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Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services (userservices@mheducation.com) for more information.

LEARNING OBJECTIVES

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

  • 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.

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

PATIENT PRESENTATION

Chief Complaint

“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.”

HPI

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 changes in bowel movements, and no BM within the prior 4 days. He presented to the ED where an abdominal/pelvic CT scan revealed a complete bowel obstruction and extensive hypodense lesions in the liver, consistent with metastases (Fig. 150-1). His preoperative CEA was 13.6 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. 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. The tumor was KRAS, NRAS, and BRAF gene wild-type, and classified as microsatellite instability-high (MSI-H; MMR-deficient; dMMR). UGT1A1 testing showed that the patient was homozygous for the UGT1A1*28 allele. Seven weeks later, chemotherapy was initiated with capecitabine, oxaliplatin (CapeOx), and bevacizumab. Except for minor fatigue and occasional nausea, the patient 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.

FIGURE 150-1.

Abdominal/pelvic CT scan with extensive liver metastases. These multiple hypodense lesions are characteristic of metastases to the liver, the most common site for distant spread of gastrointestinal malignancies. (Reprinted with permission from Kaiser M. McGraw-Hill Manual: Colorectal Surgery: http://www.accesssurgery.com.)

PMH

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