What a day yesterday in Boston! So much information, so much to think about. Here's a summary:
Dana Farber (Dr. Cleary, Onc.; Dr. Wang, Surgeon)
1.) Adding Oxi- to Xeloda or 5-FU supposedly doubles efficacy.
2.) Doctors suspect that the large adenoma in transverse colon (mass #2 found June 28) that came back with no cancer in biopsy (took 1 cm in aggregate) is actually malignant.
3.) Based on #2, doctors want husband's entire colon removed.
4.) Doctors looked at the scans and are certain that there is indeed a small cancerous spot on the right lobe of the liver.
5.) Doctors say husband needs liver resection. Without citing hard data but appearing very confident, the doctors said that surgery is the way to go and strongly recommended it over RFA. This is based on "certainty of getting it all" thinking, to paraphrase.
6.) However, before any treatment begins, Onc wants husband to a) have a third/repeat colonoscopy to do another biopsy on the giant polyp/suspected tumor and b) have further genetic testing done both on his specimens and by blood draw.
7.) IF the polyp is removable during this colonoscopy, they will do so. We encouraged them to go this route, or at least try, because husband is loathe to lose any more of his colon. (There is no question that the thing needs to come out. It's just a matter of how.)
8.) Onc says that genetics could influence a) the type of surgery done and b) whether or not he will recommend adding Panitumumab to the Xelox or Folfox. (I wasn't sure if he was referring to his MSS status or something else. Our local doctors did not send over all the records. I didn't get a chance to ask because Onc seemed in rush to finish up the appointment.)
9.) We asked about what our local doctor might have meant by Oxi- being hard on the veins. Apparently, if given through IV infusions, burns on the arms can develop, sometimes so much so as to require plastic surgery. (This was tough news for husband who really, really, really wants to avoid a port.)
10.) A "Picc" line IV might be an alternative method of Oxi- delivery but this Onc has little to no experience with it and did say that there is a risk of infection with that just as there is with a port.
11.) Onc recommends doing six cycles of chemo, then have liver and/or colon resections, and then do 6 more cycles of chemo.
12.) Onc says husband needs to start chemo ASAP.
Mass General Dr. Zhu, Onc.
1.) Adding Oxi- to Xeloda or 5-FU is the way to go for Stage IV CC, even with husband's comorbidities. He said there is plenty of data to support this and I believe him.
2.) Zhu agrees that further genetic testing and a repeat colonoscopy/biopsy is needed.
3.) We told him that husband has an appointment at Mt. Sinai July 24th to see if the giant polyp can be removed by polypectomy or another non-surgical method. He would like to see that appointment happen sooner, if possible, so I will be calling today to see what can be done, if anything, about that.
4.) Zhu says that the liver mass(es) can be "easily addressed" with RFA but he still recommends surgery. It appears that he shares the above thinking about "getting it all" is more likely with surgery.
5.) Zhu was not convinced that the foci on the liver are cancerous but because the biopsy taken during the hemi-colectomy came back positive, liver resection needs to be done in a rather be safe than sorry manner. (Husband and I are on board.)
6.) The radiology department is going to review the scans again per his instruction.
7.) Even though this is "difficult case", he is very positive and optimistic about husband's chances of beating this and moving on with his life.
8.) Zhu will be sharing the case with his team today and giving it extra attention.
9.) He does not think that husband necessarily needs chemo ASAP. His treatment recommendation is to take care of the resection(s) first and then start chemo.
10.) #9 seems to make sense because the logic is that the chemo will affect the liver in ways that there is more guesswork. I'm not clearly explaining that but it's be a very rough 24 hours.
Overall, we felt more comfortable with Dr. Zhu who took his time with us and was in no rush to finish our appointment. We also just feel more confidence in him generally. At Dana Farber, it felt like we were in a factory but as Mass General, it felt like we were being treated as individuals.
Wife of 4/12/17 Dx age 45
5/19/17 - Lap left hemi
Tumor size: 5 x 4 x 1 cm
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
CEA: 1.4 Pre-op; 2.1 2 days Post-op
Tumor extension: Invasive through muscularis propria into pericolic fat
Proximal margin: >14 cm Distal margin: >14 cm Mesenteric margin: 3 cm
Lymphovascular invasion present
Lynch - unlikely; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2