Liver surgery?

[Dennyp]

Hey all, I have some treatment decisions to make and was hoping for some collective wisdom. I have 2 lesions 1 on my diaphragm and 1 in my liver. My options are surgery to remove both tumors, this comes with a 5-8% risk of liver failure because of the location of the lesion, they would need to remove 2 veins and it’s close to a third. Option 2 is radiation to the liver and hope the diaphragm lesion behaves (I’ve been on chemo since March, diaphragm lesion is too small, to image, it was found on aborted liver surgery) chemo has fought the liver lesion to a standstill, it’s been stable since it was found. I’m not sure if I would need to continue chemo in scenario, I’m waiting to discuss with my oncologist. The third option is continued chemo. No option is curative. Thoughts?

[J-man]

Thoughts and JMO only here

1. does any option absolutely preclude any other option later ?
2. from what you have said the radiation / chemo route might be a good first choice and keep the surgery as last resort, given the risks.
3. get a second / third opinion ?

sending you my best wishes and support for your choices

[Dennyp]

Thoughts and JMO only here

1. does any option absolutely preclude any other option later ?
2. from what you have said the radiation / chemo route might be a good first choice and keep the surgery as last resort, given the risks.
3. get a second / third opinion ?

sending you my best wishes and support for your choices

Thanks for your response.

1. He said radiation will make the surgical option later unlikely.

2. That’s what I hoped but he’s says surgery is unlikely to be indicated after radiation.

3. I considered that, but he presented my case to the tumor board and got a split decision. Some thought the risks were worth it, others thought it was not. More opinions would only muddy the waters I think. He believes recurrence is 100% going to happen. I think that is why some were reluctant to recommend it. Others thought since I made it so long playing whack a mole it would be worth it. This is only my guess as to why the made their recommendations.

He said my case is a bit unusual in that surgery is even considered this many years out dealing with stage 4. So I’m in sort of uncharted waters here. As difficult as this decision will be, I’m happy to have choices.

[Rock_Robster]

Amazingly I faced a very similar decision around a year ago, just over 4 years after initial diagnosis. Do a portal vein embolisation (PVE) then resection of a significant liver lesion including 2 hepatic veins and an extrahepatic lymph node, or SBRT radiation of both liver lesion and lymph node. I wasn’t given a % risk of liver failure, but it was considered a higher risk resection. Both were considered potentially curative, but no-one was banking on this.

After a lot of discussion with the rad onc and my own reading, what became clear was that liver radiation had excellent disease control rates for up to 2 years, but after that was a lot less certain and local recurrence was a genuine risk. Of course this is also the case with surgery, but the recurrence rate is potentially slightly lower overall (and certainly at the resection site, if R0). Given at that stage we were still working with curative intent, I made the call to go for the surgery. A significant driver in my mindset was ‘no regrets’ - ie making sure that whatever call I made, I could sleep peacefully with.

I was also told that radiation would likely preclude later surgery, at least for 6 months but potentially permanently on that section of liver, which was a significant factor.

Good luck with your decision - it isn’t an easy one.

Cheers,
Rob

PS: interested in why they say neither option is curative, particularly the surgical path? I don’t know enough of your case to disagree, but important to understand the rationale.

[Pagola44]

Amazingly I faced a very similar decision around a year ago, just over 4 years after initial diagnosis. Do a portal vein embolisation (PVE) then resection of a significant liver lesion including 2 hepatic veins and an extrahepatic lymph node, or SBRT radiation of both liver lesion and lymph node. I wasn’t given a % risk of liver failure, but it was considered a higher risk resection. Both were considered potentially curative, but no-one was banking on this.

After a lot of discussion with the rad onc and my own reading, what became clear was that liver radiation had excellent disease control rates for up to 2 years, but after that was a lot less certain and local recurrence was a genuine risk. Of course this is also the case with surgery, but the recurrence rate is potentially slightly lower overall (and certainly at the resection site, if R0). Given at that stage we were still working with curative intent, I made the call to go for the surgery. A significant driver in my mindset was ‘no regrets’ - ie making sure that whatever call I made, I could sleep peacefully with.

I was also told that radiation would likely preclude later surgery, at least for 6 months but potentially permanently on that section of liver, which was a significant factor.

Good luck with your decision - it isn’t an easy one.

Cheers,
Rob

PS: interested in why they say neither option is curative, particularly the surgical path? I don’t know enough of your case to disagree, but important to understand the rationale.

I was also curious why they have told her it's not curable as well?

[Dennyp]

Amazingly I faced a very similar decision around a year ago, just over 4 years after initial diagnosis. Do a portal vein embolisation (PVE) then resection of a significant liver lesion including 2 hepatic veins and an extrahepatic lymph node, or SBRT radiation of both liver lesion and lymph node. I wasn’t given a % risk of liver failure, but it was considered a higher risk resection. Both were considered potentially curative, but no-one was banking on this.

After a lot of discussion with the rad onc and my own reading, what became clear was that liver radiation had excellent disease control rates for up to 2 years, but after that was a lot less certain and local recurrence was a genuine risk. Of course this is also the case with surgery, but the recurrence rate is potentially slightly lower overall (and certainly at the resection site, if R0). Given at that stage we were still working with curative intent, I made the call to go for the surgery. A significant driver in my mindset was ‘no regrets’ - ie making sure that whatever call I made, I could sleep peacefully with.

I was also told that radiation would likely preclude later surgery, at least for 6 months but potentially permanently on that section of liver, which was a significant factor.

Good luck with your decision - it isn’t an easy one.

Cheers,
Rob

PS: interested in why they say neither option is curative, particularly the surgical path? I don’t know enough of your case to disagree, but important to understand the rationale.

Hey Rob,

Thanks so much for your response, it’s really helpful. I’m not exactly sure why he is saying that other than the fact that I’ve been stage 4 for about 4 years and the recurrence is to 2 sites. I guess it’s to manage expectations but both surgeons and my oncologist have all told me the same thing.

[Dennyp]

Amazingly I faced a very similar decision around a year ago, just over 4 years after initial diagnosis. Do a portal vein embolisation (PVE) then resection of a significant liver lesion including 2 hepatic veins and an extrahepatic lymph node, or SBRT radiation of both liver lesion and lymph node. I wasn’t given a % risk of liver failure, but it was considered a higher risk resection. Both were considered potentially curative, but no-one was banking on this.

After a lot of discussion with the rad onc and my own reading, what became clear was that liver radiation had excellent disease control rates for up to 2 years, but after that was a lot less certain and local recurrence was a genuine risk. Of course this is also the case with surgery, but the recurrence rate is potentially slightly lower overall (and certainly at the resection site, if R0). Given at that stage we were still working with curative intent, I made the call to go for the surgery. A significant driver in my mindset was ‘no regrets’ - ie making sure that whatever call I made, I could sleep peacefully with.

See my response to Rob, I’m not exactly sure but I’m thinking it’s to manage expectations.
I was also told that radiation would likely preclude later surgery, at least for 6 months but potentially permanently on that section of liver, which was a significant factor.

Good luck with your decision - it isn’t an easy one.

Cheers,
Rob

PS: interested in why they say neither option is curative, particularly the surgical path? I don’t know enough of your case to disagree, but important to understand the rationale.

I was also curious why they have told her it's not curable as well?

[Rock_Robster]

Amazingly I faced a very similar decision around a year ago, just over 4 years after initial diagnosis. Do a portal vein embolisation (PVE) then resection of a significant liver lesion including 2 hepatic veins and an extrahepatic lymph node, or SBRT radiation of both liver lesion and lymph node. I wasn’t given a % risk of liver failure, but it was considered a higher risk resection. Both were considered potentially curative, but no-one was banking on this.

After a lot of discussion with the rad onc and my own reading, what became clear was that liver radiation had excellent disease control rates for up to 2 years, but after that was a lot less certain and local recurrence was a genuine risk. Of course this is also the case with surgery, but the recurrence rate is potentially slightly lower overall (and certainly at the resection site, if R0). Given at that stage we were still working with curative intent, I made the call to go for the surgery. A significant driver in my mindset was ‘no regrets’ - ie making sure that whatever call I made, I could sleep peacefully with.

I was also told that radiation would likely preclude later surgery, at least for 6 months but potentially permanently on that section of liver, which was a significant factor.

Good luck with your decision - it isn’t an easy one.

Cheers,
Rob

PS: interested in why they say neither option is curative, particularly the surgical path? I don’t know enough of your case to disagree, but important to understand the rationale.

Hey Rob,

Thanks so much for your response, it’s really helpful. I’m not exactly sure why he is saying that other than the fact that I’ve been stage 4 for about 4 years and the recurrence is to 2 sites. I guess it’s to manage expectations but both surgeons and my oncologist have all told me the same thing.

You’re welcome, not sure I added much but the similarities are striking.

I can accept the diaphragm met is indeed uncommon so I can see why they would be hesitant to prognosticate on it, particularly as a ‘distant’ metastasis that’s hard to properly image and track. However at the same time in my mind that really just says they don’t have enough data to make a definitive statement, and you (like me) are getting closer to an n=1 experiment. Good luck.

[Dennyp]

Amazingly I faced a very similar decision around a year ago, just over 4 years after initial diagnosis. Do a portal vein embolisation (PVE) then resection of a significant liver lesion including 2 hepatic veins and an extrahepatic lymph node, or SBRT radiation of both liver lesion and lymph node. I wasn’t given a % risk of liver failure, but it was considered a higher risk resection. Both were considered potentially curative, but no-one was banking on this.

After a lot of discussion with the rad onc and my own reading, what became clear was that liver radiation had excellent disease control rates for up to 2 years, but after that was a lot less certain and local recurrence was a genuine risk. Of course this is also the case with surgery, but the recurrence rate is potentially slightly lower overall (and certainly at the resection site, if R0). Given at that stage we were still working with curative intent, I made the call to go for the surgery. A significant driver in my mindset was ‘no regrets’ - ie making sure that whatever call I made, I could sleep peacefully with.

I was also told that radiation would likely preclude later surgery, at least for 6 months but potentially permanently on that section of liver, which was a significant factor.

Good luck with your decision - it isn’t an easy one.

Cheers,
Rob

PS: interested in why they say neither option is curative, particularly the surgical path? I don’t know enough of your case to disagree, but important to understand the rationale.

Hey Rob,

Thanks so much for your response, it’s really helpful. I’m not exactly sure why he is saying that other than the fact that I’ve been stage 4 for about 4 years and the recurrence is to 2 sites. I guess it’s to manage expectations but both surgeons and my oncologist have all told me the same thing.

You’re welcome, not sure I added much but the similarities are striking.

I can accept the diaphragm met is indeed uncommon so I can see why they would be hesitant to prognosticate on it, particularly as a ‘distant’ metastasis that’s hard to properly image and track. However at the same time in my mind that really just says they don’t have enough data to make a definitive statement, and you (like me) are getting closer to an n=1 experiment. Good luck.

Wow! You’re spot on! The imaging difficulty is really my concern. My CEA has gone down significantly so I can only infer what’s going on with the diaphragm lesion. If I chose radiation it addresses the liver lesion but not the diaphragm. It could be that the chemo I’m getting has eliminated it, but I can’t really know for sure unless someone goes in and looks at it. My surgeon basically said exactly what you said. I’m a bit of an unusual specimen since he’s usually not talking about surgical options with someone in my circumstances.

[beach sunrise]

Dennyp, I am so glad you have options available with this.
Rob, I believe I've read that Germany also does lymphs in the chest with some kind of procedure.