colorectal cancer ( crc ) is one of most common cancers and leading causes of mortality in the usa , accounting for approximately 136,000 new cases and 50,000 deaths per year.1 for metastatic or unresectable crc , standard first- and second - line treatments typically involve a combination of cytotoxic chemotherapies ( eg , folfiri [ 5- fluorouracil + oxaliplatin + irinotecan])2,3 and molecular targeted agents ( eg , bevacizumab , cetuximab , panitumumab),46 which can help to improve progression - free survival and overall survival . however , due to the nature of the disease , many patients will progress through guideline - recommended standard regimens while maintaining a good performance status . regorafenib , an oral multikinase inhibitor , which targets angiogenic , stromal , and oncogenic receptor tyrosine kinases , was approved by the us food and drug administration in 2012 for the treatment of patients with metastatic crc who have been previously treated with fluoropyrimidine- , oxaliplatin- , and irinotecan - based chemotherapy , an anti  vascular endothelial growth factor ( vegf ) therapy and , if kras wild - type , an anti  epidermal growth factor receptor ( egfr ) therapy.7 this approval was based on the correct study , which demonstrated a median overall survival of 6.4 months with regorafenib vs 5.0 months with placebo ( hazard ratio , 0.77 ; 95% confidence interval , 0.640.94 ; p=0.0052).8 among the most common adverse effects were fatigue , hand a case of an elderly patient on regorafenib who achieved stable disease for over 11 months with strategic dose modifications was presented . no ethics approval was needed for the care of this patient as all treatments were in accordance with institutional best practices . verbal consent to appear in this case study was given by the patient to dr seery . a 73-year - old indian female with a past medical history of hypertension and hyper cholesterolemia the patient had no history of smoking , alcohol consumption , or any family history of cancer . the patient initially had symptoms of hemoptysis for approximately 2 weeks and then subsequently developed hematochezia for 3 days . due to these symptoms , the patient underwent a colonoscopy , which revealed left - sided colon cancer . a left hemicolectomy was performed ; pathology revealed a stage iiib well - differentiated , kras wild - type adenocarcinoma , with one out of 15 lymph nodes testing positive . the patient moved back to india and did not receive adjuvant chemotherapy due to patient preference . in march 2011 , the patient returned to the usa with complaints of mild abdominal distention , and a subsequent positron emission tomography / computed tomography ( pet / ct ) scan showed evidence of recurrence , with ovarian and peritoneal metastases . the patient began treatment with capecitabine , oxaliplatin , and bevacizumab , and developed an anaphylactic reaction in the sixth cycle . she continued with single - agent capecitabine for an additional two cycles and completed therapy in june 2011 as there was no further evidence of disease on the pet / ct scans . the patient did not receive any additional therapy until early 2012 when she was restaged and was again noted to have diffuse metastatic disease in the peritoneum , with imaging consistent with moderate to extensive carcinomatosis . the patient received cetuximab and folfiri from february 2012 through august 2012 and achieved an excellent response , with the pet / ct scan showing no evidence of measurable disease , with some minimal hypodensities in the liver that were not pet avid . the patient did well until april 2013 when she experienced increased abdominal distention , bloating , and difficulty with defecation . the patient received a repeat ct scan that showed progression of the disease , with a large pleural - based mass in the right lower lobe with bilateral pleural effusions , ascites , and multiple peritoneal implants , as well as omental infiltration along with a possible l3 lytic lesion . also , the patient s carcinoembryonic antigen ( cea ) values had increased to 23 . as a result , the patient was restarted on cetuximab and folfiri in may 2013 ; however , a pet / ct scan 2 months later revealed a mixed response , with persistent fluorodeoxyglucose - avid right pleural disease , but also some areas of decreased activity with stable nodal disease in the left axilla , retroperitoneum , and pelvis , and increased activity in the left inguinal and right retrocrural nodes . the patient continued with cetuximab and folfiri until august 2013 , and a repeat pet / ct scan in september 2013 revealed progressive disease in the right pleural mass along with increase in size of the retrocrural and left inguinal lymph nodes and liver ( figure 1a ) . the patient was started on regorafenib 160 mg daily on september 12 , 2013 , but required a treatment interruption due to hypertension with consistent systolic blood pressure readings in the range of 170 mm hg and diastolic blood pressure in the range of 100 mm hg , as well as grade 3 fatigue during cycle 1 . the patient was started on antihypertensive medications , and regorafenib was held for 2 weeks to resolve these adverse events . the dose was then reduced again due to grade 3 fatigue , and the patient s dose was stabilized at 80 mg daily . a repeat pet / ct scan in february 2014 showed a mixed response , with increased activity in non - target lesions noted in multiple omental , peritoneal , and pelvic lesions , but decreased activity in target lesions , specifically the thoracic and liver lesions , with new activity in the right tenth rib ( figure 1b ) . specifically , a right pleural - based mass had decreased from 27.6 mm to 26.7 mm , and standardized uptake value decreased from 14.4 to 3.4 in conjunction with a decrease in disease measuring from 58.0 mm to 43.6 mm in the central pelvic mesentery superior extending to the uterine fundus . the patient s cea decreased to 3.7 , while eastern cooperative oncology group ( ecog ) performance status improved from 2 to 1 , and treatment was therefore continued at 80 mg daily . the patient s most recent pet / ct scan in august 2014 showed frank progression of disease , with an increase in number and activity of multiple metastatic pulmonary and hepatic lesions along with increased activity in omental and mesenteric implants . as of august 2015 , the patient has been on regorafenib for 11 months with progression ; however , her ecog performance status remains at 1 , and she would like to continue taking the medication as she does not have any side effects and feels her quality of life has improved . verbal consent was obtained from the patient prior to her departing our facility for hospice care . the patient s identification has been protected and any information which could potentially be used to reveal the identity of the patient has been removed . we reported on a case of an elderly woman with kras wild - type , refractory metastatic colon cancer who has received multiple chemotherapy regimens , most recently regorafenib for 11 months with minimal side effects and palliation of symptoms . the report shows that regorafenib can provide a decrease in tumor burden and improve quality of life with prolonged survival if an appropriate dose is used in terms of balancing side effects with benefits of symptom palliation . moreover , the report shows that continuing therapy beyond disease progression is no longer an absolute contraindication . this case report additionally demonstrates that close and frequent follow - ups by the primary oncologist is needed in order to monitor side effects and to find the effective and tolerable dose . in the correct study , the frequency of adverse events was shown to peak during the first cycle and gradually taper off with subsequent cycles.8 this report suggests that regorafenib can be a viable option for patients who still have a good performance status and have progressed through other regimens . importantly , patient and financial support services are in place through the reach program to help patients manage the cost of this therapy .
regorafenib , an oral multikinase inhibitor , was approved in september 2012 by the us food and drug administration for the treatment of patients with metastatic colorectal cancer . since this time , 
 however , few case reports outlining real - world usage have been published in the literature . here , we detail the clinical history of an elderly woman with kras wild - type colon cancer who received regorafenib after prior treatment with other agents . 
 we show that by employing dose modification strategies to address adverse events , this patient was able to remain on therapy for 11 months and achieve stable disease .