Stage 4 Rectal Future Treatment Plan/Options

[thephotoguy]

Hello all,

Wanted to give a little background on my mom and her previous treatments and look for some more guidance.

60 years old
MSS Stable
KRAS AMPLIFICATION
Tumor Burden - Low
NRAS Wild

-----
April 2022 - Colonoscopy Confirmed Rectal Tumor
May 2022 - PET/CT - Confirmed 2 Liver Mets
June - Sep 2022 - 6 rounds of FOLFOXIRI
September 2022 - Clean PET Scan - No Signs of cancer in Rectal or Liver
December 2022 - Robotic LAR & Ileostomy. Check of liver - no signs of mets.
Jan 2023 - April 2023 - 6 rounds of FOLFIRI (no Oxiplantin due to Neuropathy)
March 2023 - Negative Pet Scan
May - June - Xeloda & Concurrent Radiation
August 2023 - Liver Lesion on PET
November 2023 - Complete right side liver resection
March 2024 - Pet Scan - 2 new liver mets, right lower lobe lung lesion, and a mediastinal node.
On recommendation of Oncologist met with an additional Clinical Trail Oncologist at another hospital who recommended to retry FOLFOX due to previous complete resolution of cancer/mets. Potential Clinical Trial in the future.

March 2024 - Present - FOLFOX with Cetuximab (Erbitux)
Mid June 2024 - PET/CT (at the time of the PET/CT, completed Five cycles of FOLFOX with Cetuximab)

Lung - Resolution of the 2 foci in the lower lung
Lung - 5mm in size (SUV max of 0.65) - Previously 1.1 cm with SUV max of 1.87

Liver Spot 1 - 1.6 cm in size with SUV of 4.92 - Previously 6.1 x 5.5 cm in size with SUV max of 13.14
Liver Spot 2 - 1.3 cm in size with SUV of 5.29 - Previously 1.3 cm with SUV of 5.8

No new site of disease is seen.
----
CEA:
Feb - May 2024 <2.0 ng/ml (tests results only show this, nothing specific)
June 24th - 2.5 (7 days after PET/CT)
July 15th - 3.5

----
It seems that she had a "decent" PET/CT last month showing some shrinkage and stopped growth of a liver spot.

We are meeting with her oncologist soon as her bimonthly appointment. I am little concerned with the increase in CEA. Since her first diagnosis, CEA has always been low and never had large spikes but I am concerned with the increase in CEA. After diagnosis, her Oncologist said CEA was not a good marker for her.

I am wondering what peoples thoughts are? Are there any additional treatment options that we should be looking at? I have read some on Tumor Ablation and SBRT Radiation and wondered if these would be good to see if she should have done especially on the liver spots.

Thanks for any thoughts/suggestions!

[roadrunner]

My initial take is that you are at a real point of inflection here. Your mother has responded well to FOLFOX, but metastases in the liver (2) and lung (1) remain. That puts you in a grey area—some surgeons will treat such disease as “oligometastatic,” basically, limited, potentially treatable/curable metastatic disease, where others will favor a palliative approach. Because the latter was a nearly universal approach for situations like your mother’s until relatively recently, getting a sufficient number of opinions from up-to-date, open-minded doctors may be crucial here.

If (more likely when) you find a surgeon and oncologist willing to be aggressive (assuming that’s your goal), that will be the time to discuss what to attack first, and how. I know more about pulmonary metastases than hepatic disease, but surgery (preferably wedge resection), RFA, cryoablation, and SBRT are options for the lung met. I believe surgery, ablation, and HAI pump therapy could be options for the liver disease (or a combo). Not sure which they’d address first, or whether it could be simultaneous, but based on what you’ve said, these are questions I would ask, and of more than one team. This is definitely a time for action if you wish to preserve a more aggressive course—much more disease will foreclose options.

[thephotoguy]

My initial take is that you are at a real point of inflection here. Your mother has responded well to FOLFOX, but metastases in the liver (2) and lung (1) remain. That puts you in a grey area—some surgeons will treat such disease as “oligometastatic,” basically, limited, potentially treatable/curable metastatic disease, where others will favor a palliative approach. Because the latter was a nearly universal approach for situations like your mother’s until relatively recently, getting a sufficient number of opinions from up-to-date, open-minded doctors may be crucial here.

If (more likely when) you find a surgeon and oncologist willing to be aggressive (assuming that’s your goal), that will be the time to discuss what to attack first, and how. I know more about pulmonary metastases than hepatic disease, but surgery (preferably wedge resection), RFA, cryoablation, and SBRT are options for the lung met. I believe surgery, ablation, and HAI pump therapy could be options for the liver disease (or a combo). Not sure which they’d address first, or whether it could be simultaneous, but based on what you’ve said, these are questions I would ask, and of more than one team. This is definitely a time for action if you wish to preserve a more aggressive course—much more disease will foreclose options.

Roadrunner,

I appreciate your response! Personally, I am not sure if she would be "up" for another major surgery (hepatic resection) as before as it was very hard on her. We will discuss with her oncologist on what she believes the next steps should.

I am no expert by any means but would think that the first steps would be to "tackle" the liver tumors. From what I have read, ablation procedures can be repeated and since she has had the liver tumors come back I would think this might be a possible treatment option.

[beach sunrise]

Since CEA is not a good marker has the onc suggested ctDNA, CA19-9 and CA125, CA17-3 (Something like that, I have a terrible memory)?

[thephotoguy]

Since CEA is not a good marker has the onc suggested ctDNA, CA19-9 and CA125, CA17-3 (Something like that, I have a terrible memory)?

No, her oncologist hasn't. I will discuss with the oncologist those suggestions. Thanks!

[beach sunrise]

You're welcome. Part of my surveillance includes CEA, ctDNA, CA19-9, CA125, MMP9. When done together/analyzing up and down trends, it can give you a bigger picture of whats going on.
Let us know what her oncs opinion is on tracking these.