cancer on peritoneum

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aam7.00
Posts: 13
Joined: Tue Dec 17, 2019 10:44 am

cancer on peritoneum

Postby aam7.00 » Thu Mar 12, 2020 8:59 am

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
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine

JJH
Posts: 249
Joined: Mon Apr 24, 2017 7:26 am

Re: cancer on peritoneum

Postby JJH » Fri Mar 13, 2020 2:46 am

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.

aam7.00 wrote:" 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
Last edited by JJH on Sat Mar 14, 2020 1:38 am, edited 2 times in total.

boxhill
Posts: 490
Joined: Fri Apr 06, 2018 11:40 am

Re: cancer on peritoneum

Postby boxhill » Fri Mar 13, 2020 8:07 pm

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.
F, 64 at DX CRC Stage IV
3/17/18 blockage, r hemi
11 of 25 nodes,5 mesentery nodes
5mm liver met out
pT3 pN2b pM1
BRAF wild, KRAS G12D
dMMR, MSI-H
5/18 FOLFOX
Neulasta 6/28
7/18 CT NED
11/18 CT NED
12/18 MRI 5mm liver mass, 2 lymph nodes in porta hepatis
12/31/18 Keytruda
6/19 Multiphasic CT LNs normal, Liver stable
6/28/19 Pause Key, predisone for joint pain
7/31/19 Restart Key
9/19 CT stable
Pain: many fails before Celebrex helps
12/23/19 CT stable

Rock_Robster
Posts: 471
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: cancer on peritoneum

Postby Rock_Robster » Fri Mar 13, 2020 10:25 pm

boxhill wrote: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
Male 38; Australia
10/2018 Dx 3.5cm RC adenocarcinoma, 12cm from AV
Mod diff, EMVI+ LVI+. 4 liver mets
pT3N1aM1a; Stage IVa. MSS, NRAS (G13R)
CEA: Oct-18= 12; Nov-18= 14, Mar-19= 2.4, Aug-19 <2.0, Mar-20=2.2
11/18- FOLFOX x6
3/19- Liver resection
5/19- 25 x pelvic VMAT radiation; complete metabolic response
07/19- ULAR (robot), temp ileo, 1/27 LN
08/19- Missed a liver spot
08-11/19- FOLFOX x1, FOLFOXIRI x1, FOLFIRI x5
12/19- Liver resection #2
02/20- Ileostomy reversed
03/20- PET & MRI = NED!

Wewillfight
Posts: 22
Joined: Sun Mar 03, 2019 5:27 am

Re: cancer on peritoneum

Postby Wewillfight » Tue Mar 17, 2020 7:43 pm

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.
40 y/o
Diag Nov 2016 stage IIIc, surgery, colostomy, 2 lymph involved
6 months FOLFOX
NED
Nov 2018 recurrence , surgery , some spread to pertineum
Jan-June 2019 Folfiri+Cetux
Clear scans
August 2019: small bowel inflammation, partial blockage symptoms

aam7.00
Posts: 13
Joined: Tue Dec 17, 2019 10:44 am

Re: cancer on peritoneum

Postby aam7.00 » Sat Mar 21, 2020 9:10 am

boxhill wrote: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.
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine

aam7.00
Posts: 13
Joined: Tue Dec 17, 2019 10:44 am

Re: cancer on peritoneum

Postby aam7.00 » Sat Mar 21, 2020 9:13 am

Rock_Robster wrote:
boxhill wrote: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
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine

aam7.00
Posts: 13
Joined: Tue Dec 17, 2019 10:44 am

Re: cancer on peritoneum

Postby aam7.00 » Sat Mar 21, 2020 9:15 am

Wewillfight wrote: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
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine

boxhill
Posts: 490
Joined: Fri Apr 06, 2018 11:40 am

Re: cancer on peritoneum

Postby boxhill » Sun Mar 22, 2020 9:01 am

Excellent! Hope it goes well.
F, 64 at DX CRC Stage IV
3/17/18 blockage, r hemi
11 of 25 nodes,5 mesentery nodes
5mm liver met out
pT3 pN2b pM1
BRAF wild, KRAS G12D
dMMR, MSI-H
5/18 FOLFOX
Neulasta 6/28
7/18 CT NED
11/18 CT NED
12/18 MRI 5mm liver mass, 2 lymph nodes in porta hepatis
12/31/18 Keytruda
6/19 Multiphasic CT LNs normal, Liver stable
6/28/19 Pause Key, predisone for joint pain
7/31/19 Restart Key
9/19 CT stable
Pain: many fails before Celebrex helps
12/23/19 CT stable


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