Presentation on theme: "Alexander Stein University Cancer Center Hamburg, Germany"— Presentation transcript:
1 Alexander Stein University Cancer Center Hamburg, Germany ESMO Consensus Conference: Interactive Session on Colorectal Cancer Guidelines A clinical case presentation on advanced colon cancer (first and second line therapy)Alexander SteinUniversity Cancer Center Hamburg, Germany
3 Case presentation male, 64 years of age, ECOG 0 no relevant comorbidityroutine abdominal ultrasound revealed suspicious liver lesionsCT chest/abdomen3 liver lesions up to 2.5cm3 suspicious pulmonary lesions up to 1cmsingle bone lesion 1.8cm mixed osteoplastic/osteolytic (left os ileum)thickening of colonic wall (descendens)
5 Case presentationcolonoscopy: non obstructive tumor without bleeding signs colon descendenshistology: adenocarcinomaCEA value 245 ng/mlcolon carcinoma with synchronous liver and lung metastates and potential bone involvement
6 Further diagnosticsPET scan liver and lung lesions positive, bone lesion negativebone scan weakly positivedetermination of KRAS status wildtypeESMO consensus guidelines for management of patients with colon and rectal cancer 2012.KRAS mutation precludes efficacy of treatment with anti-EGFR antibodies and KRAS status determination is therefore mandatory before treatment [I, A].
7 Acc. to ESMO guidelines next step should be ... start pure palliative chemotherapy for metastatic diseasediscuss patient within MDT according to clinical presentation and determine treatment aim and clinical grouping
8 Definition of treatment strategy The optimal strategy should be developed according to the characteristics of the patient and be discussed in the multidisciplinary team and should incorporate the (potential) view of the patient as well.Patients can be individually divided into the 4 clinical groups, by parameters describing localization, extent, and resectability of the disease, tumour dynamics, co-morbidity, potential of the patient to tolerate chemotherapy and secondary surgical treatment [IV, B].
9 Clinical groups for first line treatment stratification clinical presentationtreatment aimtreatment intensityclearly R0-resectable liver and/or lung metastasescure, decrease risk of relapsenothing or moderate (FOLFOX)1liver and/or lung metastases onlywhichmight become resectable after induction chemotherapy±limited/localized metastases to other sites, e.g. locoregional lymphnodesphysically able to undergo major surgery (biological age, heart/lung condition)maximum tumour shrinkageupfront most active combination regimen2multiple metastases/sites, withrapid progression and/ortumour-related symptoms/risk of rapid deteriorationco-morbidity allows intensive treatmentclinically relevant tumour shrinkage as soon as possibleat least achieve control of progressive diseaseupfront active combination: at least doublet3never option for resectionand/or no major symptoms or risk of rapid deteriorationand/or severe comorbidity (excluding from later surgery and/or intensive systemic treatment, as for groups 1+2)abrogation of further progressiontumour shrinkage less relevantlow toxicity most relevanttreatment selection according to disease characteristics and patients preference re toxicity and efficacy:“watchful waiting”sequential approach: start withsingle agent, ordoublet with low toxicityexceptional triplets
10 Clinical coursePatient was considered potentially curative (group 1) by MDT despite the unclear single bone lesion.
11 Acc. to ESMO guidelines primary tumor should be managed by ... resection of primary tumor before chemotherapyupfront chemotherapy and delayed resection in case of major response (but still unresectable mets)upfront chemotherapy and resection only in case of local symptoms
12 Clinical course primary tumor was left in situ Potentially resectable metastatic disease after chemotherapy (group 1)For initially unresectable metastatic disease, most active available induction treatment should be chosen [V, C]. If metastases become resectable surgery for primary and metastases should be performed.Palliative surgery, stenting, laser ablation, or (chemo)radiation in case of unresectable disease, even after systemic treatment should be confined to bleeding or obstruction and as minimal invasive as possible and non invasive measures applied first [V, C].
13 Treatment algorithm for synchronous metastatic colon cancer synchronous metastatic colon cancer with intact primaryR0/R1 resectable metastasesunresectable metastasessingle, <2cmliver met3 months preop FOLFOXintensive upfront chemotherapyresectability achieved?yesnoresection of primary and metastases (simultaneous or delayed)continue chemotherapyresectability achieved?6 months postop FOLFOX3 months postop FOLFOXcontinue initial treatment for a total of 6 monthsyesnosurgery of primary: individual decision (e.g. complications or emergency)
14 Clinical course FOLFOX + bevacizumab restaging after 2/4 months: partial response (RECIST)restaging after 6 months (PET/CT):liver mets: one remaining with 1.4cm (PET positive)lung lesions: complete responsebone lesion: unchangedcolonoscopy witout macroscopic evidence of residual primary tumor, biopsy negative (local CR)decreased tolerability with peripheral neuropathy G2 and asthenia G1
16 Clinical course major response liver and complete response lung-metastases and primary tumorDecision was made by MDT to classify the patient as potentially curative based on age, ECOG, major response and unchanged bone lesion. However, resection or RFA of remaining central liver met. seemed technically difficult.
17 Further management? maintenance (5FU/Cape and/or bevacizumab) complete stop of treatmentconsider locally ablative procedure
18 followed by complete stop of treatment helical tomotherapy with 10x 4Gy for liver metastasis and as a precaution for the bone lesionfollowed by complete stop of treatmentIf metastases are not resectable due to their location additional measures like radiofrequency ablation or stereotactic body radiotherapy (in specialized institutions) should be considered, although the benefit is not formally proven [III, B].
19 Clinical courseno evidence of disease for 10 months, followed by progressive disease with 4 new liver and disseminated pulmonary lesions, single bone lesion unchangedremaining toxicity: PNP G1 (12 months after last oxaliplatin administration)
20 Acc. to ESMO guidelines further treatment should be ... restart FOLFOX + bevacizumabchange to irinotecan based second line (FOLFIRI +/- targeted agent)
21 Reinduction reinduction FOLFOX + bevacizumab In first line treatment patients should be treated as long as possible by restart of the former first line regimen (reinduction), when the toxicity (especially neurotoxicity) allows such reinduction.restaging after 2 months: stable diseaserestaging after 4 months: progressive disease (multiple new liver lesions)