Transcript Metastatic Colorectal Carcinoma

COLORECTAL CANCER
Infusion
Reactions
INTRODUCTION
 Albert, 83M
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Retired fashion designer and entrepreneur
Presented to Cabrini Brighton for C6 chemotherapy
Metastatic CRC with liver met
FOLFOX6 regimen with good effect
HOPC
 Nov 2014
 U/S and CT-CAP revealed extensive metastatic disease involving
entire liver
 Suspected to be secondary to a previously resected sigmoid polyps
 Initial presentation
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Persistent nausea, anorexia and generalised weakness
Bowel symptoms of constipation
Weight loss 5kg
Denied symptoms of liver disease
Deranged LFT
HOPC
 Hx of colonic polyps
 Routine colonoscopy for many years
 Dec 2012
 Polypectomy with histopathology revealing adenocarcinoma
 Follow-up CT showed no evidence of nodal or distant metastasis
 Follow-up colonoscopy all clear
HOPC
 Referral to A/Prof. Gary Richardson
 Work-up
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PET scan – bowel and liver involvement
Tumour markers – CEA and CA19-9
Liver core biopsy – moderately differentiated adenocarcinoma
Colonoscopy + biopsy – recurrent adenocarcinoma
 CRC grade IVA
CHEMOTHERAPY
 FOLFOX6 regimen
 Oxaliplatin, Leucovorin, 5FU, Bevacizumab
 Serum CEA
 LFTs
 Side ef fects
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Fatigue – exercise tolerance and sleep
Bowel symptoms
GORD
Infusion reaction
Weight stable
Hypertension well controlled
Nil other significant chemo toxicity
PAST MEDICAL HISTORY
 Ongoing issues
 Hyperlipidaemia – on Lipitor
 IHD and hypertension – on Coversyl and Tenormin
 Inactive issues
 Gout – on prophylactic allopurinol
 AF – asymptomatic since 1999
 Meningioma – excised in 1997
 NKDA
SOCIAL HISTORY
 Lives at home with wife
 Breast cancer
 Previously IADL
 Golfed twice weekly, walked 18 holes
 Cleaner fortnightly
 Currently more fatigable
 Golf once a week, requires buggy
 Still gardens
 One daughter
 Lives nearby and helps
SUMMARY
 Albert 83M
 Currently C6 of FOLFOX6 regimen for metastatic CRC with liver met
 Has been progressing well on treatment with decline in serum CEA
and improvement in LFTs
 Has had relatively minor side effects from chemo
 But most recently had an infusion reaction that settled with anti histamines, and since have had oxaliplatin removed from regimen
ISSUES
1. Metastatic CRC with liver met
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Chemotherapy and post-chemo management
2. Medical management of IHD
3. Decline in function and exercise tolerance
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EP and OT assessment
4. Social issues
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Age
Assistance with ADL
INFUSION REACTION
INFUSION REACTION
 Definition
 An unexpected reaction that cannot be explained by the known
toxicity profile of the drug
 Virtually all chemotherapeutic agents have the potential to
initiate an infusion reaction
SIGNS AND SYPMTOMS
 Standard Infusion Reactions (SIRS)
 Cutaneous
 Flushing, itching, urticaria ± angioedema
 Respiratory
 Cough, nasal congestion, SOB, chest tightness, wheeze, hypoxia
 Cardiovascular
 Dizziness or syncope, tachycardia, hypotension, hypertension
 Gastrointestinal
 N/V, abdo pain and diarrhoea
 Neuromuscular
 Sense of impending doom, tunnel vision, dizziness, seizures, severe
back/chest/pelvic pain
 Anaphylaxis if more severe
TIMING AND RISK FACTORS
 Usually occurs during or within a few hours of drug infusion
 Occasionally one to two days after administration
 Infusion reactions found to be more common in these settings
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IV administration
After multiple cycles of certain agents
Prior infusion reactions to drug of same chemical class
History of multiple drug allergies
COMMONLY IMPLICATED AGENTS
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Taxanes
Platinum
Doxorubicin
L-asparaginase
Procarbazine
Etoposide
Bleomycin
Cytarabine
Ixabepilone
GRADE
MANAGEMENT OF SIR
 Immediate
 Symptomatic management ± resuscitation
 Rechallenge
 Reduced infusion rate
 Premedication
 Desensitisation techniques
OXALIPLATIN AND PLATINUM DRUGS
 Classic type 1 IgE-mediated allergic reaction
 Characterised by
 Pruritus, urticaria, bronchospasm, facial swelling and hypotension
 Abdominal pain, nausea, vomiting and diarrhoea are also relatively
common in platinum drug-induced anaphylaxis
 One study of 272 patients receiving oxaliplatin found 48
(18%)patients who developed infusion reaction despite
prevention regimen of famotidine and dexamethasone 3
 Another study suggested benefit from higher doses of
dexamethasone in conjunction with H1 and H2 receptor
blockers (7% vs. 20% reaction rate)