HAI pump or liver resection? Next steps?

[Vana3]

Is anyone aware of what qualifies you for a HAI pump? Or a liver resection? I have very small spots on liver, 2 that are under 3cm and up to 4 more that have disappeared since starting chemo. I have done 6 treatments. When I had my colon surgery they found one omentum deposit which was removed. I have no evidence of disease at this time anywhere else besides liver...according to PET, MRI, and CT scans.
We want to be aggressive but it seems like the omentum spot is an issue. Should I be getting exploratory surgery to check my abdomen for peri Mets so that I can be considered for more aggressive liver treatments? We are trying to figure out what’s the correct next step...

[ginabeewell]

Have you asked if you are operable? Or if not, what’s preventing you from being operable? If you haven’t had a surgical consult, I would think now is the time to request it.

The HAI pump is primarily used when mets are contained to the liver, so I’m not sure how the deposit you referenced would or world not impact that. Some patients use it to get to the point of being resectable, and others it seems wind up using it primarily to prevent recurrence. It didn’t help me to shrink my mets much. Luckily a surgeon was still willing to do a two-part resection. And I’m glad I have it if only to prevent recurrence!

I found that my home hospital was pretty dismissive of the pump, even though they were one of very few institutions that offered it. Ditto Cleveland Clinic when I had a consult there. So don’t be surprised if you get a lukewarm response if you ask about it. Sounds like MSK in NY and City of Hope in CA are the only two places really pushing the pump these days.

[Rock_Robster]

The criteria for HAI are usually hospital policy-driven. In some centres this means no metastatic disease outside the liver; others (like MSK & NIH) might be ok with some lung stuff if it’s minor and stable. I’ve not heard of anywhere taking on synchronous peri mets, but please don’t take that on any good authority.

Criteria for liver resection are constantly evolving and very surgeon-dependent. However some common ones are:
- The ability to preserve 25-35% of healthy contiguous liver mass
- The ability to achieve a margin of at least 1mm
- Ability to preserve or reconstruct major vasculature (eg hepatic artery, portal vein, etc)
- For some surgeons, extrahepatic disease is an issue. Others might be ok with organs that could also be treated curatively (eg lungs), but might hesitate with distant nodal disease (particularly the hepatic nodes)

Depending on how far “under” 3cm they are, the remaining spots might also be possible candidates for ablation rather than resection. Ultimately not much of these are hard-and-fast things; the best bet is to get to a high-volume, aggressive surgeon at a major centre and get their opinion directly.

It sounds like you’ve done a decent job of ruling out the omentum mets as a current issue; and if you have liver-limited disease you should get a much more positive reception from liver surgeons, and potentially a path to curative treatment. If they want an abdo scope to be sure then I guess you could do that too (or maybe they could do at the same time as liver surgery). If resectable now, then it seems more likely you would do surgery first then consider adjuvant HAI to reduce recurrence risk (if it’s available where you are).

Best of luck,
Rob

[Vana3]

Thank you so much Gina and Rob for your insights! My small town hospital set me up with a surgeon to talk to last week and he contradicted himself quite a bit through out the conversation which was concerning, but his opinion was pretty negative so the Extra hepatic disease was a major issue for him, he went as far as saying I need a debulking surgery which was confusing to me since there is no evidence of disease in abdomen at this time. When I had the colon resection in July our surgeon scoped my entire abdomen, he found the one small nodule and everything else looked so clear he did not think this spot was even cancerous. All abdomen scans have been clear since...
Our specialist at Dana Farber believes if things remain stable that meeting a surgeon for a liver resection is a next step.
We thought we should ask about the Hai pump as well... we are going to send our info to Dr.Kemeny at MSK and find out her opinion.... but I think you are right that we need to go to a specific liver surgeon that’s willing to be aggressive and get the opinions from the right doctors I guess...