As a result, the patient was restarted on cetuximab and FOLFIRI in May 2013; however, a PET/CT scan 2 months later revealed a mixed response, with persistent fluorodeoxyglucose-avid right pleural disease, but also some areas of decreased activity with stable nodal disease in the left axilla, retroperitoneum, and pelvis, and increased activity in the left inguinal and right retrocrural nodes. 

There was also resolution of pleural effusion and ascites. The patient continued with cetuximab and FOLFIRI until August 2013, and a repeat PET/CT scan in September 2013 revealed progressive disease in the right pleural mass along with increase in size of the retrocrural and left inguinal lymph nodes and liver (Figure 1A).

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The patient’s CEA was 8.3 in October 2013. The patient was started on regorafenib 160 mg daily on September 12, 2013, but required a treatment interruption due to hypertension with consistent systolic blood pressure readings in the range of 170 mm Hg and diastolic blood pressure in the range of 100 mm Hg, as well as Grade 3 fatigue during cycle 1.

The patient was started on antihypertensive medications, and regorafenib was held for 2 weeks to resolve these adverse events. After this treatment interruption, regorafenib was restarted at a dose of 120 mg. The dose was then reduced again due to Grade 3 fatigue, and the patient’s dose was stabilized at 80 mg daily.

A repeat PET/CT scan in February 2014 showed a mixed response, with increased activity in non-target lesions noted in multiple omental, peritoneal, and pelvic lesions, but decreased activity in target lesions, specifically the thoracic and liver lesions, with new activity in the right tenth rib (Figure 1B).

Specifically, a right pleural-based mass had decreased from 27.6 mm to 26.7 mm, and standardized uptake value decreased from 14.4 to 3.4 in conjunction with a decrease in disease measuring from 58.0 mm to 43.6 mm in the central pelvic mesentery superior extending to the uterine fundus. The patient’s CEA decreased to 3.7, while Eastern Cooperative Oncology Group (ECOG) performance status improved from 2 to 1, and treatment was therefore continued at 80 mg daily.

The patient’s most recent PET/CT scan in August 2014 showed frank progression of disease, with an increase in number and activity of multiple metastatic pulmonary and hepatic lesions along with increased activity in omental and mesenteric implants. As of August 2015, the patient has been on regorafenib for 11 months with progression; however, her ECOG performance status remains at 1, and she would like to continue taking the medication as she does not have any side effects and feels her quality of life has improved.