Long-term Successful Treatment of Metastatic Colon Adenocarcinoma in a Celiac Disease Patient With Gluten-Free Diet and Limited Chemotherapy

Abstract

Introduction: Metastatic colon cancer (CC) is a leading cause of death, and little information exists of a “cure” of the disease long-term. CC increases with advanced age, giving support to the theory of tumor surveillance. Alternatively, metastatic CC also increases in the context inflammation or over-activity of certain components of the immune system, which can be considered to fuel cancer growth and spread. Here, we describe a case diagnosed with metastatic CC and celiac disease concomitantly, and successfully treated with gluten-free diet (GFD), with dramatic and rapid response limited chemotherapy. Case Report: A 49-year-old white female presented with chronic fatigue, intermittent rectal bleeding for 1 year, and increasing intermittent lower abdominal pain for 1 month. Her past medical history was significant for anemia all her life. Physical examination was unremarkable except for thin hair and palor. Labs revealed iron deficiency anemia. A colonoscopy was performed, revealing a large fungating mass at the rectosigmoid junction. An EGD was also performed on the same day to evaluate her life-long anemia. Biopsies of the duodenum revealed with severe villous atrophy, increased lymphocytes, and crypt proliferative activity, compatible with celiac disease. Anti-gliadin antibodies, tissue transglutaminase IgA, and endomysial antibodies were all positive. A staging CT scan showed multiple liver lesions in the caudate lobe and medial and lateral left lobes. The patient was started on a GFD and supplemental parenteral nutrition. Thenafter, a low anterior resection of the primary tumor and needle biopsies of the liver lesions during surgery were performed. Pathology confirmed invasive, moderately differentiated adenocarcinoma with normal MLH1 and MSH2 staining, and with 2 of 9 lymph nodes positive for cancer. Liver biopsies were also positive. One month following surgery, FOLFOX chemotherapy regimen was initiated. Two weeks into FOLFOX, a right upper quadrant US was done for increasing liver function tests that revealed 2 not-well-defined liver lesions. A restaging CT scan 3 months following surgery revealed no evidence of tumor. The patient eventually completed 12 cycles of FOLFOX and has had review of biopsies at multiple institutions confirming all the findings. She has been followed for 10 years with imaging with complete resolution of her metastatic CC. Conclusion: The restoration of an impaired immune system can potentially improve tumor surveillance and/or remove abnormal inflammatory responses to tumor, which promote cancer cell growth. This case proposes that if a patient’s inherent immune system can be individually optimized, it is theoretically possible to potentially cure metastatic CC.