The Efficacy and Tolerability of Xeliri-Aflibercept Combination in A Metastatic Colorectal Cancer Patient After 5-Fu- Induced Symptomatic Bradycardia: A Case Report and A Brief Review of Literature

Abstract

5-Fluorouracil (5-FU) and oral fluoropyrimidines are the backbone of colorectal cancer (CRC) chemotherapy, but these have many traditional and cardiotoxic side effects. Rechallenge is usually not recommended due to high mortality rates after ischemic symptoms and other cardiac side effects, but replacing these drugs with another fluropyrimidine, or bolus 5-FU, can be considered for some patients. Aflibercept combined with a FOLFIRI regimen is an accepted second-line therapy for metastatic colorectal cancer (mCRC) patients. XELIRI is another effective and feasible irinotecan and fluoropyrimidine combination, which is more toxic than the FOLFIRI regimen and is not routinely recommended. However, modified doses of XELIRI (mXELIRI) were found to be non-inferior to FOLFIRI. The efficacy of the mXELIRI and aflibercept combination has not investigated yet. We present a patient with infusional 5-FU-induced sinus bradycardia that we could not continue FOLFIRI-aflibercept due to this cardiac side effect. We replaced infusional 5-FU with reduced dosages of capecitabine and irinotecan as in the mXELIRI regimen and combined those with aflibercept. The patient tolerated this regimen well without cardiac or severe gastrointestinal side effects, and had 12 months of progression-free survival. Replacing capecitabine with infusional 5-FU might be an option for some patients experiencing 5-FU-related sinus bradycardia. However, oncologists should arrange the treatment plan according to the risk/benefit ratio. Aflibercept combined with mXELIRI may be an alternative regimen for patients who refuse port catheter placement or who are not able to receive infusional-5-FU due to adverse side effects.