The Use of Lanreotide Autogel® in the Treatment of Intestinal Obstruction in a Patient with Adenocarcinoma
In January 2012, a 60-year-old woman presented with a 3-month history of increasing abdominal pain and a change in the stool pattern with a single episode of anal red blood loss in the past week. She had a medical history of hypercholesterolemia and had previously undergone appendectomy. An ultrasound of the abdomen showed several masses dispersed over the peritoneum, compatible with significant peritoneal metastasis. Diffuse ascites fluid was also noted and could not be tapped. Clinical examination and auscultation showed a slightly enlarged abdomen with good peristalsis of the intestine. No clangor was noted. Colonoscopy revealed a large ulcerating lesion at the level of the sigmoid colon, which was diagnosed as a moderately differentiated adenocarcinoma after biopsy.\nNo surgery was performed due to the presence of peritoneal carcinomatosis. Chemotherapy with 18 biweekly cycles (1 cycle every 2 weeks) of FOLFIRI and bevacizumab (Avastin®, Roche) was started. FOLFIRI was administered according to the following schedule: day 1, irinotecan 180 mg/m2; days 1 and 2, leucovorin 100 mg/m2, 5-fluorouracil bolus 400 mg/m2 and 5-fluorouracil infusion 600 mg/m2. Avastin was given at a dose of 5 mg/kg every 2 weeks. If the patient had responded to this treatment, the possibility of performing debulking surgery and hyperthermic intraperitoneal chemotherapy would have been considered. The abdominal pain disappeared after the first month of chemotherapy, while the ascites disappeared after 6 weeks. There was also a slight regression of the peritoneal masses.\nDuring the 5th, 6th and 7th cycle of chemotherapy, the patient was hospitalized because of clinical signs of intestinal subocclusion (vomiting, absence of stools and flatus) that evolved into complete obstruction. A CT scan of the abdomen did not reveal the cause of the obstruction or deterioration of the oncological lesions. Based on this observation, a FOLFIRI-induced mucositis, motility disturbances due to peritoneal metastasis or a combination of these two factors were suspected. During hospitalization, fluids, alizapride (Litican®, 300 mg/day; Sanofi-Aventis) and methylprednisolone sodium succinate (Solu-Medrol®, 40 mg/day; Pfizer Inc.) were administered intravenously, paracetamol (1 g/dose) was administered intravenously 4 times a day and octreotide (Sandostatin®, 0.5 mg/dose; Novartis) was administered subcutaneously 3 times a day until the obstruction resolved. Oral consumption of food and fluids was withheld, and a nasogastric tube was placed. At each of the 3 hospitalization episodes, an enema was performed. After the first episode of obstruction, the dose of FOLFIRI was decreased to 75%, while the dose of Avastin was not decreased. All episodes of obstruction resolved after 3 days, and the chemotherapy was reintroduced after 1–2 weeks following resolution of the obstruction. After the third episode of obstruction, we initiated treatment with lanreotide Autogel 120 mg, injected deep subcutaneously once every 4 weeks. The 120-mg dose was chosen based on our experience that the 90-mg dose has a lower efficacy. The treatment with lanreotide Autogel continued during the remaining 11 cycles of chemotherapy, and no further episodes of intestinal subocclusion or obstruction occurred.\nBecause tumor response following the 18 cycles of chemotherapy was not sufficient, debulking surgery or hyperthermic intraperitoneal chemotherapy treatment were not recommended. After a 3-month break in the chemotherapy treatment requested by the patient, a second-line chemotherapy course was initiated. Lanreotide Autogel administration was continued during this treatment break. The patient is currently undergoing second-line chemotherapy with FOLFOX4 at 75% of the usual dose, administered once every 2 weeks in 12 cycles according to the following schedule: day 1, oxaliplatin 85 mg/m2 at 75%; days 1 and 2, 75% of leucovorin 100 mg/m2, 5-fluorouracil bolus 400 mg/m2 and 5-fluorouracil infusion 600 mg/m2. The 4-weekly lanreotide Autogel injections have been continued without interruption to support the quality of life of the patient. No new episodes of obstruction occurred until November 2013, and the patient reported no side effects due to lanreotide Autogel.