Why you really need to know your tumor genetics

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LPL
Posts: 561
Joined: Fri Apr 22, 2016 12:49 am
Location: Europe

Re: Why you really need to know your tumor genetics

Postby LPL » Wed Mar 13, 2019 5:03 pm

AmyG, best of luck next week! I have only given birth to 3 so I know nothing.... :lol: compared to you.
I am in France and there I understood it as they wanted a few chemo (4-6) (folfox for hubby - he is kras mutant) before liver surgery, even if the tumors where resectable up front as my husband’s tumor were. Only if it was 1 single liver met they resected it at the same time as the primare tumor (DH’s primary colon tumor was in recto-sigmoid junction).
That was explained to me as the protocol here.
Will be thinking of you and I hope everything will be fine with your new baby <3
Regarding questions. Important to know MSI-status and mutations, they have done tests on your colon tumor? You have no such info in your signature.. Also try to ask for CA19-9 before(!) surgery (especially if you are Kras mutant). I’m sure others have more question advice for you.
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

Pyro70
Posts: 16
Joined: Mon Jan 21, 2019 4:25 pm

Re: Why you really need to know your tumor genetics

Postby Pyro70 » Wed Mar 13, 2019 5:41 pm

Hey Pyro!

My tumor was left sided, sigmoid colon was damn near totally obstructed. As for why not starting with liver resection, I was under the impression they wanted it smaller to be sure they can obtain clear margins. I believe my met is in segment 6 or 7. Due to being pregnant, no one has really wanted to deal with me much.

As soon as I'm given the all clear from OB, oncology will basically start over with me. CT of chest, abdomen and pelvis, MRI of the liver, restaging and presumably changing any plans based on what they find.

I want to be sure they are treating me appropriately, so if there's a list of questions I should be asking at my next appointment let me know!!


I would think a single 4.7cm tumor should be fully resectable. It’s big, but only one tumor. If there is any debate about this, I would make sure it’s reviewed by a surgeon or a multidisciplinary tumor board. If all you have is a resectable liver lesion, there is still a chance at a cure. Personally I would push for surgery sooner than later. Only a minority of patients ever see their tumors downstage from chemo and it comes at the cost of liver toxicity. So if it’s resectable now, it should be done soon. If there is some reason you can’t handle surgery right now, they can also use percutaneous ablation or use SBRT (radiation). There have been no RCTs directly comparing the modalities, but they are assumed to have similar levels of local control as surgery, but surgery is still the “gold standard”.

Good luck.
Dx Jan 2017 stage IVB w/ PC age 35
FOLFOX
SEP 17 HIPEC 1, anastamosis leak
XELODA
MAR 18 HIPEC 2
JUN 18, ileo reversal and 2nd anastamosis leak

AmyG
Posts: 60
Joined: Tue Dec 25, 2018 8:08 pm

Re: Why you really need to know your tumor genetics

Postby AmyG » Wed Mar 13, 2019 8:04 pm

You guys are super helpful :D

I know that the oncologist meets with a tumor board and I have yet to be referred to a liver surgeon. I will be seeing the oncologist early next month, and I will try to get more clarification of why they want chemo first instead of surgery now.

Can you point me in the direction of some studies to back this up, so I have something in writing with me when I suggest surgery first? I can google pretty well, but I'm really not sure what my best resources for that type of information would be!
42 dx @ 9wks pregnant w/baby #8 8/18
Originally thought to be stage 2, no lymphnodes involved 9/18
Spot on liver found prior to bowel resection 9/18
Liver biopsy, it's malignant 12/18
Stage IV, 1 liver met 4.7cm
2019 plan is to deliver baby early and start FOLFOX w/Avastin

Rock_Robster
Posts: 51
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Why you really need to know your tumor genetics

Postby Rock_Robster » Wed Mar 13, 2019 8:32 pm

Hi Amy,

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.

Rob
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
4/19 - Planned long-course chemoradiation

Pyro70
Posts: 16
Joined: Mon Jan 21, 2019 4:25 pm

Re: Why you really need to know your tumor genetics

Postby Pyro70 » Thu Mar 14, 2019 1:18 am

Hi Amy,

As mentioned up-to-date is good go to source. It’s basically intended to be the most current (up to date) reference for physicians. Their guidelines are frequently reviewed and updated by expert physicians and the articles include references to the source studies. The article below is likely most relevant for you. As mentioned if your physicians deviate from these guidelines, they should be able explain why they are deviating. Up-to-date recommends going straight to surgery in your case (based on what we know now, and assuming it is resectable), but doing a short course neo-adjuvant therapy certainly isn’t unreasonable either. However in your case, if your next scans don’t show any new areas of disease, I would favor going straight to surgery since you’ve already been watching it for a few months and it (hopefully) hasn’t grown very fast.

https://www.uptodate.com/contents/manag ... 1389771102
Dx Jan 2017 stage IVB w/ PC age 35
FOLFOX
SEP 17 HIPEC 1, anastamosis leak
XELODA
MAR 18 HIPEC 2
JUN 18, ileo reversal and 2nd anastamosis leak

Rock_Robster
Posts: 51
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Why you really need to know your tumor genetics

Postby Rock_Robster » Thu Mar 14, 2019 2:17 am

Thanks Pyro, that’s exactly the UpToDate article I was looking for. It also links to the NCCN guidelines. I was right on the “4 lesions” edge, but was also influenced by MSK’s (and my oncologist’s) advice.
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
4/19 - Planned long-course chemoradiation

AmyG
Posts: 60
Joined: Tue Dec 25, 2018 8:08 pm

Re: Why you really need to know your tumor genetics

Postby AmyG » Thu Mar 14, 2019 12:35 pm

That's just the type of information that I was seeking, thank you!!

I had no idea that website was even a thing, super helpful.

Thanks again yall. :D
42 dx @ 9wks pregnant w/baby #8 8/18
Originally thought to be stage 2, no lymphnodes involved 9/18
Spot on liver found prior to bowel resection 9/18
Liver biopsy, it's malignant 12/18
Stage IV, 1 liver met 4.7cm
2019 plan is to deliver baby early and start FOLFOX w/Avastin


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