this patient has a right-sided tumor, the choice of bevacizumab with FOLFOX was a reasonable choice.Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterised by severe hypophosphataemia and osteomalacia, with renal phosphate wasting that occurs in association with tumour. In some patients who are RAS, BRAF wild-type, HER2-negative, and left-sided colon cancer, there is also a possibility of using an anti-EGFR agent, such as cetuximab or panitumumab, up front because those are the patients that benefit most from this. This was combined with a biologic that is anti-VEGF attached to bevacizumab, which is a common biologic. Anything less than that, we could have a lower ECOG PS.Īs far as this patient is concerned, a doublet cytotoxic is very reasonable. The TRIBE2 study that established the survival benefit of FOLFOXIRI, which is triplet cytotoxic over doublets, allowed only patients with ECOG PS 0, especially if they were beyond ages of 70-so 71 to 75 patients, and all of them had to have ECOG PS0. In some cases, the first-line cytotoxic option is a triplet cytotoxic which is 5-FU, oxaliplatin, and irinotecan or FOLFOXIRI with bevacizumab. The first-line therapy options are usually a combination of cytotoxic chemotherapy with a biologic attached to them. It should also be remembered that the patient has a right-sided colon cancer because they have a 9-cm ascending mass lesion. Those are a couple of points that are noteworthy. Furthermore, the PS of the patient is 1, which has implications in how aggressive you can be with cytotoxic chemotherapy. It’s very clear that the patient has an unresectable disease, and therefore surgery is definitely not an option. With regard to molecular profiling, this patient has had some focused testing around RAS and BRAF, but I would have done either a next-generation-sequencing panel or at least have status for HER2 amplification on expression, and also NTRK fusions, which are also targeted with subsets. We also want to notice that certain comorbidities can affect our treatment decisions in metastatic colorectal cancer, like high blood pressure, especially whether it’s controlled. Interestingly, it’s strange that the patient developed this disease in a rather short interval from the last colonoscopy, which was completely negative. In August 2020, the patient had progressive disease and was given regorafenib. Patient was then switched to FOLFIRI and cetuximab and received this treatment until August 2020 with stable disease as the best response. In June 2019, the patient had increasing symptoms of shortness of breath and fatigue, and scans showed disease progression in both the lungs and the liver. This was followed by maintenance chemotherapy between May 2018 and June 2019. The patient received about 4 months of this treatment with scans at 2- and 4-months showing response. The patient was diagnosed with stage IV colorectal cancer, and the ECOG PS of the patient was 1.Īt that time, the patient was started on treatment with bevacizumab and FOLFOX. CT scan showed widespread lesions spread across the liver. The molecular profiling showed a microsatellite stable tumor, which was KRAS, NRAS, and BRAF wild type. The colonoscopy revealed a 9-cm mass in the ascending colon biopsy of this showed a poorly differentiated adenocarcinoma. With regard to her past medical history, it’s significant only because of a hysterectomy done about 12 years ago and high blood pressure, which is controlled with lisinopril.ĭuring the clinic work-up, the patient was found to be anemic with an elevated CEA of 6 ng/mL. Her last colonoscopy was about 2 years ago and was negative, and she also had some unintentional weight loss. This patient presented with a 2-month history of bloating and abdominal discomfort. Kanwal Raghav, MBBS, MD: Today we’ll be discussing a case of a 72-year-old woman with metastatic colorectal cancer.
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