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Case History

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Image not available. A 63-year-old woman had a left hemicolectomy for a Dukes C carcinoma of the descending colon, with 2/12 lymph nodes positive for tumour (pT4 N1 MX). Carcinoembryonic antigen (CEA) was raised preoperatively, but returned to the normal range 4 weeks after the surgery. She is referred for consideration of adjuvant treatment. She has no relevant past medical history.

How should this patient be further assessed?

If no further sites of disease are found, what is her prognosis with no adjuvant treatment, and how is the prognosis altered by 5-fluorouracil?

Should this patient be offered adjuvant treatment containing irinotecan, oxaliplatin or monoclonal antibodies (cetuximab or bevacizumab)?

How would have the management have differed if the tumour had been a Dukes B carcinoma of the colon (pT4 N0 MX)?

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Background

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How should this patient be further assessed?

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Image not available. Radiological imaging should be done to exclude the presence of distant metastases and complete tumour staging. The commonest site for distant metastases is the liver and adequate imaging of this site is therefore a priority. Few studies have defined the optimal imaging modality in this situation. Ultrasound and computed tomography (CT) are the most widely available modalities, and both have potential benefits and drawbacks. Current UK guidance suggests that all patients should have a staging CT scan of the abdomen and pelvis.1 This is largely based on the greater sensitivity (although lower specificity) of CT over ultrasound scanning for the detection of liver metastases.

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An elevated preoperative CEA which fails to normalize can be considered a poor prognostic factor. However, it is not an independent prognostic factor due to confounding associations with increasing tumour stage and poor histological differentiation.2 Routine blood tests and an electrocardiogram (ECG) should also be done to assess for comorbidities.

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If no further sites of disease are found, what is her prognosis with no adjuvant treatment, and how is the prognosis altered by 5-fluorouracil?

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Dukes C tumours have a 60% risk of disease recurrence, whereas Dukes B and A tumours have a much lower risk of recurrence of 20% and 10%, respectively. Adjuvant fluoropyrimidine-based chemotherapy is well established for Dukes C tumours, resulting in approximately a 25% reduction in the risk of death.3–5 This is equivalent to an absolute benefit in 5-year overall survival of 4–12%. Online resources, such as the Mayo clinic database (www.mayoclinic.com/calcs/), allow the estimation of an individual's risk of recurrence and the potential benefit of adjuvant chemotherapy.

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The optimal 5-fluorouracil (5-FU) regimen has evolved over the past 15 years. Bolus 5-FU given at a dose of 370–500 mg/m2 is the basis of most adjuvant regimens. A total of 6 months 5-FU modulated by low-dose folinic acid currently appears to be an optimal regimen. Longer periods of treatment or higher doses of folinic acid do not result in superior ...

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