When developing my treatment plan, this was one of the areas I struggled with the most. As I was very lucky to be resectable at diagnosis, I didn’t want to delay in removing the liver mets. However the risk of further metastasis was so high that the need for early systemic chemo coverage was also prominent, or my chances of getting through the full treatment plan without further spread were low.
There are of course also risks of doing chemo first - including possibility for growth of tumours on chemo, possibility for liver damage (which I did experience, mildly); and also that the tumours may shrink so much as to make resection difficult (not such a big ‘risk’ in my mind, but whatever!).
In the end I got three opinions - my local oncologist, Dana-Farber and MSK - and all were aligned that starting with some chemotherapy is logical (4-6 rounds max), then rapidly reassessing and moving to resection if a good response. If there was progression on the neoadjuvant chemo, then they were very concerned about starting surgeries until the systemic disease was under control.
I found information from, I believe, the NCCN guidelines, and also UpToDate.com (actually very reputable primary sources, despite the name), which suggested if dealing with up to 4 resectable liver mets then chemo first was discretionary. MSK I believe were more conservative and said they might go straight to surgery (without chemo first) in the case of a ‘single’ liver met only. With all this in mind, my oncologist’s view was that there is no research supporting a single best approach - provided the full course of FOLFOX was done either before, between or after surgeries.
I’m sorry I don’t have the sources at hand but I’ll do some more digging and post what I can find.
So far it seems to have been a reasonable decision for me - I responded well to the first 4 rounds of FOLFOX, shrinking the liver mets by about 25-30%. I did two more rounds (given response was good) then had the liver surgery last week. After resection they found ‘extensive necrosis’ of tumour cells, suggesting the chemo did its job. It also gives confidence when it comes to adjuvant chemo that finishing the FOLFOX makes sense.
Your case may differ to mine in that you’ve already had your primary removed, so you wouldn’t be delayed as much in recommencing chemo. It might not be such a big deal to take care of the liver mets then get back onto chemo as quickly as possible. Best of luck for working it out - it’s not easy.
Male 36 years; Melbourne, Australia
10/2018 Dx: 3.5 cm rectal adenocarcinoma, 10 cm from verge. Well/mod diff (G1-2), T3bN1bM1a.
3 enlarged local lymph nodes and 4 liver lesions.
Mutation in NRAS (G13R; exon 2, codon 13). MSS; MMR proficient.
11/18 - 6 rounds neoadjuvant FOLFOX
12/18 - DVT, started clexane
3/19 - Liver resection, clear margins