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Case history

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Image not available. A 72-year-old man attended for colonoscopy after a positive bowel screening result. A stricturing lesion, 25 cm from the anal verge, was found and a biopsy confirmed a moderately differentiated adenocarcinoma. A staging CT scan of the chest, abdomen and pelvis demonstrated the primary tumour, as well as multiple liver and peritoneal metastases.

As the sigmoid colon cancer was stricturing, and the scope could not be passed through it, the patient underwent an anterior resection. Pathology demonstrated peritoneal surface involvement, invasion of the greater omentum, 2/12 positive nodes and extramural venous invasion. Pathological staging was T4bN1M1. Extended RAS mutation testing was undertaken and he was found to be RAS wild-type.

His medical history included prostate cancer in 2003, which had been treated with radiotherapy.

Postoperative routine blood tests were satisfactory: normal renal and hepatic function and baseline carcinoembryonic antigen (CEA) 29 mg/l (CEA had been 300 mg/l at the time of his initial diagnosis).

He was initially treated with eight cycles of irinotecan modified de Gramont combined with cetuximab. A CT scan showed that this stabilized his disease. He was subsequently enrolled in the Molecular Selection of Therapy in Colorectal Cancer: A Molecularly Stratified Randomised Controlled Trial Programme (FOCUS4; focus4trial.org).

What is the treatment intent for this man?

What is the evidence base for his treatment choice?

What is the function of RAS and its importance in the colorectal cancer population?

How else could this patient's tumour be molecularly stratified to improve his treatment and offer him a personalized approach to maintenance therapy?

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What is the treatment intent for this man?

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The optimal treatment strategy for patients with metastatic colorectal cancer should be determined after discussion at a multidisciplinary team (MDT) meeting. It should depend on the site and extent of metastatic disease and on the patient's performance status (PS), organ function and comorbidity.

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Following the 2011 NICE guidelines,1 the intention of treatment for this man is that of palliation. Systemic anticancer treatment should be given with the aim of improving both quality of life (QOL) and survival.2 It is widely accepted that patients who have metastatic colorectal cancer and liver metastases should have their case discussed with a hepatobiliary surgical team in the context of an MDT meeting, for consideration of resection with curative intent if possible. After liver resection, the 5 year survival rate has been reported to be 37–58% in selected groups of patients.3 Fong et al.4 described the use of a scoring system that stratifies patients according to independent factors such as nodal involvement, resection margins, number of liver metastases, size of largest tumour (>5 cm) and preoperative CEA levels to calculate an overall score; the higher the score the more guarded the prognosis. Of note, Fong et al.4 also described the presence of peritoneal disease as a contraindication to liver resection and therefore an independent prognostic factor.

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