There are more and more interactions between surgeons and oncologists for patients with metastatic colon cancer.
Colon cancer is very special since we can cure metastatic disease which is not usually possible for cancer. In colon cancer we talk about cure and not only survival. Because we can cure, we need to make sure we don’t miss any opportunity to do so.
Over the last five years our approach in patients with metastatic disease with liver-limited lesions has changed. We know that with more successful chemotherapies, we are able to convert more and more patients to a situation which allows a surgical resection with the intention to cure. Not all surgeries will cure, but it gives us a chance to cure.
The selection of chemotherapy will become more and more important because the more effective the chemo is the more likely we can pursue a curative resection. We also need to be aware of toxicities of chemo and targeted agents which can create liver toxicities and may jeopardize a successful liver resection.
For patients with unresectable liver lesions who become resectable, we now recommend doing the surgery as we don’t want to continue chemotherapy which increase the risk of liver injuries. As soon as the liver tumors become resectable, surgery should be done.
There is much more discussion about patients who have one or two lesions that can be resected. Should they receive chemotherapy.?
Last week I had a patient who fit into this category. He was resected for his primary tumor but developed one liver metastases. He is getting different opinions about what should he do. First chemotherapy then surgery, first surgery and then chemo, or only surgery.
Depending the doctor he saw, he had different recommendations for all three options. He was confused and wanted to know my opinion.
There is no right or wrong, but I think there is a better way to strategize in these cases. We always recommend chemotherapy first for about three months and then do the surgery followed by chemotherapy after surgery. What are the advantages? This scenario allows us to test if our chemotherapy works. We repeat the CT scan after six weeks. If tumors are same or smaller, we start planning the surgery knowing that we need to wait six weeks after the last dose of Avastin.
Knowing that these tumors are controlled over the months makes the surgery more successful since we are always concerned that there are more lesions not being able to be detected. When the visible tumors shrink, there is a better chance we will also kill cancer cells not visible on CT or PET scan.
There is always a concern if the liver lesion is resectable that the tumor might grow, and the lesion would become unresectable. We know if tumors grow under aggressive chemotherapy, it is unlikely that a surgical resection would have been successful either.
The biggest fear that the surgeons and the oncologists have is that the lesion responds too well and disappears. That makes it very difficult for the surgeon to find the lesion during surgery. We know that even with complete resolution on PET and CT and normalization of CEA, we still find tumor cells in about 30-50% of these lesions so we always want to remove the area of the lesions.
It is very critical for patients with liver lesions to consult with a hepatobiliary surgeon early. He should be part of the team from the start.
February 11, 2009 at 10:33 am, Dan said:
Following successful liver resection with no immediate evidence of remaining disease via CT scans and CEA, is it appropriate to resume aggressive post-surgery chemotherapy right away or to wait until detectable lesions appear on subsequent scans and tests? Thank you very much for your insights, Dr.Lenz.
February 11, 2009 at 1:21 pm, Heinz-Josef Lenz said:
in my group we usually give chemotherapy after successfull resection similar to a successful removal of the primary cancer. the lenght depends on how much chemo you may have received prior to resection if no we give 6 months. hope this helps
February 12, 2009 at 10:51 am, Dan said:
Yes that does help, thanks again.
April 18, 2009 at 9:29 pm, Scott Drumheller said:
Dr. Lenz
My wife is a 30 year DX stage four cancer patient. Upon intial diagnosis ther were four liver mets and lung nodules and primary rectal tumor. Our doctor stated pallaitive care and off we went. No K-ras no surgical consult. After a year on chemo nothing has changed except her lesions are smaller and the lung nodules to small to biopsy remain present in both lungs with change (smaller) in one of the suspect nodules. We talked with a surgeon who looked at her scans stating all her disease was resectable in the liver and rectum. Her latest PET was negative for metabolic activity. They want to proceed now with surgery even in light of the nodules in the lungs. Can chemo knock out small nodules or is it a fact that evn the smallest of nosules not removed will resultin progression and return of disease. We have been on first line chemotherapy for a year as her CEA has dropped continuously and just outside normal range. All her bllod work looks great but we are just a bit hesitant. I read of many pretreated areas to be resected with steroe tactic radiosurgery but do not have a lot of information to suuport. It certainly appears that shrinkage is significant. Would you entertain that prior to surgery or does it really make a difference if a tumor has srunk another CM or not?
April 24, 2009 at 2:18 am, greta said:
How far are we away from chemotherapy being an obsolete treatment for most cancers? The shock and awe approach to targeting a cancer cell by destroying most of the other useful cells in the body just seems so archaic. Are those powerful drugs themselves carcinogenic and leaving markers to attract future malignancies? Are we locked into chemotherapy because it is big business, very big business? If you were diagnosed with a malignancy, would you agree to a full and long ongoing chemo regimen?