Stage D Colon Cancer - Forum

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Doctor Green

Re: Stage D Colon Cancer - Ärzteforum

Post#11 »

As I was going through all the responses to the Stage D colonic cancer- I thought - am I the only mad or normal person left? No, no. thanks God- John Kennedy is normal or mad too. He is my buddy tonight.

We are told that this patient is far from being obstructed; remember-ca rectum very rarely obstructs!

We are told that her liver is full of met's. Obviously, when the liver seems operable or treatable with the combination of surgery, chemoembolization +/- crypsurgery- both the primary lesion and liver should be addressed. But when the battle is lost in the liver as is probably the case here- nothing will help. Liver perfusion is a technique whcih for 20 years is looking for its success and indications.

Liver failure is a gentle kiss of death- more comfortable than useless implication of unnecessary therapies.


Arizona

Re: Stage D Colon Cancer - Ärzteforum

Post#12 »

It seems it takes a brave man these days to say there is nothing to be done. Why do we feel pressurised into futile efforts at palliation - is prolonging life our primary goal? I think giving chemotherapy to patients like this can easily fall into the same category as feeding gastrostomies into demented patients. Prolong life or prolong suffering?

The usual reply is that the relatives expect something to be done. Sure they do, but that's just part of a natural response to such dreadful news. It needs counselling and not knee jerk chemotherapy.

The best surgeon

Re: Stage D Colon Cancer - Ärzteforum

Post#13 »

I would like to ask you what is the standard deviation of the median survival that you cited. Of course, patients often do not often behave as the average...if one were to administer some sort of therapy (chemo, intra-arterial, etc.) and the patient dies quickly, well then the patient obviously had a bad tumor. If the patient lives longer than expected, then the therapy "worked...."

I would recommend no treatment for this patient. I would recommend against this patient spending any of her remaining time in a hospital.

Marcel

Re: Stage D Colon Cancer - Ärzteforum

Post#14 »

Liver mets were described as "the gentle kiss of death". I recognise several good ways to die and several bad ways to die, and short of an expensive (time and effort) discussion of euthanasia, which I hope we DON'T have here, surgeons are in a position to influence mode of death.

Good modes:
Liver mets (with chlorpromazine for pruritus)
Bilateral basal pneumonia
Uraemia
Adequate relief of pain and distress by opiates

Bad modes:
Rectal CA with tenesmus
Painful nerve involvement by tumour

I think it is too easy to maintain hydration in a patient dying without complaints of thirst. In patients with big fluid loss of fluid from the gut I think it is merciful to not replace the potassium and let the patient fade with hypokalaemia.

I think it's wrong to put a gastrostomy into a patient with CA oesophagus in most cases.

I think it is utterly wrong to let any patient die in pain, or by other symptoms which can be relieved by opiates.

Perhaps I should add also the category of wasteful keeping alive, which means not cancelling the antibiotics, withdrawing the IV etc. Maybe this is no longer an issue anywhere except the occasional case I see. Or maybe it's taken to signify to the relatives that one doesn't care, rather than that one does care, and also includes other reasons.

I'd be grateful to learn from the experience of others.

Critical

Re: Stage D Colon Cancer - Ärzteforum

Post#15 »

Please do not give me chemotherapy unless there is a reasonable chance either of cure, or of SUBSTANTIAL increase in quality life. i.e. if I have advanced metastatic colon cancer, please let me be.

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Billroth

Re: Stage D Colon Cancer - Ärzteforum

Post#16 »

I have been watching with great interest the large number of postings related to this topic, I was amazed with the diversity of replies ranging from doing nothing, to the gentle kiss of liver failure, passing through Hartmann's, stent, intaarterial chemotherapy, chemoembolization. Also there was one or two replies addressing resection of the primary & chemo-immunotherapy.

Colorectal cancer is a common malignancy and the incidence of this disease is increasing. Approximately 50% of patients with colorectal cancer die from recurrent disease following an apparently curative resection of the primary tumor and the liver is the most frequent site of relapse. Although only a small proportion of patients will benefit from resection of liver metastases, this form of treatment offers the only possibility of cure.

Surgery is currently the first-line treatment option for primary colorectal cancer (CRC) and resectable metastatic disease. Cytotoxic chemotherapy is used for adjuvant treatment as well as for the treatment of advanced disease; the combination of 5-fluorouracil (5-FU) plus leucovorin is currently the standard chemotherapeutic regimen used in most centers. In many countries patients with CRC do not receive chemotherapy because some clinicians perceive that the benefits of such treatment do not compensate for the potential negative effects on patient quality of life in terms of toxicity and inconvenient dosage schedules. However, recent evidence suggests that the use of cytotoxic chemotherapy can lead to an improvement in quality of life and effective palliation in CRC. A number of new treatment options are becoming available for the treatment of this malignancy.

The following active areas of research and/or treatment approaches are currently investigated in many clinical trials: (1) approaches for enhancing 5-FU/leucovorin activity; (2) novel delivery of 5-FU or 5-FU precursor agents; (3) new thymidylate synthase inhibitors; (4) new platinum analogues; (5) topoisomerase I inhibitors; (6) targeting specific proteins or pathways important for the growth, survival, or metastasis of CRC cells; (7) biologic response modifiers, including monoclonal antibodies; and (8) gene therapy. As the cellular mechanisms involved in CRC are further defined and chemotherapy or biologic agents more precisely targeted, response rates and ultimately survival will hopefully improve in this patient population.

Hepatic resection remains the only potentially curative treatment for metastatic colorectal cancer, Resection of liver secondary tumors improves 5-year survival from 0% to approximately 30% and offers the only possibility for cure

Data support the concept that patients with unilobar metastatic disease who undergo surgical resection with tumor-free surgical margins can be afforded a significant opportunity at long-term survival with acceptable morbidity, mortality, and hospital stay. Also, certain patients with bilobar or extrahepatic disease (or both) who undergo complete resection can enjoy a long-term survival. In these subgroups of patients resection should be considered on an individual basis.

Overall, hepatic resection appears to be an important means of curing patients with metastatic colorectal cancer isolated to the liver. The only absolute contraindication to surgery was the impossibility of a radical removal of tumor: if residual disease will remain after the hepatic resection, this operation is not indicated. A possible second contraindication to surgery is the presence of tumor in the hepatic or celiac lymph nodes

Rehapectomy may be performed safely and may provide the only chance of long-term remission in patients presenting with technically resectable liver recurrence in the absence of widespread extrahepatic disease. In conclusion, repeat hepatectomy for recurrent liver metastases is a viable option for the well selected patient. It is a low risk surgical procedure and may augment survival in the patient with well documented metastases limited to the liver.

There are current studies suggesting that hepatic and pulmonary resection can result in long term survival in select patients with hepatic and pulmonary metastases from colorectal carcinoma because surgery remains the only potentially curative treatment.

Colorectal cancer is an aggressive disease, and it should be managed with an aggressive surgical approach and there are lots of evidence that it works. To my mind your patient will need initial surgical excision of the primary, with assessment of extrahepatic involvement, a combination of 5-fluorouracil (5-FU) plus leucovorin should be given, then wait for a period of 3-4 months. At the end of this interval a thorough assessment is made for recurrent local, regional or extrahepatic metastatic disease before making a decision to do a liver resection if technically feasible.

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الجراح

Re: Stage D Colon Cancer - Ärzteforum

Post#17 »

I would perform a resection of the primary tumor and primary anastomosis. Whether she will live to obstruct is not prdictable. Chemo therapy can be discussed with the patient. IH arterial pump has not been shown to improve survival.

Arizona

Re: Stage D Colon Cancer - Ärzteforum

Post#18 »

I appreciate the time you spent to educate me of the various therapeutic options and the "proper" aggressive approach if one is to have any chance of success.

Part of me wishes to be as aggressive as possible, but the poor woman has surgically unresectable liver disease. I've heard isolated reports of being able to downstage the disease process with aggressive chemotherapy, but at what cost?

I can tell you one thing for sure. If I were the patient, I would accept no treatment except that for impending obstruction and comfort measures for pain. I've often said that I would take one last scuba trip to the Cayman's, start heading down the wall and keep going deeper and deeper until nitrogen narcosis takes me to a pleasant place.

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