Abstract
The liver is the commonest site for metastases in colorectal carcinoma; other isolated sites are considered extremely rare. 5-fluorouracil (5-FU) is the backbone of treatment for metastatic colorectal carcinoma (mCRC) and without it survival may be significantly reduced. It is primarily metabolised by dihydropyrimidine dehydrogenase (DPD). Testing for DPD deficiency is not a routine practice and toxicity will only manifest following drug challenge. There are limited standardised treatment guidelines in managing patients with severe drug reactions following 5-FU exposure. We describe a delayed presentation of life-threatening DPD deficiency in a patient with colorectal carcinoma and mediastinal lymphadenopathy. We describe our experience with chemotherapy in this difficult clinical scenario and highlight the importance of histological confirmation in unusual sites of metastatic disease.
Highlights
Colorectal carcinoma is the third most common malignancy and the second leading cause of cancer deaths worldwide.[1]
The prognosis for metastatic colorectal carcinoma (mCRC) has improved since the 1990s when standard of care with 5-FU/leucovorin (FF) was associated with a median survival of 12 months.10,11 5-FU remains the backbone of treatment and is one of the commonest prescribed chemotherapeutic drugs; more than 80% is inactivated in the liver by the enzyme dihydropyrimidine dehydrogenase (DPD).[4,12]
Standardised uptake values (SUV) on FDG-positron emission tomography (PET) scans ≥ 2.5 are accepted as malignancy; any metabolically active process may result in FDG accumulation.[15]
Summary
Colorectal carcinoma is the third most common malignancy and the second leading cause of cancer deaths worldwide.[1]. As a result of the resistant neutropaenia, he was not a suitable surgical candidate and conservative management with total parenteral nutrition, analgesia, repeat cultures and escalation of antibiotics was instituted He deteriorated with signs of a multi-systemic inflammatory response: acute liver failure, encephalopathy, FIGURE 2: Axial post-contrast computed tomography (CT) scan of the pelvis demonstrates pneumatosis coli of the rectum with extra-luminal air. The patient remained disease-free without chemotherapy for 13 months On surveillance imaging, he was found to have a solitary segment 4A liver metastasis, amenable to local resection (left partial hepatectomy). He was found to have a solitary segment 4A liver metastasis, amenable to local resection (left partial hepatectomy) Sixweeks after surgery, he was commenced on intravenous irinotecan 200 mg/m2, oxaliplatin 85 mg/m2 (IROX) and bevacizumab 7.5 mg/kg.
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