From palliative to curative treatment – a case of stage IV mucinous colorectal cancer

Colorectal cancer (CRC) is the third most common cancer in the world and in Sweden, next to breast cancer and prostate cancer. In Sweden, more than 6,000 people are diagnosed with CRC and around 2800 people die of the disease every year. CRC generally has a worse prognosis than for example breast cancer and prostate cancer. As a comparison, 61-65% patients with CRC are alive 5 years after diagnosis, compared to patients with breast cancer and prostate cancer where approximately 90% are alive 5 years after diagnosis.
Today, CRC is treated with surgery, chemotherapy, radiotherapy and antibodies. The antibodies are also called targeted drugs. The antibodies used in CRC can reduce the tumor’s ability to form new blood vessels (for example the drug bevacizumab) and can inhibit growth factors that normally induce tumor cell growth (for example the drugs panitumumab and cetuximab). These antibodies have prolonged the survival for some categories of CRC patients with over 2.5 years. We know that patients with a so-called KRAS-mutation in the tumor do not benefit from antibodies that can inhibit growth factors, whereas patients with no KRAS-mutation do. However, there are no markers that we know of that predicts the effect of antibodies that reduce the tumor ability to form new blood vessels.

Today scientists all over the world try to subgroup CRC tumors in an attempt to a) develop new effective cancer drugs and b) predict who benefits from a certain therapy and who does not. One of the subgroups is mucinous adenocarcinoma (MAC) which is defined as > 50% mucin in the tumor and constitutes of approximately 6-19% of all CRC. The mucin makes the tumor mucus-like in its’ appearance and perhaps it is because of this that MAC are more rarely radically surgically removed. MAC is also associated with a poorer response to chemotherapy and chemoradiotherapy.

At our clinic, at the Univerity Hospital in Linköping, Sweden, a 27-year old woman presented with very locally advanced MAC in the colon with liver metastases. She was at first given conventional chemotherapy, but rapidly deteriorated. She lost weight and slept most of the day. She had several severe infections with low white blood cell counts and suffered a blood clot in the lung artery.  A computed tomography showed that the tumors unfortunately had not shrunk. She was considered palliative, meaning that the intent of the following treatment was to slow the progression of cancer and prolong life. She was given continuous low-dose chemotherapy with capecitabine, a drug that is taken orally once every day, in combination with the antibody bevacizumab every other week. This meant that she could stay at home and only had to go to the hospital to get the bevacizumab injections. Continuous chemotherapy with capecitabine is used in several places in the world, including patients with CRC, but not to any greater extent and there are few studies in this area.

Our patient, the young woman, tolerated the treatment very well and within a short time she even began to feel better, being able to stay up most of the day. After 2 months she described herself as feeling fresh and alert, and had gotten her appetite back. Her blood tests were restored to normal. A CT now showed that the tumors had shrunk. She underwent surgery, and is now 2 years later, still alive and well, with no sign of recurring cancer.

 

Publication

From palliative to curative treatment – stage IV mucinous adenocarcinoma, successfully treated with metronomic capecitabine in combination with Bevacizumab and surgery- a case report.
Vernmark K, Albertsson M, Björnsson B, Gasslander T, Sandström P, Sun XF, Holmqvist A.
BMC Cancer. 2015

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