Description

A 56-year-old man was diagnosed with rectal cancer, multiple lung and liver metastases, and paraaortic lymph node metastasis. He underwent a sigmoidoscopy and was treated with 10 courses of modified FOLFOX6 chemotherapy plus bevacizumab and three courses of FOLFIRI plus bevacizumab without any adverse skin effects. Because of RECIST progression of the disease with these treatments, the regimen was changed to FOLFIRI plus aflibercept. After two courses of the new regimen, the patient developed a skin ulcer around his stoma (figure 1). This was diagnosed as an adverse effect of aflibercept, and the regimen was changed to FOLFIRI alone. Although the ulcer was improving after 5 weeks, metastasis progressed. Therefore, we initiated FOLFIRI plus ramucirumab treatment. Skin ulceration did not occur with this regimen, and he was safely treated with effective chemotherapy again (figure 2).

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Figure 1

Skin ulceration after using aflibercept.

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Figure 2

Skin ulceration after changing to ramucirumab.

Skin ulceration around a stoma is a rare adverse effect of aflibercept.1 Although skin ulcers with bevacizumab have been reported, there has only been one report concerning ulcerations on an abdominal wound scar that was associated with aflibercept.2 These agents affect different vascular endothelial growth factor (VEGF) pathways: aflibercept inhibits VEGF-A, VEGF-B and placental growth factor; bevacizumab inhibits VEGF-A; and ramucirumab inhibits VEGF receptor-2 (VEGF-A, VEGF-C and VEGF-D binding).3

This may be the first report of skin ulceration around stoma associated with aflibercept. Appropriate care of the stoma and changing the treatment regimen should enable the continuation of effective chemotherapy combined with antiangiogenic agents.