Advice deciding between staged vs combined surgery

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hustlingpanda
Posts: 1
Joined: Sat Jan 22, 2022 12:05 am

Advice deciding between staged vs combined surgery

Postby hustlingpanda » Sat Jan 22, 2022 1:02 am

Hi all, this is my first post here and let me say I'm so glad this forum exists!

I was diagnosed with stage 4 colon cancer / liver mets just last year in May of 2021. Colon was 40% obstructed near splenic flexure and liver was about 80% covered in mets. Oncologist started me immediately on a course FOLFOXFIRI every other week, and added panitumumab to the mix about 3 cycles in. So far I've been extremely lucky - all tumors have shrunk by a large amount to the point where my colon obstruction is pretty much gone (still have tumor there / thickening of the walls) and my liver mets are down to 1 small (~3cm on the left side) and an 8x10cm on the right side that crosses over the middle. I also have a small tumor in my abdomen which is likely a lymph node but which might be peritoneal. My doctors say it's impossible to tell for sure until they open me up. After 12 cycles of chemo I've reached a point where resection is a possibility now and my team has proposed the following:

  • Chemo
  • Microwave ablation of the small liver met
  • Chemo
  • Laparoscopic resection of colon tumor + lymph node(s) (if that's what it is)
  • Chemo
  • Open resection of the remaining liver disease
  • Chemo (2-3 cycles)

I just had a PET scan today and assuming everything looks ok I'd be starting with the ablation sometime in February, which puts me at around June for the final surgery.

A couple of weeks ago, I got a second opinion at another hospital where the surgeon there recommended that I do a combined surgery, during which 2 teams will first perform the liver resection (and ablate the small tumor while I'm open on the table) and then the colon surgery. He says it's a little bit riskier but it's fewer surgeries and only one (albeit longer) recovery period.

My original surgeon feels like the liver operation is too intense to combine it with the colon surgery. He thinks I'm having too much liver removed to handle both at the same time. Both places are planning to resect between 80% and 70% of my liver.

Has anyone here had a combined liver + colon resection where they removed a large portion of the liver? What's the recovery like?

I've read a few posts on here about people who have had both but I'm not sure if their case is different because maybe the liver resection wasn't as complicated. I'm leaning towards the combined surgery so I can just get it all done in one go / asap, but I hope I'm not biting off more than I can chew. Any thoughts or advice? Many thanks in advance!

Detox
Posts: 61
Joined: Fri Apr 28, 2017 5:27 pm

Re: Advice deciding between staged vs combined surgery

Postby Detox » Mon Jan 24, 2022 12:02 am

That's great news on your shrinking tumors, a good sign.

I did surgery on both colon and liver at the same time, removing 1 met from my liver and a large part of my cecum.

The recovery period was about a week in the hospital.

Doctors did tell me the best thing to do is go in and get everything out in one shot, rather than having multiple surgeries, which makes sense since the less surgery you have to do, the better.

Rock_Robster
Posts: 1027
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Advice deciding between staged vs combined surgery

Postby Rock_Robster » Mon Jan 24, 2022 3:36 am

This is a great (and important) question.

There is quite a bit of research suggesting that combined surgeries are generally safe, and lead to a lower overall complication rate, fewer total days hospital stay, shorter overall treatment periods and less cost to patients. Interestingly (and perhaps surprisingly) it does not appear to actually have an effect on overall median survival rates, so the “get it all out now” mindset is potentially more around the personal impact on you and also disruption to your life, perhaps rather than reducing risk of spread or chemo resistance during the extended treatment period.

The big issue here however is - this is a big operation (in terms of % of liver), and you’ve also recently had heavy chemotherapy. I’ve heard rules of thumb suggesting 25% is the minimum residual liver segment needed to survive without any chemo exposure; and 35% with chemo exposure (due to likely liver injury). And you’re really walking the line here. The scary part about post-op liver failure is that it isn’t just a case of potentially a longer recovery or the need for more intensive support - if your liver fails post-resection there is often little that can be done and this can take you out very quickly and permanently. Not to scare you, but these are high stakes. I would be very inclined to defer to the guidance of very experienced specialist surgeons on this one, and don’t stop getting opinions until you’re comfortable.

Not an easy call; best of luck.

Rob

PS: for info, although my liver resection was small, I went for separate procedures as they wanted to do radiation before the rectal surgery but didn’t want to delay the liver. In the end all went fine; I had to have a 2nd liver resection shortly after for a lesion that was missed the first time - surgeon reckons it was always there but hiding (so I don’t think a combined surgery would have avoided that).
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


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