The "intestinal" road is long, step by step ｜ A case of MCRC reviewing classic cases by multi -line, OS has exceeded 39 months

*For medical professionals for reading reference

The standardized diagnosis and treatment of late colorectal cancer brings survival and "excellent" to patients

Up to now, colorectal cancer (CRC) has become the third place in the world and the second place in the world in the world's second place [1]. Facing the incidence and mortality of CRC's high level, my country has also focused on creating the standardized diagnosis and treatment and full management model of CRC, and strives to bring longer survival benefits to patients with CRC. Implementing the standardization and full -process treatment of CRC's front line to the backline has also brought new requirements and challenges to the front line clinicians.

To this end, the Chinese Clinical Oncology Society of Colorectal Cancer and He Huang Medicine joined hands to host the 2022 "Young Good Medical Sound -Given Global Condition Speech Speech", inviting many clinicians to share the clinical first classic classic classic classic classic classic classic Diagnosis and treatment cases, and invited many fields to participate in the review, the meeting content is rich and detailed. At the North China Station on August 6, Dr. Cheng Yurong, a "" Intestinal Road Man "brought by Dr. Cheng Yurong, a Cancer Hospital Cancer Center of the Capital Medical University. Looking back on the wonderful.

Retrospective

▎ Basic situation

Female patients, 40 years old;

The current medical history: In May 2019, there were no obvious causes of "blood" in patients.

Personal history and past history: no special;

Examination: No obvious abnormalities;

Admission colonoscopy Tips: A rectum of about 12cm from the anus can be seen in a ring of cauliflower -like campaigns throughout the week. Improve the pathological examination tips: ulcer -oriented glandular cancer;

Admitted full -belly CT reminder: The intestinal wall is limited to thickening, local intestinal cavity becomes narrow, intestinal wall abnormal enhancement and surrounding enlarged lymph nodes, consider rectal cancer lymph node metastasis;

▎ diagnosis and treatment

After the patient was admitted to the hospital, the pre -surgery related examination was performed.

Postoperative pathological tips: (rectal) ulcer -type adenocarcinoma, neutralization, part of which is mucus adenocarcinoma (5%), tumor size is 5cm*4cm*7cm, and the cancer tissue stove to invade the pulp layer. There is no clear tumor dwarf. See a high -level tubular gland tumor for the intestinal mucosa. None of the remote, proximal, and circular edges were seen. Peripheral lymph nodes can be visible to metastatic cancer (1/16) and one cancer nodule;

Immunization group: MLH1 (++), MSH2 (+++), MSH6 (+++), PMS2 (++) HER2 (1+), Ki67 (60%+);

Gene test: KRAS No. 2 outer appende, NRAS/Braf/PIK3CA has not changed;

▎ Diagnosis

Dividered adenocarcinoma (PT3N1CM0, IIIB stage), PMMR, HER-2 (1+), KRAS 2 outer sub-explicit submissives;

疗 Treatment plan and efficacy assessment

Postoperative adjuvant chemotherapy: XELOX8 cycle, the last chemotherapy time is November 20, 2019, no progressive survival time (PFS) reaches 15 months;

▎ Condition changes

In July 2020, there were no obvious cause of irritating dry cough in the patient, with abdominal distension;

Laboratory inspection: CA125: 975.6 U/ml; CEA: 34.95 ng/ml; CA199: 112.08 ng/ml;

Full abdomen CT: The rectal cancer is abnormally enhanced by the nodule, the lower abdomen and pelvic cystic lumps are abnormally enhanced, and the peritoneum and large ketic membrane are thickened.

Immunization group: Calretinin, MC (a small number of leather cells+), D2-40 (scattered in intercipate cells+), WT-1 (间 免 cell+), TTF-1 (-), CK7, CK7, CK7, CK7, CK7, CK7, CK7 (Intective cells ++), Napsina (-), CK5/6 (spare cell+), CK20 (scattered+), Ki67 (about 3%+), CD68 (tissue cell+), Vimentin (-), CDX, CDX -2 (scattered in individual+), villin (scattered+), satb2 (-);

Chest water cytology: It can be seen in a small amount of tumor cells, combined with medical history and immunohistochemistry: the source of the intestinal tract;

Tips for colonoscopy: 10cm of rectal mucosa is congested and edema; diagnosis of mirroring: mirror diagnosis: possibilities of rectitis; pathological tips chronic mucosal inflammation;

Figure 1 July 2020 The whole abdomen CT

2 First -line treatment (July 2020 -October 2020)

The diagnosis of patients is: Differential adenocarcinoma (high) postoperative IVB stage, accompanied by lung metastases, pleural metastasis, peritoneal metastasis, ovarian metastasis, and carcinogenic thoracic effusion and medium -sized peritoneal effusion. The patient is currently 41 years old, ECOG is 0 points, organ function is good, non -complicated, and the treatment attitude is positive. Discussion by the Multi -Disciplinary Diagnosis and Treatment Team (MDT) gave patients with thoracic pouring Bevarzab and 4 -cycle Bevar Miparture+Folfiri first -line treatment scheme.

Efficacy assessment

The patient's peritoneal metastasis, the pleural effusion of the thoracic and abdominal cavity reached partial relief (PR), the lung metastatic disease disease stabilized (SD), and the volume of ovarian metastatic lesions increased significantly.

2 Second Line Treatment (December 2020 -July 2021)

Based on the patient's ovarian metastases, the risk of tumor rupture, and ovarian metastases are not sensitive to chemotherapy. At the same time, the patient's early treatment tolerance is better, and the treatment attitude is positive. The patient's behavior is arranged by MDT discussion: abdominal tumor reduction (CRS+HIPEC). Pelvic disease damage resection+peritoneal damage resection+enteric membrane disease damage resection+appendix resection+abdominal adhesion+uterine fibroid divorce; peripheral intravicidomidomy treatment (DDP), and then continued systemic treatment. Surgical pathology: Ovarian mass right, ovarian mass left (giving test of tunnels) is neutralized adenocarcinoma, part of which is mucus adenocarcinoma, accompanied by large tumor necrosis, tumor size 26*21*4.5cm, 11*8*4.5 cm. The combination of immunohistochemistry and medical history is considered the source of the rectal; (pelvic foundation peritoneal) can be seen in the fibrous fat connective tissue for examination of the severiated adenocarcinoma.

Gene test: KRAS gene P.G12C mutation, MSS, PD-L1 (-);

The perioperative surgery period from December 2020-April 2021, the patient's 8-cycle Bevarzumab+Folfiri joint treatment, April 2021-July 2021, then Bervar Miparture+Cardiabin treat.

Efficacy assessment

Disease control SD, new hair nodules appear in the lungs during the follow -up period.

2 Third Line Treatment (August 2021 -Case Reporting Deadline)

August 30, 2021 Imaging evaluation Tips: New hair nodules in the lungs of patients, and the original stable nodules increase, suggesting that the lungs develop diseases (PD). Three -line treatment plan. The beginning of the dose of the nignib is 5mg. During the period, the patient had a little proteinuria and mild hypertension. After adjusting it to 4mg, the tolerated tolerance was better; in April 2022, it was found to be an empty lesion lesion in the upper lung of the right lungs. Neighboring spotted slices, Yu did not see obvious changes.

Figure 2 Pulmonary CT progress map

From March to April 2022, patients with lung mold infection occurred, and they improved after the treatment of ambush anticoccus antibacterial treatment. By the end of the case report, the patient continued to use 呋喹inib for treatment. The overall situation SD, the total survival period (OS) reached 39 months.

Expert Reviews

Instructor: Professor Wang Li, Beijing Luohe Hospital Affiliated to Capital Medical University

Comment expert: Professor Jia Yitao of Hebei Provincial People's Hospital

Professor Wang Li said that for the wonderful cases of the above -mentioned advanced CRC with multiple transitional patients, it is not easy for OS to exceed 39 months. For the treatment options of this patient, it is always based on the full management of metastatic colorectal cancer (MCRC). The treatment of each line is discussed by MDT on the basis of the reference guide. This is inseparable. Professor Jia Yitao also believes that this typical case interprets the choice and decision -making of each patient's treatment and decision to laid a solid foundation for the patient to obtain a longer PFS. On the basis of good tumor control in the whole body, boldly gives patients for local treatment. When ovarian metastasis occurs, the local treatment of CRS+HIPEC for patients in the second -tier treatment brought 9 months of PFS for the patient. And when the original nodule of the patient's lungs increased and a new hair nodule appeared, the targeted drug generated by the antibodilized blood vessel generated by the three -line therapy was selected, which brought the PFS of 11 months to the patient and the current continued continued continued Benefit. It is expected that 续citinib will bring longer and safe survival benefits to patients in the future.

Essence

KRAS mutations, differentiated adenocarcinoma (PT3N1cm0, IIIB) in the rectal (high) adenocarcinoma (PT3NN1CM0, IIIB period). After multiple discussions of MDT, it is based on the basis of systemic treatment. Treatment of effective control of the disease, the three -line tadpinib treatment plan has been nearly one year so far. The total OS of this real -world treatment of patients has reached 39 months, and the serum tumor marks are stable. It is prompted that the patient tolerate the patient with good tolerance for the treatment of patients with a significant survival benefit for the backline of patients with advanced CRC.

Figure 3 Patient's disease diagram

references:

[1] .sng h, flace j, siegel rl, et al. Global Cancer Statistics 2020: GLOBOCAN ESTImates of 249.

*This article is only used to provide scientific information to medical people, and does not represent the viewpoint of this platform

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