Topic: 36 year old with CC update

I just got the results from my first follow-up CT (abdominal/pelvic and chest) after 6 chemo visits. Thankfully my liver mass is shrinking as well as lymph nodes (peri-portal and mesenteric). No bone/organ or soft tissue involvement seen.  I am still waiting to hear from my surgeon whether I can have my resection now vs having more chemo since it seems to be working and have it shrink more. If it were up to me I would have my resection tomorrow. The longer it is in me the more I worry about metastasis.
On another note I had my first chemo session after a port insertion last week. I have to admit everyone who said to go for it was absolutely correct. It made chemo so easy and even took an hour off of my drip time.
For those of you who have had a resection, how long was your recovery time? Did you continue chemo therapy afterwards? What can I expect post-op.
Thanks,
Katherine

Re: 36 year old with CC update

Hi, Katherine, just wanted to say we LOVE the shrinkage word! Congratulations. Glad to hear you advocate for the port but above all else you seem to be on a good road. Please continue to keep us posted as posts like yours give hope to everyone!

THANK YOU FOR LOVING ME! Teddy ~In our hearts forever~ATTITUDE is EVERYTHING

Re: 36 year old with CC update

( I just posted this on the surgery, resections and treatment options thread, curious to see what people think about this topic)

I just  completed six treatment sessions of chemotherapy (gem/cis). On my first follow-up Ct scan I am happy to report that there has been shrinkage with my intrahepatic tumor as well as the surrounding lymph node involvement. This afternoon I heard from my surgeon about his next plan of action. He told me that since my tumors seem to responding well to the chemo, he wants me to continue with chemo for a total of 6 months at which point he will perform a resection as well as a procedure called HIPEC where "heated chemotherapy solution is pumped through your abdomen for 2 hours. This is performed at the same time as the resection" He says that with the removal of all detectable tumors and HIPEC there is now hope for long-term survival. I have to admit that I was slightly disappointed with his plan. I was hoping for surgery ASAP.  I know that CC is an aggressive cancer and I keep fearing metastatic growth. Has anyone had this HIPEC procedure? How long have your surgeons wanted to wait to perform your resections while continuing on chemo?  When I first sought out opinions when diagnosed I was told by 3 surgeons that I was a surgical candidate but they want to try chemo first. What worries me is the "most aggressive" surgeon is the one suggesting this course of action which involves waiting a total of 6 months before resection. Im assuming the HIPEC is to take care of my lymph nodes in my abdomen that were swollen on initial scan and have now shrunk.   
Thanks,
Katherine

Re: 36 year old with CC update

To add to Katherine's post, I think the big question is, what is the optimal length of time for neoadjuvant therapy to allow surgery? I know others have had it, was anyone afraid of waiting too long to get the surgery if they were responding to chemo after the first few rounds (first treatment was 10/10/16)?  Did anyone wish they did more chemo before surgery to optimize the outcome?
We will of course be asking the surgeons these question also.

-Billy

Re: 36 year old with CC update

I haven't had HIPEC, but I have had two resections and an HAI pump insertion. My first resection was at age 32 and they took my whole left lobe and the second was at age 33 after a recurrence and took wedges out of my right lobe and did RFA. After both surgeries, I was back at work after three weeks. I pushed WAY too hard though and I don't recommend that course of action. Since you're young like me and if you're otherwise generally healthy, then hopefully the recovery won't be terrible. My pain was well managed. My worst surgery was the third when I had an HAI pump inserted. The recovery does seem to be getting harder for me, but I know I am chock full of adhesions and scar tissue at this point, so they have to get through that mess before even doing the surgeries. None of my surgeries were laproscopic. I have a big chevron scar, which some younger doctors surgeons I have seen is from an older technique. I trust my surgeon though.

I had six months of neoadjuvant chemo and three months of adjuvant with the first surgery. Then I had my first recurrence and we went right to surgery. I was taking Xeloda when I had my second and we went right to the pump insertion. I had three months of HAI chemo as a part of a clinical trial at MSKCC, which was stopped because it did massive damage to my bile ducts. Luckily the tumor was gone by that point and (knock on wood) I haven't had to have treatment for the cancer since February 2015. I'll be dealing with the collateral damage from the HAI chemo (which is significant and a very long story) for the rest of my life.

So I guess my point is that there's no "right" way. Everyone is different. If you're confident with your doctor and have sought out at least one more opinion (preferably two), then trust their judgement. I completely understand the instinct to have that thing out of your body as soon as possible though. It's very strong.

Be well

Re: 36 year old with CC update

Today I met with the surgical oncologist who would be performing the HIPEC procedure during my resection. She made a lot of good points as to why I would be a good candidate for this additional procedure which is to use the localized chemo to hopefully kill any cancer cells found in my peritoneal cavity. I have already received 3 months of chemotherapy and the surgeons are still saying that my surgery would only take place after I finish the 6 month course to make sure that the cancer is still responding well to the chemo. They say that the tumor already in my liver is not my enemy.. it is the free floating cancer cells in my system that are looking for a place to settle down and grow...which is what the chemo is supposed to be taking care of.  The only apprehension that I have is the waiting until April/May to have this surgery performed. If the surgeon that I am using for a second opinion proposes surgery before that (and not performing the HIPEC procedure) I don't know which direction I would pursue.

Re: 36 year old with CC update

Surgery scheduled!!
Two weeks ago I had my second abdominal/pelvic/chest CT scan after completing 5 months of Gem/Cis. I am thankful to report that my tumor has continued to shrink (a decrease in size of 30% since diagnosis), my abdominal lymph involvement could not be seen on the current CT scan and my CA 19-9 (which has been an good indicator for me) has decreased from 17,000 at diagnosis to 1,700 after three months of chemo to 112 two weeks ago. I met with my surgeon (Dr. Schwartz at Mt Sinai hospital in NYC) and we are "go-ahead" with a surgery date.... 3/23/17. Dr. Schwatrz says that the tumor shrank in such a way that it shrank pulling away from ducts and major blood vessels making getting clean margins more likely. I am still also scheduled for the HIPEC (hiperthermic intra- peritoneal chemo) to be performed while I am still in the operating room. I have stopped chemo until then to optimize healing post resection and am feeling pretty good. The cumulative effects of the chemo was kicking my butt fatigue wise. I must admit that at the time of diagnosis this is the best result I could have asked for and I am very thankful for that, but the anxiety I currently feel about the actual operation is insane. I have daily crying spells thinking about my own mortality.  Does anyone else have experiences like this?  Dr Schwartz says the operation should last about 5 hours and I should be in the hospital for about 5 days. How long did it take before those who had a resection felt like they were "back on their feet"  and able to get around their house with ease? I am a physical therapist in a rehabilitation center...constantly transferring patients in and out of their bed/wheelchair so I know it will be a while before I am cleared to go back to work.
Any tips or suggestions that you have are greatly appreciated.

Re: 36 year old with CC update

First of all, what wonderful news you are scheduled for surgery.

I was trying to remember how I felt in the weeks before my resection.  What I recall is rushing through a massive to do list, getting the house and family organized.  I felt like closets had to be cleaned, papers filed, supplies laid in.  I had about the worst luck in this regard as our heating system failed the week before surgery and had to be replaced and then my parked car got smashed by a hit and run driver the night before surgery.  I was on the phone with the insurance company as I was being wheeled into the surgical suite.  In retrospect, while not fun at the time, all my household issues kept me distracted and I ended up not worrying that much about the surgery itself.  I am not sure the exact lesson in this, perhaps it is to keep busy and focused in the days prior.

As to the rigors of the surgery itself, I was initially in the ICU for maybe two days, somewhat out of it, then increasingly more alert over several more days until I was discharged after a week.  I was fortunate not to have complications.  If I had to do the experience over, I would try to walk more while in the hospital, which is hard initially.   Also the drugs are initially pretty intense - my first act after waking up after surgery was to send a selfie to my boss showing all my tubes and machines in their glory, so maybe another piece of advice has to do with prudent access to the cell phone while in the ICU.

Once home, I did need occasional oxygen for about a week.  I had a drain that had to be emptied periodically, which was removed after three weeks.  Showering was complicated due to the stitches and bandages plus the drain.  I ended up wrapping my midsection in Saran Wrap before taking a shower.  After a few days home, I was walking outside a bit.  I got myself off the pain medication within three weeks so I could drive again, and stitches were removed also after three weeks.  I was back at work (to a desk job) after two months.

The hospital arranged a visiting nurse who came about five times over the first ten days, to take vitals and check my incision.  Diet was initially soups and juicing, it took maybe a week to get back to more normal eating.

This is what I remember.  All this said, each person's experience is different so hopefully others will chime in with additional experiences and advice.  Looking back it was not the easiest period of my life but all manageable and my recovery was steady over the weeks following.  My advice to someone going into this surgery would be that -- like most challenges in life -- it is something to work through, with time and patience and accepting there may be possible bumps along the way.

P.S. I found helpful prior to surgery reading the blog of a British fellow named John Finch who describes his day-by-day experience with a liver resection in extreme detail - if you would like this level of detail.  http://www.johnfinch.me.uk/diary.html

I wish you the best possible experience and results.  Regards, Mary

Not a medical doctor!

Re: 36 year old with CC update

Dear Katherine,

I'm easing back into the board this evening and was so sorry that I didn't see this sooner, but so thrilled to read about your upcoming surgery.  Some are fortunate to be operated on right away, but you went through the hardships of chemo too. 

The apprehension is real, but not sure if I would use the term insane.  I can not pretend to understand  the apprehension, but I can say that even as just a family member,  I have been faced with my own mortality over the past few years-  so actually maybe as the patient the term insane does make sense.

My love and hugs are with you for a successful surgery and a quick recovery,

Catherine

Not a medical Professional-  just someone who got caught up in this lousy disease.

Re: 36 year old with CC update

I am currently 2 1/2 weeks s/p right liver resection. They also removed my gallbladder, part of my omentum and 2 lymph nodes. I was told by the surgeons that the HIPEC procedure was not done because my peritoneal cavity looked disease free when they were searching for signs of additional disease. My surgeon said that my remaining liver looked healthy, however there are signs of PSC. When I went for my first follow-up visit my surgeon stated that one of the two lymph nodes that were removed tested positive for cancer cells and he was able to obtain clear margins, the closest was 1mm. He said that if it were up to him he would resume chemotherapy and possibly even radiation as a preventative measure for recurrence. I have already completed 5 months of chemotherapy prior to surgery.  The cancer had invaded my blood vessels too but my doctor thinks he got it all.
Has anyone had a similar experience to this? I have heard that there is no proof that additional post-op chemo reduces likelihood of recurrence but I think it can't hurt to have a systemic defense for this scary disease.

Re: 36 year old with CC update

Dear Katherine,

How wonderful to hear you had a successful surgery!

You asked about similar experiences.  In my case (intrahepatic), I had clear margins but close in one area (also 1mm) due to a vein.  My lymph nodes had not looked concerning in the pre-surgery scans and were not sampled as part of the surgery.  I was told later this was because the surgery was difficult and the surgeon was "concerned about morbidity."  The pathology report cited that the tumor was large, poorly differentiated and showed vascular invasion.  But the tumor was cleanly removed and no signs of cancer spread, so the surgeon was happy with the result.

He did recommend, due to the bad pathology, that I pursue adjuvant treatment.  I was referred to a radiation oncologist who felt that with the close margin and unknown lymph nodes ("we have to assume they may have cancer") I should consider a protocol that had some success with extrahepatic patients, especially those with R1 margins or positive nodes. Below is the citation for the protocol.  I had four cycles of gemcitabine and capecitabine followed by five weeks of IMRT radiation to the tumor bed and related lymph nodes, together with capecitabine.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4534524/

I tolerated both fairly well.  The capecitabine caused problems for my feet (hand-foot syndrome) that got pretty bad at the very end, but mostly cleared up later.  Also, my lymphocytes dropped way low halfway through the radiation.  They crawled back over the bottom limit of normal a couple of months after treatment ended. 

I have been NED now for 17 months post-surgery and have my fingers tightly crossed this continues for a good while.  If I had it to do over again, I would still choose this post-surgery treatment.

There is a debate (and not much clear evidence) over whether adjuvant treatment is worth doing.  I didn't understand why anyone would choose NOT to have adjuvant treatment until my lymphocyte level dropped, which gave me some insight regarding one potential risk, which is possible weakening of the immune system.  Nevertheless, I personally wanted to feel I had pursued all avenues. 

Best wishes for a continued good recovery. 

Regards, Mary

Not a medical doctor!

Re: 36 year old with CC update

Hi, I had a resection in July 2015, they took the liver left lobe out and I had clean margins and no cancer anywhere else, however I now wish they had done chemo as after 6 months clear, 2 small lesions showed up on the rest of my liver. I now have been on chemo for 14 months, 6 months on Gemzar/Cisplatin and now on Gemzar only.  The oncologist calls it maintenance chemo.  The lesions have stayed small with minute increase in one of them.  Having a scan next Monday so fingers crossed  it will be okay.   Wishing you all the very best.

Re: 36 year old with CC update

Hi, Brigitte, wanted to wish you the very best for next Monday. Just let the tech know that your family here will not accept anything but good news! Yep! If it would all be that easy, right? Sending you all good wishes, vibes and hugs for some great news!

THANK YOU FOR LOVING ME! Teddy ~In our hearts forever~ATTITUDE is EVERYTHING

Re: 36 year old with CC update

Brigitte.....good luck tomorrow.  Tons of good wishes are heading your way. 

I am quite familiar with the  study mentioned by Mary ( SWOG  S0809 ) as it was approved during the time I served on the NCI Task Force for Hepatobiliary Cancer.  It included extraheptic and gallbladder patients only. I believe you have intrahepatic disease, correct?

At this time we don't know how  qualified intrahepatic patients would fair with the same treatment protocol.

Tons of good wishes are heading your way for Monday's scan to reveal stable disease.

Hugs
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: 36 year old with CC update

Marion,

In my case, my doctors recommended adapting the SWOG S0809 adjuvant treatment for me even though my CCA is intrahepatic.  In the SWOG S0809 reporting, it is clearly stated that intrahepatic was excluded and in fact, there is a review of the study I saw praising it for not including all types of CCA.

The other (chemo-only) option I was offered is an adjuvant treatment used for pancreatic cancer that has a good study behind it.  I don't think there are many (or any) intrahepatic patients represented in the studies of adjuvant CCA treatments, or if so, the numbers are small.  So doctors have to improvise!

Regards, Mary

Not a medical doctor!

Re: 36 year old with CC update

Mary...agree.  Although we see a tremendous increase in research for our cancer much is still left to discover.  Physicians make choices based on their personal experience as well as of studies of related diseases.
All research studies are statistically averaged out, hence there always are patients fairing extremely well.  They way I look at it,  someone always is on top of the scale, anyone of us can be that person.


Hugs
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: 36 year old with CC update

I am currently about 12 weeks s/p right liver resection. I took 8 weeks off from work and was able to return full duty (I am a physical therapist) without any difficulty. I resumed chemotherapy a month after my surgery due to a positive lymph node and only 1mm clean margins. I was switched to gem/oxaliplatin because the cisplatin was resulting in considerable hearing loss. I seem to be handling this new cocktail of drugs with less fatigue but that could also be because  I receive treatments only every other week instead of two weeks on/ one week off. This past monday was my 4th treatment. I am feeling pretty good and getting used to what a "new normal" feels like but I have to admit sometimes the weird noises, sensations or abdominal distension cause my mind to wonder. I was so happy when my CA-19 came back at 23 after my resection and this past week it was up in the 40s. ( Not freaking out yet, I'll wait for the results of my first scan which is scheduled for July) I also have had to have 2 neulasta injections due to low WBC counts.
  My oncologist initially told me that I would have 2-3 months of post-op chemo followed by radiation which is what brings me back here.  How did anyone respond to the radiation? Is it easier/more difficult than chemo? Did you switch to an oral form of chemo while on radiation or have it included with the traditional form? My oncologist hinted that I would.  As usual, all tips are greatly appreciated and I am so grateful for this site.
Katherine

Re: 36 year old with CC update

Katherine....so thrilled to hear from you.  I have learned that following surgery the CA 19-9 can be all over the place hence you may very well be worried for no reason.

The new "normal" includes just what you describe.  Some years ago the subject of "letting gas" in particular was a mainstay of our conversations, not sure why people don't comment on it anymoe.  Haveing said that, you may want to consider using enzymes prior your meal intake. 

Personally I have not experienced radiation but many others have.  I hope they will come forward and engage with you. 

You are doing great, keep it up

Hugs
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: 36 year old with CC update

Hi Katherine,

It is great to hear you are doing so well.

You asked to hear about experiences with radiation.  Here are some observations re my five weeks of IMRT radiation with capecitabine concurrently.

I need to preface this by saying that the center which treated me was wonderful in every way:  efficient with caring, patient-oriented staff, top notch doctors and modern facilities.  So my description below should not be viewed as in any way complaining about the provider.

I found radiation tougher than chemo.  It is logistically different in nearly all aspects.  Chemo was once a week with some weeks skipped.  Radiation was every day.  Chemo appointments were long, usually a couple of hours.  Radiation was in and out within 30 minutes.  Chemo was slow and nurturing:  here is your recliner, have some tea, bring your family, do you want a magazine.  Radiation was get down to business fast.  Get in there, put on a robe, zapped and done.

The radiation made me tired but it sometimes felt like it was not the treatment, but rather getting myself there every day while I was holding down a job.  For me, radiation treatment took some patience - I found the experience a little unnerving til I got used to it. 

My treatment center had the patients change into gowns.  I usually had one of the last appointments of the day, and the gowns left were either extra small or extra large.  I opted for extra large, which made me feel I looked like the school nurse at Hogwarts. 

The patients file in and out pretty fast as the treatments last maybe 10-15 minutes from start to finish.  When you come in to the treatment room, you first lay on a table on a mold shaped to your body.  The technicians move you around until the beams line up to the small tattoo dots that had been placed during the treatment planning session.  Once you are in position, they leave the room, a large metal door clicks shut behind them, and they speak to you via speakers in the room.

Soft music played in the background.  A large gantry with scanning and treatment functions rotates around you.  It looks like a Star Wars weapon.  The first step is a scan to be sure everything is lined up correctly, then the treatment itself which involves several passes by the rotating gantry.

In my case, I had to hold my breath during the treatments, which is something the technicians practiced with me until I could time my breathing as needed.  I figured out some prayers that matched the timing of the breath holds, which made that aspect easier.

The technicians then tell you they are done, come back in, and help you off the table.  At that point, you are finished, get redressed and head home.  My abdomen felt warm after treatment and initially I would crave milkshakes and was hitting McDonalds on the way home.

Other than fatigue, which deepened over time and hung on for a few months after, I had a little bit of a reflux problem which responded well to over the counter treatment.  No nausea.  I generally felt fine during the treatment other than some hand-foot problems from the capecitabine. The radiation lowered my lymphocyte count quite a bit - if I recall correctly to a level considered an adverse event - but it bounced back to normal range within a few months.  I was initially concerned about this, but the doctor pointed out that my lymphocytes had not stopped the cancer in the first place so their temporarily lower levels were not something to worry about.

The center where I was treated had a nutritionist on staff who recommended a high protein diet and plenty of water. 

That is what I remember.  The five weeks were tedious, but I got through it in good shape.  It has been 13 months for me since I finished treatment, and I have no regrets.

Hope this is helpful.

Regards, Mary

Not a medical doctor!