No chemo after liver resection?!

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NeVadasMitis
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Joined: Thu Feb 02, 2017 3:34 pm

No chemo after liver resection?!

Postby NeVadasMitis » Tue Mar 28, 2017 3:10 pm

Well, I've just received a bit of a surprise. My dad went for his liver resection post-op appointment today. He is doing fine: liver and abdomen good. Still a thingy on his lung, but it's only slightly bigger than at Christmas. The bit I wasn't expecting is that his oncologist (who is a respected oncologist, very involved in immunotherapy research, knows what he's doing, etc.) is not recommending chemo, at least not for now. We had thought there would be chemo for sure, if not to prevent recurrence in the liver, then at least to "mop up" any micrometastases that might be floating around. Not sure what to make of this recommendation. He says that the research does not show a convincing positive relationship between post-op chemo and longer survival, so he doesn't recommend it.

Is anyone else following this path of liver resection without the chemo security blanket chaser? :shock:
DD dx Dec.2012, age 57, Stage I CRC
2013/01 complicated resection
2016 summer/fall CEA slowing rising...(2.1, 2.8, 3.1)
2016/12 scan shows "something" on RL of liver; fna biopsy ordered
2017/01 confirmed 1 met to liver (1.5x2 cm); Stage IVa; cea 3.1
2017/02 5mm node on lung
2017/03 liver resection
2017/05 wedge resection of lung node
2017/09 CEA rising....5.6, 8.9...
2017/12 pet confirms cancer is back in hepatic lymph node

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CRguy
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Re: No chemo after liver resection?!

Postby CRguy » Tue Mar 28, 2017 4:25 pm

Not liver, BUTT lung met : ... I was given the option of chemo or no chemo, as "pseudoadjuvant" chemo was considered controversial.
My Onc recc'd the chemo so I did FOLFOX having only had Xeloda twice previously.

That was in 2010 and I am still here ..... so who knows ?
The more experience Oncs have with the chemo / no chemo options ... the more refined their suggestions become and with the amazing new options for treatments ( POG, Immuno, "vaccine" etc. ) I am sure there is a heckofa lot more refining to be done.

I chose chemo because I wanted to be sure I had thrown everything I could at the beast !

JMO

Cheers and best wishes to your Dad as well
CRguy
Caregiver x 4
Stage IV A rectal cancer/lung met
17 Year survivor
my life is an ongoing totally randomized UNcontrolled experiment with N=1 !
Review of my Journey so far

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dianetavegia
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Re: No chemo after liver resection?!

Postby dianetavegia » Tue Mar 28, 2017 5:21 pm

No studies have shown chemo to help with prevention of recurrence after a successful hepatic resection as long as the surgeon got clear margins.

Chemo is poison. The less we take, the better. Someone once said, 'Save it in case you need it later'.

I had NO chemo after my liver resection 5 years ago on April 11th.

Diane
Stage III cc surgery 1/7/09. 12 tx FOLFOX
Stage IV PET = 1.5cm liver met. HR 4/11/12

14 years since dx and 11 years post liver resection.
Pronounced CURED and discharged by onc

“O Lord my God, I cried out to You, And You healed me.” Psalms 30:2

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CRguy
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Re: No chemo after liver resection?!

Postby CRguy » Tue Mar 28, 2017 6:31 pm

dianetavegia wrote: Someone once said, 'Save it in case you need it later'.

...AND coming over from your other topic Diane,
MAKE SURE SOMEONE KEEPS LOOKING FOR YOU ... or it won't matter :twisted:
Caregiver x 4
Stage IV A rectal cancer/lung met
17 Year survivor
my life is an ongoing totally randomized UNcontrolled experiment with N=1 !
Review of my Journey so far

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MikeManess
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Location: Forney, Texas

Re: No chemo after liver resection?!

Postby MikeManess » Tue Mar 28, 2017 9:14 pm

I had liver surgery in December to remove two spots from my liver. Fortunately, the chemo killed everything and the pathology report said there was no active cancer in the liver wedges. That being said, my oncologist has me on mop-up chemo for at least 6 months, tomorrow will be my 6th round of mop-up.

There are two thoughts in my mind about this. First is that I want to kill anything floating around in me. Butt 2nd thought is that I don't want to become resistant to chemo in case I need it later. However, my oncologist has gotten me this far, so I'm willing to follow his recommendation and continue chemo. I should mention that my CEA level is rising since surgery, although the scans are clear.
3/11/16 Colonoscopy - 9 benign polyps, 1 large cancerous tumor in right ascending colon
4/19/16 Right colectomy
6/3/16 Two liver spots detected, added Avastin to Folfox
12/20/16 Liver surgery. Pathology shows no active cancer cells
6/7/17 Final chemo
12/5/17 Port removed
05/23/18 Liver tumor discovered in scans
04/04/19 Radiation treatment
08/15/19 Additional radiation treatment
08/21/19 NED again

NeVadasMitis
Posts: 20
Joined: Thu Feb 02, 2017 3:34 pm

Re: No chemo after liver resection?!

Postby NeVadasMitis » Tue Mar 28, 2017 9:32 pm

Thanks for sharing your thoughts and experiences. It's good to know it's not unheard of to NOT follow up with chemo, and maybe even a good thing to still have it unused in the arsenal it in case it is needed down the road.

Instead of freaking out about possible micromets, I will try to focus on the fact that the margins were good enough that this is the recommended course of action.

:)
DD dx Dec.2012, age 57, Stage I CRC
2013/01 complicated resection
2016 summer/fall CEA slowing rising...(2.1, 2.8, 3.1)
2016/12 scan shows "something" on RL of liver; fna biopsy ordered
2017/01 confirmed 1 met to liver (1.5x2 cm); Stage IVa; cea 3.1
2017/02 5mm node on lung
2017/03 liver resection
2017/05 wedge resection of lung node
2017/09 CEA rising....5.6, 8.9...
2017/12 pet confirms cancer is back in hepatic lymph node

stu
Posts: 1613
Joined: Sat Aug 17, 2013 5:46 pm

Re: No chemo after liver resection?!

Postby stu » Wed Mar 29, 2017 8:48 am

Hi,
My mum has never used post op chemo. Her liver has been clear for six years. She is over a year for her lung and scanning well . She balances quality with need. If she has active disease and needs surgery , she takes it. It there is no visible disease she takes it. :D The other thing we pay attention to is the speed of growth.Her liver mets grew quickly and the lung slowly so she is also open to flexible approaches.
I wish you all the best,
Stu
supporter to my mum who lives a great life despite a difficult diagnosis
stage4 2009 significant spread to liver
2010 colon /liver resection
chemo following recurrence
73% of liver removed
enjoying life treatment free
2016 lung resection
Oct 2017 nice clear scan . Two lung nodules disappeared
Oct 2018. Another clear scan .

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dianetavegia
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Re: No chemo after liver resection?!

Postby dianetavegia » Wed Mar 29, 2017 8:51 am

CRGuy, not to worry! If I have to change doctors I will, but I plan to stay on top of this!

Waiting for the CEA and Chest CT are causing major anxiety last night and this a.m. The results can take a few days to be posted.
Stage III cc surgery 1/7/09. 12 tx FOLFOX
Stage IV PET = 1.5cm liver met. HR 4/11/12

14 years since dx and 11 years post liver resection.
Pronounced CURED and discharged by onc

“O Lord my God, I cried out to You, And You healed me.” Psalms 30:2

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LPL
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Location: Europe

Re: No chemo after liver resection?!

Postby LPL » Wed Mar 29, 2017 9:47 am

Diane wrote:
No studies have shown chemo to help with prevention of recurrence after a successful hepatic resection as long as the surgeon got clear margins.

Maybe I misunderstand.. You say "prevention of recurrence" and not overall survival.
To me it looks like the following study showed that for some (high risk score) patients adjuvant chemotherapy is benefitial. Quote: " It improved survival markedly in high-risk patients"

From (2014) http://bmccancer.biomedcentral.com/arti ... 407-14-174
" A total of 297 patients with potentially curative resection of CRC liver metastases were analyzed. These patients had no neoadjuvant therapy, no extrahepatic disease and negative resection margins. The primary endpoint was overall survival. Patients’ risk status was evaluated using the Memorial Sloan-Kettering Cancer Center clinical risk score (MSKCC-CRS). Multivariable analyses were performed using Cox proportional hazard models.
Results
A total of 137 (43%) patients had a MSKCC-CRS > 2. Adjuvant chemotherapy was administered to 116 (37%) patients. Patients who received adjuvant chemotherapy were of younger age (p = 0.03) with no significant difference in the presence of multiple metastases (p = 0.72) or bilobar metastases (p = 0.08). On multivariate analysis adjuvant chemotherapy was associated with improved survival in the entire cohort (Hazard ratio 0.69; 95% confidence interval 0.69–0.98). It improved survival markedly in high-risk patients with a MSKCC-CRS > 2 (HR 0.40; 95% CI 0.23–0.69), whereas it was of no benefit in patients with a MSKCC-CRS ≤ 2 (HR 0.90; 95% CI 0.57–1.43)."

On the other hand - in This Review paper from 2016 https://www.ncbi.nlm.nih.gov/pmc/articl ... rt=classic they say this: " The management of CRC patients after surgical resection of metastases is still debated. In these patients, the current international guidelines recommend an adjuvant strategy for 6 mo: postoperative adjuvant chemotherapy or peri-operative chemotherapy (3 mo before surgery and 3 mo after surgery)[3,5]. However, there is no standard treatment and the effective role of systemic adjuvant chemotherapy remains controversial."

When my DH was diagnosed I believe that these were the guidelines (in Europe). From (2014) http://www.esmo.org/Guidelines/Gastroin ... tal-Cancer
" There are two potential strategies for (neo-)adjuvant therapy in patients with resectable liver metastases: postoperative adjuvant chemotherapy with FOLFOX for 6 months or perioperative chemotherapy (3 months before and 3 months after resection of the metastases). In patients with resectable liver metastases, perioperative combination chemotherapy with the FOLFOX regimen improves the PFS by 7%–8% at 3 years, although the survival is not significantly longer [I, B] [52, 53]. The trials of modern postoperative adjuvant chemotherapy have many shortcomings, but it is suggested that an oxaliplatin-based chemotherapy for 6 months after resection of metastases improves the outcome, unless patients were failing an adjuvant treatment (oxaliplatin-based) for stage II or III diseases within 12 months. However, there are no data from randomised trials available to support this approach. The selection of perioperative chemotherapy or postoperative adjuvant chemotherapy may be influenced by the biology of the disease, the timing of metastases (synchronous versus metachronous) or the number and size of metastases. There is no evidence that adding a biological to a cytotoxic doublet improves the outcome in resectable metastases compared with a cytotoxic doublet alone in combination with resection of the metastases [51, 52, 57–60]. Recent data even suggest that the addition of cetuximab to FOLFOX may be harmful to patients with resectable metastases [II, D] [62]. " ... " In patients presenting synchronously with a primary colon cancer and metastases and suffering from symptoms of the primary tumour (e.g. occlusion and bleeding), a resection of the primary tumour should be considered before starting chemotherapy. In patients with metastatic rectal cancer with symptoms of the primary tumour, irradiation (possibly combined with chemotherapy) of the primary tumour should be considered after discussion with the radiation oncologist in order to obtain optimal symptom control of the primary tumour [51]."

It is the same text in the 2016 patient info version from ESMO (= EUROPEAN SOCIETY FOR MEDICAL ONCOLOGY )
http://www.esmo.org/content/download/15 ... tients.pdf
"For patients who present liver and/or lung metastases* that can be operatively removed, the treatment consists of surgical resection of the metastases* and combination chemotherapy*. Chemotherapy* consists of a 6-month regimen of 5-FU/LV with oxaliplatin* (FOLFOX). FOLFOX can be given either perioperatively, meaning that it is given for 3 months before and for 3 months after surgery or, after the operation, for 6 months. "

However - The new 2016 Europian guidelines, (ESMO - for Professionals) are not that easy to interpret - maybe it has changed? At least it looks like they divide resectable patients in to many groups (see under headline 'liver metastases that are technically resectable up front') for example: " In patients with favourable oncological and technical (surgical) criteria, who have not received perioperative chemotherapy, there is no strong evidence to support the use of adjuvant chemotherapy [II, C], whereas patients with unfavourable criteria may benefit from adjuvant treatment [III, B]."
https://oup.silverchair-cdn.com/oup/bac ... A4LVPAVW3Q
DH @ 65 DX 4/11/16 CC recto-sigmoid junction
Adenocarcenoma 35x15x9mm G3(biopsi) G1(surgical)
Mets 3 Liver resectable
T4aN1bM1a IVa 2/9 LN
MSS, KRAS-mut G13D
CEA & CA19-9: 5/18 2.5 78 8/17 1.4 48 2/14/17 1.8 29
4 Folfox 6/15-7/30 (b4 liver surgery) 8 after
CT: 8/8 no change 3/27/17 NED->Jan-19 mets to lung NED again Oct-19 :)
:!: Steroid induced hyperglycemia dx after 3chemo
Surgeries 2016: 3/18 Emergency colostomy
5/23 Primary+gallbl+stoma reversal+port 9/1 Liver mets
RFA 2019: Feb & Oct lung mets

radnyc
Posts: 446
Joined: Tue Apr 06, 2010 6:32 pm

Re: No chemo after liver resection?!

Postby radnyc » Wed Mar 29, 2017 11:54 am

I would highly recommend chemo. Most studies suggest that there is a 50-75% chance of recurrence after resection:

"After liver resection, postoperative adjuvant chemotherapy is recommended for all patients, unless the patient’s physical status is unsuitable for chemotherapy or patients are unwilling to receive this therapy [8].

Nevertheless, tumor recurrence after curative resection of colorectal metastasis remains a major problem. 50% to 75% of the patients develop a recurrence of the disease within two years [8,14]. Surgical resection of the metastatic lesions with curative intent is also the treatment of choice for recurrence after liver resection for colorectal cancer liver metastasis."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4564049/

If you are physically able to handle it, I believe is the best option.


Al
DX Jan 2010, at age 47
Feb - colon resection - 2/17 nodes positive
April - liver mets - Stage 4
3 months Folfox chemotherapy
August '10 liver resection and HAI pump
7 months chemo FUDR HAI and Folfiri systemic
NED since August 2010
Last treatment April 2011
HAI Pump removed Dec 2015

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dianetavegia
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Re: No chemo after liver resection?!

Postby dianetavegia » Wed Mar 29, 2017 1:48 pm

I have 2 studies printed out to take with me regarding follow up and recurrence after HR when I see the doctor April 11th. They disagree with each other on almost every point. How many have local recurrence. Overall survival, etc.

What you have to watch for is study criteria. One study was small mets (less than 3 cm), solitary liver met with no other involvement, more than 12 months after original resection, low CEA, clear margins. The other lumped all sizes, dates, number of mets, etc. together.
Stage III cc surgery 1/7/09. 12 tx FOLFOX
Stage IV PET = 1.5cm liver met. HR 4/11/12

14 years since dx and 11 years post liver resection.
Pronounced CURED and discharged by onc

“O Lord my God, I cried out to You, And You healed me.” Psalms 30:2

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dianetavegia
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Facebook Username: Diane Weldy Tavegia
Location: Villa Rica, Georgia

Re: No chemo after liver resection?!

Postby dianetavegia » Wed Mar 29, 2017 2:52 pm

You guys are talking about totally different scenario, too.
Synchronous (disease present at original dx) and Metrochronous (mets which appear more than 12 months after the original tumor is completely and successfully removed.) Then you have Oligometastatic disease which refers to a stage of disease where cancer has spread beyond the site of origin, but is not widely metastatic.
In such a state of limited metastatic disease burden, (few, small spots) it is hypothesized that eradication of all sites of metastatic disease could result in long-term survival, or even cure, in a subgroup of patients.
Stage III cc surgery 1/7/09. 12 tx FOLFOX
Stage IV PET = 1.5cm liver met. HR 4/11/12

14 years since dx and 11 years post liver resection.
Pronounced CURED and discharged by onc

“O Lord my God, I cried out to You, And You healed me.” Psalms 30:2

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Hannah Faulkner
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Joined: Tue Feb 14, 2017 3:14 am

Re: No chemo after liver resection?!

Postby Hannah Faulkner » Mon Apr 03, 2017 1:00 am

Sorry to hear about your dad, NeVadasMitis. In the past they used to rely on chemo but with more clarity in research chemo will no longer be fruitful
I wish you all the best


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