Targeted Therapies in MCRC - optimum time for surgery

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peterz54
peterz54 Member Posts: 341
edited March 2012 in Colorectal Cancer #1
I just reviewed the following slide show given April 2011. One of the takeaways for me is that for Stage IV crc the optimum time for liver sugery is after about the 6th treatment. This is in part to prevent toxicity to liver from too much chemo. My wife's ONC has her scheduled for 12 treatments, after which the plan is to PET scan and evaluate for options which include surgery.

Does anyone have an opinion about the best time for surgery based on experience?

Presentation

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  • mom_2_3
    mom_2_3 Member Posts: 953 Member
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    Peter
    Peter (assuming....),

    The first oncologist we met with told us the plan would be to give me 12 treatments of Folfox and Avastin and then I would re-scan. For a number of reasons we decided to get a second opinion at Memorial Sloan Kettering in NYC. The oncologist I met with there presented me with the following scenario. I would do 4 treatments of Folfox only and then scan.

    If I had a great response to chemo I would have an immediate liver resection and colon resection and I would have an HAI pump implanted to deliver chemo directly to the liver in hopes of preventing recurrence.

    If I had a good response to chemo I would do another 4 treatments and scan again.

    If I had no response to chemo I would have a surgical implantation of an HAI pump and hopefully be operable in the future due to delivery of concentrated chemo to my liver. I started with mets across both lobes of my liver, the largest being 5 cm.

    After 4 treatments I had a scan which indicated all mets had shrunk by 40%. (I actually reviewed the scans after the CT and calculated the percentage of shrinkage and my husband thought I was nuts and asked if I fancied myself a radiologist. Imagine my glee when the radiology report matched my calculation exactly!). My doctor said it had been a great response and I was scheduled for surgery, to be done 11 days later. The day I saw her for results I had my fifth treatment so it was 11 days between chemo and surgery. She had withheld Avastin as I would have had to wait longer to have the surgery.

    I had the surgery as described with the addition of the removal of my gallbladder. I was back on chemo 4 weeks after surgery and continued both systemic and HAI chemo for 8 months. I have been NED 2 yrs and 8 months and off treatment since Nov 2009.

    My doctor told me at the time of consult that 12 weeks was way too long to go with a particular treatment without knowing how well it was working. She also didn't want to miss a window of operability. My liver surgeon also remarked that my liver was started to show some stenosis from treatment so we are glad I was able to have surgery when I did. My AST and ALT have run a bit high since.

    If I were in hour position I would certainly consult for a second opinion. I do not know where your wife is looking to start treatment but an NCI facility is highly recommended. My husband and I chat sometimes about the first doctor and whether I would have had the same result if I had sought treatment at that first hospital. That doctor seemed ok and bright but he was pessimistic about my chances and told me I would have 22-24 months to live. But this oncologist treated breast, prostate, colon, liver, and brain cancers as well as lymphomas and leukemias (as well as other cancers). We didn't feel then and I still don't believe he had the expertise to treat my colon cancer like my current doctor who ONLY treats Stage IV colon (can't get an appointment with her if one is Stage 3 or below).

    I hope this helps you. You or your wife can always pm me and I will give my email or cell if you would ever like to chat. All the best to you and your family.

    Amy
  • Buckwirth
    Buckwirth Member Posts: 1,258 Member
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    mom_2_3 said:

    Peter
    Peter (assuming....),

    The first oncologist we met with told us the plan would be to give me 12 treatments of Folfox and Avastin and then I would re-scan. For a number of reasons we decided to get a second opinion at Memorial Sloan Kettering in NYC. The oncologist I met with there presented me with the following scenario. I would do 4 treatments of Folfox only and then scan.

    If I had a great response to chemo I would have an immediate liver resection and colon resection and I would have an HAI pump implanted to deliver chemo directly to the liver in hopes of preventing recurrence.

    If I had a good response to chemo I would do another 4 treatments and scan again.

    If I had no response to chemo I would have a surgical implantation of an HAI pump and hopefully be operable in the future due to delivery of concentrated chemo to my liver. I started with mets across both lobes of my liver, the largest being 5 cm.

    After 4 treatments I had a scan which indicated all mets had shrunk by 40%. (I actually reviewed the scans after the CT and calculated the percentage of shrinkage and my husband thought I was nuts and asked if I fancied myself a radiologist. Imagine my glee when the radiology report matched my calculation exactly!). My doctor said it had been a great response and I was scheduled for surgery, to be done 11 days later. The day I saw her for results I had my fifth treatment so it was 11 days between chemo and surgery. She had withheld Avastin as I would have had to wait longer to have the surgery.

    I had the surgery as described with the addition of the removal of my gallbladder. I was back on chemo 4 weeks after surgery and continued both systemic and HAI chemo for 8 months. I have been NED 2 yrs and 8 months and off treatment since Nov 2009.

    My doctor told me at the time of consult that 12 weeks was way too long to go with a particular treatment without knowing how well it was working. She also didn't want to miss a window of operability. My liver surgeon also remarked that my liver was started to show some stenosis from treatment so we are glad I was able to have surgery when I did. My AST and ALT have run a bit high since.

    If I were in hour position I would certainly consult for a second opinion. I do not know where your wife is looking to start treatment but an NCI facility is highly recommended. My husband and I chat sometimes about the first doctor and whether I would have had the same result if I had sought treatment at that first hospital. That doctor seemed ok and bright but he was pessimistic about my chances and told me I would have 22-24 months to live. But this oncologist treated breast, prostate, colon, liver, and brain cancers as well as lymphomas and leukemias (as well as other cancers). We didn't feel then and I still don't believe he had the expertise to treat my colon cancer like my current doctor who ONLY treats Stage IV colon (can't get an appointment with her if one is Stage 3 or below).

    I hope this helps you. You or your wife can always pm me and I will give my email or cell if you would ever like to chat. All the best to you and your family.

    Amy

    And the Moral of the Story is:
    Get thee to a cancer center!

    NCI Cancer Centers

    If there is not one close by don't despair, there are numerous programs to assist, including air transportation and hotel discounts. If traveling there for treatment is a challenge they can create a plan and you can do treatments nearer to home with an oncologist who will follow that plan.

    There could also be a promising trial, which comes with free medical care!

    Btw, I get scans every four months.

    Blake
  • jasminsaba
    jasminsaba Member Posts: 157 Member
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    mom_2_3 said:

    Peter
    Peter (assuming....),

    The first oncologist we met with told us the plan would be to give me 12 treatments of Folfox and Avastin and then I would re-scan. For a number of reasons we decided to get a second opinion at Memorial Sloan Kettering in NYC. The oncologist I met with there presented me with the following scenario. I would do 4 treatments of Folfox only and then scan.

    If I had a great response to chemo I would have an immediate liver resection and colon resection and I would have an HAI pump implanted to deliver chemo directly to the liver in hopes of preventing recurrence.

    If I had a good response to chemo I would do another 4 treatments and scan again.

    If I had no response to chemo I would have a surgical implantation of an HAI pump and hopefully be operable in the future due to delivery of concentrated chemo to my liver. I started with mets across both lobes of my liver, the largest being 5 cm.

    After 4 treatments I had a scan which indicated all mets had shrunk by 40%. (I actually reviewed the scans after the CT and calculated the percentage of shrinkage and my husband thought I was nuts and asked if I fancied myself a radiologist. Imagine my glee when the radiology report matched my calculation exactly!). My doctor said it had been a great response and I was scheduled for surgery, to be done 11 days later. The day I saw her for results I had my fifth treatment so it was 11 days between chemo and surgery. She had withheld Avastin as I would have had to wait longer to have the surgery.

    I had the surgery as described with the addition of the removal of my gallbladder. I was back on chemo 4 weeks after surgery and continued both systemic and HAI chemo for 8 months. I have been NED 2 yrs and 8 months and off treatment since Nov 2009.

    My doctor told me at the time of consult that 12 weeks was way too long to go with a particular treatment without knowing how well it was working. She also didn't want to miss a window of operability. My liver surgeon also remarked that my liver was started to show some stenosis from treatment so we are glad I was able to have surgery when I did. My AST and ALT have run a bit high since.

    If I were in hour position I would certainly consult for a second opinion. I do not know where your wife is looking to start treatment but an NCI facility is highly recommended. My husband and I chat sometimes about the first doctor and whether I would have had the same result if I had sought treatment at that first hospital. That doctor seemed ok and bright but he was pessimistic about my chances and told me I would have 22-24 months to live. But this oncologist treated breast, prostate, colon, liver, and brain cancers as well as lymphomas and leukemias (as well as other cancers). We didn't feel then and I still don't believe he had the expertise to treat my colon cancer like my current doctor who ONLY treats Stage IV colon (can't get an appointment with her if one is Stage 3 or below).

    I hope this helps you. You or your wife can always pm me and I will give my email or cell if you would ever like to chat. All the best to you and your family.

    Amy

    Quick question Amy ...
    Hi Amy - good luck with your upcoming scan ... praying and wishing for clear scans and continuing good health for you.

    I had a quick question about your great response to chemo - did you actually have any of your 5 lesions disappear with the induction chemo (4 sessions prior to surgery)?

    My understanding is that you were under the care of the famous Dr. K at MSK and wondered what her thoughts were/are/may have been on disappearing lesions.

    Thanks for your time.
  • mom_2_3
    mom_2_3 Member Posts: 953 Member
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    Quick question Amy ...
    Hi Amy - good luck with your upcoming scan ... praying and wishing for clear scans and continuing good health for you.

    I had a quick question about your great response to chemo - did you actually have any of your 5 lesions disappear with the induction chemo (4 sessions prior to surgery)?

    My understanding is that you were under the care of the famous Dr. K at MSK and wondered what her thoughts were/are/may have been on disappearing lesions.

    Thanks for your time.

    Jasminsaba
    Thank you for your good wishes. Keeping all parts of my body crossed!!

    None of the 5 lesions actually disappeared. The smallest were approximately 1 cm to start and shrunk down to 1/2 cm. I asked my surgeon if he thought I would have had a complete response to chemo if we had done another 4-8 rounds prior to surgery. He said it was possible but it wouldn't mean anything to him as he would still want to resect all areas where former mets had been, using previous scans if necessary. The pathology on the the largest mets was 70% and 90% necrotic. I have read that complete response to chemo is a good prognostic factor.

    Yes, I am under the care of the (in)famous Dr. K. She is fantastic! We never had a discussion about disappearing lesions. I see her on Monday, however, so if I get good news I will use my 4 minutes (joke...) of her time to ask her what we would have done if complete response had been achieved. I know of a couple of other patients there that had "disappearing" mets and they all went on to have liver resections. I think she is a proponent of "get it out." But, I will check and get back to you with her response. I asked her (after achieving remission and completing chemo) whether I should/could enroll in a vaccine trial at Johns Hopkins and she was very to the point. "No." Maybe I can get a more detailed response for your question! ;)


    All the best to you!!
    Amy
  • PhillieG
    PhillieG Member Posts: 4,866 Member
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    mom_2_3 said:

    Jasminsaba
    Thank you for your good wishes. Keeping all parts of my body crossed!!

    None of the 5 lesions actually disappeared. The smallest were approximately 1 cm to start and shrunk down to 1/2 cm. I asked my surgeon if he thought I would have had a complete response to chemo if we had done another 4-8 rounds prior to surgery. He said it was possible but it wouldn't mean anything to him as he would still want to resect all areas where former mets had been, using previous scans if necessary. The pathology on the the largest mets was 70% and 90% necrotic. I have read that complete response to chemo is a good prognostic factor.

    Yes, I am under the care of the (in)famous Dr. K. She is fantastic! We never had a discussion about disappearing lesions. I see her on Monday, however, so if I get good news I will use my 4 minutes (joke...) of her time to ask her what we would have done if complete response had been achieved. I know of a couple of other patients there that had "disappearing" mets and they all went on to have liver resections. I think she is a proponent of "get it out." But, I will check and get back to you with her response. I asked her (after achieving remission and completing chemo) whether I should/could enroll in a vaccine trial at Johns Hopkins and she was very to the point. "No." Maybe I can get a more detailed response for your question! ;)


    All the best to you!!
    Amy

    WOW
    You get 4 minutes????
  • PhillieG
    PhillieG Member Posts: 4,866 Member
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    When if the Optimum Time for Surgery
    Around noon-ish, on a Tuesday..
    Hi Peter, I too am under Dr K's care at Sloan Kettering. I did 6 months (12 treatments) of FOLFOX and 5 months (10 treatments) of Avastin. That was because Avastin came out 1 month after I was diagnosed back in Feb 2004.
    I was fortunate to have the chemo/Avastin work and it shrunk the large tumor on my hepatic artery enough so I could have surgery. Afterwards, I was treated with an HAI pump that gave targeted chemo directly to the liver along with systemic chemo.

    I don't know if there is a "Best time" for surgery that fits everyone. Each case is unique, just like we are....
    My best to your wife and to you
    -p
  • jasminsaba
    jasminsaba Member Posts: 157 Member
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    mom_2_3 said:

    Jasminsaba
    Thank you for your good wishes. Keeping all parts of my body crossed!!

    None of the 5 lesions actually disappeared. The smallest were approximately 1 cm to start and shrunk down to 1/2 cm. I asked my surgeon if he thought I would have had a complete response to chemo if we had done another 4-8 rounds prior to surgery. He said it was possible but it wouldn't mean anything to him as he would still want to resect all areas where former mets had been, using previous scans if necessary. The pathology on the the largest mets was 70% and 90% necrotic. I have read that complete response to chemo is a good prognostic factor.

    Yes, I am under the care of the (in)famous Dr. K. She is fantastic! We never had a discussion about disappearing lesions. I see her on Monday, however, so if I get good news I will use my 4 minutes (joke...) of her time to ask her what we would have done if complete response had been achieved. I know of a couple of other patients there that had "disappearing" mets and they all went on to have liver resections. I think she is a proponent of "get it out." But, I will check and get back to you with her response. I asked her (after achieving remission and completing chemo) whether I should/could enroll in a vaccine trial at Johns Hopkins and she was very to the point. "No." Maybe I can get a more detailed response for your question! ;)


    All the best to you!!
    Amy

    Thank you, Amy.
    I'm praying that you'll get your good news on Monday ... and maybe even the info for my regarding disappearing lesions =)I kid, I kid.

    You're definitely in my prayers for clear scans and I am looking forward to your positive report.

    Thanks for taking time to respond to my question ... J.