Rising Liver Enzymes - Looking for advice

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Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Rising Liver Enzymes - Looking for advice

Postby Lo-oc » Wed Apr 27, 2022 8:22 am

Hi,
I have decided to post to this forum, newly diagnosed and very discouraged, I come here often to read other's advice or words of encouragement. I have not handled the diagnosis well, and the stage 4 sent me off the deep edge. I am so inspired by reading everyone's battles so trying to buck up. I have gone through 3 cycles of Folfox 6 with the anticipation of doing 6 infusions before liver and rectal resection surgeries, then clean up with another 6 cycles. The liver surgeon told me the mets are resectable initially, but he would like to see some shrinking, especially with the met near the portal vein. Cycle 3 left my WBC low, so an injection of neulasta last cycle, and a slight reduction in bolus 5FU. Went for the fourth treatment and liver enzyme had shot up to ALT 319/AST 127, bilibrium is at .5. Dr would not treat me, sent me for US looking for blockages, none noted, and initially visible liver mets were not visible (I understand ultrasound won't pick up mets as well as CT). Going for CT/MRI next week to see what is going on with the liver. I worry about progression of disease. (I tend to always look at things worst case scenario)
My question, is such a large jump in liver enzymes a sign that I will not be able to do chemo? I need the liver healthy to have the resection, is the fluctuations due to the oxy, do these enzymes tend to go back down? I am learning that the chemo affects all differently, and these treatments don't always go without some complication. My fears are that my body will not tolerate chemo which will leave me with no options. Any advice on fluctuating liver enzymes?
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

roadrunner
Posts: 258
Joined: Sun Jan 12, 2020 8:46 pm

Re: Rising Liver Enzymes - Looking for advice

Postby roadrunner » Wed Apr 27, 2022 11:38 am

My AST and ALT were both high during chemo. They ran in the range of ALT 150/AST 60-70. Alkaline Phosphatase reached 396 once. Bilirubin was always normal.

I had no liver involvement, which cuts both ways, I think. First, it would suggest that your rises may be unrelated to your metastatic disease. But it wouldn’t confirm that, of course, and that is likely why your oncologist is being careful. In my case, at least, my oncologist felt it was the Oxi, and pulled it for one treatment, then resumed. Lovenox (enoxaparin) can also cause this kind of thing, though in my case the enzymes remained only mildly elevated after the Oxi was dropped, and we ultimately resumed it without too much trouble (though I did “sandwich” FOLFOX, 6/8 w/Oxi, and don’t recall exactly how things went. I *think* the no-Oxi rounds were 3 & 8?).

You’re focusing on the right thing, and it’s very important that your onc gets this right. FOLFOX is great stuff, even though it beats the living daylights out of you. You need to get the right balance, and this is a big part of that.

There are also a lot of research papers on this out there (I remember reading tons!) if you are so inclined.
7/19: Rectal cancer: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (side effects/reduced 70-75%)
neoadjuvant chemorad 11/19
4 rounds FOLFOX July-August 2020
ncCR 10/20; biopsies neg
TAE 11/20, tumor cells removed
Chest CT 3/30/21 small growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
CT 3/22: Clear
Thoracic CT 5/19/22 Clear
6/20/22 TAE rectal polyp benign

roadrunner
Posts: 258
Joined: Sun Jan 12, 2020 8:46 pm

Re: Rising Liver Enzymes - Looking for advice

Postby roadrunner » Wed Apr 27, 2022 11:51 am

I edited the above post to reflect what I found in my records.

I also noted that I missed a few things. My statement about your onc being careful because of the mets is probably wrong. Your enzymes alone would likely do that, as did mine. But if the elevated enzymes are due to the Oxi, yes, they come down, and as my case shows you can likely even tolerate more Oxi. Of course, YMMV, and your metastatic disease may be a factor. Your oncologist should be able to address this issue. Finally—hang in there! These are definitely tough times, but they will get better, and you have some positive things happening as well (resectable, and maybe even a response (pending the future scans)). Good luck!
7/19: Rectal cancer: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (side effects/reduced 70-75%)
neoadjuvant chemorad 11/19
4 rounds FOLFOX July-August 2020
ncCR 10/20; biopsies neg
TAE 11/20, tumor cells removed
Chest CT 3/30/21 small growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
CT 3/22: Clear
Thoracic CT 5/19/22 Clear
6/20/22 TAE rectal polyp benign

MadMed
Posts: 146
Joined: Sun May 02, 2021 5:52 pm
Location: Massachusetts

Re: Rising Liver Enzymes - Looking for advice

Postby MadMed » Wed Apr 27, 2022 6:00 pm

Same here, my ALT and AST both shot up during chemo and went back to normal afterwards. None of that concerned my onc, the only numbers she cared about are WBC and lymphocytes.
I did miss 2 treatments due to being in the ER, so i delayed chemo twice by one week. As RR said, hang in there, i was admitted twice during my treatment, once almost had an aortic disection.
Still here, still hopeful.
52M DX: RC lower rectum, guessing now 2cm from AV 4/27/2021
T3N0M0 adenocarcinoma with signet ring cell features
Tumor size 30mm
Tumor grade: G3
Baseline CEA 1.0
MSI status: MSS pMMR
Started Folfox 5/12/2021
Switched to FOLFIRINOX from session 2. 8 rounds total.
CT+MRI tumor contained shrunk 80%, no spread to other organs.
CRT started xeloda + 28 days Radiation 9/27-11/04
NED as of 4/06 CT/MRI/sigmoidoscopy
On W&W 04/06/2022

Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Re: Rising Liver Enzymes - Looking for advice

Postby Lo-oc » Wed Apr 27, 2022 6:15 pm

That’s encouraging to hear, I was only able to discuss with the PA about the liver enzymes and she didn’t tell me much, sounds like you’ve had a bumpy road as well, so nice to see you are in a good place
It’s concerning to miss a treatment, feel like I’m losing any ground I may have made even though they assure me a2week delay will be ok. It is good to get a break from the folflox and hoping the blood levels go down.
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

Rock_Robster
Posts: 690
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Rising Liver Enzymes - Looking for advice

Postby Rock_Robster » Wed Apr 27, 2022 6:28 pm

As high as those numbers might seem, that’s not a massive jump for a chemo patient. My ALT/AST got to over 800 by my 3rd round of FOLFOX, and steadily recovered by itself after that even while on chemo. My onc wasn’t the least bit concerned; said that over 1,000 he might start reducing the dose. I had a liver resection after 6 cycles with no issues.

The “normal” ranges don’t apply to patients doing chemotherapy, and he said the main thing was that I wasn’t showing any symptoms of liver injury (jaundice, fluid retention, pain etc). Also the ratios are relevant too - ideally you want AST well below ALT (as yours is).

They’ll watch WBC and neutrophils like a hawk, as things can go really bad if these get too low. But fortunately Neulasta usually works really well to boost these up (even if it does make you feel like you’ve fallen off your roof).

Four cycles might be enough to go to liver resection now anyway - might be worth checking. Many liver surgeons would prefer no more than 6 cycles due to potential for liver damage making resection riskier. I had a CT done after 4 cycles which showed a good response, so we agreed to do 2 more then go to surgery after a 4-week washout period.
40M Australia
2018 Dx RC, 12cm high
G2, EMVI, LVI. 4 liver mets
pT3N1aM1a Stage IVa. MSS NRAS G13R
CEA: Nov-18= 14; then <2. Jun-22: 5
11/18 FOLFOX x6
3/19 Liver resection
5/19 25x pelvic IMRT radiation
7/19 ULAR & ileo (reversed)
8/19 Liver lesion
8/19 FOLFOX, FOLFOXIRI, FOLFIRI x7
12/19 Liver resection
NED
11/21 Liver met & celiac node; 2-3 tiny lung things
12/21 PVE
3/22 Nodal spread & 3 liver mets. Lymphadenectomy
4/22 Liver SBRT
6/22 Liver looks good. Still some small lung things

Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Re: Rising Liver Enzymes - Looking for advice

Postby Lo-oc » Wed Apr 27, 2022 6:40 pm

That is so reassuring to hear, I appreciate the input. Rock_Robster, did they delay any of your treatments, or did your enzymes just recover? I think the CT/MRI scans will show if there is any liver injury?, I believe my other numbers are all in the normal range, will be following up with liver surgeon so may see what he thinks about a surgery before 6 rounds of Folfox. Thank you and all the best...
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

Rock_Robster
Posts: 690
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Rising Liver Enzymes - Looking for advice

Postby Rock_Robster » Tue May 03, 2022 3:20 am

Lo-oc wrote: did they delay any of your treatments, or did your enzymes just recover? I think the CT/MRI scans will show if there is any liver injury?


You’re welcome. No delays to the plan - just carried on as usual and enzymes recovered as we went.

If liver injury got bad enough then yes it would probably show up on a CT/MRI, but I don’t know for sure. They did note during my surgery that parts of my liver were a bit ‘blue’ (technically known as sinusoidal obstruction syndrome, which is common after elevated enzymes), but my surgeon wasn’t concerned and all recovered fine. Livers are remarkably tough!
40M Australia
2018 Dx RC, 12cm high
G2, EMVI, LVI. 4 liver mets
pT3N1aM1a Stage IVa. MSS NRAS G13R
CEA: Nov-18= 14; then <2. Jun-22: 5
11/18 FOLFOX x6
3/19 Liver resection
5/19 25x pelvic IMRT radiation
7/19 ULAR & ileo (reversed)
8/19 Liver lesion
8/19 FOLFOX, FOLFOXIRI, FOLFIRI x7
12/19 Liver resection
NED
11/21 Liver met & celiac node; 2-3 tiny lung things
12/21 PVE
3/22 Nodal spread & 3 liver mets. Lymphadenectomy
4/22 Liver SBRT
6/22 Liver looks good. Still some small lung things

Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Re: Rising Liver Enzymes - Looking for advice

Postby Lo-oc » Wed May 04, 2022 12:40 pm

MRI today, results show prior liver mets, shrinking (2.3 to 1.1 cm and 1.2 cm to .9cm) after 3 treatments of Folflox, the fourth was canceled due to the rising liver enzymes. There is notation of multiple hepatic cysts (are these the same as hepatic hypo-densities) ? with a .7 cm hemangioma that is stable and mild hepatic steatosis. the rectal tumor is now "difficult to discretely visualize. Meeting with rectal surgeon tomorrow, will be doing radiation. There was notation of a 4mm gallbladder polyp? not sure what that means.

with the liver, has anyone had Folflox cause mild hepatic steatosis, and if so, does that make the liver not as healthy for resection? I am not meeting with oncologist until next Monday when my fourth infusion should go forward, depending on blood work. My liver enzymes did come down from 319 to 218 ALT and 127 to 82 AST from last week's recheck. Not sure if infusion will happen, but I feel missing infusions will allow the cancer to start spreading more. I am just starting out and have a lot of treatments/surgeries going forward - IF things go according to plan.
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

stu
Posts: 1567
Joined: Sat Aug 17, 2013 5:46 pm

Re: Rising Liver Enzymes - Looking for advice

Postby stu » Wed May 04, 2022 2:48 pm

Hi ,

Honestly it does sound to me as though this is going in a good direction . That’s great shrinkage after three rounds and my mum’s enzymes went up as well . We anticipated it would . She went on to have not one but two resections in her liver . The second being 73% removed . She was 69 at the time .
She had chemo over two years and they felt a window of opportunity had opened up .
What I learnt , the liver surgeons know what they can and cannot achieve surgically . You started out operable and now in a better position . My mum had about two months with no chemo prior to surgery and it still went ahead .
It is totally understandable due to the nature of the disease to worry but it sounds as though you are responding well . You are reducing the tumour burden and will have a recovery period before surgery.
As others have said these are robust organs !
My mum is 11 years post resection next month and despite the trauma it went to her liver continues to function well .
Take care
Stu
supporter to my mum who lives a great life despite a difficult diagnosis
stage4 2009 significant spread to liver
2010 colon /liver resection
chemo following recurrence
73% of liver removed
enjoying life treatment free
2016 lung resection
Oct 2017 nice clear scan . Two lung nodules disappeared
Oct 2018. Another clear scan .

Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Re: Rising Liver Enzymes - Looking for advice

Postby Lo-oc » Wed May 04, 2022 5:05 pm

Stu:

Bless your mom, how amazing to hear how well she's done. It's helpful to hear how people have battled a stage IV diagnosis, I got caught up in hearing stage IV and looking at the statistics to realistically assess my situation. I am learning from reading other people's stories what questions to ask, what to expect with treatments and procedures. I am prepared for reoccurrence with this disease if I do get a handle on it, it's a very long battle that I'm sure I have no idea what I'm in for. Sounds like your mom has really fought it hard!
I was encouraged by the MRI results, for now I know the cancer is responsive to the Folflox - being turned away from the fourth treatment and getting no information about liver issues doesn't help
I thank all for your input!!
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

User avatar
Peregrine
Posts: 99
Joined: Tue Mar 01, 2022 1:18 am

Re: Rising Liver Enzymes - Looking for advice

Postby Peregrine » Fri May 27, 2022 11:58 am

Lo-oc wrote:... My question, is such a large jump in liver enzymes a sign that I will not be able to do chemo? I need the liver healthy to have the resection, is the fluctuations due to the oxy, do these enzymes tend to go back down? I am learning that the chemo affects all differently, and these treatments don't always go without some complication. My fears are that my body will not tolerate chemo which will leave me with no options. Any advice on fluctuating liver enzymes?

FYI, here is the section on Hepatotoxicity from the Oxaliplatin manufacturer's package insert:

    5.6 Hepatotoxicity
    In the adjuvant treatment trial, increased transaminases (57% vs 34%) and alkaline phosphatase (42% vs 20%) occurred more commonly in the ELOXATIN arm than in the fluorouracil/leucovorin arm. The incidence of increased bilirubin was similar on both arms. Changes noted on liver biopsies include: peliosis, nodular regenerative hyperplasia or sinusoidal alterations, perisinusoidal fibrosis, and veno-occlusive lesions.

    Consider evaluating patients who develop abnormal liver tests or portal hypertension which cannot be explained by liver metastases, for hepatic vascular disorders. Monitor liver function tests at baseline, before each subsequent cycle and as clinically indicated.


    Reference: https://www.accessdata.fda.gov/drugsatf ... 023lbl.pdf

Also, please note that there is a special kind of MRI that does angiogram-like images showing blood flow patterns in the liver. Is this the kind of MRI you had? https://radiopaedia.org/articles/liver-protocol-mri

Lo-oc
Posts: 21
Joined: Sat Mar 26, 2022 4:40 pm

Re: Rising Liver Enzymes - Looking for advice

Postby Lo-oc » Fri May 27, 2022 2:27 pm

Thank you for the links. I appreciate your time in sharing a lot of really helpful information !!!
2/22 - Dx with stage 4 rectal cancer 4cm on/1cm from AV - age 60
T4, poorly diff., EMVI + MSS
3/22 - CT/MRI 2 liver mets 2.1 cm and 1 smaller close to hepatic vein
3/22 Infusion - plan 6 treat. Folflox 6, liver res., chemoradiation, rectal surgery 6 more cycles Folfox
5/5 - CT/MRI, lung nodules no change, liver lesions red. to 1.1 and .9cm, rectal tumor/suspicious lymph node red..

User avatar
Peregrine
Posts: 99
Joined: Tue Mar 01, 2022 1:18 am

Re: Rising Liver Enzymes - Looking for advice

Postby Peregrine » Sat May 28, 2022 1:55 pm

Lo-oc wrote:Thank you for the links. I appreciate your time in sharing a lot of really helpful information !!!

You're welcome.


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