The patient is a male, 70 years of age. The patient has always been in good health. Episode of hematochezia after taking FANS in 2003. The results of a colonoscopy and CAT scan carried out in November 2003 were within normal limits. In ______, following a positive FOTB, the patient had a colonoscopy which showed a bleeding lesion of the ascending colon. On _______, the patient had a right hemicolectomy and multiple hepatic resections for secondary lesions. At X moderately differentiated ulcerated adenocarcinoma of large intestine - pT3N1M1 (1n + 4/18) G2.

Following surgery, by his own initiative, the patient had a PET scan which showed two hepatic lesions in segments IV and VII, which were confirmed by a subsequent CAT scan. On _______ the patient began first-line chemotherapy with FOLFOX regime, of which he had 6 cycles, completed on _______. On ______, the patient had a CAT scan of his chest and abdomen: The results were negative for recurrence of his condition.

The results of a PET scan carried out on ______ were as follows: No high metabolic activity pathology.
The results of a CAT scan of the patient’s abdomen carried out on ______ were as follows: Hepatic recurrence at segment III.
The results of a PET scan carried out on ______ were as follows: Confirmation of the secondary hepatic lesion: Suspected secondary adenopathy of celiac tripod.
On _____, RF-thermoablation treatment of hepatic lesion at segment III of liver.
On _____, a CAT scan showed that good results were achieved with thermoablation procedure.
On _____, stereotaxic radiotherapy was carried out on celiac tripod lymphadenopathy at I.
On ______, a CAT scan showed three small localized secondary lesions in the patient’s lungs: Hepatic PD: PR on celiac adenopathies.
On ______, the patient began FOLFIRI regime chemotherapy which was completed on _______ after 16 cycles. On ______, primary lesion EGFR: negative.
A CAT scan carried out on ______ showed that the patient’s condition was stable. On ______, the patient began chemotherapy with FOLFIRI + Cetuximab regime, which was completed on 12______.
A CAT scan carried out on ______ showed that the patient’s condition was stable. From _______ to ______ the patient was in weekly therapy with Cetuximab alone.
A CAT scan carried out on ______ showed pulmonary and hepatic PD. From _______ to _______ the patient has been having 4 cycles of FOLFOX regime chemotherapy.
A CAT scan carried out on ______ showed further PD of pulmonary lesions and a small volumetric decrease of known secondary hepatic lesions.

General condition: Good general conditions; normal defecation and micturition; varied diet.

Program: By his own initiative, the patient consulted a surgeon, who proposed performing a left hepatectomy on ______.

Aware of the possible risks and benefits of surgery, the patient confirmed his willingness to have the surgery.

Prior to this date, the patient had a total body PET scan on ______. This was followed-up after the surgery. The results of the PET scan carried out on ______ were as follows: Multiple extensive dishomogeneous hyperaccumulations of radiopharmaceutical drug localized in the liver. Associated abnormal hyperfixations in both lungs, more evident at base. The patient was admitted to hospital for the relevant surgical procedure.

The patient was admitted to hospital on: ________ . Reason for hospitalization: Liver mts from Colon C.

Therapy during hospitalization: Exploratory laparotomy. Surgical biopsy of nodular lesion in liver S6-S7.

Conclusions The patient was hospitalized for secondary liver lesions; he had already had a colic resection and multiple liver metastasectomies. Chemotherapy cycles. Bilateral pulmonary metastases. The patient has had an explorative laparotomy and surgical biopsy of nodular lesion in liver S6-S7. The extent and distribution of lesions in both lobes contraindicate any surgical resection. Anatomopathological test: In progress. Date discharged: ______ . Blood chemistry tests at time of discharge from hospital: 

GB: 7.88	Plts: 264	Glu: 90	K+: 4	AST: 24
GR: 3.85	INR: 1.07	Urea: 24	Amil.: 3	ALT: 50
Hb: 11.5	PTT: 34.5	Creat: 0.6	Tot. prot.: 6.9	Tot. bili.: 0.6
Hct: 34.9	Fibr: 738	Na+: 137

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Thank you for the referral and the copy of the medical records for this patient.
To summarize, the patient is a 70 year old gentleman diagnosed with colon cancer in February 2004. After undergoing a right hemicolectomy, a PET scan and CT scan revealed two hepatic lesions. He was treated with 6 cycles of FOLFOX from ____ to ____ and had a complete response. Three months later a CT of the abdomen revealed recurrent hepatic disease and celiac lymphadenopathy. He underwent directed therapy with radiofrequency ablation of the liver lesion and stereotactic radiation to the celiac lymph nodes. He then received 16 cycles of FOLFIRI from to ____ and a CT scan in _____ showed stable disease. He then received FOLFIRI + Cetuximab for 1 month and a repeat CT again showed stable disease. He then received Cetuximab alone for 1 month and a repeat CT of scan showed progressive disease in the liver and new pulmonary disease. He then received 4 cycles of FOLFOX from ____ to ____. Unfortunately a CT scan in ____ showed progression of the pulmonary disease and minimal resolution of the hepatic lesions. A PET scan on _____ revealed multiple areas of uptake in the liver and both lungs.

The patient was then seen by a surgeon for consideration of a left hepatectomy. Upon surgical exploration, his liver disease was deemed too extensive for surgical resection.

The patient is inquiring about laser resection of his metastatic lung lesions in conjunction with selective internal radiation therapy for his liver lesions. The patient should be aware that neither technique has been shown to provide “curative” treatment, and it is clear from his recent hospitalization that his liver disease is too extensive for surgical resection, the only known method of providing long-term cure. My main concern is that pursing directed treatment to either the lungs or liver or both will delay the ability to treat with systemic chemotherapy. While the patient has been heavily pretreated with chemotherapy in the past, he has not yet received Avastin (bevacizumab), one of the 5 active drugs for metastatic colon cancer, the others being 5-fluorouracil, oxaliplatin, irinotecan and cetuximab. While bevacizumab is not active as a single agent, it is active with chemotherapy. I agree with Dr.____ that the patient’s best option at the present would be to pursue additional chemotherapy with bevacizumab.

I have reviewed the manuscript by Drs._____ and ______concerning laser resection of metastatic lung lesions. While this approach looks interesting, prior patients receiving this treatment had metastatic disease to the lungs alone. I am not aware of any patients with widely metastatic disease that have been treated with this technique. As a result, I do not think it is in his best interest to pursue treatment for his pulmonary disease alone as this will likely delay further systemic treatment.

The patient was also inquiring about SIRTeX yttrium-90 microspheres. Again, this is an interesting technique however the patient must know that such therapy will only potentially treat the liver disease and will have no effect on his pulmonary disease. I have reviewed the SIRTeX web site which clearly states that capecitabine is contraindicated 2 weeks before and after SIRTeX treatment. I also reviewed the medical literature regarding SIRTeX microspheres and do not see information regarding interactions with capecitabine. It is not clear if the recommendation was made based on pre-clinical studies or simply because there are no studies using capecitabine with SIRTeX and therefore there is no toxicity related information.

Summary

With respect to clinical trials, I would recommend, prior to enrolling in any phase of clinical trial, treatment with bevacizumab plus chemotherapy. Thank you for allowing me to participate in the care of this very interesting patient. I appreciate the aggressiveness with which you and he are pursuing his care.

Sincerely,

Prof. -----

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