Stage IV, what happens after surgery?

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Pyro70
Posts: 156
Joined: Mon Jan 21, 2019 4:25 pm

Re: Stage IV, what happens after surgery?

Postby Pyro70 » Thu Apr 25, 2019 11:38 pm

Tdubz wrote:my surgeon initially thought I wouldn’t need chemo either, but that I’d need to talk to a medical onc just to make sure. The onc I was assigned to is the lead for this immunotherapy clinical trial. It seems like the trial is the route they are wanting me to go. I’m not opposed to the trial at all, I just want to get the full picture of all my options.



TDubz,

To get the full picture I suggest reading the current up-to-date article on the subject:
https://www.uptodate.com/contents/management-of-potentially-resectable-colorectal-cancer-liver-metastases

Basically there isn’t a lot of data to guide decisions after hepametasectomy. irinotenic is not considered effective in the adjuvant setting. Oxaliplatin is a good option, but if you have neuropathy you’re no longer eligible. So that really only leaves 5FU/Xeloda. I think a lot of oncs would suggest that, and that’s probably what I would do assuming there is no major toxicity. Not sure what the trial is, do you have more info on it?
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

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

Re: Stage IV, what happens after surgery?

Postby mpbser » Fri Apr 26, 2019 6:26 am

The following information in this article shocks me: "In view of the available data regarding the lack of benefit from [post liver resection] adjuvant irinotecan plus fluorouracil (FU), cetuximab, and bevacizumab, we would consider that FOLFIRI (irinotecan plus leucovorin [LV] and short-term infusional FU) and any regimen containing cetuximab or bevacizumab are not acceptable options."

If this is the case, why is Dr. Kemeny's adjuvant chemo of choice Folfiri????
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

Pyro
Posts: 305
Joined: Mon Oct 12, 2015 7:40 pm
Location: Tucson, AZ

Re: Stage IV, what happens after surgery?

Postby Pyro » Fri Apr 26, 2019 8:39 am

She’s a doctor with experience, trust her or don’t. From the article:

There is no "right" approach to integrating systemic chemothertapy with surgical resection of hepatic CRC metastases, and experts have agreed to disagree about the approach to these patients.

Not sure if it’s the same one, but there is a Dr. Kemeny referenced in the notes, a few times.
Aug 2015- Stage 4 CC with liver Mets(38/m)
Sep 2015- Avastin/Folfox/Iron
Dec 2015-Not liver surgery candidate
Jan 2016- Erbitux/Folfiri, 2nd opinion at MDA in TX
Feb 2016 -MDA liver surgery
Mar 2016 -30% of left lobe rem, PVE
May 2016 - 70% of liver rem
Jun 2016-Rad
Jan 2017-perm colost @MDA
Jul 2017-Erb/FOLFURI
Nov 2017 -Lung & Liver ablations@MDA
Jan 2018 -Xeloda & Avastin mx
Jul 2018-Avast/FOLFURI
Sep 2018-Rad
Mar 2019 - Keytruda fail
Jun 2019 - FOLFURI
Aug 2019 - No more, quality time!

Pyro70
Posts: 156
Joined: Mon Jan 21, 2019 4:25 pm

Re: Stage IV, what happens after surgery?

Postby Pyro70 » Fri Apr 26, 2019 12:19 pm

mpbser wrote:The following information in this article shocks me: "In view of the available data regarding the lack of benefit from [post liver resection] adjuvant irinotecan plus fluorouracil (FU), cetuximab, and bevacizumab, we would consider that FOLFIRI (irinotecan plus leucovorin [LV] and short-term infusional FU) and any regimen containing cetuximab or bevacizumab are not acceptable options."

If this is the case, why is Dr. Kemeny's adjuvant chemo of choice Folfiri????


The big challenge here is that (almost) all the adjuvant data comes from stage iii cancer. Stage IV is potentially a different animal. I doubt the Doc mentioned would support adjuvant use of FOlFIRi for stage III. There is an argument to be made that after resection in stage IV it’s not the adjuvant setting, but instead the metastatic setting (because of the high likelihood of residual disease). In any case, I think it always warrants a discussion with the oncologist to understand the rationale for why they recommend one regime over the other and to make sure they follow the latest guidelines. (They do make mistakes - my oncologist at an NCI designated center suggested centuximab until I pointed out the latest data that it’s not really effective for right sided tumors. When I first mentioned it to her I was surprised to hear her say she wasn’t aware of that yet!). I think as a patient it’s also helpful to know all the facts and limitations of the data. If you start on FOLFIRi but it’s too toxic, you likely feel better downstaging to xeloda knowing the data for FOLFIRI is weak anyways.
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

rp1954
Posts: 1535
Joined: Mon Jun 13, 2011 1:13 am

Re: Stage IV, what happens after surgery?

Postby rp1954 » Fri Apr 26, 2019 3:39 pm

Treatments' possibilities and probabilities change with your cancer's characteristics. Old, established treatments often were so harsh, mis-aimed or incomplete in some aspect, that that they were a factor in acceptance or even survival. Some chemo could be more satisfactory if or when somebody(s) does a better job on personalized formulation, predictors and monitoring. 5FU drugs have lots of good, cheap modulation options that go untended for commercial+regulatory reasons.

The other area that I am critical, is timeliness. If you're going to fight an actual metastasis already somewhere "in the pipeline", sooner than later should be better if the treatment is mild and post-op healing is rapid. After that last surgery, we made it a point to restart chemistries, each ASAP, or even during surgery, but we were dealing with what was considered an inherently seeded situation.

Things you see in studies correlate with things like MSI/MSS, markers pre-op/post op like CEA, CA199, LDH, Kras/Braf status, location or right-left side, differentiation. You guys might want to mention those in your signatures. We were very satisfied with more guided applications of chemistry components, from 5FU to mild adjuncts that way, to gain specific advances, avoid big mistakes, and tweek ordinary problems.
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

Tdubz
Posts: 152
Joined: Sun May 07, 2017 11:01 am

Re: Stage IV, what happens after surgery?

Postby Tdubz » Fri Apr 26, 2019 8:31 pm

Pyro70 wrote:
Tdubz wrote:my surgeon initially thought I wouldn’t need chemo either, but that I’d need to talk to a medical onc just to make sure. The onc I was assigned to is the lead for this immunotherapy clinical trial. It seems like the trial is the route they are wanting me to go. I’m not opposed to the trial at all, I just want to get the full picture of all my options.



TDubz,

To get the full picture I suggest reading the current up-to-date article on the subject:
https://www.uptodate.com/contents/management-of-potentially-resectable-colorectal-cancer-liver-metastases

Basically there isn’t a lot of data to guide decisions after hepametasectomy. irinotenic is not considered effective in the adjuvant setting. Oxaliplatin is a good option, but if you have neuropathy you’re no longer eligible. So that really only leaves 5FU/Xeloda. I think a lot of oncs would suggest that, and that’s probably what I would do assuming there is no major toxicity. Not sure what the trial is, do you have more info on it?


Here is the trial.

https://clinicaltrials.gov/ct2/show/NCT03436563

I believe it’s a new immunotherapy they are testing. If you google m7824, it think you can find some more information about the drug. I’ll find more out about the trial in a few weeks if I qualify.

Here’s an article I found about m7824.

https://www.google.com/amp/s/immuno-onc ... 824/%3famp

Pyro70
Posts: 156
Joined: Mon Jan 21, 2019 4:25 pm

Re: Stage IV, what happens after surgery?

Postby Pyro70 » Fri Apr 26, 2019 8:58 pm

Tdubz wrote:
I believe it’s a new immunotherapy they are testing. If you google m7824, it think you can find some more information about the drug. I’ll find more out about the trial in a few weeks if I qualify.

Here’s an article I found about m7824.

https://www.google.com/amp/s/immuno-onc ... 824/%3famp


Thanks for sharing. Interesting trial. I’m sure many on here would appreciate if you keep us updated on how it’s going.

But I must not be understanding your situation fully. Since you’re currently NED I would imagine you’re not eligible for this trial. Im surprised finding ctDNA, despite being NED radiologicaly, would make you eligible since the science of ctDNA isn’t fully worked out yet.
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


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