What is the best course of action for a adult patient with a history of colon (colorectal) cancer, currently on FOLFOX (fluorouracil, oxaliplatin, leucovorin) chemotherapy, who presents with pain and a peripherally located hematoma 2 months after a fall?

Management of Peripheral Hematoma in a Colon Cancer Patient on FOLFOX

Stop FOLFOX immediately and do not resume oxaliplatin-containing chemotherapy until the hematoma is fully resolved and coagulation parameters are normalized. 1

Understanding the Clinical Scenario

This patient presents with a delayed complication from trauma occurring 2 months prior while actively receiving oxaliplatin-based chemotherapy. The key concern is whether FOLFOX contributed to hematoma formation or impaired resolution through:

• Thrombocytopenia: FOLFOX causes grade 3-4 thrombocytopenia in approximately 1-2% of patients, which can impair hemostasis and allow spontaneous or trauma-related bleeding 2
• Platelet dysfunction: Even with normal platelet counts, oxaliplatin can impair platelet aggregation 1
• Vascular fragility: Oxaliplatin-induced peripheral neuropathy (occurring in 81-85% of patients) may have contributed to the initial fall through gait disturbance 1, 2

Immediate Management Steps

Assess Bleeding Risk and Coagulation Status

• Obtain complete blood count with platelet count, PT/INR, and aPTT to identify thrombocytopenia or coagulopathy 1
• Check for active expansion of the hematoma on CT imaging by comparing size to any prior studies or clinical measurements 1
• Evaluate for compartment syndrome if the hematoma is in an extremity (measure compartment pressures if clinical suspicion exists) 1

Determine if Surgical Intervention is Needed

• Surgical evacuation is indicated if there is compartment syndrome, neurovascular compromise, or significant functional impairment from mass effect 1
• Conservative management with observation is appropriate for stable, non-expanding hematomas without neurovascular compromise 1

Chemotherapy Management Decisions

Holding FOLFOX

Do not administer the next scheduled FOLFOX cycle until:

• The hematoma shows clear signs of resolution on repeat imaging 1
• Platelet count is >100,000/μL and coagulation parameters are normal 1
• There is no evidence of ongoing bleeding or hematoma expansion 1

Modifying Future Chemotherapy

When resuming chemotherapy after hematoma resolution:

• Discontinue oxaliplatin permanently and continue with 5-FU/leucovorin alone if the patient has already completed 3 months (6 cycles) of FOLFOX, as oxaliplatin beyond this duration provides no survival benefit but increases cumulative neurotoxicity 1, 3
• Reduce oxaliplatin dose by 25% if resuming before completing 3 months of therapy and the patient had grade 3-4 thrombocytopenia 1
• Consider switching to single-agent capecitabine or 5-FU/leucovorin if thrombocytopenia was the primary contributor to hematoma formation 1, 4

Assessing Neuropathy as a Fall Risk Factor

Evaluate for oxaliplatin-induced peripheral neuropathy (CIPN) that may have caused the initial fall:

• Grade 3 peripheral sensory neuropathy (occurring in 13.4% of FOLFOX patients) causes gait disturbance and significantly increases fall risk 2
• Persistent grade 3 neuropathy remains in approximately 27% of affected patients even after treatment completion 2
• If grade 2 or higher persistent neuropathy is present, discontinue oxaliplatin permanently and continue only 5-FU/leucovorin, as further oxaliplatin will worsen neuropathy without improving survival 1, 3

Determining Total Duration of Adjuvant Therapy

The patient has completed 12 cycles (6 months) of FOLFOX, which is the standard duration for adjuvant colon cancer treatment 1, 3:

• No additional chemotherapy is indicated if the patient has completed 6 months of adjuvant FOLFOX for stage III colon cancer 1, 3
• If treatment was interrupted and <6 months total was received, complete the remaining duration with 5-FU/leucovorin alone (without oxaliplatin) after hematoma resolution 1, 3

Critical Pitfalls to Avoid

• Do not resume oxaliplatin if the patient has grade 2 or higher persistent neuropathy, as this significantly impairs quality of life and increases fall risk without survival benefit 1, 3
• Do not ignore thrombocytopenia as a potential contributor to delayed hematoma formation, even if the fall occurred 2 months prior 1, 2
• Do not continue oxaliplatin beyond 3 months (6 cycles) in any setting due to cumulative neurotoxicity without additional efficacy 1, 3
• Do not administer bevacizumab if considering its addition, as it requires 6-8 weeks clearance before any surgical intervention for hematoma evacuation due to wound healing complications 3

Surveillance After Treatment Completion

Once chemotherapy is completed and the hematoma has resolved:

• CEA every 3 months for 2 years, then every 6 months for years 3-5 1
• CT chest/abdomen/pelvis every 3-6 months for 2 years, then every 6-12 months up to 5 years 1, 5
• Colonoscopy at 1 year (or 3-6 months if no preoperative colonoscopy was performed due to obstruction) 1, 5