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ESMO Preceptorship Programme
83 year old gentleman with multiple comorbidities presented with bleeding per
rectum for 6 months on complete evaluation was diagnosed with carcinoma
rectosigmoid with solitary liver metastasis.
Dr. Shweta Mutha
Radiation Oncologist
Ruby Hall Clinic, Pune
Gastrointestinal tumors- Singapore 19-21 Nov 2019
ESMO PRECEPTORSHIP PROGRAMME
DISCLOSURE OF INTEREST
None
ESMO PRECEPTORSHIP PROGRAMME
Case scenario� 83 year old gentleman known Diabetic, Hypertensive, H/O IHD.
� C/C- bleeding per rectum on and off and altered bowel habits for 6
months.
� No H/O addiction, no H/O similar illness in family.
� ECOG PS- 1
� CEA- 2.64ng/ml
� Colonoscopy: Circumferential ulceroproliferative growth at 12 cm
from anal verge. Scope could be negotiated beyond the lesion.
� Biopsy: Well differentiated adenocarcinoma of rectum, muscularis
mucosa have been crossed and involved by tumor. LVSI absent.
� MRI pelvis: Irregular concentric wall thickening in proximal rectum,
with maximum thickness 11mm, length of involvement 4.4cm.
Lower margin of the lesion 11 cm from anal verge. Mild mesorectal
stranding. Few enlarged mesorectal lymph nodes measuring upto
5mm.
ESMO PRECEPTORSHIP PROGRAMME
Work Up� PET CT:23/3/2019 :FDG avid enhancing concentric growth in rectum(SUV
max=57.45)measuring 43mm in length. Mild pararectal fat stranding seen. Few
variably FDG avid subcm size nodes in pararectal region (SUV max=4.77).An
FDG avid hypodense lesion measuring approximately 10mm in diameter in
segment VIII of the liver.(SUV max 31.20).
ESMO PRECEPTORSHIP PROGRAMME
Work Up
ESMO PRECEPTORSHIP PROGRAMME
Management
� Initial plan was to give 6 cycle of chemotherapy (FOLFOX) and
reassess but patient could tolerate only 5 cycles.
� PET CT ( For response assessment ) – partial response – decrease
in metabolic activity of circumferential wall thickening involving the
proximal rectum and rectosigmoid junction, decrease in metabolic
activity of metastatic right lobe of liver lesion.
ESMO PRECEPTORSHIP PROGRAMME
ESMO PRECEPTORSHIP PROGRAMME
� Patient was given option of surgery but considering his age,
associated comorbidities, risks associated with surgery patient and
his relatives were reluctant for the same. Therefore, he was offered
definitive EBRT to pelvis, with concurrent capecitabine (825mg/m2)
and local ablative therapy to solitary liver lesion.
� Patient received EBRT to pelvis to a dose of 50Gy/25#, 2Gy/#, 5
days a week over 5 weeks using IG-IMRT technique (01.07.19 to
05.08.19) on Varian Truebeam STx.
ESMO PRECEPTORSHIP PROGRAMME
ESMO PRECEPTORSHIP PROGRAMME
� PET CT (19.09.19) – A focal metabolically active mild thickening at
rectosigmoid region –minimal residual disease/ post radiation
inflammatory changes, a hypermetabolic hypodense lesion 12mm
(SUV max 17.47) in right lobe of liver likely represent metastatic
disease. Compared to previous study, reappearance of
hypermetabolism noted with increase in size of liver lesion.
� Since surgery was denied by the patient beforehand so to treat liver
lesion by either Radiofrequency ablation or SBRT was made in
tumor board discussion.
� Patient opted for SBRT.
ESMO PRECEPTORSHIP PROGRAMME
ESMO PRECEPTORSHIP PROGRAMME
Liver lesion was treated using SBRT to a dose of 48Gy/4# @ 12Gy/#
QOD
ESMO PRECEPTORSHIP PROGRAMME
� Patient will be assessed after 3 months for response to treatment
using MRI pelvis, PET CT whole body, colonoscopy, serum CEA.
ESMO PRECEPTORSHIP PROGRAMME
� Patient is 83 year old case of metastatic rectosigmoid carcinoma
with solitary liver lesion and multiple comorbidities and medically
inoperable. (How should such patients be ideally managed? ).
� What are the nonsurgical options available to treat this solitary liver
lesion? Which is the best one and optimal time of incorporating it.
� What would have been the line of management if patient had
persistent primary disease after radical EBRT. In such scenario is it
really necessary to treat liver lesion?
� Is it mandatory to do determine tumor gene status for RAS, BRAF
and tumor MMR or MSI status in such patient. (These tests were not
done in this patient ).
ESMO PRECEPTORSHIP PROGRAMME
� If we advise the patient for above mentioned test and it turns out to
be KRAS/NRAS/BRAF WT should we give a trial of cetuximab or
panitumumab as subsequent therapy ( if the disease progresses).
� If follow up scans shows complete resolution of primary disease and
metastatic liver lesion should we observe the patient or advise him
some maintenance therapy.
ESMO Preceptorship Programme
THANK YOU