Meeting with liver surgeon tomorrow

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mpbser
Posts: 252
Joined: Wed Apr 19, 2017 11:52 am

Meeting with liver surgeon tomorrow

Postby mpbser » Thu Sep 07, 2017 2:37 pm

Husband has an appointment with a liver surgeon in Albany tomorrow. I prepared a list of questions for our appointment next week with his oncologist at Mass General and since some of them have to do with liver surgery, we will be bringing the same questions tomorrow. If you have any questions to suggest we add, please let me know! Would be most welcomed! Thanks!

1) What is Dr. Zhu's exact prescription for M----s chemotherapy? Dosages, times/weeks, besides Capeox (as M---- will not do Fol-/FU-) what about EGFR targets? They have severe side effects, like Ox-, and provided limited additional benefit, correct?
2) Do we know, and how do we know, for sure that the liver masses are from colon metastasis and are not independent hepatocellular carcinoma?

3) I asked at our first appointment why ox- is necessary, how did it come to be included in the standard of care first line therapy for metastatic CC. Dr. Zhu said that there are plenty of studies showing it dramatically improves efficacy. While I stated that I would trust him on that, M---- would still like to see some quantitative evidentiary reasoning, please.

4) What about the lesions/cysts on M----'s kidney? The first CT scan said there is a lesion and a cyst. The MRI said that it was nephrolothiasis/kidney stones. None of M----'s doctors have been talking to us about that. The last CT (August 28) scan indicates that there is one 3 cm kidney stone. I guess that is a wait and see thing.

5) If M---- agrees to Capeox, what type of port is recommended for the ox- infusions? PowerPort?

6) Now that Dr. Qadan was unable to complete the plan for the liver chip/ablation and M---- will have to return once he has healed from the colon resection for open liver surgery, should M---- have chemo to reduce the size of the liver tumor first? We have spoken to Dr. Qadan and it seems like this would be the recommendation.

7) Plan A -- heal up from last week's colectomy, then two months chemo, then liver surgery, then four months chemo versus Plan B -- heal up from last week's colectomy, then liver surgery, then chemo:

If I understand correctly, Plan A would be in the hope that chemo shrinks the right lobe tumor a bit so it would be easier to remove as it is up against a blood vessel and could be chipped out, thus saving the whole lobe.

Given its size and how fast its size may have increased since the June 30th MRI, our concern is whether chemo will be able to have any shrinking effect on it at all. If it's that rapidly growing, then chemo might just stabilize its size.

Also factoring in the tiny spots on the same lobe and the additional option of resecting that entire lobe (30% of the liver) thus avoiding any future growths and/or surgeries for that area, if husband decides to go that route, then chemo for two months prior to surgery would not seem to make any sense.

8) What is the long term difference between removing the entire right lobe compared to a wedge or chip of the tumor? E.g. the liver regenerates if wedged/chipped but an entire lobe removal would not result in regeneration?

9) Due to our very busy schedules (we go away every Columbus Day weekend for our anniversary, I have depositions in NYC, etc), we would like to lock down a specific timetable, please. For example:
• What is the specific recommended plan?
• When would that start?
• How many rounds?
• What surveillance, bloodwork, etc will be needed? (I know that CT is a preferred method but none of M----’s CTs have ever detected any of his liver masses. We would really prefer a NON-TOXIC method, e.g. ultrasounds; what about blood draws for AFP (alpha-fetoprotein), a biomarker for metastatic cancers of the liver?
• Who would do this monitoring?
• Since travel to Boston is a huge burden, what can our local oncologist do besides administer the chemo?

10) Since chemo wreaks havoc on the immune system and the healing process, if we go with Plan A, wouldn't that increase M----'s risks of infection and other complications concomitant with open surgery? Similarly, since Ox- can cause blood clots and heart problems, what heart/vascular monitoring should his cardiologist do?

11)Dr. Qadan referred to the right and left lobe masses as “tiny spots” numerous times in our phone conversations and during the consultation appointment which I participated by phone. I distinctly recall him speaking about the efficacy of RFA on spots that are less than .5 cm diameter. However, the liver MRI report indicates that the right lobe spot, the one that had been planned to be ablated, is 1.5 cm diameter. ???

12)Is it possible that the liver mass that Dr. Qadan could not chip August 21st had grown since the June 30th MRI and could that growth be related to what I suspect to be his metabolic syndrome? He was eating significantly more beef lately and late night snacking, so much so that he has put on weight in the past few weeks prior to the August 21st surgery.

13)Would the left lobe mass (one up against blood vessel) at the size seen August 21st be able to be removed without taking the entire lobe or does it have to shrink to gain some margin between it and the blood vessel?

14)We would like the images from the intra-operative ultrasound done on August 21st, please, if any were taken.
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

Klaus
Posts: 2
Joined: Thu Sep 07, 2017 6:59 am

Re: Meeting with liver surgeon tomorrow

Postby Klaus » Thu Sep 07, 2017 2:57 pm

Relative to kidney stones you might ask if potassium citrate treatment might dissolve the stone without need for surgery:
https://www.ncbi.nlm.nih.gov/pubmed/19911683

NHMike
Posts: 328
Joined: Fri Jul 21, 2017 3:43 am

Re: Meeting with liver surgeon tomorrow

Postby NHMike » Thu Sep 07, 2017 6:24 pm

I don't have anything to add but wanted to comment that you're very well organized and on top of this stuff.
Rectal Bleeding biopsy June 23, 2017, Diagnosed Stage 3B rectal cancer late July 2017 via MRI.
T3, N1b, M0.
Chemo (Xeloda) and radiation from 07/31/17 to 09/08/17.
CEA before treatment: 2.7. CEA after 14 treatments 1.9 to 1.8 after treatment.
KRAS Mutant KRAS p.Gly12Asp
In 6-week post chemo/radiation recovery period right now
Waiting for MRI early October
Planning for surgery in late October

susie0915
Posts: 167
Joined: Wed Aug 02, 2017 8:17 am
Facebook Username: Susan DeGrazia Hostetter
Location: Michigan

Re: Meeting with liver surgeon tomorrow

Postby susie0915 » Thu Sep 07, 2017 6:27 pm

Good Luck. You are a great advocate for your husband.
57 yr old mother of 3
5/15 DX T3N0MO Stage 2A
6/15 5 wks of radiation/xeloda
7/15 sigmoidoscopy/scar tissue only
8/15 Pet scan NED
9/15 LAR
10/15 Bowel blockage. 3 1/2 weeks in hospital.
early ileo rev since
surgery to repair blockage. c-diff inf
12/15 6 rds of xelox
5/16 Clear CT lung scarring/inflammation
9/16 clear colonoscopy
4/17 CT 4mm lung nodule onc thinks scar tissue
7/17 no change lung nodule
Currently NED

mpbser
Posts: 252
Joined: Wed Apr 19, 2017 11:52 am

Re: Meeting with liver surgeon tomorrow

Postby mpbser » Fri Sep 08, 2017 6:12 am

Thanks, everyone.

I am also going to ask about the routine use of tylenol and harm to the liver. He's been taking 3000 mg daily since the last colon resection, which I know is under the max daily dosage, but I'm still concerned about such long term use.
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

mpbser
Posts: 252
Joined: Wed Apr 19, 2017 11:52 am

Re: Meeting with liver surgeon tomorrow

Postby mpbser » Fri Sep 08, 2017 6:18 pm

Liver surgeon advises husband to do chemo before the liver surgery. This will likely be the recommendation of his Mass General doctors on Tuesday. So, I will need to call his local surgeon to schedule the port installation for the beginning of October and schedule the start of his chemo beginning the week after Columbus Day weekend, our anniversary weekend. That was actually the game plan before the August 21st 2nd colon surgery but we, of course, had no idea at that time that the liver would have to wait.

We also spoke about possibly needing his gall bladder removed because of the potential to develop gall stones as he loses more weight. I will definitely ask his Mass General doctors about this.
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

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LPL
Posts: 282
Joined: Fri Apr 22, 2016 12:49 am
Location: Europe

Re: Meeting with liver surgeon tomorrow

Postby LPL » Mon Sep 11, 2017 7:53 pm

Mpbser

It sounds as your DH has gotten the same advice regarding how to tackle the liver Mets and that he will be having the same routine as my DH had.
Best of Luck with the upcoming doctor visits and the Anniversery weekend !
DH @ 65 DX 4/11/16 CC recto-sigmoid junction
Adenocarcenoma pt 35x15x9mm G3(biopsi) G1(surgical)
Mets 3 Liver resectable
T4aN1bM1a Stage 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 for now :D
:!: Steroid induced hyperglycemia dx after 3chemo .. hospitalized, insulin -> Metformin
Surgeries (open):
3/18 Emergency colostomy 5/23 Primary+gallbl+colostomy reversal (+port) 9/01 Liver mets

NHMike
Posts: 328
Joined: Fri Jul 21, 2017 3:43 am

Re: Meeting with liver surgeon tomorrow

Postby NHMike » Mon Sep 11, 2017 8:13 pm

mpbser wrote:Liver surgeon advises husband to do chemo before the liver surgery. This will likely be the recommendation of his Mass General doctors on Tuesday. So, I will need to call his local surgeon to schedule the port installation for the beginning of October and schedule the start of his chemo beginning the week after Columbus Day weekend, our anniversary weekend. That was actually the game plan before the August 21st 2nd colon surgery but we, of course, had no idea at that time that the liver would have to wait.

We also spoke about possibly needing his gall bladder removed because of the potential to develop gall stones as he loses more weight. I will definitely ask his Mass General doctors about this.


What will the chemo be?
Rectal Bleeding biopsy June 23, 2017, Diagnosed Stage 3B rectal cancer late July 2017 via MRI.
T3, N1b, M0.
Chemo (Xeloda) and radiation from 07/31/17 to 09/08/17.
CEA before treatment: 2.7. CEA after 14 treatments 1.9 to 1.8 after treatment.
KRAS Mutant KRAS p.Gly12Asp
In 6-week post chemo/radiation recovery period right now
Waiting for MRI early October
Planning for surgery in late October

mpbser
Posts: 252
Joined: Wed Apr 19, 2017 11:52 am

Re: Meeting with liver surgeon tomorrow

Postby mpbser » Tue Sep 12, 2017 6:19 am

Thank you, LPL!

We are heading to Boston today for his appointments with his Mass General doctors. The final chemo decision will be made upon receiving the information we get today. Since it may begin as soon as the first week of October, husband will have to decide very soon. Will post updates!
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

mpbser
Posts: 252
Joined: Wed Apr 19, 2017 11:52 am

Re: Meeting with liver surgeon tomorrow

Postby mpbser » Wed Sep 13, 2017 11:35 am

UPDATE. Just sent this to husband's local oncologist:

Dear Dr. ----

I am writing this letter on behalf of my husband, M----. He had an appointment yesterday at Massachusetts General Hospital with oncologist Dr. Zhu, colorectal surgeon Dr. Cusack, and liver surgeon Dr. Qadan at which final decisions were made about the next steps in his treatment.

M---- has decided to go with the following protocol:

• Xelox/Capeox (21 day/3 week cycles)
• 2-3 months at SVMC: Preferably scheduled for October 11, November 1, November 22, December 13, and January 3
• First day of cycle 1: Oxaliplatin 85 mg/m2 Then: Capecitabine 1000 mg/m2 2x/day orally for 14 days
• First day of cycle 2: If Oxaliplatin tolerated in cycle 1, then 110 mg/m2 for this cycle
• First day of cycle 3 and onward: If Oxaliplatin tolerated in cycle 2, then 130 mg/m2
• Capecitabine can be lowered to 850 mg/m2 if necessary
• When chemo completed, earlier than January if M---- can’t tolerate, he will have a liver MRI done at Mass General to check the status of the liver masses.
• Liver surgery at Mass General will be scheduled and exact method will of course be determined by the MRI findings.

I called Dr. Cope’s office to schedule the port installation procedure for preferably the last week of September. Per Dr. Zhu’s recommendation, M---- requires at least one week between the port installation and the first day of chemotherapy.

Please have the above schedule arranged for the infusions. Thanks in advance.
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

JJH
Posts: 142
Joined: Mon Apr 24, 2017 7:26 am
Location: Europe

Re: Meeting with liver surgeon tomorrow

Postby JJH » Wed Sep 13, 2017 1:09 pm

mpbser wrote:...M---- has decided to go with the following protocol:

• Xelox/Capeox (21 day/3 week cycles)
• 2-3 months at SVMC: Preferably scheduled for October 11, November 1, November 22, December 13, and January 3
• First day of cycle 1: Oxaliplatin 85 mg/m2 Then: Capecitabine 1000 mg/m2 2x/day orally for 14 days
• First day of cycle 2: If Oxaliplatin tolerated in cycle 1, then 110 mg/m2 for this cycle
• First day of cycle 3 and onward: If Oxaliplatin tolerated in cycle 2, then 130 mg/m2...

I had a look at your proposed schedule. I like the fact that the infusions are scheduled for Wednesdays since that will leave two more weekdays when DH can go to the infusion center before it closes for the weekend, in case there are any problems. But I notice that the 3rd infusion is scheduled the day before Thanksgiving, and it is not clear if the hospital will be fully staffed for the long weekend. Since the third infusion is scheduled to be the largest ever for 0xaliplatin, I would think that DH would have to be monitored closely for reactions and would need access to medical support on Thanksgiving weekend if he couldn't manage to tolerate cycle 3.

That's my main concern.

mpbser
Posts: 252
Joined: Wed Apr 19, 2017 11:52 am

Re: Meeting with liver surgeon tomorrow

Postby mpbser » Wed Sep 13, 2017 1:17 pm

Thanks for the heads up, JJH. That's something to consider, for sure.
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

User avatar
Bev G
Posts: 5837
Joined: Thu Jan 07, 2010 11:19 pm
Facebook Username: Bev Golde
Location: Quechee, VT

Re: Meeting with liver surgeon tomorrow

Postby Bev G » Wed Sep 13, 2017 6:49 pm

The gall bladder is often removed at the time of liver resection. The primary reason for this is that if gall bladder disease were to develop, getting to the organ to take it out can be VERY difficult due to scar tissue from the liver resection.
58 yo Type1 DM 48 years
12/09 Stage IV 2/22 nodes + liver met, colon resec
3 tx FOLFIRI, liver resec 4/10
9/10 6 mos off chemo, Neg PET&CTC CEA nl
2/11 finished total 10 rounds chemo

9/13 ^17th clean PET/CT NED for now

NHMike
Posts: 328
Joined: Fri Jul 21, 2017 3:43 am

Re: Meeting with liver surgeon tomorrow

Postby NHMike » Wed Sep 13, 2017 8:20 pm

I like the algorithmic style of chemo treatment.
Rectal Bleeding biopsy June 23, 2017, Diagnosed Stage 3B rectal cancer late July 2017 via MRI.
T3, N1b, M0.
Chemo (Xeloda) and radiation from 07/31/17 to 09/08/17.
CEA before treatment: 2.7. CEA after 14 treatments 1.9 to 1.8 after treatment.
KRAS Mutant KRAS p.Gly12Asp
In 6-week post chemo/radiation recovery period right now
Waiting for MRI early October
Planning for surgery in late October

ashima2016
Posts: 31
Joined: Thu Dec 01, 2016 10:56 am

Re: Meeting with liver surgeon tomorrow

Postby ashima2016 » Thu Sep 14, 2017 3:28 pm

mpbser wrote:
• First day of cycle 1: Oxaliplatin 85 mg/m2 Then: Capecitabine 1000 mg/m2 2x/day orally for 14 days
• First day of cycle 2: If Oxaliplatin tolerated in cycle 1, then 110 mg/m2 for this cycle
• First day of cycle 3 and onward: If Oxaliplatin tolerated in cycle 2, then 130 mg/m2



I thought the standard dosage for oxi is 85 mg/m2. Increasing the dosage to 130 mg/m2 seems pretty aggressive. You won't really know whether he tolerates the Oxi well as the hand foot syndrome could be lagged till 6 months later.

Xeloda itself could cause worse hand foot syndrome too.

I am not a healthcare professional, just a thought.


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