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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify common symptoms associated with colon cancer at presentation and with disease progression.

  • Describe the treatment goals associated with early and advanced stages of colon cancer.

  • Design an appropriate chemotherapy regimen for colon cancer based on patient-specific data.

  • Formulate a monitoring plan for a patient receiving a prescribed chemotherapy regimen for colon cancer based on patient-specific information.

  • Recommend alterations in a drug therapy plan for a patient with colon cancer based on patient-specific information.

  • Use pharmacogenetic test results to design an appropriate drug therapy plan for a patient with colorectal cancer.

  • Educate patients on the anticipated side effects of irinotecan, capecitabine, fluorouracil, oxaliplatin, bevacizumab, ziv-aflibercept, ramucirumab, regorafenib, cetuximab, panitumumab, and trifluorothymidine/tipiracil hydrochloride.

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PATIENT PRESENTATION

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Chief Complaint

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“The pain below my right ribs is getting worse. Also, I’m having more numbness, cramping, and burning sensations in my hands and feet, especially when I’m working a lot. I don’t think I can tolerate it much longer.”

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HPI

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Peter Robinson is a 56-year-old man who presents with worsening pain in his hands and feet and increasing RUQ pain. He was diagnosed with stage IV colon cancer 11 months ago after presenting with abdominal pain, bloating and distention, a history of intermittent BRBPR, and no BM within the prior 4 days. He presented to the ED where a barium enema revealed an “apple core” lesion in his descending colon that was suggestive of malignancy (Fig. 150-1). An FDG-PET/CT scan showed a complete bowel obstruction and several areas of focal intense uptake in the liver, consistent with metastases. His preoperative CEA was 5.6 ng/mL. He subsequently underwent a laparotomy with a left hemicolectomy and lymphadenectomy. The pathology revealed a moderately differentiated adenocarcinoma with extension through the bowel wall to the serosal surface. The tumor was KRAS and NRAS gene wild-type. Ten of 13 lymph nodes were positive for tumor. Biopsy of a liver lesion confirmed hepatic metastases. A CT scan of the chest showed no evidence of lung metastases. Seven weeks later, chemotherapy was initiated with capecitabine, oxaliplatin (CapeOx), and bevacizumab. Except for occasional nausea, he generally tolerated the chemotherapy well. However, over the past 2 months he has been experiencing worsening redness and pain on the palms of his hands with numbness and tingling in his fingers and toes. Six days ago he received his 19th cycle of chemotherapy. UGT1A1 testing showed that he was homozygous for the UGT1A1*28 allele.

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FIGURE 150-1.

Annular, constricting adenocarcinoma of the descending colon. This radiographic appearance is referred to as an “apple-core” lesion and is always highly suggestive of malignancy. (Reprinted with permission from Mayer RJ. Gastrointestinal tract cancer. In: Fauci AS, Kasper DL, Longo DL, et al., eds. Harrison’s Principles of Internal Medicine, 17th ed. New York, McGraw-Hill Education, 2008:577.)

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