SRS and liver met

[jacqueline1102]

Greetings all,

I have a quick question as needing some help. I have IBC with one liver met which shrunk from 4.6 cm to .9 x .75. My radiology doc spoke with me briefly about SRS on the liver met. I have only had the one liver met which has shrunk after the TCH trio and now just on herceptin. I also had a right MRM and finsihing radiation. Has anyone heard of SRS or had this done? What are the side effects? And how long were you stable before there was any progression or were you able to stay no evidence of disease? Thanks so much for any advice and help. What I have found thus far indicates that this procedure is done with colon cancer patients but not so much with breast cancer patients.

Take care,

Jackie

[Lori R]

Jackie,
I don't have first hand information to share with you, but I did want you to know that SRS was discussed as a potential option for my single liver met.

During my consultation at the University of Colorado medical center, the fact that I continued to battle a single liver met and was in great physical condition...we opted for the "gold standard" and went for the liver resection. Unfortunately, during the resection the surgeon was able to identify cancerous nodes that did not appear on scans. Oh well....I am glad I went for the gusto. I know I tried everything. But, surgery does come with significant risks.

During the consultation, the radiologist who would have managed the SRS treatment said the average progression free results were in the 3-5 years. I believe the challenge is stabalizing the liver as it moves when we breath. Also, uncertainty as to how the liver reacts to radiation.

Do NOT let anyone count you out because of breast cancer vs. colon cancer. There was a hint of reluctance in my case as well. When the Drs. saw that I was realistic about what the surgery might buy me, they were all in for moving forward.

Keep on fighting for what is in your heart. Good Drs. will direct you. It was the radiologist who suggested the surgery as she thought given the available data it seemed like the best option.

Lori

[Lauriesh]

I don't know anything about srs, but I did have ablation done for my one liver met. Has that option been discussed? It is a very easy procedure and I have been NED for 16 months now following this procedure.




Laurie

[jacqueline1102]

Thank you, Lori and Laurie, for your response. It seems like these procedures are rare. I had researched the RFA but when the radiology oncologist mentioned SRS I was a little surprised as I had not heard about SRS. I had also read about the liver resection which kinda scares me. Next Tuesday is my last radiation so I will ask lots of questions. Thank you again, ladies. Have a relaxing fourth of July.

[jml]

Hi~
I haven't ever heard of SRS, but have had both RFA to a liver lesion, then a liver resection to remove the R lobe with lesion 11 months later.
If you're still seeing shrinkage/response to TCH & solo Herceptin, why not stay the course and allow the drugs to finish what it's already started? I would think it's premature to look at other options if the current treatment is still working.
I was dx'd Stage IV, with a single liver met from 1st diagnosis and after a year of treatment I got to NED for a year.
Then the liver lesion popped back up , but because I was NED everywhere else, RFA seemed like a good option.
Unfortunately the RFA, was incomplete/unsuccessful bc the lesion was too close to the main portal vein to get a good "burn" around the periphery.
The lesion of course "grew back" and after a year of watching it grow & recede, on & off chemo, we finally decided on the liver resection.
After the resection, my liver remained NED for 5 years, while the disease popped up in other parts of my body.

Disease has returned to nodes pretty much everywhere - lung, chest, abdomen, etc- but by the Grace of God, my current regiment of oral Methotrexate & oral Cytoxan +Herceptin has helped me find my way back to NED!
NED in the Head, NED in body, including liver.

Hope this info is helpful~

Keep the Faith

Jml






Dx-5/17/02 - 33 yo; Stage IV - L IDC w/single liver met
1) Herceptin + Navelbine x 8 weeks - No response; progress to innumerable,immeasureable liver mets
2) ISIS 2504 + Herceptin - 6 mos, partial response
3) Taxol + Herceptin x 13 weeks to NED!
NED for 1 year
9/04 - Single liver lesion recurrence
Taxol + Herceptin - on/off to beat back lesion
12/05 - R Hepatectomy; Liver NED until 2009
3/06- Local recurrence - Left breast, IDC & DCIS, but holding treatment while continue to heal from Hepatectomy.
12/06 - L mastectomy + reconstruction through 8/07
10/07 - Recurrence - supraclav nodes
4) Gemzar + Herceptin - on/off controlling nodes thru
9/08 - 7wks Rads to supraclav nodes
10/08 - Acute Renal Failure - nodes in belly stricturing kidneys. placed permanent ureteral stents
Back on Gemzar + Herceptin, but no longer responding.
5) 05/09 - Tykerb + Xeloda - partial response x 5 mos
6) 10/09 - Xeloda + Herceptin - no response, disease progresses
7) 2/10- Ixempra + Herceptin - partial response x 12 wks.
Discovered single brain lesion x 4mm & liver lesions growing while screening for TDM1 + PI3Kinase study.
6/10 - Novalis to treat brain met - SUCCESSFUL!
8) 6/10 - Chemo-embo w/Adriamyacin to de-bulk liver lesion.
9) 8/10 - Screened & Started TDM1 EAP
Immediate response, disease in belly responds dramatically.
2/11- questionable progression of lung nodules
Discontinue TDM1
10) 3/11 - PI3Kinase + Herceptin - intial good response in 1st 6 weeks but LFT's elevated.
11) 7/11-Discontinue PI3Kinase + Herceptin study;
Disease progression - 2 small lesions in colon – docs have never seen this before in BC
11) 8/11 –Start new combo Halaven+Herceptin
10/14/11 -Completed 3 cycles (9 wks)Halaven+Herceptin...
10/18/11 - Scanxiety time -1st scans since starting this regimen
Good interval response, continue on H+H!
10/25/11 – new 2mm questionable spot in brain? Due to Novalis or new disease?
Re-scan in 8 weeks.
1/3/12- Disease progression; 50%increase size & SUV-R lung, middle lobe 6cm lesion.
R supraclav node multiple, miscellaneous nodes in belly. Colon lesions fired up.
12)Herceptin+ metronomic Cytoxan + Methotrexate.
…on a hope & a prayer. Only chemo I haven’t been on is Taxotere.
Hurry up Pertuzumab & TDM1!
Follow Up Brain Scan on 1/18/12…pleasepleaseplease be okay. I can’t take much more.
1/18/2012- 8 new spots in 8 weeks since last Brain MRI
one 2cm spot in brain stem, one 2cm spot in R temporal lobe.
No symptoms, THANK GOD!
1/25/12 – Start WBR x 15 rounds
2/10/12 – Oral Cytoxan WORKING! Melted supraclav node & undetectable by US!
2/14/12 – FINISH 15 rounds WBR
6/12/12- Continuing on oral Methotrexate BID & Cytoxan qpm, but on chemo break
for 3rd week due to low counts.
6/15/12 – Yay! Resume chemoJ
6/25/12 – Chemo break again due to low counts L
6/28/12 – PET Scan & Brain MRI this week…
NED IS BACK!!! NED in the HEAD, NED in the BODY!

[Jackie07]

Below is one of several reports located through PubMed:

Radiat Oncol. 2012 Feb 1;7:16.
Stereotactic body radiation therapy for liver tumours using flattening filter free beam: dosimetric and technical considerations.

Mancosu P, Castiglioni S, Reggiori G, Catalano M, Alongi F, Pellegrini C, Arcangeli S, Tozzi A, Lobefalo F, Fogliata A, Navarria P, Cozzi L, Scorsetti M.
Source

IRCCS Istituto Clinico Humanitas, Rozzano (Milano), Italy. pietro.mancosu@humanitas.it

Abstract

PURPOSE:

To report the initial institute experience in terms of dosimetric and technical aspects in stereotactic body radiation therapy (SBRT) delivered using flattening filter free (FFF) beam in patients with liver lesions.
METHODS AND MATERIALS:

From October 2010 to September 2011, 55 consecutive patients with 73 primary or metastatic hepatic lesions were treated with SBRT on TrueBeam using FFF beam and RapidArc technique. Clinical target volume (CTV) was defined on multi-phase CT scans, PET/CT, MRI, and 4D-CT. Dose prescription was 75 Gy in 3 fractions to planning target volume (PTV). Constraints for organs at risk were: 700 cc of liver free from the 15 Gy isodose, Dmax < 21 Gy for stomach and duodenum, Dmax < 30 Gy for heart, D0.1 cc < 18 Gy for spinal cord, V15 Gy < 35% for kidneys. The dose was downscaled in cases of not full achievement of dose constraints. Daily cone beam CT (CBCT) was performed.
RESULTS:

Forty-three patients with a single lesion, nine with two lesions and three with three lesions were treated with this protocol. Target and organs at risk objectives were met for all patients. Mean delivery time was 2.8 ± 1.0 min. Pre-treatment plan verification resulted in a Gamma Agreement Index of 98.6 ± 0.8%. Mean on-line co-registration shift of the daily CBCT to the simulation CT were: -0.08, 0.05 and -0.02 cm with standard deviations of 0.33, 0.39 and 0.55 cm in, vertical, longitudinal and lateral directions respectively.
CONCLUSIONS:

SBRT for liver targets delivered by means of FFF resulted to be feasible with short beam on time.

[jacqueline1102]

Thanks so much, jml and Jackie. I so appreciate the time everyone has taken to respond to my question. Much to ponder.

[Joan M]

Jackie,

I had both a wedge resection and RFA, but for my lung, not my liver. The last time I had cancer in the lung was August 2008 (I also had one brain met, and treated it with a craniotomy followed by targeted radiation, and that was in 2008, as well).

I had early stage breast cancer in 2003, which recurred in the lung in 2007. Since becoming stage 4, I have not had chemotherapy, only Herceptin.

Most breast cancer oncologists really look down on local treatments. They say that once the cancer becomes stage 4, it's systemic and should be treated systemically. I would agree, and even though I had local treatments, I'm still taking Herceptin, which is a systemic treatment. It's just not chemotherapy. Thus far, I've been NED for 44 months, but who knows when that could change. Jml was NED for 5 years.

There seems to be a movement within some breast cancer oncology circles to consider local treatments for women who have very limited disease, such as nodules in only one or two places, which is called oligometastasis (check it out online). Afterward, patients would receive an adjuvant round of chemotherapy (which is like having chemotherapy for early stage disease). If all is still well, the patient would just continue on Herceptin. I didn't go the chemotherapy route and took only Herceptin, and the nodule which had been treated with the wedge resection in 2007 recurred a year later. But since the ablation of that second nodule with RFA in 2008, the lung has been clear.

Last fall I attended a conference for women with metastatic breast cancer at Johns Hopkins Hospital, and a surgeon spoke about local procedures. Since he was a gastrointestinal guy, he mentioned liver mets a lot, and he also said that RFA, as well as cryoablation (freezing, rather than burning), and chemoembolization (arterial) is reserved for patients who are inoperable. But was I clearly operable and opted for RFA. Interventional radiology procedures have been done in the liver for both primary and secondary (mets) liver cancer for many years. RFA is radiofrequency waves (and I believe pretty harmless). SRS is radiation. RFA can be repeated, which is often not the case with radiation.

Click on the presentation by Kenzo Hirose to see and hear his session on treating mets with local procedures. It's an excellent comprehensive overview of treating metastatic breast cancer with local procedures.

http://mbcn.org/special-events/categ...sentations/P6/

The more cancer meetings I attend, the more I'm hearing about using local procedures as an option for treating metastatic breast cancer. It's another option, and I would like several options for controlling my disease.

Dr. Edith Perez who was one of the principal investigators of an adjuvant Herceptin trial thinks that local procedures should be considered. I recently saw her at the annual meeting of the American Society of Clinical Oncology in Chicago. Dr, Perez was also interviewed recently and was asked about surgical procedures and she is looking into setting up a clinical trial to give everybody chemo but first to treat patients in one arm of the trail with a local procedure. Here is a 15-minute video and the transcript, where she discusses surgery for metastatic breast cancer:

http://www.medpagetoday.com/clinical...stCancer/32835
Others at the conference were also mentioning local procedures during sessions about metastatic breast cancer.

As an aside, what's happening with your tumor markers? Are they elevated? Have they ever been elevated?

Regardless of which treatment you choose, good luck with your choice.


Joan

[jacqueline1102]

Thank you, Joan. Thank you for the website links as well. This gives me some things to think about.

Take care,

Jacqueline (Jackie)

[CoolBreeze]

I also had a liver resection. It's a pretty rare surgery among breast cancer patients, so finding this many in one place is a treat! Joan is right, the oligo mets theory is becoming more accepted and they are starting to treat those of us with limited mets more aggressively.

I would not say - at all - that the liver surgery was an easy surgery. But, I'm glad did it. I had a more difficult time than others I think, since I got C-diff six weeks post-surgery. I nearly died from that and am still healing from it. (Surgery was in early October, I got septic with c-diff on Thanksgiving).

They removed all of the left lobe (which had two mets) and they found a spot in the right lobe with an unexpected met that they used microwave ablation on.

Before they do these surgeries, they do want to see response to chemo. You don't "let chemo finish the job" as somebody said, but you get some response and then they may do the surgical route. If they don't think it will do any good and you won't respond via chemo, they aren't going to take chances on you. In fact, if you get complete response they typically won't do the surgery. But there is still cancer cells there and you may be giving them time to move around.

I think you have to go to a major cancer center to get these newer treatments. Don't expect your home town oncologist to do them.

However, after my difficult experience, it appears that I'm NED. It's a cautious NED because although my UCSF surgeon thinks my PET scans show normal activity post-resection/ablation my oncologist isn't so sure. I've remained on Abraxane and herceptin. I may get to take an Abraxane break for a bit, which I'm looking forward to!

Good luck with your decision. I know it's not easy but you are lucky to live in a time where limited mets are treated aggressively and not just left to grow.

[jacqueline1102]

Thanks so much, Coolbreeze. I am happy to hear that you are cautiously NED as your treatment team has said. Indeed, it is much to think about. Thank you so much for sharing your story. There is so much wisdom with this site.

Thank you,

Jackie

[norkdo]

Coolbreeze, I followed your blog through your operations last fall and I am delighted to hear you are NED!! Yay!! Congratulations!!