Case report

The following report describes a patient with metastatic CRC who was treated with regorafenib. No ethics approval was needed for the care of this patient as all treatments were in accordance with institutional best practices. Verbal consent to appear in this case study was given by the patient to Dr Seery.

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A 73-year-old Indian female with a past medical history of hypertension and hypercholesterolemia was diagnosed in September 2010 with left-sided adenocarcinoma of the colon. The patient had no history of smoking, alcohol consumption, or any family history of cancer.

The patient initially had symptoms of hemoptysis for approximately 2 weeks and then subsequently developed hematochezia for 3 days. Due to these symptoms, the patient underwent a colonoscopy, which revealed left-sided colon cancer.

A left hemicolectomy was performed; pathology revealed a stage IIIB well-differentiated, KRAS wild-type adenocarcinoma, with one out of 15 lymph nodes testing positive. The patient moved back to India and did not receive adjuvant chemotherapy due to patient preference.

In March 2011, the patient returned to the USA with complaints of mild abdominal distention, and a subsequent positron emission tomography/computed tomography (PET/CT) scan showed evidence of recurrence, with ovarian and peritoneal metastases.

A biopsy was performed, which revealed CK20 positivity, consistent with colonic adenocarcinoma. The patient began treatment with capecitabine, oxaliplatin, and bevacizumab, and developed an anaphylactic reaction in the sixth cycle.

She continued with single-agent capecitabine for an additional two cycles and completed therapy in June 2011 as there was no further evidence of disease on the PET/CT scans. The patient did not receive any additional therapy until early 2012 when she was restaged and was again noted to have diffuse metastatic disease in the peritoneum, with imaging consistent with moderate to extensive carcinomatosis.

The patient received cetuximab and FOLFIRI from February 2012 through August 2012 and achieved an excellent response, with the PET/CT scan showing no evidence of measurable disease, with some minimal hypodensities in the liver that were not PET avid. Therapy was discontinued at that time as the patient preferred an active surveillance approach. The patient did well until April 2013 when she experienced increased abdominal distention, bloating, and difficulty with defecation.

The patient received a repeat CT scan that showed progression of the disease, with a large pleural-based mass in the right lower lobe with bilateral pleural effusions, ascites, and multiple peritoneal implants, as well as omental infiltration along with a possible L3 lytic lesion. Also, the patient’s carcinoembryonic antigen (CEA) values had increased to 23.