A CASE OF ADVANCED COLON CANCER Andrea Luciani MD, PhD U.O. Oncologia Medica Ospedale S. Paolo- Polo Universitario ASST Santi Paolo e Carlo Milan, Italy

I declare no Conflicts of Interests. Disclosure I declare no Conflicts of Interests.

Geriatric assessment Performace status 1 ADLs ok IADLs needs some help doing long distance walking MNA SF 10- Lost 10 Kg in two months MMSE: fine GDS 5 items: 1/5 Polypharmacy: Cardioaspirin; Amlodipine Comorbidities Hypertension Inguinal hernia Transient ischemic attack 2011: radical prostatectomy for adenocarcinoma. Gleason 3+4, pT2cp N0 Mxe : RT Familiarity: brother with a prostate cancer diagnosed at 79 years old, sister with uterine cancer at 70 years old

Sudden onset of hematochezia. Colonoscopy (20/09/2018): substonosis at descending colon due to 4 cm due to ulcerate mass. Actinic proctitis. In right colon 25 mm diameter mass with ulceration. Biopsy: lesion at right colon : tubular-villous adenoma with low grade dysplasia. Lesion at sigmoid colon: ulcerated adenocarcinoma. Molecular biology : mutation at exon 12 k-ras. B-RAF not mutated

BASAL CEA: 494 ng/ml

MDT: chemotherapy resection of T  chemotherapy  metastasectomy Started chemotherapy with FOLFOX4 regimen at full dosage After 2 cycles diarrea G2 and fatigue G3. Stop treatment for three weeks with full recovery of non-heme toxicity and improvement of fatigue (now G1)

The patient started 3° cycle of chemotherapy The patient started 3° cycle of chemotherapy. The doses were reduced by 25%. After one week access to day hospital for severe fatigue and sub occlusive symptoms Blood counts showed severe anemia (Hb 7,7 g/dL) The patient was admitted to the surgical department

Right colectomy + anterior resection of rectum Right colectomy + anterior resection of rectum. EI colonic adenocarcinoma G3 pT3N1b At day 7th after surgery onset of sepsis (pos for E Fecalis, P. Areuginosa e S. Anginosus) and diagnosis of rectal fistula Non further surgery was proposed. After one month of medical treatment the patient was discharged

Geriatric assessment 2 Performace status 1 ADLs needs some help dressing and bathing IADLs needs more help walking MNA SF 10- MMSE: fine GDS 5 items: 3/5 Starting chemotherapy with DeGramont-Bevacizumab. After the third cycle diagnosis of pulmonary embolism. Stop Bevacizumab start anticoagulation

RESTAGING AFTER 4 CYCLES: PARTIAL RESPONSE

Questions How would you classify the fitness level of the patient at diagnosis (GA1)? What do you think about the first MDT decision? How would you have dealt with the side effect diarrhea? What do you think about the surgical approach? How would you classify the fitness level of the patient at GA2? What treatment would you recommend at this stage?