"Love" circuit turns, "" shakes straight on ｜ 呋喹 呋喹 联 ““ ““ ““ MCRC backline new breakthrough

*For medical professionals for reading reference

他 培 呋喹 呋喹 呋喹 呋喹 呋喹 呋喹 呋喹 呋喹, the fourth -line therapy belt patients to break through the adversity

As one of the most common malignant tumors, colorectal cancer (CRC) has a growth trend in its incidence and disease mortality. The latest data shows that its mortality rate is second [1] in the global malignant tumor, while metastasis is the main reason for the death of patients. In addition to the lymphatic metastasis near local lesions, the most common method of CRC's most common metastasis is to metastasis to liver, lungs, and tumors to directly break through the abdominal planting metastasis caused by the intestinal wall. [2] At present, CRC needs to be more standardized and fulfilled in management models. At the same time, it is necessary to provide patients with personalized diagnosis and treatment solutions under the diagnosis and treatment of multidisciplinary cooperation (MDT). In the process, many experts and clinical first -line doctors explore and try in the actual diagnosis and treatment process, and strive to strive for more survival time for patients with MCRC.

In this context, the China Clinical Oncology Society of Clinical Oncology Specialty Committee and He Huang Medicine joined hands to host the 2022 "Young Good Medical Sound -Specification of Global Colorectal Cancer Management Cases". Many complex or representative MCRC cases emerged during the activity. Many experts commonly commented and discussed the problems in the actual diagnosis and treatment of the disease. Review and analysis of the success of the case, the deficiencies were correct. Take precision macro in a large number of clinical cases to jointly explore better diagnosis and treatment plans to promote the standardized diagnosis and treatment of MCRC. Dr. Zhang Yan from the Department of Internal Medicine from the Second Affiliated Hospital of Zhejiang University Medical College of Medical College of Medical College of Medicine, brings us an example of a "love 'loop turning,' 呋 'up" MCRC multi -line therapy Wonderful cases.

Retrospective

▎ Basic situation

Male patients, 57 years old;

Current medical history: On March 8, 2018, patients appeared "the number of abdominal pain is reduced for half a month, and occasionally with blood", admission treatment;

The past history, personal history, and family history are not special;

Examination: soft abdomen, gently tenderness in the left lower abdomen, no vibrato pain, not touching the abdominal mass, migrant voicing negative, normally intestinal sound;

Laboratory check tips: CEA: 9.7ng/ml; HB117g/L;

Anal fingering: 6cm in the finger, no lumps, no blood stains;

Tips for colonoscopy: The mirror is 25cm in the anus. Improve the pathological examination tips: medium differentiated adenocarcinoma;

CT reminder: The chest CT prompts the right lower lung nodule to consider metastasis; abdominal CT prompts the posterior peritoneal, and the lymph nodes are enlarged by the iliac blood vessels;

Figure 1 March 9 and 10, 2018, chest and abdomen CT images

▎ diagnosis and treatment

After the patient was admitted to the hospital, the relevant examination was performed to exclude the taboos of the surgery. On March 14, 2018, the laparoscopic primary stove wasolated;

Postoperative pathological tips: Dividen the adenocarcinoma in the sigmoid colon, part of which is papillary cancer, the size is 3.5 cm*2.5cm, soaked to the lower layer of the slurry, the vascular violations are positive, no neurological violations are seen, and the intestinal lymph nodes are 4/9 positive. 7 cancer nodes;

Immunization group tips: MSH2 (+), MSH6 (+), MLH1 (+), PMS2 (+);

The remaining pathological tips (liver tumors): metastatic colon cancer, gland squamous carcinoma. The tumor is infiltrated to the gallbladder mucosa layer. No cancer was seen on the liver tissue, and no cancer was seen by the gallbladder tissue;

Genetic tips: KRAS G13D mutation, NRAS wild type, HER2 (-), braf wild type, MSS;

▎ Diagnosis

Differentiated adenocarcinoma beside the iliac vascular, laculinity lymph nodes, and right lower lung metastases (PT3NN2M1B, IV), MSS; MSS;

8 First -line treatment (April 15, 2018 -December 5, 2018)

Treatment plan: 12 cycles of Bevarzumab+ Folfiri chemotherapy (Ilidekang+ fluoropicidine);

Effective assessment: In the process of 12 cycles of chemotherapy, shadowing suggests that the lung lesions continue to shrink; the lymph nodes beside the iliac blood vessels and the post -peritoneum continue to shrink;

Adverse reactions: Patient's osteoma toxicity -IV neutral granulocyte lack of fever; digestive toxicity -delayed diarrhea;

Figure 2 CT image of the lung

Figure 3 abdomen CT image

Patients have IV -degree bone marrow suppression during the treatment, and the relevant examination tips are improved: UGT1A16, 28 sites have changed, and Ili will be reduced. After 12 cycles, the patient's disease relief (PR) is recommended. It is recommended that patients continue to maintain treatment. Due to serious adverse reactions during the treatment of patients, the patient refused to maintain treatment and followed up on regular follow -up. During the follow -up process from January 2019 to September 2020, the patient had a new lung nodule, considering the possibility of metastasis, increased after 4 weeks, and after 4 weeks, the nodules were reduced after the lung three -dimensional orientation radiation therapy (SBRT). The lymph nodes next to the iliac blood vessels and post -peritoneum remain stable. During the follow -up follow -up process, the patient had multiple nodules in the lungs, and at the same time, the tumor invaded the left ureter, accompanied by the mild pelvis accumulated water. Evaluate the progress of patient disease (PD);

Figure 4 CT follow -up image after the first line of treatment

Figure 5 August 29, 2020

Figure 6 September 1, 2020 On the abdomen CT image

2 Second Line Treatment (September 3, 2020-February 3, 2021)

Treatment plan: Bevarzumab+XELOX chemotherapy (Osarin Platinum+Cardiabine) 6 cycles;

Effective assessment: 2 cycles, 4 cycles Treatment of the lungs, iliac blood vessels, and post -peritoneal lymph node lesions stabilized. After 6 cycles, the lung lesions increased significantly, accompanied by new hair nodules; The stagnation of the side ureter has increased significantly. Prompt after treatment PD;

Adverse reactions: neurotoxicity: CTCAE grading-I;

Fig

Figure 8 The second -line treatment mid -abdomen CT image

On March 1, 2021, the patient laboratory inspection prompts that creatinine indicators were 157UMOL/L; March 5, 2021 after the double J pipe implantation failed to perform left renal fistula; on March 8, 2021, the patient's creatinine indexes resumed normal to normal It

2 Third Line Treatment (March 10, 2021 -June 1, 2021)

Treatment plan: 4 cycles of crickets+vinsiumab; 4 cycles;

Effective assessment: After 2 cycles, the lungs increase slightly, and the lymph node lesions beside the iliac blood vessels and laculinity are kept stable, indicating that the disease is stable (SD). After 4 cycles, the lung lesions increased significantly, and the new hair nodules were accompanied by the lungs, and the lymph nodes beside the iliac blood vessels and the posterior peritoneal increased to varying degrees. Prompt after treatment PD;

Figure 9 Three -line treatment mid -lung CT image

Figure 10 Three -line treatment mid -abdominal CT image

2 Fourth Line Treatment (July 1, 2021 -August 21, 2022)

Treatment plan: Sininib+Schidi Mipida+Capiojab 16 cycle;

Effective assessment: After 2 cycles, most of the lungs were significantly reduced, some lesions disappeared, and the lymphadenopathy lesions beside the iliac blood vessels and laxes of the peritoneal were reduced to varying degrees; most of the lesions of the lungs were basically disappeared after 14 cycles, and the lymph nodes beside the iliac vessels and laculinoma were stable. Prompt PR after treatment;

Adverse reactions: hypertension: CTCAE grading-I; proteinuria: CTCAE grading-I;

Fig

Figure 12 Four -line treatment mid -abdominal CT image

Expert Reviews

Instructor: Professor Chen Jiaqi, Affiliated to Zhejiang University Medical College

Comment expert: Professor Wang Yaxu, the Second Hospital of Chongqing Medical University, Professor Professor of Chongqing Hospital of Traditional Chinese Medicine

Regarding the overall treatment of the patient, Professor Chen Jiaqi said that the primary stove symptoms were considered in the initial treatment, the primary stove was removed, and the genetic test was improved. The first -line treatment adopts the Bevarzumab+ Folfiri chemotherapy scheme, and the patient obtains PR. Considering the small tumor load, at the same time, the patient refused to continue chemotherapy, adopted a suspension of treatment and observation and waiting methods. During the follow -up process, the patient was found to be PD, and new hair nodules appeared after the lung SBRT treatment. The effect of second -line treatment and third -line treatment brings 9 months of no progressive survival (PFS) to patients. Professor Wang Yaxu said that in the bold and innovative attempts of the four -line therapy, based on the treatment of vininib+viniumab, a small dose of Koribetaba was used to bring the patient's PFS for 14 months. Essence Its bold and innovative attempts bring excellent results, but whether it can be copied in the later period requires more evidence -based medical evidence and deeper research and exploration. Professor Ji Weichi said that for the four -line treatment, ogininib, as a targeted drug generated by anti -vascular production, has a synergistic effect in the treatment of CRC to a certain extent, which can improve the treatment effect [3]. As of the patient statistics of the patient's onset, the patient has obtained 54 months of total survival (OS), and it is also expected to bring more long -lasting survival benefits to the patient.

Essence

The case of multiple cases of metastasis of the B -shaped colon is long. Based on the early first -line specification treatment, the patients have brought longer survival benefits, but the treatment of second- and third -line standards cannot effectively control the patient's disease. In the four -line treatment, the treatment plan for the treatment of crickets+Xinyi Midel Mipida, although there are currently no clinical research and real world cases related to the actual efficacy, the patient has obviously benefited in this treatment plan. , Whether you can learn more about the future. In short, the treatment of MCRC, in principle of the treatment of the guidelines, to the patients to standardize and fully diagnose and treat patients is the basis for patients to benefit patients.

Figure 13 Diagnosis and treatment of patient diagnosis and treatment

references:

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

[2]. Zhou Jiaming, Wu Xiaofeng, Wu Yuanhui, etc. The tumor metastasis part, incidence and prognosis of colorectal cancer deaths [J]. Journal of Sun Yat-sen University (Medical Science Edition), 2022,43 (2): 289-296.

[3]. Dai Kejun, Lu Xujing, Zhou Xifa, et al. Anrontinib capsule combined with Korioca's clinical study of patients with colorectal cancer [J]. China Clinical Pharmacology Magazine, 2022,38 (7):631-634.*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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