A 57-year-old patient diagnosed with stage T3N1M0 adenocarcinoma of the colon. He was treated with resection followed by postoperative FOLFOX chemotherapy (fluorouracil, leucovorin and oxaliplatin) for 6 months. In a routine control, two years later, carcinoembryonic antigen (CEA) elevation to 30 ng/mL (previously less than 2 ng/mL) was detected. She has no symptoms, physical examination is unremarkable, chest X-ray is normal. CT scan shows a 3 cm mass in the right hepatic lobe that is captured on PET. No other alterations are observed in CT or PET. What is the most correct approach?
We are faced with a situation of probable liver metastasis from a localized colon adenocarcinoma treated 2 years ago. Probable because we do not have histological confirmation, although as it usually happens, what else could it be? As this is a situation of oligometastasis and the treatments for advanced colon adenocarcinoma allow prolonged survival with good quality of life in these patients, if there is nothing to contraindicate surgery, this should be the first option (correct answer 3). I attach the algorithm proposed by the NCCN in situations of recurrence (http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf). In case of an unresectable situation, chemotherapy treatment would be considered with the intention of converting the single metastatic lesion into a resectable one. Since more than 12 months have passed since FOLFOX treatment, the same scheme could be used, although FOLFIRI+bevacizumab would also be useful. Capecitabine monotherapy, in the patient's current situation, would also not be a good starting option, since the responses are lower compared to FOLFOX or FOLFIRI plus antiangiogenic combinations. Hepatic radiotherapy could be considered, since there are SBRT techniques that achieve very good results, but in this case it is best to start by asking for an assessment by the surgeons and if they rule out surgery we would consider RT.
Chemotherapy with FOLFIRI (fluorouracil, leucovorin and irinotecan) plus bevacizumab.
Monochemotherapy with capecitabine.
Assessment for surgical resection of the hepatic lesion.
Hepatic radiotherapy.
In case of an unresectable situation, chemotherapy treatment would be considered with the intention of converting the single metastatic lesion into a resectable one. Since more than 12 months have passed since FOLFOX treatment, the same scheme could be used, although FOLFIRI+bevacizumab would also be useful.
Capecitabine monotherapy, in the patient's current situation, would also not be a good starting option, since the responses are lower compared to FOLFOX or FOLFIRI plus antiangiogenic combinations.
As this is a situation of oligometastasis and the treatments for advanced colon adenocarcinoma allow prolonged survival with good quality of life in these patients, if there is nothing to contraindicate surgery, this should be the first option (correct answer 3).
Hepatic radiotherapy could be considered, since there are SBRT techniques that achieve very good results, but in this case it is best to start by asking for an assessment by the surgeons and if they rule out surgery we would consider RT.