TUMOR BOARD SESSION

MULTIDISCIPLINARY APPROACH TO OPTIMAL

MANAGEMENT OF COLORECTAL CANCER

LIVER METASTASES

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Panel & Disclosures

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Arya Amini, MDAssistant Professor

Department of Radiation OncologyChief of Thoracic Radiotherapy

City of Hope

• Grant/Research Support from Genentech.• Consultant for Reflexion.• On the Speakers Bureau for AstraZeneca, and Takeda Pharmaceuticals.

Misagh Karimi, MDDirector of Operations

Assistant Clinical ProfessorDepartment of Medical Oncology & Therapeutics Research

City of Hope

• Nothing to disclose.

Aram Lee, MDAssistant Clinical Professor

Department of Interventional RadiologyCity of Hope

• Consultant for Genentech.• On the Speakers Bureau for Genentech.

Mustafa Raoof, MD, MS, FACSAssistant Professor

Department of SurgeryDepartment of Cancer Genetics and Epigenetics

City of Hope

• Nothing to disclose.

Case #1

▪ 58 yr old C female

▪ CRC with Synchronous liver mets

▪ 10/19/2020 presented with GI obstruction

▪ 10/19/2020 status post rectosigmoid resection and colostomy placement. Pathology showed invasive adenocarcinoma, low-grade (moderately differentiated). Tumor extends to serosal surface (pT4). Margins negative. No lymphovascular invasion. 20 lymph nodes evaluated and none showed metastasis. MSS by IHC.

▪ KRAS p.G12F;MMR pro by IHC, TMB 5; PDL-1 0 ; APC mutation;

▪ 11/17/2020 C1 FOLFOX Bev X 6 cycles with great PR

▪ 2/8/2021 switched to maintenance Cap Bev

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Case #1: Imaging Before Liver Resection 3/15/21

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Case #1

▪ 7/16/21 Signatera negative

▪ Cape Bev maintenance started 5/14/21

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Case #1: 4-months post-resection

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Case #2

▪ 40 yo F who presents with synchronous colorectal cancer liver metastases

▪ October 2018: Presented with intermittent abdominal pain, 3 months post-partum

▪ December 2018: Acute worsening of pain, evaluated in ER

▪ PMH: HTN

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Case #2

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Case #2

▪ March 2019, BRBPR, Hb 6.8

▪ Lower endoscopy on 4/6/19: Circumferential nearly obstructing colon mass in the descending

colon at 40 cm from the anal verge with contact bleeding and friability.

▪ Bx: Colon adenocarcinoma, KRAS WT, MSS, BRAF WT

▪ CEA 544

▪ Staging CT demonstrated the following:

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Case #2

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Case #2

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Case #2

▪ The patient was evaluated and treated at the outside hospital

▪ May 2019 – December 2020: FOLFOX + Avastin 12 cycles

▪ CEA 544 → 52

▪ CT demonstrated the following

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▪ What would be the next step

Case #2

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Case #2

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Case #2

▪ FLR 30%, planned extended right

▪ March 2020, PVE (Right portal and segment 4)

▪ Chemotherapy changed to FOLFOX + Erbitux to get more response

▪ FLR 1 month later was 41%

▪ Continued tumor shrinkage but central mass still abutting the left portal inflow. CEA 544 → 52

→ 26

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▪ What would be the next step

Case #2

▪ April 2020

▪ Extended Right hepatectomy, Segment 2 Ablation

▪ Hepatic Artery Infusion pump placement

▪ All liver disease resected except 1mm thick 1cm x 1cm residual disease on the left portal inflow

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▪ What would be the next step

Case #2

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Case #2

▪ Underwent SBRT, 40 Gy in 5 fractions

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Case #3

▪ 55 yo M who presents with metastatic colorectal cancer with liver metastases

▪ Prior treatment history includes:

o FOLFOX cetuximab

o FOLFIRI bevacizumab

o FOLFIRI + HAI infusion with FUDR

▪ Due to continued progression he was referred for palliative Y90 radioembolization of his liver

metastases

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Case #3

▪ Pre-Y90 radioembolization

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Case #3

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Intraprocedural hepatic angiogram Immediate post Y90 PET scan

Case #3

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- Early post radiation changes in the right lobe- Tumor markers

- CEA 2657 -> 1626- CA19-9 893 -> 443

- Two enlarging central lesions in the untreated medial left lobe

- What treatment options should be considered?

Case #3

▪ Underwent SBRT, 40 Gy in 5 fractions

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Questions

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