New to liver mets. Need advice please

[betula]

Hi all,

My husband was diagnosed with rectal cancer in 12/2016. He had chemo, radiation, surgery and more chemo he was good for a bit. Then in follow up CT scans in June of 2018 they found a recurrence at his original location and two small mets to the lungs. They said the lung mets were inoperable. They put him on folfiri which he had a hard time with but was also having small bowel obstructions and the same time. He made it through about 8 folfiri treatments. Eventually he had surgery to correct the problem causing the small bowel obstructions and was then put on 5fu for maintenance which is going fine.

So here we are more than a year after being diagnosed stage IV with the lung mets and they have grown just a very small amount but at last scan they found "hypodense lesions suspicious for metastatic disease"on his liver. There is one in segment 5 measuring 1.8 x1.4. Another one that is very small and no measurement with it is in segment 8. Prior scan in June did not show these. All liver function tests are fine. He does continue to have low hemoglobin and occassionally has blood transfusions or iron.

Unfortunately I was not at the doctors appointment when this was discovered but will be going to the one on Monday. Husband said they would keep an eye on these lesions and rescan soon. My question is will they look at the possibility of an ablation or resection given he has other lung mets and recurrence at the original location? I feel like all I have read about are people on their initial diagnosis that have liver mets getting resections, etc.

My husband tumor is KRAS g12v and the oncologist has a "vaccine" that has been created for his mutation and it can be only used after chemo is deemed to be no longer effective. At the last appointment the oncologist alluded to these lesions showing it is not effective any more. This vaccine has always been presented to us as the last effort for his cancer. I feel like the oncologist is so anxious to use this vaccine because from what I understand it has never been used before and I worry that he would forgo other things just to be the first to use this vaccine. Obviously that would not be ethical but I can't help but wonder.

Sorry for this being so long but if you have any info on what to expect for the liver lesions, I would appreciate it as this is new territory for us.

My best to all,
Betsy

[Rock_Robster]

Hi Betsy,

Whilst I’m not a doctor/surgeon and haven’t seen his scans, depending on the locations those two liver lesions do sound potentially within the realm of resectable or ablatable (presuming those measurements are centimetres). The question is whether surgery would confer a material survival benefit in the presence of extrahepatic disease, and whether the potential risks and negative impacts of surgery warrant this.

Many surgeons are reluctant to operate if there will still be macroscopic disease left. The argument here is that if complete removal can’t be obtained, then the benefits do not justify the negative effects of surgery - in particular a couple of months off chemo, the diminished quality of life and risk of complications, plus the risks of creating a pro-metastatic environment for remaining tumours.

That said, isolated lung disease does sometimes appear to be an exception. Lung mets sometimes can grow very slowly, and may be treatable in future through things like ablation or radiation (SABR). Have they said why the lung mets are not considered operable, or considered any alternative treatments?

Since it was identified last year - have they proposed any intervention for the local recurrence? Whilst I would definitely still be getting the opinions of high-volume hepatobiliary and thoracic surgeons, rectal surgery may end up being the more complex consideration here - and perhaps a liver procedure (if appropriate) could be combined with that.

Best of luck,
Rob

[Rob in PA]

Hi Betsy,
I'm wondering, have the lung mets been considered for SBRT (stereotactic body radiation therapy)? I had several lung thingies zapped with SBRT which was quite successful.
I do understand that some docs don't like to do surgery on mets if it is in multiple organs, but perhaps if he got the lung thingies zapped, then he possibly would be a candidate for liver resection.
I had liver mets and had over 60% of my liver resected successfuly. It grew back within 4 weeks....amazing thing that liver!

Anyhow, best of luck to you and your husband Betsy

Rob from PA