Liver mets: ablation vs. surgery, pros? cons?

Please feel free to read, share your thoughts, your stories and connect with others!
hopie
Posts: 90
Joined: Fri Jan 18, 2019 12:15 pm

Liver mets: ablation vs. surgery, pros? cons?

Postby hopie » Thu Feb 14, 2019 7:39 am

Hello everyone,
My mom's oncologist mentioned ablation and surgery as our options, which we'll decide according to her response to chemo. She has 4 mets, largest one around 2 cm in Segment 3. Others are "subcapsular" (don't know what this means yet) and in Segment 7.

What I've understood from some articles was that ablation is for smaller mets and it is less invasive. But it is not as effective, especially in terms of recurrence. If her mets get smaller with chemo and they suggest ablation, should we push for surgery?

I would love to hear people's experiences with either treatment. Thanks a lot in advance!
Caregiver to my super-mom (62), diagnosed Dec 2018
Sigmoid colon, Stage IV
G3, Poorly differentiated adenocarcinoma (5,5 x 4 x 1 cm)
T4N2bM1
13 positive out of 23 lymph nodes, largest one 1,8 cm
4(?) mets in liver, located at Segment 3 & 7, largest one 2 cm
LVI & PNI present
Clear surgical margins
MSS, KRAS G13D mutant
Laparoscopic anterior resection, Jan 2019

First chemo 11 Feb 2019 (Folfox). 25/2/19 Folfox + Avastin.

User avatar
Jack&KatiesMommy
Posts: 590
Joined: Wed Dec 21, 2011 1:08 pm
Location: Columbus, OH

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby Jack&KatiesMommy » Thu Feb 14, 2019 1:03 pm

Surgery is the gold standard. The best chance for a possible cure is with resection. But if that is not possible, ablation has been producing excellent results.
Cynthia
Cynthia
Mommy to Jack (8) now (16) and Katie (4) now (12)
(My Most Precious Things)
Dx 8/11 Stage IV CRC (liver mets) CEA 2,600+
9/11 Folfiri 2/12: Failed Liver Resection
5/12 HAI pump/removed primary
4/13 Liver Resection
8/13-12/15 (10) RFAs lungs
5/17: Upper Left Lobe of lung resected.
02/18: 3 new mets lymph nodes lung:
05/18: Keytruda (MSS w/Intermediate TMB): CEA: 66.4, 39.2, 23.8, 13, 3.5 1.8, 1.0, 2.8 3.9, 5.0, 5.6, 1.5, .8, .8, 1.1, 1.1, .7
7/18; 9/18; 11/18; 2/19 Clear CT scans

hopie
Posts: 90
Joined: Fri Jan 18, 2019 12:15 pm

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby hopie » Thu Feb 14, 2019 2:12 pm

Dear Cynthia,
Thanks a lot for your response. I know surgery is what I should wish for, but it seems everything depends on my mom's response to chemo so I'm trying to understand the "extent" of "excellent results," if that makes sense (sorry if it doesn't, not a native speaker).

I know everyone's different and we can't really know much before they happen, but waiting and not knowing is just too hard sometimes. Seeing so many strong people here definitely helps though.
Caregiver to my super-mom (62), diagnosed Dec 2018
Sigmoid colon, Stage IV
G3, Poorly differentiated adenocarcinoma (5,5 x 4 x 1 cm)
T4N2bM1
13 positive out of 23 lymph nodes, largest one 1,8 cm
4(?) mets in liver, located at Segment 3 & 7, largest one 2 cm
LVI & PNI present
Clear surgical margins
MSS, KRAS G13D mutant
Laparoscopic anterior resection, Jan 2019

First chemo 11 Feb 2019 (Folfox). 25/2/19 Folfox + Avastin.

hiker
Posts: 139
Joined: Thu Aug 09, 2018 10:15 am

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby hiker » Thu Feb 14, 2019 2:51 pm

Hey hopie,

Unfortunately with cancer, there are no guarantees. Some people have surgery and never have a recurrence...some do. Some people have ablations and never have a recurrence...some do. I've never been a patient person, but I've had to learn patience since being diagnosed with cancer. We all want answers and a guarantee that if we have a certain treatment we will be cured. But it just doesn't work like that.

Your mother's diagnosis sounds just like mine - except that I'm KRAS wild. See my signature for my journey. I think I'm doing pretty good considering I'm quickly approaching the expiration date I was originally given and I'm currently cancer free.

I wish your mother well.

hiker
Colonoscopy 2/17, 5cm tumor descending
Diagnosed stage iv, liver mets 3/17
Colon resection 3/17
Told surgery not an option, get my affairs in order
Meet w/MSK team 5/01/17
Folfox(3rds) 5/17-6/17
Liver resection/implant HAI pump 7/17
HAI pump chemo(5rds) 8/17-2/18
Folfiri+Vectibix(11rds) 8/17-2/18
Spot on chest CT 10/17
Lung biopsy (that was fun) 11/17
Nocardia bacterial infection w/spread to brain (this is serious) 11/17
IV antibiotics 12/17-2/18
Oral antibiotics 3/18-12/18
Clear of cancer since surgery

Gravelyguy
Posts: 178
Joined: Thu Jul 05, 2018 6:03 pm

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby Gravelyguy » Thu Feb 14, 2019 3:34 pm

Hopie,

I had two liver tumors at diagnosis. They were both operable right away but because my rectal tumor was so low, I did 4 rounds of chemo with Vectibix before surgery to shrink the primary tumor.

One of my liver tumors was resected as it was along the bottom of my liver and easy to take out. When biopsied they could find no sign of cancer just scar tissue where it had been. The other tumor was also small but deeper in my liver. They ablated it because to do a wedge resection on such a small tumor did not make sense because of how much liver would have to be cut out to get to it. In the end, my surgeon guessed 98% of my liver was untouched. So far so good. No recurrence in either spot.

Also, I believe subcapsular means that the tumors are on or near the surface of the liver. Those should be easier to resect like my first tumor.

Hope this helps,

Dave
6/17 dx mCRC t3n1m1 very low rectal tumor 2 liver Mets 1.3 cm and .9 cm

6/17 begin 4 rounds Folfox w/Vectibix
9/17 short course radiation
10/17 rectal and liver resection LAR with coloanal anastomosis (no rectum left)
11/17-3/18 8 rounds Folfox
6/18 still NED!! Takedown
8/28/18 still NED! CEA .8 new low for me
10/18/18 colonoscopy clear
12/12/18 clear scans, CEA .9 still NED!
6/11/19 clear scans CEA 1.0

hopie
Posts: 90
Joined: Fri Jan 18, 2019 12:15 pm

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby hopie » Fri Feb 15, 2019 5:21 am

Dear hiker,
I'm as impatient as it gets as well, especially with things beyond my control. I think I'm just trying to minimize the unknown by at least having an idea of the potential paths we might find ourselves on. I'm glad you're doing fine and cheers for being cancer free!! Sorry for the language but I hope you send a picture from one of your favorite spots on earth to those who gave you an expiration date with a caption that says "shove it!" It's one thing to not infantilize people and be honest with them about the terms of their disease, quite another to universalize their incompetency to provide an effective treatment to lack of options. I'm glad you had other options and that you found them.

Dear Gravelguy,
Thank you so much for explaining subcapsular! That makes me really happy. That your mets were all dead is also very promising. Were these liver procedures both done at the same time along with your primary tumor removal?

I wish my mom's surgeon had dealt with hers during her first surgery... I'm not sure if it's the radiologists doing a bad job or mom's body going crazy but we jumped from no mets (Dec 16) to 1 met (8mm, Jan 4) to 2/3 mets (10 mm, Jan 9) to 4 mets (20mm, Feb 4). I'm just scared that her mets will become inoperable as time goes by. I so so hope she responds to chemo the way you did!
Caregiver to my super-mom (62), diagnosed Dec 2018
Sigmoid colon, Stage IV
G3, Poorly differentiated adenocarcinoma (5,5 x 4 x 1 cm)
T4N2bM1
13 positive out of 23 lymph nodes, largest one 1,8 cm
4(?) mets in liver, located at Segment 3 & 7, largest one 2 cm
LVI & PNI present
Clear surgical margins
MSS, KRAS G13D mutant
Laparoscopic anterior resection, Jan 2019

First chemo 11 Feb 2019 (Folfox). 25/2/19 Folfox + Avastin.

radnyc
Posts: 375
Joined: Tue Apr 06, 2010 6:32 pm

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby radnyc » Fri Feb 15, 2019 9:57 am

Depending on the size and location numerous studies have shown that ablation is just as good as surgery. And without the trauma associated with surgical resection. In either case the important thing is to find a COMPETENT team to do it!
DX Jan '10, at 47
Feb - colon resection - 2/17 nodes
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 '11
HAI Pump removed Dec '15

hopie
Posts: 90
Joined: Fri Jan 18, 2019 12:15 pm

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby hopie » Fri Feb 15, 2019 10:26 am

Dear radnyc,
Thanks a lot for your response.
I've read those studies too! But I've been reading so many studies that conflict on SO MANY things that I guess I'm feeling the need to hear from actual people. Unfortunately, we're not in the US so the centers mentioned here are out of reach for us, but I'm doing lots of research. Her oncologist works at a hospital that's associated with MD Anderson and I just found a liver center that has done good work. I just cannot wait to add NED to my signature...
Caregiver to my super-mom (62), diagnosed Dec 2018
Sigmoid colon, Stage IV
G3, Poorly differentiated adenocarcinoma (5,5 x 4 x 1 cm)
T4N2bM1
13 positive out of 23 lymph nodes, largest one 1,8 cm
4(?) mets in liver, located at Segment 3 & 7, largest one 2 cm
LVI & PNI present
Clear surgical margins
MSS, KRAS G13D mutant
Laparoscopic anterior resection, Jan 2019

First chemo 11 Feb 2019 (Folfox). 25/2/19 Folfox + Avastin.

rp1954
Posts: 1520
Joined: Mon Jun 13, 2011 1:13 am

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby rp1954 » Fri Feb 15, 2019 4:26 pm

We largely favor surgery in general, beyond standard limitations, and have pushed hard to try to improve upon standard pre-surgical practices. We don't have experience with liver operations per se but there may be areas of mutual interest here.

One, we focused on prevention of metastasis in the run up to surgery, metastasis that is often associated with CA199 + E-selectins or KRAS/BRAF mutations, during the gaps between chemo and surgery. Avastin has a 6 week surgical gap, and various 5FU based treatments are withheld 2-4 weeks on either side. We used several items instead of Avastin e.g. cimetidine, MK4 and IV vitamin C to modify VEGF-A and somewhat related cancer biology; treatments far more operation friendly than Avastin. We added even more friendly chemistries in the pre-operative period. We used them up to major abdominal surgery itself and immediately after or starting within a week if likely to increase bleed time. Likewise we expanded 5FU treatment closer to surgery by less intense 5FU treatments with faster clearance in good tissues (e.g. metronomic oral UFT) closer to the surgical date. Liver operations will be a little more conservative on counting days off.

Second, we couple natural immune modulators (and unnatural like cimetidine) with chemo and surgeries. Both to inhibit and shrink cancer sites, and to reduce their spread. We have seen unusual shrinkage in some liver masses, following immune modulations to (immuno)chemo, in part guided by molecular aspects of blood chemistry and cancer biology.

Potentially, closer in improvements to immune and chemo treatments could allow more flexibility in liver resections, with less huge margins and fewer "futile" inoperable patients.
watchful, active researcher and caregiver for stage IVb/c CC. surgeries 4/10 sigmoid etc & 5/11 para-aortic LN cluster; 8 yrs immuno-Chemo for mCRC; now no chemo
most of 2010 Life Extension recommendations and possibilities + more, some (much) higher, peaking ~2011-12, taper to almost nothing mid 2018, mostly IV C

hopie
Posts: 90
Joined: Fri Jan 18, 2019 12:15 pm

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby hopie » Sat Feb 16, 2019 6:51 am

Dear rp1954,
Thank you so much for these! I want to make sure I fully understand as I’m new to the scene and haven’t been able to fully internalize all the terms just yet. What exactly is metastasis associated with? What's E-selectins, in particular? My mother has a KRAS mutation (G13D), but her CEA and CA199 levels are within normal range per the ones established by this particular lab. How did you go about optimizing which components to use? Do you target particular biomarkers or experiment and observe?
Caregiver to my super-mom (62), diagnosed Dec 2018
Sigmoid colon, Stage IV
G3, Poorly differentiated adenocarcinoma (5,5 x 4 x 1 cm)
T4N2bM1
13 positive out of 23 lymph nodes, largest one 1,8 cm
4(?) mets in liver, located at Segment 3 & 7, largest one 2 cm
LVI & PNI present
Clear surgical margins
MSS, KRAS G13D mutant
Laparoscopic anterior resection, Jan 2019

First chemo 11 Feb 2019 (Folfox). 25/2/19 Folfox + Avastin.

User avatar
O Stoma Mia
Posts: 1600
Joined: Sat Jun 22, 2013 6:29 am

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby O Stoma Mia » Sat Feb 16, 2019 3:03 pm

hopie -

It's good to see that you are interacting with rp1954. He has a lot of expertise and experience to offer.

If you want to familiarize yourself with what he has said in the past about e-selectin (and other topics like Cimetidine) you can use the link inside the post below to find the relevant posts. Just click on the "link to all of rp1954's previous posts" in the post below and put SELECTIN in the search box, and you will retrieve his earlier posts in that area.

https://coloncancersupport.colonclub.com/viewtopic.php?f=1&t=57693&p=454654#p454654

You can do the same thing for CIMETIDINE if you are looking for information on protection against metastasis pre- and post- surgery.

There are some members here who, in a different context, have followed this advice and apparently have been very happy with the results -- for example: a Cimetidine user

hopie
Posts: 90
Joined: Fri Jan 18, 2019 12:15 pm

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby hopie » Mon Feb 18, 2019 2:46 pm

Dear O Stoma Mia,
Thank you again so much for coming up with useful links <3

Mom's oncologist gave her a proton pump inhibitor medicine (called pantpas), not sure if with a similar intent. They told us that it's a bit risky to start taking supplements or additional medicines as they might interact with the chemo or her body can just produce allergies or something. But after I'm done researching these, I'll definitely ask mom's oncologist and nutritional specialist about adding these.

And I've been meaning to ask you for a while since your signature tells me only that you're a crucial member of this forum and are a very helpful and organized person! I hope you don't mind my asking: what brought you here?
Caregiver to my super-mom (62), diagnosed Dec 2018
Sigmoid colon, Stage IV
G3, Poorly differentiated adenocarcinoma (5,5 x 4 x 1 cm)
T4N2bM1
13 positive out of 23 lymph nodes, largest one 1,8 cm
4(?) mets in liver, located at Segment 3 & 7, largest one 2 cm
LVI & PNI present
Clear surgical margins
MSS, KRAS G13D mutant
Laparoscopic anterior resection, Jan 2019

First chemo 11 Feb 2019 (Folfox). 25/2/19 Folfox + Avastin.

User avatar
O Stoma Mia
Posts: 1600
Joined: Sat Jun 22, 2013 6:29 am

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby O Stoma Mia » Tue Feb 19, 2019 3:33 pm

hopie wrote:... I hope you don't mind my asking: what brought you here?

Here's the story:

I was on the Internet looking for information on quality of life after ileostomy reversal, since it was almost time for my scheduled ileostomy reversal surgery. The search engine found some links to "reversal logs" and "takedown logs" on the Colon Talk website, so I clicked on them. This also led to another thread on something called LARS - - an acronym that I had never heard of before and that had never been mentioned by any of my doctors. So I spent some time here trying to familiarize myself with the jargon and trying to learn enough new technical keywords so that I could find the kind of information I was looking for.

When I was first diagnosed, I knew next to nothing about rectal cancer. Earlier, when I had been at university, I hadn't taken any pre-med or science courses at all - no organic chemistry courses, no molecular biology courses, no physiology courses, no anatomy courses. So, in order to understand my current diagnosis and all of the tests and medical reports that were coming in after my diagnosis, I had to learn everything from the beginning, almost like taking a crash course in "Rectal Cancer 101", but without the benefit of having a professor or a proper syllabus.

At the time of my diagnosis, I looked far and wide for a comprehensive, easy-to-read book on rectal cancer, complete with footnotes, illustrations, scientific references, a technical glossary, a proper index and table of contents, etc., but I couldn't find anything at all. So I set out to create my own rectal cancer knowledge-base. I bought a new computer with a 580 gigabyte hard drive and I started collecting articles, documents, and scientific references that I thought would be of use to me. That was over 6 years ago. Now my computer's hard drive is almost full. What I have now is a rather unstructured collection of various documents and reference links, mainly in the area of rectal cancer, including topics like neo-adjuvant chemo/radiation, low anterior resection syndrome (LARS). I sometimes share what I have with others if I think the information might help.

If there is information that you are looking for but cannot find, please let me know this week, and I'll see if I have it anywhere. I will be going out of town soon for an extended period of time with no Internet access, so I will be off-line until I return.

rp1954
Posts: 1520
Joined: Mon Jun 13, 2011 1:13 am

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby rp1954 » Tue Feb 19, 2019 6:12 pm

What's E-selectins, in particular? My mother has a KRAS mutation (G13D)

E-selectin stands for Epithelial cell, sialyl Lewis adhesion molecules that increase the efficiency of metastatic spread by cancer cells. The best indicators of this Velcro-like mechanism's involvement are a patient's tumor tissues pathologically stained with CA199 and CSLEX1 antibodies. The CSLEX1 antibody is a specific CD15s variant. The CSLEX1 marker is not easily available, clinically, outside of Japan. CA199 alone does ~4/5 to ~5/6s of the marker pair's work. Basically e-selectin is involved in about 2/3 of advanced CRC patients (3s and 4s) at diagnosis or surgery, and is very predictive of recurrence risk for stage 2 patients where detected. Blood measurements are affected by other body sources of CA199; ideally healthy patients range 0 - 19 with a genetic few up to 22. Other "benign" disease processes can raise CA199 higher and overlap or amplify cancer cases' CA199. Other blood panels (e.g. inflammation, thyroid, sugar)can help control, rule out, or adjust for this - definitely more work and more slop factor. But if tumor CA199 is present, a few good uses along the way can make or break treatment success.

If you report any CA199 preop/post op data, it may help future readers as well as yourselves. CA199 during Folfox is usually overwhelmed by interferences after a few treatments. For us, with metronomic 5FU, milder drugs, anti-inflammatory supplements, steady blood sugar etc, and no recurrence, CA199 was very steady.

her CEA and CA199 levels are within normal range per the ones established by this particular lab.

It's best to not rely on "normal ranges" for CEA and CA199 for series of levels. They are statistically developed around single readings at some point in time (diagnosis, pre-op, post-op, chemo follow up) rather than a series of readings, which can be far more sensitive, especially in patients with low markers, near or below the cutoff at diagnosis.

CA199 interpretation is clinically developed around pancreatic cancer, with lab cutoff scores 34 - 40 units most commonly at 37. Often PanCan patients have CA199 readings in the hundreds or thousands. The upper 50-90% of initially diagnosed CRC patients are mostly in the 19 - 60 units range; about 3/4 of advanced CRC patients could theoretically produce some rising CA199 series of measurements from their tumors' growth. As a practical matter, any CRC patient with a pre-op CA199 about the teens should consider CA199 tissue stains. Especially for CA199 above 19 or 22 I'd be cracking the whip to get a pathologist to stain the tumor tissue for both CA199 and CSLEX1, in light of previous cimetidine research.

How did you go about optimizing which components to use??

By (m)any means

Do you target particular biomarkers or experiment and observe?

Both
watchful, active researcher and caregiver for stage IVb/c CC. surgeries 4/10 sigmoid etc & 5/11 para-aortic LN cluster; 8 yrs immuno-Chemo for mCRC; now no chemo
most of 2010 Life Extension recommendations and possibilities + more, some (much) higher, peaking ~2011-12, taper to almost nothing mid 2018, mostly IV C

hopie
Posts: 90
Joined: Fri Jan 18, 2019 12:15 pm

Re: Liver mets: ablation vs. surgery, pros? cons?

Postby hopie » Wed Feb 20, 2019 6:22 am

O Stoma Mia wrote:
hopie wrote:... So I spent some time here trying to familiarize myself with the jargon and trying to learn enough new technical keywords so that I could find the kind of information I was looking for.
[...]
What I have now is a rather unstructured collection of various documents and reference links, mainly in the area of rectal cancer, including topics like neo-adjuvant chemo/radiation, low anterior resection syndrome (LARS). I sometimes share what I have with others if I think the information might help.


Dear O Stoma Mia, thank you so much, happy to know more about you! I got here with a similar objective (learning more) and this forum has helped me remain sane and on top of things! Thanks a lot for sharing your knowledge with us.

That said, I have access to medical journals and if anyone of you cannot get access to something they need, please let me know!

And another thing: I've been thinking about two things. First, preparing a facts list, something like: 1. CEA is important, but it's not always indicative of the course of the disease. 2. Stats are old, like, super old and invalid. 3. It is vital to get your CEA, CA 199 checked BEFORE surgery etc etc. I've learned many of those through extensive reading, but I think it would help newcomers to have them as a list. Please let me know if anyone's interested in helping me prepare such a list and we can start a new thread.

And second, inspired by mpbser's recent topic about pump vs no pump, maybe we could gather data from people here that brings together their mutation status, cea levels, ned durations, diets, meditation, tests etc. I'm a social scientist by training, so dull statistics never satisfy me, I'm always interested in the stories behind them. And I love the idea of "an ethnography of NED." Again, let me know if anyone would be interested in gathering such data!
Caregiver to my super-mom (62), diagnosed Dec 2018
Sigmoid colon, Stage IV
G3, Poorly differentiated adenocarcinoma (5,5 x 4 x 1 cm)
T4N2bM1
13 positive out of 23 lymph nodes, largest one 1,8 cm
4(?) mets in liver, located at Segment 3 & 7, largest one 2 cm
LVI & PNI present
Clear surgical margins
MSS, KRAS G13D mutant
Laparoscopic anterior resection, Jan 2019

First chemo 11 Feb 2019 (Folfox). 25/2/19 Folfox + Avastin.


Return to “Colon Talk - Colon cancer (colorectal cancer) support forum”



Who is online

Users browsing this forum: ilovemyfrenchie, MetastaticEquilibria, Rock_Robster and 38 guests