Wedge resection vs. full lobe removal?

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Reviresco
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Joined: Mon Mar 26, 2018 3:47 pm
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Wedge resection vs. full lobe removal?

Postby Reviresco » Tue Nov 20, 2018 10:03 am

So… my latest MRI shows two mets on the right side of my liver. One is about 3 cm and it’s way up high in the dome. The other is 6mm, lower down.

My local team in Maine and my team at Dana Farber both recommend surgical resection, giving me best chance for cure. But they disagree on the technique.

The surgeon at Maine Medical Center proposes an open surgery with wedge resection of the larger met, and either resection or RFA of the smaller one.

The surgeon at Dana Farber/ Brigham & Women’s is not sure he can achieve clear margins on the larger met if he does a wedge. So he would do a formal right hepatectomy (removal of the right lobe). This would obviously take care of the second met at the same time, plus any micromets that might be brewing.

There are pros and cons to both of these approaches. I’d love to hear your thoughts. Thanks!

Trevor (Reviresco)
42 year old male, dx CC 3/22/18
9.5 x 5.5 x 2.5 cm tumor in ascending colon. T3N1Mx
MSI-H, Lynch Syndrome (PMS2 mutation)
4/4/18 Right hemicolectomy
1 of 25 lymph nodes, clear margins
Four cycles Capeox chemo. CEA 1.4
8/27/18 CT scan shows one liver spot. Two radiologists say it's not a met.
11/12/18 Oops... CT and MRI confirm liver met.
11/28/18 Liver resection
2/14/19 Recurrence in liver
4/9/19 Liver resection #2
8/22/19 Recurrence in liver. CEA 11.7
8/30/19 Started immunotherapy (Ipi-Nivo combo)

martd
Posts: 125
Joined: Tue Nov 21, 2017 3:48 pm
Location: Phoenix, Az

Re: Wedge resection vs. full lobe removal?

Postby martd » Tue Nov 20, 2018 10:47 am

The liver will regenerate, most likely even grow back to it's original size. I had over half my liver removed along with my gallbladder in July. I recovered quickly with no problems other than an incisional site infection. Either way it will be an open surgery and sounds like good advice about not knowing if other Mets are starting.
49 y/o male dx 11/2017 crc
Stage 4 with 17 liver Mets, cea 490
RAS, BRAF WT Tp53 LOF
12 rounds folfox , avastin
5/18 cea 2.8 liver resection and pve
7/18 part 2 liver resection, remove right side of liver
Surgical site mrsa infection, wound vac
8/18 cea .9 cCR, rectal tumor is gone
Rectal surgery postponed, watch and wait
10/18 clear scan CEA .7
01/19 clear scan CEA .9
04/19 clear scan CEA .9
07/19 clear scan CEA 1.0

FightCRC
Posts: 52
Joined: Fri May 25, 2018 10:39 pm

Re: Wedge resection vs. full lobe removal?

Postby FightCRC » Tue Nov 20, 2018 11:41 am

Congrats on being resectable!

Both recommendations sound reasonable, with DF being more aggressive.

I would also encourage you to seek another opinion at MSKCC, where they do the HAI pump. In your case, I would guess (and that's all it is, you do need to consult with them to find out for sure) that they would do the wedge/ablation on the right lobe, and implant the pump at the same time. The pump would serve as adjuvant therapy and hopefully take care of any micromets. This would allow for the preservation of more of your liver.

If micromets are a concern, then the left lobe should be treated, as well. The pump will do that.

Best of luck to you, whatever you decide to do.

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Phuong
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Re: Wedge resection vs. full lobe removal?

Postby Phuong » Tue Nov 20, 2018 4:32 pm

martd wrote:The liver will regenerate, most likely even grow back to it's original size.

Just to clarify, the liver will regrow with a resection, but not with a lobectomy. With the lobectomy, whatever remains will grow to about 2/3 of your full liver. Still plenty of liver to have normal function.
Phuong
http://sonofamotherlessgoat.net/
dx'd Stage III Rectal (T3 N1 M0)
Now Stage IV mCRC

Reviresco
Posts: 26
Joined: Mon Mar 26, 2018 3:47 pm
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Re: Wedge resection vs. full lobe removal?

Postby Reviresco » Fri Nov 23, 2018 12:14 pm

martd wrote:The liver will regenerate, most likely even grow back to it's original size. I had over half my liver removed along with my gallbladder in July. I recovered quickly with no problems other than an incisional site infection. Either way it will be an open surgery and sounds like good advice about not knowing if other Mets are starting.


Thanks MartD! I'm going with an amazing surgeon who used to be at Maine Medical Center, but now is with Central Maine Medical Center. She will do the surgery with another surgeon who came up from Boston who specializes in liver resections and transplants. We feel very confident in this team, and they are highly recommended by my oncologist at Dana Farber. They are going to open me first laparascopically, then ultrasound the entire liver to decide on the surgical plan.
42 year old male, dx CC 3/22/18
9.5 x 5.5 x 2.5 cm tumor in ascending colon. T3N1Mx
MSI-H, Lynch Syndrome (PMS2 mutation)
4/4/18 Right hemicolectomy
1 of 25 lymph nodes, clear margins
Four cycles Capeox chemo. CEA 1.4
8/27/18 CT scan shows one liver spot. Two radiologists say it's not a met.
11/12/18 Oops... CT and MRI confirm liver met.
11/28/18 Liver resection
2/14/19 Recurrence in liver
4/9/19 Liver resection #2
8/22/19 Recurrence in liver. CEA 11.7
8/30/19 Started immunotherapy (Ipi-Nivo combo)

Reviresco
Posts: 26
Joined: Mon Mar 26, 2018 3:47 pm
Contact:

Re: Wedge resection vs. full lobe removal?

Postby Reviresco » Fri Nov 23, 2018 12:15 pm

Phuong wrote:
martd wrote:The liver will regenerate, most likely even grow back to it's original size.

Just to clarify, the liver will regrow with a resection, but not with a lobectomy. With the lobectomy, whatever remains will grow to about 2/3 of your full liver. Still plenty of liver to have normal function.


Thank you Phuong! Fortunately I've never been a heavy drinker or drug user so my liver is very healthy - except for those damned cancer spots!!
42 year old male, dx CC 3/22/18
9.5 x 5.5 x 2.5 cm tumor in ascending colon. T3N1Mx
MSI-H, Lynch Syndrome (PMS2 mutation)
4/4/18 Right hemicolectomy
1 of 25 lymph nodes, clear margins
Four cycles Capeox chemo. CEA 1.4
8/27/18 CT scan shows one liver spot. Two radiologists say it's not a met.
11/12/18 Oops... CT and MRI confirm liver met.
11/28/18 Liver resection
2/14/19 Recurrence in liver
4/9/19 Liver resection #2
8/22/19 Recurrence in liver. CEA 11.7
8/30/19 Started immunotherapy (Ipi-Nivo combo)

Reviresco
Posts: 26
Joined: Mon Mar 26, 2018 3:47 pm
Contact:

Re: Wedge resection vs. full lobe removal?

Postby Reviresco » Fri Nov 23, 2018 12:26 pm

FightCRC wrote:Congrats on being resectable!

Both recommendations sound reasonable, with DF being more aggressive.

I would also encourage you to seek another opinion at MSKCC, where they do the HAI pump. In your case, I would guess (and that's all it is, you do need to consult with them to find out for sure) that they would do the wedge/ablation on the right lobe, and implant the pump at the same time. The pump would serve as adjuvant therapy and hopefully take care of any micromets. This would allow for the preservation of more of your liver.

If micromets are a concern, then the left lobe should be treated, as well. The pump will do that.

Best of luck to you, whatever you decide to do.


Thanks Fight! I totally hear you about the MSKCC opinion. At this point, because I'm resectable and only have the two small mets, I'm going to proceed with surgery next week with a team that we feel great about. The tumor at the dome of my liver is growing fairly aggressively and I have a window now to remove it now, hopefully with clear margins and without needing to remove the right lobe. Because of my Lynch Syndrome, both of my oncs propose watch and wait after that, because conventional chemo could do more harm than good, and they don't yet deploy immunotherapy in the adjuvant setting after a resection with curative intent. I am an excellent candidate for immunotherapy (probably opdivo and yervoy) if I recur after this surgery.
42 year old male, dx CC 3/22/18
9.5 x 5.5 x 2.5 cm tumor in ascending colon. T3N1Mx
MSI-H, Lynch Syndrome (PMS2 mutation)
4/4/18 Right hemicolectomy
1 of 25 lymph nodes, clear margins
Four cycles Capeox chemo. CEA 1.4
8/27/18 CT scan shows one liver spot. Two radiologists say it's not a met.
11/12/18 Oops... CT and MRI confirm liver met.
11/28/18 Liver resection
2/14/19 Recurrence in liver
4/9/19 Liver resection #2
8/22/19 Recurrence in liver. CEA 11.7
8/30/19 Started immunotherapy (Ipi-Nivo combo)

martd
Posts: 125
Joined: Tue Nov 21, 2017 3:48 pm
Location: Phoenix, Az

Re: Wedge resection vs. full lobe removal?

Postby martd » Fri Nov 23, 2018 3:25 pm

That sounds like a very good plan. Hopefully they are able to do the resection laparoscopically also. My first resection was laparoscopic, recovery went really good, except I was feeling to good and over did it, was a little to active and ended up in alot of pain for 3 days. I should have sat on my ass like I was supposed to and take it easy. Hoping everything goes smooth for you.

Dan
49 y/o male dx 11/2017 crc
Stage 4 with 17 liver Mets, cea 490
RAS, BRAF WT Tp53 LOF
12 rounds folfox , avastin
5/18 cea 2.8 liver resection and pve
7/18 part 2 liver resection, remove right side of liver
Surgical site mrsa infection, wound vac
8/18 cea .9 cCR, rectal tumor is gone
Rectal surgery postponed, watch and wait
10/18 clear scan CEA .7
01/19 clear scan CEA .9
04/19 clear scan CEA .9
07/19 clear scan CEA 1.0

mpbser
Posts: 953
Joined: Wed Apr 19, 2017 11:52 am

Re: Wedge resection vs. full lobe removal?

Postby mpbser » Sat Nov 24, 2018 8:20 am

My husband had one tumor in a tricky spot quite close to a hepatic blood vessel in the left lobe. I can't recall whether it was a vein or artery. Anyway, his liver surgeon at Mass General originally presented three choices: lobectomy, "wedge" resection, or RFA. As we got closer to decision-making time, my husband ruled out RFA because he didn't like the 90%/10% odds of that treatment. He wanted the 100% he could get with clear margins from an excision. He went into surgery, which had to be open due to his girth no matter what excision method, not knowing exactly how it would happen because his surgeon was not definitive about it. His approach was very hands-on; he needed to be in there to decide. His liver surgeon had the skills to get 1 mm away from the blood vessel and clear margins. It was a very unique procedure that greatly impressed our surgeon friends.

I suppose the surgeon was thinking that he would try this technique but if it failed he would do a lobectomy. We were very happy about how it turned out.
Wife 4/17 Dx age 45
5/17 LAR
Adenocarcinoma
low grade
1st primary T3 N2b M1a
Stage IVA
8/17 Sub-total colectomy
2nd primary 5.5 cm T1 N0
9 of 96 nodes
CEA: < 2.9
MSS
Lynch no; KRAS wild
Immunohistochemsistry Normal
Fall 2017 FOLFOX shrank the 1 met in liver
1/18 Liver left hepatectomy seg 4
5/18 CT clear
12/18 MRI 1 liver met
3/7/19 Resection & HAI
4/1/19 Folfiri & FUDR
5/13/19 HAI pump catheter dislodge, nearly bled to death
6-7 '19 5FU 4 cycles
NED


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