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Multidisciplinary Approaches in Metastatic Colorectal Cancer

Panelists:John L. Marshall, MD, Georgetown University Hospital;Tanios Bekaii-Saab, MD, Mayo Clinic;Cathy Eng, MD, FACP, MD Anderson Cancer Center;Daniel G. Haller, MD,FACP,FRCP, University of Pennsylvania;Tara E. Seery, MD, UC Irvine
Published: Friday, Jul 29, 2016



Transcript:

John L. Marshall, MD:
Okay, let’s get a little specific, Cathy. There’s a 54-year-old patient—rectal bleeding, scope, sigmoid lesion, non-obstructing, biopsy-positive scan, three liver lesions, a little ditzel in the lung, CEA (carcinoembryonic antigen) 50—what else needs to be done, who needs to see that patient?

Cathy Eng, MD: For any patient, just as you’re describing—the person with rectal bleeding—I like to get the team involved early on. I would contact my colorectal surgeon to get his viewpoint and make sure he agrees with me that it’s appropriate and that patient is ready for therapy. We would want to give some neoadjuvant therapy in that setting. However, I would not initiate it until I’ve spoken to my surgeon.

John L. Marshall, MD: So, they bring him in. Any testing you’d do in this patient—three liver lesions, one ditzel in the lung, sigmoid lesion?

Cathy Eng, MD: I would definitely do some MSI testing.

John L. Marshall, MD: You’re going to do MSI—molecular testing—we’re sending that off, that’s cooking. You’ve got 2 weeks; you can go on vacation before that’s back.

Cathy Eng, MD: It won’t necessarily change my treatment, but it would help me make decisions in the future if it’s needed. When tissue is available, you want to utilize it immediately. You don’t want to have to search for it somewhere down the road.

John L. Marshall, MD: Does your liver surgeon need to see this patient?

Cathy Eng, MD: The liver surgeon probably should see the patient as well.

John L. Marshall, MD: Any other imaging?

Daniel G. Haller, MD: I think finding out about that lung is the most important because that’s going to drive a lot of decision making as to whether or not it’s liver only.

Cathy Eng, MD: It’s a small one.

Daniel G. Haller, MD: If it’s malignant, it’s going to drive the treatment. If it truly is related to colon cancer, it’s hard to find out. If you start this patient on FOLFOX in a total neoadjuvant approach, it’s going to disappear.

John L. Marshall, MD: That’s bad, right? If it goes away, it’s bad.

Daniel G. Haller, MD: That’s bad if it disappears. It may be hard to find, but you have to at least think about that up front.

John L. Marshall, MD: Anybody PETing this patient?

Tanios Bekaii-Saab, MD: I probably would PET this patient.

John L. Marshall, MD: What if I gave an 8-mm pera-aortic lymph node?

Tanios Bekaii-Saab, MD: On a PET or…

John L. Marshall, MD: No, a CT. They are getting a PET now? No? Nobody’s PETing? I’m PETing.

Tara E. Seery, MD: I always PET for initial staging.

Cathy Eng, MD: I don’t always PET.

John L. Marshall, MD: Yes. But I think if I’m going to surgery, maybe.

Cathy Eng, MD: Yes.

John L. Marshall, MD: And maybe that lung thing lights up.

Cathy Eng, MD: And the liver surgeon would appreciate it.

John L. Marshall, MD: They like it, right?

Tanios Bekaii-Saab, MD: Yes, only if there is surgical intent. I think a PET has been shown to have impact in at least in one study. This is how you’re going to find about that pera-aortic lymph node, or even that little ditzel that may actually be…

Cathy Eng, MD: But the little ditzel is not going to show up in a PET, it’s too little.

John L. Marshall, MD: It won’t, right? PET will be negative.

Tanios Bekaii-Saab, MD: It depends on the PET scan. If it’s an MD Anderson PET scan, maybe.

John L. Marshall, MD: It’ll show up on that one.

Tanios Bekaii-Saab, MD: It actually could cut you off. If it’s negative, that doesn’t mean it’s not cancer, but if it’s highly positive—and we’ve even had 8-mm ditzels show up—that’s all shown up on a PET scan. They may just help guide therapy. That doesn’t mean the patient wouldn’t be eligible for targeted approaches, but the management would change a little bit, and the outlook would change.

Daniel G. Haller, MD: And, John, what you said about if the thing in the lung shrinks, that’s probably the best test for a small thing. If you give them FOLFIRINOX, for example, or FOLFOX and it doesn’t disappear or shrink, it’s probably a benign thing.

John L. Marshall, MD: Most of us present these patients in tumor boards, but a lot of folks don’t, or don’t have access to a tumor board. It often falls to the oncologist to make some decisions about resectability and who needs to be seen. I’m always struck by how much the rules have changed around that over the last decade. It started with an isolated liver lesion and that was the only one we would do, and then it didn’t matter how many—it was just how much liver you had back. From an oncologist’s perspective, Tara, what do you think are the key elements that oncologists need to be aware of to make that referral?

Tara E. Seery, MD: Number one, you have to think of how much disease is in the liver and how the liver function is. I’m assuming this is a normal liver function. It’s also how young the patient is and what your goals are. You have to realize, are you going to try for cure in this patient? Or are you for containment? If you’re going for cure, then you have to give your aggressive chemotherapy up front. They have to see the surgeon right away, so they’ll follow the patient. When it’s ready, they’ll do the treatment. But now, we actually have other therapies. We have the Y90 that you can give with the chemotherapy that showed some progression-free survival in the liver—not in the other places, but if that’s the majority of the area and someone doesn’t want surgery or can’t have surgery, that’s another option to consider.

John L. Marshall, MD: What’s the wackiest thing you ever took out, then you can have the floor?

Daniel G. Haller, MD: A retroperitoneal lymph node.

John L. Marshall, MD: So, all of our in-the-box data is around liver. But we’ve all taken out lung lesions and stuff. We’ve done HIPEC (hyperthermic/heated intraperitoneal chemotherapy) for colon cancer, we’ve done peritoneal operations. This is without a lot of evidence. We get that patient to, as you described, stage 4 no evidence of disease—some of whom we’re curing and some of whom we’re not. We’ll come back to that.

Daniel G. Haller, MD: When you have success… The other patient I remember had a right and a left pera-aortic lymph node as the only place of recurrence. We ended up taking it out, radiating it, and the guy is still free of disease. One thing we have to do is keep our recommendations fairly simple—not because the doctors are simple, but we’re spoiled; we only do GI cancer. In most practices, the next patient will have melanoma and they’re on nivolumab, and the next patient has lung cancer.

John L. Marshall, MD: Or there’s a pregnant woman.

Daniel G. Haller, MD: Yes, exactly.

Cathy Eng, MD: You’re absolutely correct, and we have experts.

John L. Marshall, MD: And we know when to bend the rules. You see this in surgery, too, where you’ll have very good GI surgeons who will say, “I’m not going after that lymph node,” but some of our gang who have been pushing the envelope for a while say, “Okay, I’ll do it for you,” knowing a risk benefit. We get to push the envelope more, and we need to forgive our folks that don’t and give them that permission to do that.

Transcript Edited for Clarity

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Transcript:

John L. Marshall, MD:
Okay, let’s get a little specific, Cathy. There’s a 54-year-old patient—rectal bleeding, scope, sigmoid lesion, non-obstructing, biopsy-positive scan, three liver lesions, a little ditzel in the lung, CEA (carcinoembryonic antigen) 50—what else needs to be done, who needs to see that patient?

Cathy Eng, MD: For any patient, just as you’re describing—the person with rectal bleeding—I like to get the team involved early on. I would contact my colorectal surgeon to get his viewpoint and make sure he agrees with me that it’s appropriate and that patient is ready for therapy. We would want to give some neoadjuvant therapy in that setting. However, I would not initiate it until I’ve spoken to my surgeon.

John L. Marshall, MD: So, they bring him in. Any testing you’d do in this patient—three liver lesions, one ditzel in the lung, sigmoid lesion?

Cathy Eng, MD: I would definitely do some MSI testing.

John L. Marshall, MD: You’re going to do MSI—molecular testing—we’re sending that off, that’s cooking. You’ve got 2 weeks; you can go on vacation before that’s back.

Cathy Eng, MD: It won’t necessarily change my treatment, but it would help me make decisions in the future if it’s needed. When tissue is available, you want to utilize it immediately. You don’t want to have to search for it somewhere down the road.

John L. Marshall, MD: Does your liver surgeon need to see this patient?

Cathy Eng, MD: The liver surgeon probably should see the patient as well.

John L. Marshall, MD: Any other imaging?

Daniel G. Haller, MD: I think finding out about that lung is the most important because that’s going to drive a lot of decision making as to whether or not it’s liver only.

Cathy Eng, MD: It’s a small one.

Daniel G. Haller, MD: If it’s malignant, it’s going to drive the treatment. If it truly is related to colon cancer, it’s hard to find out. If you start this patient on FOLFOX in a total neoadjuvant approach, it’s going to disappear.

John L. Marshall, MD: That’s bad, right? If it goes away, it’s bad.

Daniel G. Haller, MD: That’s bad if it disappears. It may be hard to find, but you have to at least think about that up front.

John L. Marshall, MD: Anybody PETing this patient?

Tanios Bekaii-Saab, MD: I probably would PET this patient.

John L. Marshall, MD: What if I gave an 8-mm pera-aortic lymph node?

Tanios Bekaii-Saab, MD: On a PET or…

John L. Marshall, MD: No, a CT. They are getting a PET now? No? Nobody’s PETing? I’m PETing.

Tara E. Seery, MD: I always PET for initial staging.

Cathy Eng, MD: I don’t always PET.

John L. Marshall, MD: Yes. But I think if I’m going to surgery, maybe.

Cathy Eng, MD: Yes.

John L. Marshall, MD: And maybe that lung thing lights up.

Cathy Eng, MD: And the liver surgeon would appreciate it.

John L. Marshall, MD: They like it, right?

Tanios Bekaii-Saab, MD: Yes, only if there is surgical intent. I think a PET has been shown to have impact in at least in one study. This is how you’re going to find about that pera-aortic lymph node, or even that little ditzel that may actually be…

Cathy Eng, MD: But the little ditzel is not going to show up in a PET, it’s too little.

John L. Marshall, MD: It won’t, right? PET will be negative.

Tanios Bekaii-Saab, MD: It depends on the PET scan. If it’s an MD Anderson PET scan, maybe.

John L. Marshall, MD: It’ll show up on that one.

Tanios Bekaii-Saab, MD: It actually could cut you off. If it’s negative, that doesn’t mean it’s not cancer, but if it’s highly positive—and we’ve even had 8-mm ditzels show up—that’s all shown up on a PET scan. They may just help guide therapy. That doesn’t mean the patient wouldn’t be eligible for targeted approaches, but the management would change a little bit, and the outlook would change.

Daniel G. Haller, MD: And, John, what you said about if the thing in the lung shrinks, that’s probably the best test for a small thing. If you give them FOLFIRINOX, for example, or FOLFOX and it doesn’t disappear or shrink, it’s probably a benign thing.

John L. Marshall, MD: Most of us present these patients in tumor boards, but a lot of folks don’t, or don’t have access to a tumor board. It often falls to the oncologist to make some decisions about resectability and who needs to be seen. I’m always struck by how much the rules have changed around that over the last decade. It started with an isolated liver lesion and that was the only one we would do, and then it didn’t matter how many—it was just how much liver you had back. From an oncologist’s perspective, Tara, what do you think are the key elements that oncologists need to be aware of to make that referral?

Tara E. Seery, MD: Number one, you have to think of how much disease is in the liver and how the liver function is. I’m assuming this is a normal liver function. It’s also how young the patient is and what your goals are. You have to realize, are you going to try for cure in this patient? Or are you for containment? If you’re going for cure, then you have to give your aggressive chemotherapy up front. They have to see the surgeon right away, so they’ll follow the patient. When it’s ready, they’ll do the treatment. But now, we actually have other therapies. We have the Y90 that you can give with the chemotherapy that showed some progression-free survival in the liver—not in the other places, but if that’s the majority of the area and someone doesn’t want surgery or can’t have surgery, that’s another option to consider.

John L. Marshall, MD: What’s the wackiest thing you ever took out, then you can have the floor?

Daniel G. Haller, MD: A retroperitoneal lymph node.

John L. Marshall, MD: So, all of our in-the-box data is around liver. But we’ve all taken out lung lesions and stuff. We’ve done HIPEC (hyperthermic/heated intraperitoneal chemotherapy) for colon cancer, we’ve done peritoneal operations. This is without a lot of evidence. We get that patient to, as you described, stage 4 no evidence of disease—some of whom we’re curing and some of whom we’re not. We’ll come back to that.

Daniel G. Haller, MD: When you have success… The other patient I remember had a right and a left pera-aortic lymph node as the only place of recurrence. We ended up taking it out, radiating it, and the guy is still free of disease. One thing we have to do is keep our recommendations fairly simple—not because the doctors are simple, but we’re spoiled; we only do GI cancer. In most practices, the next patient will have melanoma and they’re on nivolumab, and the next patient has lung cancer.

John L. Marshall, MD: Or there’s a pregnant woman.

Daniel G. Haller, MD: Yes, exactly.

Cathy Eng, MD: You’re absolutely correct, and we have experts.

John L. Marshall, MD: And we know when to bend the rules. You see this in surgery, too, where you’ll have very good GI surgeons who will say, “I’m not going after that lymph node,” but some of our gang who have been pushing the envelope for a while say, “Okay, I’ll do it for you,” knowing a risk benefit. We get to push the envelope more, and we need to forgive our folks that don’t and give them that permission to do that.

Transcript Edited for Clarity
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