Met in caudate lobe and artifactual spots

[mpbser]

My husband has "New 1.6 cm enhancing focus in caudate lobe (segment 1) w/o definite restricted diffusion, indeterminate but a new met is not excluded" according to his December 3rd MRI. Interestingly, there was "A focus of high signal 1.6 cm in segment 8 on low B value DWI images" reported from his MRI in January 2018. Same exact MRI machine, but different radiologists' reviewing and reporting. The segment 8 spot turned out to be not seen on the December 3 MRI so is considered to have been artifactual.

I know that radiologists are not always exactly correct about the positioning of masses. For example, the radiologists report that the resected liver spot was in segment 4a. However, it was certainly in segment 4b because using intraoperative ultrasound, his surgeon reported that the lesion was at the "bifurcation of segment 3 and 4B pedicles."

When at the consultation last week, we looked at the MRI and the oncologist could barely see what the radiologist saw in the caudate. I happened to catch it and pointed it out to him. It's a perfectly circular very faint spot. I plan on looking at the images carefully this weekend, comparing the two MRIs, if I can get the software to work on my computer.

What are the chances of this caudate lobe spot and the segment 8 spot being the same, unchanged in size, spots just being looked at differently?

Here's the thing. His Mass General (MGH) oncologist and liver surgeon want it biopsied (husband has asked for it to get ablated at the same time because that just seems to make sense).

However, I did a search on this forum for "caudate lobe" and see that that was the location for Bev G's one liver met. She wrote that her "liver tumor was NOT accessible for biopsy (posterior caudate lobe of liver). No way in the world to biopsy it." The little caudate lobe (segment 1) is considered the most technically difficult locations for surgery or ablation. I had raised this issue with husband's MGH oncologist last week during our consultation. He expressed his confidence in the interventional radiologists and assured us that if it could be done, it would be done well.

I am so grateful that we are going to MSK next week to see what they recommend. In the meantime, we should be getting a call from MGH to schedule this percutaneous ablation procedure with the radiologist. I do have questions for him, too.

If anyone has any experience with the caudate lobe, I would love to hear about it.

[mpbser]

Well, isn't that funny. The doctor called a few seconds after posting that. I asked him the question about the possible artifactual coincidence and he basically told me no, that's probably not it. (ie I'm not getting it right). He basically doesn't think that a radiologist would confuse segment 8 with the caudate. Hmmmmmmm

Anyway, the verdict is that he doesn't think anything should be done right now with the caudate spot because of its size. It's too small to ensure that they won't miss it with biopsy and ablation. The images of this segment's spot are not consistent enough with metastasis for him to be overly concerned with intervening at the moment.

He does want to biopsy and microwave ablate the segment 6 spot and get clear margins. He is planning on it being an outpatient procedure, barring any complications, and wants to get him in soon, hopefully early January.

[mpbser]

PS Apparently, at least at Mass General, the caudate is a piece of cake to biopsy and they do that there all the time.

[mariane]

I had a met (around 1.5-2cm) in caudate lobe, removed in 10/2015 by dr. D'Angelica in MSKCC. Still no recurrence. Dr. D'Angelica removed 10+ mets from my liver. They were all badly located near important anatomical structures - vena cava, other blood vessels, also caudate lobe. The caudate lobe met I had removed first during HAI pump placement. Surgeons in MSKCC can deal with this location. Good luck!

[NHMike]

I looked at MGH's options for liver surgery and they are impressive so they have a lot of techniques available. I think that it's great to have the options of MGH and MSK. I'm also quite impressed with the folks that go through this surgery and clean up mets and stay cancer free for years.

[mpbser]

Wow, mariane. It's awesome to read your signature and success.

I was just reflecting this morning on how my husband had a CT-guided biopsy of his segment 5 spot that turned out benign. I honestly don't get why at least biopsying the caudate spot right now isn't warranted. It's the same size as the segment 5 spot and risking missing it wasn't a major concern then. I also want to know if the interventional radiologist will use contrast-enhanced ultrasound guidance as an ancillary technique. I have so many concerns and questions.

I also just read his CEA result from our visit to MGH Dec 13th: 2.9. This is the HIGHEST he has ever had. Ugh.

We go to MSK on Wednesday. I am really looking forward to hearing Dr. Kemeny's recommendations. Obviously, at some point we are going to have to get a divorce from MGH if/when we decide to go with MSK. It's a little awkward right now with this overlap.