Liver mets: resection, ablation, SBRT, Y-90, anything else?

[Deleted User]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031144/

Here is an amazing summary article on Y-90 efficacy. If I read it right, it is both good and bad news due to 11.2 mo mean overall survival rate but that Y-90 does help control tumor growth. I know it is controlling mine and I have passed the mean OSR so I am looking for more studies that are more current

Dee

sandibeach57

I posted in liver mets thread, but thought this info would benefit others.

I had progression (widespread liver mets) in March 2020 and started Xeloda in April. It has successfully killed active mets except for one stubborn lesion.

The lesion could not be biopsied due to its location. My rad onc said the IR would have to go thru my lung and diaphram to reach it. We all agreed that was not happening!

I will have SBRT to that lesion over a 3 day period, about 45 minutes each.

Microwave ablation could not be done due to location of lesion. My rad onc said the Y90 is used more for multiiple lesions.

My gold marker fiducials have been placed to the approx area in liver and I have completed the mapping..with those tiny skin tattoes. Similation is in a few days. Then SBRT will be March 15, 17, 19. I am scared, but also anxious to get that growing lesion killed.

If anyone has had SBRT to liver, please advise on the side effects.

moth

SandiBeach, congrats on getting SBRT organized! I hope it goes well. Can you post how big the lesion they're targetting is?

Rosie24

Sandibeach, I hope your sbrt is not too difficult and knocks that stubborn lesion out of your system. Thanks for explaining how your team decided on sbrt. I thought I might be in line for that at some point but my team suggested microwave ablation for me. I look forward to hearing how you're doing. 😊

sandibeach57

Moth: 14 x 23 mm lesion

sadiesservant

Thanks for posting the article Dee. Good information although I agree the liver mets stats aren’t exactly cheery.

moth

SandiBeach, thank you! Fingers crossed for you. So happy to hear of all these interesting IR approaches & I hope we start seeing much longer pfs and os times after reducing tumor burdens.

[Deleted User]

SandiBeach

That is terrific about SBRT to the liver. I had it to my lung and experienced some fatigue but that’s all. Glad you get to stay on your meds too. Keep us informed!

Dee

Rosie24

BevJen, How are you doing? I thought of you when I read my post ablation CT report. it says “it’s unclear if a residual subcentimeter focus of hypo density represents post ablation change or the possibility of residual metastatic neoplasm. Recommend attention on follow up imaging.” . I may be following in your footsteps with a redo. 🙁

BevJen

Hi, Rosie,

I'm doing okay at this point in time (other than stuff that's probably related to being on keytruda or who knows what else.)

I will tell you that my interventional radiologist uses MRIs for post ablation checks. He says that things can be seen more clearly on them. This is what it said on my post October ablation MRI, about a month after:

"Persistent nodular enhancement and restricted diffusion along the inferior aspect of the treatment
region, measuring 1.6 cm, concerning for residual tumor with interval growth."

So somewhat similar language to yours. This was enough for my IR to tell me that we could either wait and see how things go, or we could go back in. So we went back in. He felt that this language was strong enough to indicate that there was more there.

If it were me, I think I'd push your IR about whether there is more there. My IR has me do follow up scans every three months for the first year or so after ablation, and I'm sure you'll be on a similar schedule, but I probably would rather get an idea now rather than three months from now.

I just looked back and I see that you will talk with your doc in late March, which is only about a month after your procedure, correct? So I'd push for more info at that time. Perhaps he/she will do an MRI to see what it shows.

Good luck, and I hope you get more info.

Rosie24

Thanks Bev. It actually took me a few reads to take in all of my report. I’ll see (or telehealth with) the IR in about three weeks but haven’t been called to schedule yet. The wording on my report does sound similar to yours.

I’m wondering if you or anyone else experienced feelings of fullness in your upper abdomen after your ablations? It comes and goes for me and sometimes is more on the left but mostly it’s across the center. I wouldn’t say it’s painful but I’m aware of it. I have a primary care physical this week and MO next week so I’ll mention it to them, but I thought I’d ask here too. In general I’m feeling pretty well but there’s always that doubt about what’s really going on

BevJen

Rosie,

I definitely felt some sensation on my right (liver) side for some time after the ablation. I didn't have any sensations that I can recall on my L side or across the center -- but then, that could relate to where your liver lesions were. I only had one removed each time, so that could explain your different sensations.

Rosie24

BevJen, thanks again. I think it’s all kind of random for me, as to where I’m feeling things. Nothing yet today so I guess I’ll just keep watching. I have had a decreased appetite which is something good for me. I hope your treatment symptoms are getting more manageable. You’ve been a big help

nicolerod

I cannot believe that March 22nd was 3 months since my Y90 and my liver still hurts .

HopeandGratitude

Well, I am scheduled for Y90 on April 22, mapping on April 12. If all goes well, I will have treatment only in the right anterior of my liver, which includes Segment 8 (1 tumor) and Segment 5 (1 tumor). A good way to preserve the rest of the liver from exposure for now. And a good way to take care of anything else that might be small but active in this area.

I had a tumor (liver) biopsy (ugh) and it came back ER pos 80%, PR pos 30% and Her2 neg (I assume that’s by FISH). I haven’t gotten the path report addenda yet but my MO told me. My original tumors that are still quiet were ER pos (90%), PR neg (0%) and Her2 neg by ISH and low by IHC. So why is verzenio holding the 8 of them in check while 2 new tumors appear? I realize it could be any number of mutations, but I am not sure it’s worth further testing (ie Foundation 1) at this time since we plan on zapping those 2 new ones and keeping me on verzenio for now. Anyone think differently?? God willing, the rest of them stay quiet!! And maybe no new ones for awhile. 🙏

My fear, of course, is that Verzenio stops working and those 8 become active again. These are the thoughts that bring me nightmares.

s3k5

Nicole, that's exactly what I was thinking. Three months later you are still going through so much pain.

s3k5

For those of you who had Y-90 done for the liver mets, how long after the procedure did you have pain? I had microwave ablation to a single large lesion and the pain lasted about two weeks. Since Y-90 targets multiple liver lesions, does the pain last longer? Other than pain, did anyone have any other side effects?

I understand each person's experience is different, but preparing for the general (expected) side effects is helpful. Was it an overnight stay at the hospital?

Any other tips to prepare for this procedure would be welcome!

BevJen

HopeandGratitude,

I don't know what to say about another biopsy, but interestingly, I had some stuff that was similar to your situation. In May 2019, my interventional radiologist wanted to use chemoembolization on all of my liver tumors -- the largest was about 2 cm, and there was another group of about 5 sub centimeter lesions. We did MWA to the largest one. From summer 2019 until September 2020, everything held. Then another 1.2 cm liver lesion showed up, but the others still didn't change in size. That was the one I had ablated in October 2020 and re-ablated in December 2020. But those other ones -- they've done nothing.

Just fyi -- I don't think they would take out any other things they see in there unless you have given them explicit direction to do so?

HopeandGratitude

Ben-Jen,

Well, I was thinking with Y90, since the beads travel through the blood vessels within the segments, that if there was an active met present but too small for detection, it could also be treated. The procedure is not like ablation where they target a specific tumor, but rather treat a lobe or portion of a lobe. Make sense? I am just trying to have hope wherever I can!

BevJen

Hope,

Yes, that does make sense. I was in an ablation state of mind! Sorry.

nicolerod

Wait Hope....did you say you went from ER+ PR- to ER+ PR+???? I didn't think the PR could go from negative back to positive...I heard so many ppl say that if a person is ER+ PR- HER2- they will most likely go TNBC if anything???

You all know my experience on Y90 but I think it's a great treatment....so I really don't have much to add for those that want to do it...except what you all already know about what happened to me. .

moth

studies show that loss of marker is more common but gain of marker can also happen

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC67693...

"Negative conversion occurred more frequently than positive conversion in hormone receptors. Negative conversion occurred in 8 cases (5.3%) for ER and 37 (24.3%) for PR, whereas positive conversion occurred in 1 case (0.7%) for ER and 3 (2.0%) for PR. Negative conversion of PR was the most frequent change among all biomarker alterations. HER2 negative conversion occurred in 9 cases (5.9%) and positive conversion in 3 (2.0%). "

HopeandGratitude

hi Nicole. My recurrence in 2018 was ER+ (90%), PR+ (30%). That mass was in upper left quadrant of chest and that along with a positive lymph node was removed in 2018. Diagnosed with liver mets in Mar 2019. First liver biopsy (now the quiet tumors) in Mar 2019 was ER+ (>90%), PR- (0%), then ER+ (>90%), PR- (<1%) from bone biopsy when it went to bone, then with new liver tumors ER+ (80%), PR+ (30%). My original breast cancer (2002) was ER+,PR+.

nicolerod

Moth Thanks for that.

Hope...my original was ER+ 100% and PR+ 95%. then recurrence ER+ 100% and PR-.....

[Deleted User]

Hopeandgrattitude- prayers for upcoming y-90. Mine was Jan 2020 and I just felt a discomfort in the liver area for a few weeks which I consider minor. I did ask for the prednisone pack to help with any fatigue. I also took something to calm my stomach.

since you are ER positive the combo of Verzenio(cdk 4/6) and Faslodex (serd)could be what is holding most of your tumors in check. My trial doc said the “backbone" of one helps the other.

Thoughts on biopsy for ngs

1. It might be prudent to get the NGS testing especially an ESR1 determination. It could be the reason for the 2 outliers. I don't know if it is too late to send some of your latest biopsy samples to foundation 1 or TEMPUS. I would ask if they need to get another biopsy before y-90 if needed for NGS. Or

2. You can wait for after the y-90 and see if any new tumors appear (hopefully not) and biopsy at that time for an NGS.

FYI- Faslodex did not work for me but my trial serd is working so far. I have the ESR1 mutation and my drug targets that. Y-90 killed off the older tumors and reduced my total tumor burden buying me time.

Dee

HopeandGratitude

Thanks Dee. All great information. VERY much appreciated. I was a bit concerned on possible ESR1 mutations popping up. I know my MO had sample prepped to send to Foundation 1 but we hadn’t made a decision yet.

Interested in your trial SERD. Is it oral

[Deleted User]

Hopeandgrattitude- my trial is oral🙌🏻 I hated those Faslodex shots. I really did not think I would respond to another hormonal therapy and was ready to jump to treating the Neuroendocrine. But ARV-471 worked for the first 8 weeks and I am hoping for many, many more!

TEMPUS had a special plan-$100 for their test if you fill out their paperwork.

Dee

vbishop

I have liver mets (3 small lesions) and extensive lymph mets in chest and neck. It seems nothing we try works for long; I am on #5 in 18 months.

I feel fine. However, I've decided to change my diet. It's the only thing I have control over. Anyone else making major dietary changes? Is it helping? Hurting?

I appreciate your feedback.

[Deleted User]

vbishop- I am sorry you are having trouble finding a TX that works.

Your bio does not list all 5 but I understand your frustration and was in your boots just a few months ago.

Diet is a good thing to control, mostly because it gives you a sense of well being which is an important part of the journey. My friend with ovarian cancer had good results with a plant-based Natural/fresh food diet- dropped her tumor markers tremendously.

I don't know your history. So if you know all this then forgive me.

You posted on the local treatment thread so I assume you are open to it. Y-90 could be an option for the liver mets. It helped me to Whack-a-mole while I kept looking for a systemic drug that worked. You need an interventional radiologist consult for ablations and biopsies.

SBRT may be an option for small lymph mets. I had SBRT to a lung met. You would need a radiation oncologist consult

One other thing I would suggest is start looking for a clinical trial that could hit the Er/pr status. I found ARV-471 to give me stable disease. 6th treatment for me and I am now2 years from finding metastasis.

If you have had NGS testing like Foundation 1 or TEMPUS then you know your mutations- if not that is another step you could take.

Hope you find a treatment that works. Local treatments can reduce tumor burden, give us time to find the next step.

Dee

s3k5

Based on my conversation with the IR, she wants to hold off on doing Y-90 for the liver Mets since there are too many lesions scattered all over both the liver lobes. She said it would be too much radiation if she treats all of them which could cause liver failure. She wants to wait another 6 weeks to see how my current regimen would work and then revisit the local treatment.
Has anyone gone through this kind of situation? I wasn’t expecting this.

I am really getting anxious. I had no idea the liver was so full of lesions, since the scan reports never specify the details. I am also skeptical about this anti-androgen therapy doing anything to reduce my tumor burden. Even the various chemotherapies didn’t reduce the size of my liver Mets. All I got was a ‘stable’ report after each regimen.

Is there anything that could work on these stubborn liver Mets? I have gone through 13+ lines of treatments in the past 6 years.