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Management of Liver-Dominant Unresectable Colorectal Cancer

Panelists: John Marshall, MD, Lombardi Comprehensive Cancer Center; Alan P. Venook, MD, Helen Diller Family Comprehensive Cancer Center; Tanios Bekaii-Saab, MD, The Mayo Clinic; Johanna Bendell, MD, The Sarah Cannon Research Institute
Published: Wednesday, Mar 01, 2017



Transcript:

John Marshall, MD:
We’re going to shift gears: liver dominant disease. We see a lot of those patients who essentially are not resectable. The newest embedded member of our multidisciplinary team is the interventional radiologist (IR). It’s not just ports anymore, right? So, they’re coming to our tumor boards. We’re constantly sending patients back and forth for evaluation. Alan, I think I tagged you to give us a big broad overview for our oncology viewers of the different techniques that these guys and gals have available to them and our role in that referral process and decision making.

Alan P. Venook, MD: I’ve never met an interventional radiologist who isn’t ready to treat our patients, and I think the issue is, what are the modalities? TACE, or chemoembolization, is not something to use in colon cancer patients. At least the series have suggested very little activity. The real appeal is that the interventional radiologists can do RFA, for example—percutaneous radiofrequency ablation. Perhaps you send them there, although surgery is superior if that’s an option. The real role is for intrahepatic radiation, or localized radiation, which we find can be remarkably effective in selected patients. Now when to use it is a very good question and that has been studied pretty rigorously, actually. The activity against liver metastases is substantial. It’s generally tolerated pretty well. Again, I think the issue is, is this the right patient for it, when do you do it? The other thing we will do, for example, is external beam radiation, which may be appropriate in selected patients. So, there is a definite role for modalities in the liver. If you think back historically, the first example was the intrahepatic pump, which was really very popular maybe 20 years ago, and in parts of New York City is still very popular. For chemotherapy, there’s a big advantage to the fluoropyrimidines when given directly into the liver, and the results in those patients can be phenomenal. And the reason is because almost all patients with metastatic disease to the liver ultimately succumb to liver progression.

John Marshall, MD: That’s a really nice review of the different modalities. I was going to add this concept of growing liver. So, we embolize one side, the other side grows. In partnership with our surgeons, IR, and chemotherapy, we’ve gotten into quite an intricate dance to try and get very complex patients to no evidence of disease. And it really does help. I know how we pull that off because I am in the doctor’s lounge with all of these people and everybody is right there. I worry about our partners and friends in the community whose offices are not at the hospital or not living with this and how they coordinate that. All of us have tips and we do it our easy way, but we have to make sure that these guys are doing this in a coordinated effort. Everybody agree to that?

Tanios Bekaii-Saab, MD: Absolutely.

Transcript Edited for Clarity

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Transcript:

John Marshall, MD:
We’re going to shift gears: liver dominant disease. We see a lot of those patients who essentially are not resectable. The newest embedded member of our multidisciplinary team is the interventional radiologist (IR). It’s not just ports anymore, right? So, they’re coming to our tumor boards. We’re constantly sending patients back and forth for evaluation. Alan, I think I tagged you to give us a big broad overview for our oncology viewers of the different techniques that these guys and gals have available to them and our role in that referral process and decision making.

Alan P. Venook, MD: I’ve never met an interventional radiologist who isn’t ready to treat our patients, and I think the issue is, what are the modalities? TACE, or chemoembolization, is not something to use in colon cancer patients. At least the series have suggested very little activity. The real appeal is that the interventional radiologists can do RFA, for example—percutaneous radiofrequency ablation. Perhaps you send them there, although surgery is superior if that’s an option. The real role is for intrahepatic radiation, or localized radiation, which we find can be remarkably effective in selected patients. Now when to use it is a very good question and that has been studied pretty rigorously, actually. The activity against liver metastases is substantial. It’s generally tolerated pretty well. Again, I think the issue is, is this the right patient for it, when do you do it? The other thing we will do, for example, is external beam radiation, which may be appropriate in selected patients. So, there is a definite role for modalities in the liver. If you think back historically, the first example was the intrahepatic pump, which was really very popular maybe 20 years ago, and in parts of New York City is still very popular. For chemotherapy, there’s a big advantage to the fluoropyrimidines when given directly into the liver, and the results in those patients can be phenomenal. And the reason is because almost all patients with metastatic disease to the liver ultimately succumb to liver progression.

John Marshall, MD: That’s a really nice review of the different modalities. I was going to add this concept of growing liver. So, we embolize one side, the other side grows. In partnership with our surgeons, IR, and chemotherapy, we’ve gotten into quite an intricate dance to try and get very complex patients to no evidence of disease. And it really does help. I know how we pull that off because I am in the doctor’s lounge with all of these people and everybody is right there. I worry about our partners and friends in the community whose offices are not at the hospital or not living with this and how they coordinate that. All of us have tips and we do it our easy way, but we have to make sure that these guys are doing this in a coordinated effort. Everybody agree to that?

Tanios Bekaii-Saab, MD: Absolutely.

Transcript Edited for Clarity
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