Liver Palliation

[Haybrant]

Haven't done much liver palliation but got referred a couple guys. One has multiple liver mets from ampullary adeno clustered predominantly at the liver dome with a good deal of referred pain despite increasing narcotics. May have more mets but equivocal by PET unlikely causing an issue. Primary is active as well, has a stent in. Hes old and is declining chemo.

2nd guy has a liver chalk full of colon ca mets has failed 4th line systemic therapy, KPS 60, quite fatigued from narcotics no systemic options Im guessing he has 2-3 months.

I was thinking partial liver for the first guy and whole liver for the 2nd guy. Both have good liver function, Childs A. What do you use for whole liver? Is there a kidney constraint you try to keep to. Not sure the 2nd guy is sick enough for 700 x 1, was considering 400 x 5 or 300 x 7 but interested to hear what has worked for you. Thanks

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[Gfunk6]

300 x 7 is the standard dose I use

 

[Haybrant]

300 x 7 is the standard dose I use

thanks Gfunk. How about for partial?

 

[Gfunk6]

300 x 10 for partial, but this is a rare scenario


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[Haybrant]

300 x 10 for partial, but this is a rare scenario


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Ive heard this a good deal but why is that. SBRT? Sent to IR? Does it seem reasonable in the scenario I described.

For whole liver is there a kidney constraint you aim for; this guys kidney is fully in the way and opposes the area of the greatest disease bulk.

 

[seper]

RTOG study shows 21 Gy/7 fx to whole liver is safe.

 

[Palex80]

Do IMRT to spare the kidney?

 

[Haybrant]

had this scenario come up again but in a different context. Elderly 80 yo man is presenting with high bulk of colon mets to the liver, dominant mass is 13 cm but there are mets throughout. Chemo naïve. He has a lot of discomfort but he didn't look bad when I saw him and he wasnt on narcs and I suggested he should start with chemo when I saw him 3 days ago. Looks like hes worsened though with more discomfort and is inpatient, didn't start his chemo. His AST/ALT were both 100 and tbili was 1.2. Tbili has increased to 2.2 now. Would you palliate his liver now and treat whole liver? Doesn't have much distant disease, pretty much all in the liver.

 

[evilbooyaa]

I'd have a discussion with the treating med-onc. I think chemo is better here but if med-onc isn't willing to give chemo with those LFTs (which aren't horrible) then you have to go for it.

I think TACE/Y-90 to the whole liver is a no-no, but haven't seen this scenario too much so not overtly familiar with it.

 

[Ray D. Ayshun]

Princess Margaret has an 8 gy x 1 trial from a few years ago. I've seen success with it, and no otv issues...