cancer on peritoneum

[aam7.00]

Hello Folks,

I need suggestion on my treatment.

BACKGROUND : I was diagnosed with Colon cancer-stage 3c( rectosigmoid junction). I had chemo-radiation for 5 weeks and surgery was scheduled for feb, but was cancelled when they found multiple peritoneal nodules in the peritoneum and small bowel mesentery. They measured three nodules measuring .5cm, .8 cm and 1 cm. They decided for neoadjuvant chemo and once the disease is contained, they will go for CRS with or without HIPEC

I have been reading the forum and a few papers on the internet, where they mention upfront surgery if the PCI index is low( less than 6).
I believe the PCI index is low in my case, still, although I have spoken to three oncologists and they all agree on chemo first, so I am not sure if I am headed to the right direction

MSI testing revealed i am not eligible for immunotherapy, however, I tumour gene type TP53.
The doctor said, its wild type, but i am not sure if its KRAS OR NRAS? can anyone please confirm

One doctor says, he will go for 5FU+ oxaliplatin+ Bevacizumab and other one says, capecitabine+ Oxaliplatin+cetuximab, so i am also confused about my chemo regimen.

Please advise

Regards,
Aamir

[JJH]

Hi Aamir -

From what you have said so far, it looks like your biomarker test results are:
- MSI status = "MSS (microsatellite stable)" i.e., not MSI-high
- KRAS/NRAS status = "KRAS wild-type" i.e., not KRAS/NRAS mutated
Is that correct?

Your current stage seems to be:
Stage = "Stage 3b , mCRC recurrent with mets to peritoneum"
Is that correct?

In the United States, treatment standards are outlined in the NCCN Rectal Cancer guidelines. You can read the relevant sections there to get an idea what they recommend as treatment for mets to peritoneum.

The 2017 NCCN guideines for Rectal Cancer are contained in this 154-page document:
https://www2.tri-kobe.org/nccn/guideline/colorectal/english/rectal.pdf

The discussion on peritoneal mets is found in section MS-31 and starts on page 76 of the document. It covers the topics of:

Peritoneal Carcinogenesis and
Cytoreductive Debulking (CRS) with Heated Intraperitoneal Chemotherapy (HIPEC)

The discussion of chemotherapy treatment plans is found in section MS-36 and starts on page 81 of the document.

" 5FU+ oxaliplatin+ Bevacizumab and other one says, capecitabine+ Oxaliplatin+cetuximab"

Please note that the 2 regimens you mentioned above are known by several different names, including:

1. = FOLFOX+Avastin(bevacizumab)
   
2. = XELOX+Erbitux (cetuximab) = CAPEOX+Erbitux (cetuximab)

You can look through section MS-36 above to see what they say about these regimens.

- - - -

There is another resource that you could consult. It is the MD Anderson decision tree for deciding optimal therapy regimens under various scenarios:

https://www.mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/cancer-treatment/ca-treatment-colon-web-algorithm.pdf

[boxhill]

My only comment is that if you want a surgical opinion you should consult a surgeon, not a series of oncologists. Where I am, one can be referred to the tumor board, which includes surgeons, radiologists of various types, oncologists, et al.

[Rock_Robster]

My only comment is that if you want a surgical opinion you should consult a surgeon, not a series of oncologists. Where I am, one can be referred to the tumor board, which includes surgeons, radiologists of various types, oncologists, et al.

I completely agree with this, and even more so for peritoneal surgery. This is a specialised area and the outcomes can depend significantly on the skill of the surgeon, so making sure you’re at a high-volume practice is important. Depending on where you live some folk here may be able to suggest some names too.

Good luck,
Rob

[Wewillfight]

Be aggressive. Push very hard for HIPEC , try every HIPEC specialist centre and push push push.

Dont hang around and dont count on chemo for Peri stuff

Sending lots of support on your battle ahead.

[aam7.00]

My only comment is that if you want a surgical opinion you should consult a surgeon, not a series of oncologists. Where I am, one can be referred to the tumor board, which includes surgeons, radiologists of various types, oncologists, et al.

I followed your suggestion, met a new experienced surgeon, he was surprised that the PCI score wasn't documented. He called the previous surgeon and asked him about the PCI index and he gave a vague answer.
That's when he decided to do a diagnostic laproscopy, had it this morning ( Indian standard time), and found out a PCI score of 2. So, no more palliative chemo and we are going for surgery. He has taken a sample of peritoneal fluid for cytology.

Getting discharged from the hospital now.

[aam7.00]

My only comment is that if you want a surgical opinion you should consult a surgeon, not a series of oncologists. Where I am, one can be referred to the tumor board, which includes surgeons, radiologists of various types, oncologists, et al.

I completely agree with this, and even more so for peritoneal surgery. This is a specialised area and the outcomes can depend significantly on the skill of the surgeon, so making sure you’re at a high-volume practice is important. Depending on where you live some folk here may be able to suggest some names too.

Good luck,
Rob

My previous surgeon , eve though he cancelled LAR due to peri mets, he failed to document PCI score and verbally said its low.
My current surgeon did a diagnostic laproscopy today and found PCI index is 2. So, I'm cleared for surgery, and chemo is to be stopped

[aam7.00]

Be aggressive. Push very hard for HIPEC , try every HIPEC specialist centre and push push push.

Dont hang around and dont count on chemo for Peri stuff

Sending lots of support on your battle ahead.

Thanks for your support

Looks like there is some silver lining, had a diagnostic laproscopy and found out PCI score is 2, so going for surgery in a week or so. Current surgeon feels, I shouldn't have been put to chemo

[boxhill]

Excellent! Hope it goes well.