No Resection Because of Multiple Liver Mets

Well, I have not yet had the resection surgery but it is scheduled for next week. I was told no by many because of one 7 cm main tumor and two smaller ones and many little ones throughout the liver, but with a robust response to chemo the surgery is a go and we will clean up afterwards, say my oncologist and surgeon. All said the response to chemo was key, that everything had to shrink or disappear. All said that once there is intrahepatic metastasis, there is disease throughout, even that which cannot be seen on scans.

The "many little ones throughout the liver" may have been the deciding factor, but because of her statement, "once there is intrahepatic metastasis, there is disease throughout," I think they would have come to the same conclusion with just the 7 cm main tumor and two smaller ones, which is similar to what you had.

Holly22a, did your surgeons address what they would have done if the "many little ones" were not present?

Thank you all for your responses to my case. @ Bruce, actually, you have it backwards in my case. Dr. Kato said no to surgery at first also. Every single surgeon I consulted with said, "do the chemo first and IF there is a robust response, surgery can be a go." (chemo was 1000 mg/m2 gem and 70 mg/m2 cis, a big dose) So I am very lucky that there was a huge response, not just in tumor blood markers, but in size and PET activity also. Main tumor went from 6.7 cm to less than 2 cm, many little ones just completely disappeared, etc. So Dr. Kato was no different than the others on that score. I chose Dr. Kato from the beginning because I like the way his mind works and I like Columbia/Pres Hospital, and because the oncologist and radiation guy are fantastic people and docs, too. You just have to have a whole team that you "mesh" well with and can communicate well with.

Also, Choti and others said no before the MRI showing "all the little tumors" -- they just assumed that with mets, they would be there unseen.

But the truth is (for any of us) if there are ANY mets to the liver, there is microscopic disease you cannot see. If you have one main tumor and two other little ones, you can be assured you have other smaller ones that do not show up on any scans of any type - - yet. Every surgeon told me this also.

And there is no safe section of the liver once you have mets. You can resect out the tumors but what you have left you will have to be vigilant about. Adjuvant therapy, further treatments like rfa or stereotactic radiation, etc. will be needed to "clean up" the remaining liver. That is what I heard from all the surgeons. That is why ICC comes back so relentlessly! Actually, 'comes back' is not the right word - - it was there all along and it has just grown to where it can be seen on a scan. But at this time you are working on eradiating tiny tumors, not a big one.

So I am not a doc either, although I know I am not the only one on these boards who has been studying my liver anatomy like a med student, lol! I just wanted to correct any misunderstandings. The one thing I heard over and over was the necessity of a great response to chemo. If a case is initially unresectable and does not respond or grows on chemo, few surgeons, even Dr. Kato, will go in with any high hopes.

So I am off to surgery and will keep you posted as always! Thanks!

Thanks for clearing that up Holly.  That's fantastic that you had such a great response to just four cycles of GemCis.  My wife has finished three cycles but hers is adjuvant therapy since she was resected with R0 results but with one positive lymph node. 

Did the doctors think there may be some connection between your being cHCC-CC, instead of pure CC, and the great response?

Incidentally, according to the AJCC Cancer Staging Manual, 7th ed., the staging for IHCC with multiple tumors, with or without vascular invasion, no regional lymph node metastases, and no distant metastases is T2bN0M0 and Stage II.  The staging for my wife, who is IHCC, solitary tumor without vascular invasion, one regional lymph node metastases, and no distant metastases, is T1N1M0 and Stage IVA.  She would have been Stage IVA even if she had multiple tumors in her liver.  And yet, they resected her right away.  it just seem strange that they would resect a IVA and deny resection to a II.  Eventually, I should be able to calculate survival probabilities for Stage II without resection vs. Stage IVA with resection, but I need more data in the database to make the answer statistically significant.

My wife's surgeon is Dr. Trevor Reichman at Ochsner Hospital in Jefferson Parish, LA, right outside New Orleans.  An Ochsner Emergency Room doctor ordered a CT scan on my wife late at night, saw the tumor in the liver and an enlarged lymph node close to it, and put her in the hospital.  The next day she had all kinds of doctors visiting her, including about a dozen residents from Australia.  Dr. Reichman called it CC right from the beginning without the benefit of a biopsy.  I was impressed with him because he did liver transplants, had a PhD as well as an MD, and authored papers on liver resection.

Julie - I gave some data for adjuvant therapy following resections in the following topic:

http://www.cholangiocarcinoma.org/punbb … hp?id=9174

I'll take a further look in my database for doctors and hospitals that prescribe adjuvant therapy and those that do not.  My first impression is that doctors are tending to prescibe it more than they use to because of papers showing that it increases survival rates.

At this point we don't know if our doctor will give my wife radiation treatments because she has unexplained temperature spikes that show up from 13 to 19 days after her first chemo treatment in a cycle.  This has presented itself in each of four cycles.  The doctor says that radiation can be hard on the liver.  The planned radiation was to be around the surgical markers in her liver, because that is a common place where recurrence takes place.  We should find out about the radiation treatments this Monday when we meet with the doctor to discuss a CT scan which my wife had today.

Bruce

Julie,

Looking at your past posts, I see that your father's oncologist did not recommend  adjuvant therapy for your father following his R0 resection.

I checked my limited database developed from about a 9% sample of  previous posts to these boards and found the following regarding adjuvant therapy for intrahepatic cc patients who had R0 resections.

From May 2001 to June 2008, 5 patients had no adjuvant therapy, 2 had chemo only and 1 had both chemo and chemoradiation.

From November 2008 to Sept 2012, 1 patient had no adjuvant therapy, 7 had chemo only, and 3 had chemo and chemoradiation.  Chemoradiation included radiation combined with 5FU or Xeloda pills.

So, it appears from this limited data, that oncologists started changing their tune about adjuvant therapy being helpful to R0 patients around 2008.

Since mid-2008, the only oncologist (besides your dad's doctor) I have found who didn't recommend adjuvant therapy for an intrahepatic cc R0 patient, was associated with Mayo Clinic in Rochester, MN.  Others who did were associated with Emory University Hosp., Atlanta, GA; Sherman Health, Elgin, IL; Kaiser; Cleveland Clinic, Cleveland, OH; University of Pittsburgh Medical Center, Pittsburgh, PA; a hospital in Lebanon; Jewish Barnes, St. Louis, MO; Kings College Hospital, London, England; and Ochsner Hospital, Jefferson, LA.

Bruce

Hi Bruce!  All went well. Then I had y90 3 weeks out and am back on chemo already two more weeks out. The proverbial "kitchen sink" approach. I am planning to post all about the experiences - - i am really just coming back from one hell of a month. Thanks for asking! There won't be any scans for another month since the y90 leaves the liver all inflamed and the mri's are "scary" according to my interventional rad doc.

Thank you so much Marion! I will be posting more soon! xox