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RESEARCH TO PRACTICE (RTP): What is your approach to treatment of liver metastasis and the approach to the therapy — whether or not to administer neoadjuvant therapy and to shrink the tumor or whether or not you decide to utilize a perioperative approach up front?
DR BLANKE: A lot of factors go into it this decision-making process, but to simplify matters, if the patient is not particularly at high-risk and their disease is resectable without major liver morbidity, I take them to the OR.
On the other hand, if they have synchronous disease where you think it’s the tip of the iceberg or it’s kind of a borderline resectability, I have a low bar for administering neoadjuvant therapy.
We don’t have any proof right now with regard to one of your questions — pre versus post. All we know is perioperative is better than no perioperative. It’s a randomized trial question right now, but we don’t know. There’s no proof that you have to do it beforehand. So, if we don’t need to convert disease to resectability and they don’t want, basically, just the test of time, I tend to do it afterwards.
RTP: Another audience question was: What’s the time limitation of where you decide when to re-treat?
DR BLANKE: There’s no magic number, obviously. I tend to want it to be longer, at least a year or so, not three months. Three months would make me nervous. But you have to also balance the fact that that’s essentially progression on therapy, which bodes poorly for resection results. You have to balance all these issues and take it on a case-by-case basis.
RTP: The next set of related audience questions was: For rectal cancer with concurrent resectable lung or liver metastases, should therapy be systemic or local? With or without oxaliplatin? Does it make a difference if the patient is symptomatic?
DR BLANKE: I had to laugh because in thinking about the first part of this question, I said, “It depends on if the patient is symptomatic.” If the primary is bleeding, that’s one concern. If it’s significantly painful, that’s another. But if basically they have a completely asymptomatic primary that’s not obstructing, I believe you need best systemic therapy. You have to include your most potent chemotherapy, and of course you would consider whether or not to add a biologic in as well.
RTP: What is your approach to resection of the primary?
DR BLANKE: It depends. If the patient is never going to have resectable mets, they’re not curable. So I do not think you have to resect the primary. Given the data for the efficacy of modern chemo/biologic therapy, I am seeing very long-term control of the primary. I don’t even necessarily radiate the patient. I am definitely in the minority. On the other hand, I’ve been doing this a long time, and I haven’t gotten in trouble yet, so I believe it to be an okay strategy.
RTP: Let’s discuss the case submitted by an audience participant involving a patient with newly diagnosed rectal cancer, T2/N1 based on MRI/TRUS with three liver metastases, determined to be resectable.
The related audience questions are: What should be the initial treatment strategy? How long would you administer chemotherapy/XRT? Would you then move to abdominoperineal resection (APR) and liver resection or perhaps administer three months of neoadjuvant chemotherapy before or after APR?
DR BLANKE: Here we have somebody who has slightly higher-risk disease because they have synchronous metastases.
I would like to have just a couple of months to make sure they don’t have 20 mets next time you image them. So I would tend to use my best systemic therapy, which would be FOLFOX or FOLFIRI with a biologic, but plan on only administering it for a brief period, probably three months because you can argue about neoadjuvant RT being better in general, and that’s true, but the fact is, they’re not going to see the best systemic therapy in their liver. That’s the issue that is most life threatening. So I loathe to administer just 5-FU/RT.
Now, you could opt for FOLFOX/RT with the idea that it’s not helping the primary, but it might be helping the metastasis. Then it gets very complicated. It depends on what my surgeon says about whether they could excise everything at once or whether they would do sequential, which tumor they’re going to operate on first. But I would not, most likely, administer neoadjuvant chemo/RT. If the patient were cured by surgery, I would give them postoperative RT.