43 M with Cirrhosis and a newly diagnosed rectal adenocarcinoma. Rectal cancer: Locally advanced -moderately to poorly differentiated adenocarcinoma, pMMR/MSI stable. - He was evaluated by surgical team and mass was thought to be unresectable. MRI pending. - S/p laparoscopic sigmoid colostomy creation and tunneled peritoneal catheter placement for recurrent ascites. Multiple paracentesis (x3) with negative cytology. - Also having perirectal abscess after surgery.Getting IVAbx. - CT AP, showed multiple enlarged lymph nodes in the retroperitoneum,? metastatic rectal cancer ?infection. - Clinical staging - T2-3, Nx Planned for Total neoadjuvant therapy with 5FU continuous chemoradiation with an assessment for resection after this. MRI Pelvis to evaluate staging purposes is pending. 1.) For the TNT, Does the sequence of matter? - CHEM+RT --> CHEMO or CHEMO --> CHEMO+RT? v 2.) Patient has Child Pugh B9 cirrhosis (Bili1.3, Alb 1.8, INR 1.3, Mod ascites). Is there any contraindication to FOLFOX?
Based on those labs and estimated degree of liver dysfunction, I would think the ascites is less likely malignant. Plus, with ascites enough to prompt a drain, I would have expected them to be able to see peritoneal disease if present at the time of surgery. No right answer for order of TNT. If you do chemo first followed by chemoRT, it is important to wait 8 weeks before reassessing response if you consider for non operative management to see the full response. For this reason, I think it is easier to start with chemoRT. Plus, I think the RT is less likely to cause issue with the cirrhosis as compared to the chemo alone. No definite dose changes of FOLFOX for liver dysfunction but I would not give the bolus to minimize cytopenias.