14. shweta mutha esmo presentation · dr. shweta mutha radiation oncologist ruby hall clinic, pune...

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


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.


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).


Work Up


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.


� 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.


� 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.


Liver lesion was treated using SBRT to a dose of 48Gy/4# @ 12Gy/#

QOD


� Patient will be assessed after 3 months for response to treatment

using MRI pelvis, PET CT whole body, colonoscopy, serum CEA.


� 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 ).


� 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

14. shweta mutha esmo presentation · dr. shweta mutha radiation oncologist ruby hall clinic, pune...

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