Continue with trial or surgery?

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Markdale
Posts: 110
Joined: Wed Dec 02, 2020 4:45 pm

Continue with trial or surgery?

Postby Markdale » Mon Mar 13, 2023 7:47 pm

I recently got a surgical consult and the surgeon will operate and cut out the Mets that he can see on the scans. I discussed with the trial oncologists and they think that surgery is not the best option because of the high possibility of more Mets appearing after surgery.
The trial I am on initially lowered my cea considerably but now is almost back to where it started and there has been small growth in the target lesions. I want to stay on the trial for the tislelizumab, I’m not eligible for immunotherapy pd1 blockers. They have also increased the dose 15mg to 50mg and plan to increase the dose again to 150mg after the next safety meeting.
I’m leaning towards getting the surgery because I can’t live in a what if scenario and there has been no reduction in the size of the Mets after nearly 4 months on the trial.
Any advice or thoughts will be greatly appreciated
09/20:Diagnosed colonoscopy
10/20: LAR tumour t3n2m1 4/24 lymph nodes.
11/20: pet scan confirmed Mets
11/20: folfoxiri - 10/6/21. 12 rounds in total
1/1/21 thoracotomy 1 met removed
2/2022 sabr to 2 lung nodule
09/22 PET scan progression of sabr’d nodules
10/22 phase 1 trial bispecific antibody
9/23 added pd1 blocker
12/23 bilateral VATS all visible (7) lesions removed
3/24 radiation to acromion bone met + chest lymph nodex2

Rock_Robster
Posts: 1038
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Continue with trial or surgery?

Postby Rock_Robster » Mon Mar 13, 2023 10:33 pm

Look they’re right to say that the risk of recurrence after surgery is high, but it’s pretty rare for an otherwise fit patient to not be overall better off from an R0 resection if it’s possible, even if ‘only’ from an overall survival benefit and reduced disease burden (which may mean other treatments can be more effective). I would also be strongly favouring the surgery, as it really is the only currently credible path to durable NED for an MSS patient at present (do they think the trial drug could have curative potential?).

Could you restart the trial drug after surgery without measurable disease? I presume not. I guess the question is also whether you could be eligible for the trial drug again if needed, but perhaps also likely not as you would have already been exposed to it and they usually want patients naive to the experimental drug.
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

Markdale
Posts: 110
Joined: Wed Dec 02, 2020 4:45 pm

Re: Continue with trial or surgery?

Postby Markdale » Tue Mar 14, 2023 12:45 am

Thanks rock, once there is nothing to measure I cannot continue with the trial. I just don’t want to miss out on an opportunity the trial might give me to get to ned, but surgery is probably the best option.


How are you handling xeloda?

Mark
09/20:Diagnosed colonoscopy
10/20: LAR tumour t3n2m1 4/24 lymph nodes.
11/20: pet scan confirmed Mets
11/20: folfoxiri - 10/6/21. 12 rounds in total
1/1/21 thoracotomy 1 met removed
2/2022 sabr to 2 lung nodule
09/22 PET scan progression of sabr’d nodules
10/22 phase 1 trial bispecific antibody
9/23 added pd1 blocker
12/23 bilateral VATS all visible (7) lesions removed
3/24 radiation to acromion bone met + chest lymph nodex2

Rock_Robster
Posts: 1038
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Continue with trial or surgery?

Postby Rock_Robster » Tue Mar 14, 2023 9:20 am

Markdale wrote:How are you handling xeloda?

Much better thanks - I’m now doing 3,000 mg/d which is a much more sustainable dose, along with celecoxib twice daily. The cele plus 40% urea cream before bed has done a great job at keeping the HFS at grade 1 max now. Markers and last scans have all been fairly stable, routine scans again in 3 weeks.
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

roadrunner
Posts: 480
Joined: Sun Jan 12, 2020 8:46 pm

Re: Continue with trial or surgery?

Postby roadrunner » Tue Mar 14, 2023 12:52 pm

Mark: Your situation is obviously pretty complicated, and this decision depends in great part on your subjective preferences and perspective, so I’m not going to try to advise, but instead list a few questions that I would want to be able to answer before I made it:

1. Apart from your trial oncologists and the surgeon who’s offering surgery, have you talked to others familiar with your history to get their views on the likelihood of follow-on disease? What are the opinions? Odds? Likely timing?
2. Since surgeons can find additional disease when they “go in” and palpate the lung, have you discussed your surgeon’s approach in that regard?
3. What specific surgical procedures are being offered (wedge v. segmentectomy v. lobectomy) and how much tissue would be taken/remain? Will the surgeon make the call once he’s in?
4. Since you’ve had minimal-to-low growth on the trial, do the trial oncologists think that will continue, or do they have a reasonable hope that increased doses will do better? Do they think the drugs are restraining metastasis at present? What do your non-trial oncs think of that?
5. If the drugs appear to be having a stabilizing effect that might improve, can you just delay the surgery a bit?
6. Have you considered other, non-surgical options? (I know that SBRT failed, but it can generally be repeated (including by a different provider), and there are other ablation techniques that may preserve more tissue).

That’s what I can think of for now. Hope it helps.
7/19: RC: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/19-10/19 4 rds.FOLFOX neoadjuvant, 3 w/Oxiplatin (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 growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
6/20/22 TAE rectal polyp benign)
NED from 3/22 - 3/23
4 cycles FOLFIRI
LUL VATS lobectomy for radio resistant met 7/7/23


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