Targeted Therapies in MCRC - optimum time for surgery

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

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 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????

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.