Postby Rock_Robster » Wed Dec 01, 2021 11:08 pm
Hi all, bit of a long post, but appreciate any and all advice and thoughts on offer.
After resolving a mix-up with the surgeon reviewing the wrong patient’s imaging (really), it looks like what I’m dealing with now is:
1. A definite single recurrent liver lesion (30x24mm) in a difficult spot near the start of the right hepatic vein, and an avid portacaval node inside the liver
2. A suspicious celiac node outside the liver - still only 10mm but some tracer uptake
3. Four tiny indeterminate lung lesions, ~2mm or less. Not PET-avid, too small to biopsy.
#1 is resectable, but it’s a high-risk surgery as it involves removing and reconstructing the hepatic vein. The key risk is catastrophic bleeding, which for a large vessel near the heart probably results in a quick finish. I got the impression my surgeon would however do the op if #1 were the only issue. The other option to treat this lesion would SBRT radiation (with a somewhat reduced dose due to proximity to the heart). It is too close to the vessel to ablate, and IRE is no good due to surgical clips in-field.
#2 is also likely resectable. However his view is that *if* this node is metastatic, then this represents distant nodal disease which means there is likely no overall benefit to me from having liver surgery now. And certainly not enough benefit to justify a high-risk surgery. SBRT ablation on this node could also be an option.
#3 is highly indeterminate. Clearly in the setting it’s concerning, but they’re also small enough to be a lot of other things - infection, inflammation, artefacts. No way to confirm yet.
So the plan now is that the MDT radiologist is going to go through all of my past scans, and see if they can correlate this celiac node. If they can convince themselves it’s perhaps not malignant, then he is likely to recommend liver surgery now - and they’ll also grab that node to be safe. And we check the lungs again in a couple of months.
If they decide the node is positive, then it sounds unlikely he will operate now. The recommendation would likely be some systemic chemotherapy to confirm response, then either SBRT radiation on everything (liver, node, and possibly lungs), or if it was a good nodal response (ie turned PET-negative) then perhaps surgery could be back on the table. This would also give time to learn a bit more about the lungs (but risks further progression somewhere).
The other idea would be to go ahead with the surgery now even if they decide the node is positive; remove everything cancerous they can see, hope I survive the operation, and then hope for the best. If something recurs, we deal with it (surgery, ablation, SBRT or chemo). I don’t think he is likely to support this option, but I don’t mind it.
I’m talking to my oncologist again tonight, and will discuss chemo options and also start floating trials ideas.
I’m open to any and all thoughts folk have, particularly around the potential benefit of complete resection of visible disease even in the setting of potential distant nodal progression (which might suggest non-curative intent for the surgery).
Thanks as always,
Rob
41M Australia
2018 Dx RC
G2 EMVI LVI, 4 liver mets
pT3N1aM1a Stage IVa MSS NRAS G13R
CEA 14>2>32>16>19>30>140>70
11/18 FOLFOX
3/19 Liver resection
5/19 Pelvic IMRT
7/19 ULAR
8/19 Liver met
8/19 FOLFOX, FOLFOXIRI, FOLFIRI
12/19 Liver resection
NED 2 years
11/21 Liver met, PALN, lung nodules
3/22 PVE, lymphadenectomy, liver SBRT
10/22 PALN SBRT
11/22 Liver mets, peri nodule. Xeloda+Bev
4/23 XELIRI+Bev
9/23 ATRIUM trial
12/23 Modified FOLFIRI+Bev
3/24 VAXINIA (CF33 + hNIS) trial