One year ago, almost to the day, I was asked to see a very pleasant 67-year-old surgeon. He was personally referred by the radiologist who had just completed a rather disturbing CT scan of the abdomen. It revealed extensive metastatic disease to the liver.
His story is of interest on several levels. On the one, he had absolutely no symptoms.
Annual Blood Test Shows a Surprise
It seems that his wife, an RN, had suggested that he might add a CEA to his routine annual blood work. The result at 619 was fully 100 fold higher than the normal range (0-2.5). A CT scan was conducted immediately and I met the patient the next day.
With the most likely source being the colon, I referred the patient to a gastroenterologist who conducted a colonoscopy and biopsy that confirmed a large mass in the splenic flexure (the area of the colon on the left side of the abdomen near the spleen). As treatment options were being considered, I referred the patient to my surgeon for a laparoscopic biopsy of the liver.
While additional studies were being completed, we began treatment with the most widely used colon cancer treatment option known as FOLFOX plus Bevacizumab (Avastin). Further analyses revealed a striking finding as he was found “wild type” (non-mutated) for the common colon cancer genes; K-Ras, N-Ras and B-Raf. The moniker applied to these colon cancer patients is “triple negative”. They constitute a relatively uncommon, but ideal population for treatment with drugs that target the epidermal growth factor (EGFr) pathway.
Delivering A Triple Whammy
Recognizing that Bevacizumab (the blood vessel blocking agent) enhances the effect of FOLFOX chemotherapy, we examined the new landscape of “triple negative” disease. This offered the possibility of additional sensitivity to Erbitux (the EGFr blocking agent). We reasoned that these two very different but potentially synergistic assaults on his cancer could be used to our advantage and decided to combine both attacks on his cancer simultaneously resulting in a hybrid regimen that delivered a triple whammy of chemotherapy plus two different antibodies.
One more hurdle lay ahead.
The patient had suffered a needle stick during a surgical procedure many years earlier and had contracted hepatitis C. Although he had been treated before, he had never cleared his viral load. Now as I contemplated chemotherapy for his colon cancer I resolved to treat the hepatitis C as well. In collaboration with our liver specialist we proceeded with the newest form of anti Hep-C therapy (ledipasvir + sofosbuvir) at the very same time that cancer chemotherapy was being administered.
By the spring of 2016 with six cycles of treatment completed and the hepatitis C cured, the CEA had fallen to normal and the PET/CT was clear. The patient was referred to surgical colleagues for consideration of liver tumor resection at the same time as removal of the colon cancer primary.
The findings revealed no residual tumor in the colon and scant “atypical” cells in the liver. The patient recovered from surgery and returned in excellent physical condition.
We consolidated our success with several additional cycles of both antibodies combined with FOLFOX, the very same combination that had worked so well pre-op.
No Work Interruption & Great Results
Upon my visit with the patient recently I was reminded that he had suffered almost no side effects of the treatments and that he had continued his busy surgical practice throughout the entire course of therapy. But it was a review of his absolutely normal blood counts, blood chemistries, liver function tests, CEA (1.5), CA 19.9 (7) and most strikingly - normal PET/CT that has left a the lasting impact.
I manage many advanced cancers, but rarely do I see so good a response in metastatic colon cancer. The patient appears to have been exactly the right candidate for exactly the right treatment. Sensitive to FOLFOX he was potentiated by the EGFR inhibitor Erbitux and further potentiated by VEGF inhibitor Bevacizumab. Whether he is cured only time will tell, but his outcome speaks volumes for treating the right patient the right way the first time.
As always, I appreciate your thoughts and comments.