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Hello, everyone. It's great to have you. Um Today we are joined by Beatrice, er, talking about gi oncology. Uh as always put your questions in the chat. We want lots and lots and lots of questions. Um And at the end of the event, you will have your feedback form in your email box. We want you to fill that out and I will then be passing on the feedback to Beatrice and fingers crossed. She might even do another talk for us. Um I will be passing all that on but as you've submitted your feedback form, your uh attendance certificate will be on your meal account. All right. So I'm not gonna talk, I'm gonna pass us straight over to be center. Well, thank you. So, yeah, hi, everyone. So, uh I'm, I'm a medical oncologist, uh specializes in gi uh based in North America. Um And today, uh I've been asked to speak to you about gi oncology, which is um a little challenging because we only have an hour to cover all of gi oncology. But I think what I'm hoping that folks will take away here is um, first of all, when you have a patient that you think might have a gastrointestinal cancer. Um, what are the sorts of steps that should be taken? What kind of, um, uh, tests work up or would be appropriate? And then very broadly speaking, what sorts of, uh, management plans, um, might be considered and what sorts of referrals might be necessary for someone that you've diagnosed with a gastrointestinal cancer. So, to start with, when we speak about gi or gastrointestinal cancers, um There's quite a few, uh we count everything from the esophagus all the way down to the anus. So, so the whole track there um as well as the pancreas liver, um and gallbladder as those are connected with um digestion as well. I also put down at the bottom here, neuroendocrine tumor that's in bracket just as a reminder that um there's different kinds of cancer that can arise from the same organ. So for example, a pancreatic cancer, most pancreatic cancers will be uh what's called adenocarcinoma. And that's a specific kind of pathology that is um uh pretty aggressive, um pretty fast moving, but occasionally in the same pancreas, you can get a neuroendocrine tumor which can be slower growing and is treated quite differently. So, it's just important to note when you're considering these cancers. Um the site of origin is important, but the pathology is also important as it gives us quite a bit of information about how the cancer could behave and also how um it could be treated. So I know that there's a chart here and I'm hoping to make this interactive with a lot of questions. So to start off with things and just kinda see who's on the call. Um, do you have any idea what types of, uh gi cancers are common where you're based? And if you don't want, you don't have to put where you're based or what your name is. You can just put a kind of cancer into the chart. Um And I'll just give it a few moments to see if anybody uh is interested in interacting with us here. So I see hepatocellular carcinoma, pancreatic cancer and rectal cancer. Those are certainly some pretty common ones. Colorectal cancer. Yes. Colorectal cancer and HC. Yes. So what we're seeing here? Stomach, stomach. Absolutely. So usually in Asia, in Asian populations, things like stomach cancer, esophageal cancer and HC are common. Uh HCC is also common in African populations, whereas perhaps in North America and especially Western Europe, colorectal cancers can be more common as well. All right. So let's start with looking at diagnosis and work up first. So generally speaking, um to diagnose a cancer, you need a piece of tissue that's looked at under the microscope. And as I just mentioned, this is really important because it can be different kinds of cancer that come up in the same organ that are treated quite differently. So, it's important to know what you're dealing with there is one exception here. And as some of you might know that's HC. So the concern with biopsying hepatocellular carcinoma, which is a primary kind of liver cancer is that you can get seeding, which means that as the needle comes out of wave on the biopsy, little cancer cells can be tracked and actually lead to metastasis or spread of the cancer. So if you have imaging findings that are suspicious for hepatocellular carcinoma, do not biopsy this please. You can diagnose this with imaging but everything else ideally, yes, we'd like a piece of the cancer to try and figure out what kind it is. Um other things that you're probably going to need if you think somebody has a gi cancer um taking a look at it if it's possible. So, colonoscopy from the bone endoscopy from the top or if you're dealing with something in the uh bile duct area, you might want to do an E RCP, go down and take a look inside, get some brushings, get some tissue routine, blood work. So in oncology, we do a lot of blood work. Um when someone comes to see us for the first time, we'll do kind of the standard panel which will be CBC electrolytes, tumor markers, creatinine liver function. Just because if we're giving um drugs that are gonna be affecting the whole body or if we have a cancer that again could be affecting the whole body, we want to know what kind of shape all the organs are in and how the person is doing overall in terms of imaging. Uh Generally speaking, you will get full body imaging. So ct scans of the chest abdomen and pelvis, sometimes uh you'll get reports that are a bit unclear and then an MRI might be helpful. There's also a few other um situations where you might want an MRI to start off with and we'll talk about that in a moment and then pet scans. So pet scans in general are recommended when you're doing, um, work up for esophageal cancers or gastric cancers. And then again, in situations where there might be some unclear uh uh uh uh findings. For example, if you're not sure whether a cancer has metastasized and then anal cancer as well, a pet scan is usually quite routine in the initial workup. So, um, the way I've done this because we certainly want people to get involved and I don't wanna just be speaking at you for, um, the next hour is I have a few cases now and I'm gonna throw them up. There will be a question at the end of each one and you can just go on the chat again and just share your answers and we'll see how things go. So the first case that we have here is Mister Patel. He's a 50 year old gentleman. He's got a history of heavy alcohol use and he comes in with three months of dysphasia. So he's having trouble swallowing on upper endoscopy. Uh, they see a friable mass in the distal esophagus. So that's all you have right now. It's been sent to you. And maybe you're the oncologist, maybe you're the internist, um, maybe you're the resident working in the clinic. But I'd like you to just think about and put in the chart if you don't mind five investigations that you think Mister Patel could benefit from right now. So it's an esophageal mass. Um And that's all we know. See a CT scan. Yes, absolutely. You want CT scans, CBC and endoscopy? So, absolutely, we need to get some blood work on this gentleman. See it says biopsy. Absolutely. We need to get a biopsy on this gentleman chest X ray and upper gi study. Um So that's good. And I think that's helpful if you don't have access to maybe some of the more advanced imaging techniques. Um you always have to make do with what you have, see LFT S tumor markers. Uh Yes, absolutely. Pet scan. I see. Somebody said barium swallow biopsy. Ok. So some really good thoughts coming out there. This is kind of what I said, if you have access to um kind of everything that you might want, the biopsy is important because again, we need to confirm this diagnosis of cancer. See what kind we're dealing with. Look at some of the receptors, et cetera that might help guide treatment depending on what the rest of the tests find. Um Endoscopic ultrasound is sometimes recommended um especially when you're doing the biopsy to look locally and see the spread of the cancer. A full panel of blood work, as some of you mentioned, CBC, uh your metabolic panel with your electrolytes, liver function, kidney function, tumor markers as well. There's none that are really standard with esophageal cancer, but some people will definitely do them as they can be helpful if they're positive in tracking the cancer CT scan, you're going to want to go all the way up to the neck, all the way down to the pelvis for esophageal just because sometimes you can get some neck lymph nodes which are involved in a pet scan again, as I mentioned for esophageal and gastric cancers if you have access to it. Now, of course, if you don't have access to all of these things, um the key is to get uh as much imaging as you can. So make sure that you get imaging of the chest and if that's all and all you have is an x-ray can be done. But if you have access to CT scans or pets, that's helpful. Barium swallow. I wouldn't say so much at this point because really what that's gonna tell us is that there's a mass in the esophagus, but we already know that from the endoscopy. So don't really need to do another one. unless you're concerned about something, uh, something changing, I mean, yeah, like a fistula or something like that. Um, only if there's suspicion. So, in esophageal cancer we don't do routine, uh, brain imaging that's different for something like lung cancer where it would be routine to do some kind of brain imaging and then laparoscopy. So that's just a little surgery where they take a camera and look inside the belly to look for metastatic disease. Um That would only be if you see something on the scans that you're concerned about and want to take an actual look. It's not routine with esophageal cancer. All right. So, next case. So all of these cases, I'm kind of just highlighting different points about different kind of cancers. Um So don't worry, uh none of these are really standard um in the way that we might think about it, uh they all have a bit of a twist to them. But uh keep thinking, uh you know, practice is how we learn. So we have here, Missus Thompson, she's a 45 year old lady. She's got a BRCA two mutation, uh which is associated with pancreatic cancer. And indeed, she's been found to have a pancreatic uh mass on imaging. She's got abdominal pain. Um They do a CT scan of the chest um because remember we want CT scans of the whole body and that shows six lesions in the lung. So they biopsy one of those and it's positive for adenocarci of the pancreas. So we have a pancreatic cancer. Now that's spread to the lung. They do do the tumor marker ca 99 which is a pretty routine uh tumor marker to test for in pancreatic cancer. And hers is elevated at 879. Her bilirubin is 78 micromoles per liter, which is elevated and in American units, that would be 4.56 mg per deciliter. Um whichever one you're more familiar with for either case, that is quite elevated uh above the normal baseline. So in this situation, and this might be a little challenging for some. So don't worry if you don't know, but can you think about what you might want to do next for this patient? So she's got metastatic lung or metastatic pancreatic cancer that spread to the lung and her bilirubin is quite high. So I see a pet scan, I see an Mr CPA pet CT, a lot of pet CT S staging tests. Ultrasound LFT S. Yes. Yes. Yes. Yes. So the blood work is a good point. Um Presumably when you did the bilirubin, you would have had the rest of the blood work as well. Um Pet scan is a, is an interesting point. So pancreatic cancer, pet scan isn't usually standard, I think in this case, given that we have the biopsy from the lung that's showing the pancreatic cancer. We don't need more imaging. Um We kind of know what we're dealing with and the problem in this situation, somebody says, supportive management. Yeah, that's kind of more what I'm getting at. Um, and we'll see this more in the second half of the talk when we talk about um treatment. But for pancreatic cancer that's spread, we usually would want to do chemotherapy. However, you need a good liver function and you need um, a low enough bilirubin that shows that the liver is able to um process and um excrete toxins from the body and this bilirubin is too high. We would be concerned about the liver's function. So, yeah, the folks who are mentioning things about um either taking a closer look at what's going on in the liver. So ERCPM RCP or if you're able to do some kind of stent or drainage, um you're probably gonna have to recruit our other interventional radiology colleagues or gastrointestinal ton uh the regular uh gi folks to see if they can help us with this procedure because um when we have somebody with this situation, we want to go and see if we can open up uh the uh drainage from the liver and try and um get that bilirubin to come down. So again, just kind of thinking about the different cancers, some of the different ways they might present. Um and some of the different things that we might need to think about for folks. So if you have somebody with cancer in the liver pancreas gallbladder area. They come in with elevated bilirubin. Uh One of your first questions is, can we stent this? Can we drain this? Can we get the liver working better again? All right. Yeah. E RCP is what I have written down here. All right. Next case. So we have now, Mister Wang, he's 55 years old. He's got ultrasound findings concerning for a primary liver cancer. Um So this would be your hepatocellular carcinoma. Uh There is 15 centimeter hypoechoic tumor visualized and there's all kinds of different criteria um that we're not gonna talk about today. It's quite complicated um as to what uh HTC would look like under I CT scanner, under MRI scanner. Um but we're just gonna assume for these uh purposes and that's what this looks like. So now if we have somebody who has HCC uh findings on imaging more or five tests or up to five tests that we might want to do for this individual triphasic liver CT. Excellent. So you want to make sure that you have the right imaging um to diagnose HCC because some kinds of CT S and MRI S may not have the resolution necessary to confirm that diagnosis. So you folks are absolutely right. That's a son. I think now there are four other tests that we can think about though. I see Steven here is mentioning a number of different blood works including a FP, which is gonna be the tumor marker associated with HCC. So that's excellent. So you mentioned of a pet scan, um a good thought, but in HC, it's not really necessary. Um Usually the CT scans and your MRI are going to be good enough. I he mentioned of a biopsy. Is anybody else out there who would biopsy another gu guided biopsy, tissue biopsy? Ok. So I think the key to remember again with HCC and primary liver cancer is that you want to be very careful. You don't want to uh biopsy, right? Because for these individuals, radiographic findings are enough and you're concerned about seeing, you're concerned about tracking that uh needle out um and uh uh spreading the cancer more. So you want to be very careful, you don't wanna do biopsy for uh individuals with suspicion for HCC. Rather you want to make sure that you have your good imaging. So your MRI um or uh uh a liver directed CT scan CT of the whole body looking for metastatic disease. Um A FP is your tumor marker of choice. Um But no biopsy, if you're suspecting HCC, OK. These cases are all tricky. Uh This isn't actually a case, it's just a question. Um Yes. So I mentioned MRI S before I mentioned that often they're um used for uh patients and cases uh where the imaging findings are unclear, but there are some cases, there are some kinds of tumors where you'd want to start uh with an MRI um just as, as basic baseline imaging. And one of those is colon or rectal, you could just have a little vote in the chart whether um folks think or know which one it is. OK. So I see two volts for rectal. I see. Soel is saying CT scan is better and that is, that is a good point. And CT scan is certainly not gonna be replaced by the MRI. You're going to want to do both CT scan of the chest abdomen and pelvis. A lot of people are saying rectal. So yes, that's absolutely right. Um And the reason being that rectal cancer is pretty aggressive um and the way that we manage it locally and we're gonna see that in another slide or two depends on how invasive it is. So, are there lymph nodes involved? How deep is the tumor into the wall of the rectum? And the MRI is what's gonna help us see those structures in enough detail to make those judgments. CT scan isn't enough colon cancer. There's no role for routine uh MRI imaging there. Uh It's going to be more the rectal. So just something else to think about. Ok. So I think we've uh kind of spoken about work up in general now. So broadly speaking, you're going to want your tissue biopsy, uh you're going to want um CT scans, chest, abdomen and pelvis. If you can get it, you're going to want full blood work on everybody, making sure that you're checking all your electrolytes, your liver function, your kidney function, your CBC. And then in individual cases, depending on what kind of cancer you're dealing with. For example, esophageal and gastric, you might want your pet scan for rectal cancer, you might want your MRI and then being careful for HCC that you're not going to do the biopsy there uh due to the risk of seeing. But broadly speaking, that will give you the information that you need in order to start making some treatment decisions um with your patient. So, very broadly speaking, um when we're thinking about cancer, in general, gastrointestinal cancers are no different, um we want to divide treatment into localized and metastatic. So when cancer is a localized, usually the goal is to cure it when cancer is metastatic or spread outside of its initial organ, usually the goal is uh controlled. So to slow the spread of the disease or to provide the patient more time and sometimes to help symptoms as well, but the goal is not to cure. Um and it's very important to be upfront with patients when you have that kind of a situation. Um because first of all, as healthcare providers, um I would consider it at least your duty to to tell the patient and to inform them what's going on. Um But also it can be helpful for patients in planning, right, in planning the treatment that's best for them planning with their families, things that might need to be done if time is shorter than what they might be hoping for. Um When we have localized cancers, usually the treatment is to cut it out. That's the, the, the, the bare bones of it. Uh you cure cancer by taking it out of the body. So it can no longer divide and spread and cause the person grief. Um One of the big exception is anal cancer. So if you have anal cancer, that is um beyond at two. So beyond a very, very small polyp, um chemotherapy and radiation together is usually enough to get um uh uh good control and even cure. Um for the rest of the cancer surgery is usually somewhere in there and referral to a surgeon is quite prudent uh for patients who have higher risk localized uh cancer. And we'll see some examples of what that could be. Um sometimes there is a role for adjuvant therapy, either chemotherapy or radiation. And then for patients who have metastatic or unresectable disease, usually some sort of drug therapy um is going to be um on the table for that patient. In any case, uh treatment of cancer usually requires a multidisciplinary approach. So you can have um surgeons, radiation oncologists, uh medical oncologists like me who give drug therapies, um uh palliative care. So those are doctors who focus on symptoms, support and management um uh primary care doctors as well. So the patient's uh gi um but communication is key. So speaking about uh the patient's case and speaking about treatment options. Um and speaking with each other as a team as well is very important. And someone uh Steven has mentioned neoadjuvant therapy, which absolutely um there is a role for that as well. So in patients again, who may have higher risk uh disease, um or maybe disease that is not initially resectable by the surgeon giving chemotherapy or some kind of therapy, maybe radiation therapy before to try and shrink things um to make the surgery easier may be used as hard. It's a good point. I forgot to put that on this slide. So a treatment option, so broadly speaking, kind of what do we have in our toolbox for treating um gastrointestinal cancers. So surgery as I mentioned, radiation uh and radiation is usually when you have a specific spot that you can target. So in the curative setting, for example, rectal or esophageal, you can target the mass or in palliative or metastatic settings. Um may be a specific area that is causing pain such as a specific bone lesion. Well, it's important to know that there is a limit of how much can be radiated because radiation does have side effects and we can't fry a whole person and we have to target the beams to a very small part of them uh localized therapies. So there are options for things like um giving chemotherapy directly um uh uh at a specific liver tumor um or ablations, for example, can be given chemotherapy. So, as you mentioned, adjuvant after surgery, new adjuvant before surgery and then palliative intent and then targeted therapies. So, there are therapies out there against specific um cell receptors um such as VEGF. Um and then there's also immune therapies as well, which then chemotherapy that triggers uh So chemotherapy kills the cell specifically um or assists in killing the cell. Immune therapy stimulates the patient's own body to attack and kill cancer cells. Um So just a different side effect profile and sometimes uh depending on the cancer, depending on the um uh vell receptor statuses, um can actually work better than chemotherapy, which can be nice. So again, a few more cases just to highlight some different um points. So I think Steven is asked about brachytherapy, um brachytherapy, I'll put in with radiation. So this is a kind of uh radiation where you actually implant or you have a radioactive. Um I don't wanna say things that's not a good term. Um but uh like radioactive scenes or radioactive um seeds. OK. Uh That you would implant. Um for example, in someone with a prostate cancer um or cervical cancer to my knowledge, there's no standard role for brachytherapy in gi cancers. Although um we would have to ask the radiation oncologist that it's not something I've seen too much of, but it's definitely uh a good thought and a good point. All right. So the first case we have here. So this is kind of just highlighting what I would say is kind of the biggest thing to keep in the back of our minds when we're considering treatment options for patients with uh gi cancers or any cancer. So here we have Missus Musa. She's an 80 year old lady. She comes uh to your clinic with metastatic biopsy, proven colon cancer. It spread to the liver, lungs and bone. Now she's bedbound and spends most of the day sleeping. So, what treatment plan would you recommend to this patient? And it might be a little difficult if you haven't done much clinical work. But I see some people have Agassi Nicoletta, Adrian Mohammed. Yes, absolutely. So folks are uh didn't want anything here. Uh I thinking um ha have, have their minds in the right place. So, cancer that spread is incurable, right? Which means that unless there's another comorbidity or something else that happens, that takes a patient's life, we would expect the cancer to take the patient's life at some point. And one of the most prudent things, um or the most important things for any physician, especially oncologists is to know when a patient um is able to take treatments and when it might be better to step back. Um and focus more on supportive management or palliative care, making patients comfortable but not giving uh systemic drug therapies or, or other therapies with side effects that may worsen a patient's quality of life. So, in general, when we have somebody who's not able to eat or drink, um who's not able to get out of bed and walk around, um giving our treatments that we have, uh is not necessarily a good idea or not a good idea at all, honestly. Um because the side effects and the risk from that uh versus the benefit is just not there. Um And yes, as uh some folks are saying in the chart communication is key, having uh conversations, uh honest conversations with patients with families, often you'll need to have several conversations. Um and try and figure out how we can best support this patient in a way that is not providing cancer directed therapies. Now, if I change the case a little bit and I say, OK, well, you know, this is not metastatic anymore. It's a localized uh stage two esophageal cancer that she has. Um and she comes to clinic, she's in a wheelchair. It sounds like she spend most of the day sleeping in bed. Um How does that change your treatment recommendation? Because now it's not metastatic. Now it's a localized stage two. Uh Someone here has said chemotherapy and radiotherapy would be harmful. Ok. Does anybody else have any ideas about that chemotherapy as a bridge to surgery? Excellent point. But why she be gone from a stage two cancer? That's a good point. Absolutely. So a lot of the, the uh comments here are applicable and we'll just save them for a moment. Um that localized stage two esophageal cancer. Um the treatment would usually be some combination of chemotherapy and radiation before. So in the neoadjuvant setting, uh and then having surgical resection afterwards with maybe some treatments afterwards. However, that is a lot of treatment, right? Chemotherapy and surgery and, and radiation together, um does have side effects and the surgery for an esophageal cancer quite can be quite intense. Now, presumably, if you have an elderly patient who comes in with a poor performance status, they would have other comorbidities that are making them not the strongest. And it's important to keep those in mind, right? Because when we have our patients, especially our older patients or perhaps or sicker patients, the cancer is not the only thing that's going on in their body sometimes. And um, it might be, for example, that she has bad lung disease or bad heart disease, uh, or a bad liver, maybe she has liver cirrhosis, um, that is affecting her, affecting her performance status. And we actually expected that other illness to take her life before the cancer would. Uh, somebody said she might be too old for surgery. Yes. Or she might be too sick for surgery. So, just to keep in the back of our minds again, even though somebody may not have metastatic cancer treating the cancer. If they are older frail or sicker may not be in the patient's best interest. So we still have to look at their performance status and if they are in bed all day, they're not able to eat or drink, not necessarily from the cancer. But for another reason, another illness that they have, um we just have to be careful with that and um make sure that we're not giving treatments that a patient is not fit enough to handle. Now, for everybody who is interested in actually treating, um we can talk now about esophageal cancer treatment. So I've made Missus Mussa a little long younger now. She's 60 years old, she's active and healthy, so no longer bedbound. Um And she comes in with this localized stage two biopsy, proven esophageal cancer. So I would say in this patient's case broadly speaking, there would be three main components to a treatment plan, but it's OK if you only come up with two, the third part is kind of optional depending on what happens with the first two parts. So I'll give folks a minute now to think about. I think a lot of the answers that were coming from the previous question might be more applicable here. Does the treatment extend the life of missus moussa more than the expected date of the disease itself? Um Yes, that's something that uh we definitely that, that is actually a very good point going back to the last uh question um that uh we have to think about. Uh and that, and that's actually a very concise and nice way to say it. Um When we're looking at a patient, we want to think if we're giving this patient treatment, are we actually extending life or are we helping symptoms or are we simply giving something that we think may actually shorten life expectancy which we don't want to do um at all? Ok. So here somebody says esophagectomy and adjuvant chemotherapy. OK. Uh surgical resection with a new adjuvant treatment, surgical resection, chemo radiation surgery, chemo plus radiation. OK. So some good thoughts coming out here what I would say here. So when we have uh a localized esophageal cancer, this is one of those that um is a, is a little not so straightforward. Um So I mentioned before, you have a cancer that's localized, usually cut it out and then if it's higher risk you'd give adjuvant therapy. Um and that's kind of a, a older approach to esophageal cancer. But we have some good studies now. Um And the last few years, I actually don't know how long it's certainly since I've been in training anyway. Um where because esophageal cancer is so high risk, we give chemotherapy and radiation before the surgery um to try and shrink things to try and get control. Um And then you have a surgical resection and then based on the pathology, if there's cancer left over when they do the surgery. Um So the chemo and the radiation wasn't enough to wipe the, uh, cancer out altogether. There's actually a role for adjuvant immune therapy. Um, so that's usually the decision that's made after the surgery, but having this multitiered approach of chemo and radiation first, then surgery, then maybe immune therapy is usually how esophageal cancers are treated. Now, if it is a very small stage one, that's amenable to, uh, maybe even just, uh, like a little sweeping or something like that. Uh You don't need to go for this whole uh whole uh rigmarole of chemo and radiation, et cetera. Um But that would usually be how things go. Hope that makes sense. All right. Moving on to the next case then. So we have here um Mister Harris. Oh To a question in a case, I me a static cancer like before but a younger patient. Yes. What would be the course of action? Absolutely. Um So we can speak about that. Uh Let's go back. So let, let's say this one. So it again, the biggest thing it depends on is the performance status and the health of the, the patient. So if you have somebody who's bedbound, if you have somebody who um isn't able to eat and drink and is very weak, it doesn't matter how old they are. If they're 20 if they're 80 the advice to go for supportive care, palliative care um as the uh uh mainstay of treatment would be what's recommended. Now, if you have somebody who has uh metastatic esoph, he has colon here. Um But if you have metastatic esophageal cancer, um it really depends on the receptors and the pathology that you see. Usually it's a combination of chemotherapy and immunotherapy that we would start with um sort of a whole body uh systemwide treatment because it is metastatic cancer. Um but that would usually be what's recommended for someone who is fit and healthy and able to tolerate. Ok. So moving on to the next question. So this is uh now to colon cancer, metastatic colon cancer. So we've got Mr Harris, he's a, a younger gentleman, 55 years old, we can say for our purposes that he's healthy, he's got no other issues and he's co the colon cancer that spread to one spot in the liver. So now this is tricky again, this is um another bit of a, a unique situation. Um but does anybody know off the top of their head or maybe they can take a guess about what you would recommend um to treat Mister Harris with? So it's called colon cancer and it's spread to one spot in the liver. See, Mohamed says colon resection with liver tumor, brachy or ablation. Ok. Um What it says, no chemotherapy followed by colectomy with resection of liver, liver residue depends on what patient is able and willing to tolerate. Yes, absolutely. And all of these have to be conversation with patient. But uh for our purposes, we'll assume that he's ready to take anything and he's uh fit enough for it to chemo followed by colectomy. So neo chemo resection of liver and colectomy together. All right. Chemo with immunotherapy chemotherapy chemo with lobectomy of liver. Yes. Ok. So there's a couple of different approaches that one can take here actually. And from the evidence that we have from studies, there's no one standard approach. What we do know is that patients with what's called oligo metastatic uh colon cancer, which means they have colon cancer that spread to only a couple of spots. So in the case of Mr Harris, only one spot, technically, in a small percentage of patients, these uh cancers can actually be cured. OK. So this is one of the exceptions where I said before that metastatic cancer cannot be cured and the gi oncology. Well, let's say probably this is the only exception that a small percentage of patients can get long term survival or even a cure um from this kind of a cancer by cure. Just mean. Well, what do I mean with that? They live long enough, you know, many, many years and then they die of something else. So how to go about doing this? Nobody really knows there's different ways, different approaches. Um Usually what I see and what I would do is a consideration of chemotherapy in the neoadjuvant setting. Um plus or minus some localized treatment to the liver. So maybe your ablation or some chemotherapy or radiation directive uh to the liver and then consider a surgery afterwards. If the liver spot is very small and easy to uh take out surgically, our surgical colleagues may consider cutting out the um colon cancer with a spot on the liver. And then yes, you can consider chemotherapy afterwards. But this is one of those situations where presenting at a tumor board is very important. Um discussing with your colleagues from radiation and surgery or medical oncology, if you don't go to medical oncology, because there's different ways to approach this. Um And a large part will be depending on when the level of the spot is. How big is the spot? Um Probably at some point, chemotherapy and surgery are both in this patient's future. But just a question of what order do you do them? What kind of response do you want to see? Just thinking about things? Now, another question, I don't think I have it here. Do I have it here? Uh Yes. No, I don't. Ok. So if we have the same Mister Harris who comes in with colon cancer, um that spread to multiple spots in the liver, the lungs and maybe the bone. Ok. So I'm changing things up here. So instead of just one spot instead of that oligo metastatic colon cancer, he now has widely metastatic colon cancer. Um Do folks know what the treatment might be for that? I'm going a little quickly through my slide so I can throw out a few extra questions. So somebody says palliative care, which, you know, it's a good point to that. It's always an option for patients, right? Even if they're fit and healthy, they may choose not to go for any cancer directed therapies, maybe uh based on their own goals or their own sense of what quality of life is. So, maybe something they've seen someone else go through. So it's always on the table. Absolutely. Chemotherapy is pretty standard for colon cancer. Yes. Uh, radiation therapy for uh widely metastatic disease is not usually used unless there's a spot of particular concern. And in colon cancer it's usually not standard unless there's one spot that's causing you particular trouble. Um, immunotherapy is an interesting point. Um The reason being that uh in the colon cancer world and colorectal cancer world, if you have specific um uh findings on your pathology, um that are quite rare, but they can be there. Uh They can be an option, but for most patients, it's not an option unless you have these specific pathological findings. Um And your surgery would usually not be on the table for someone who has widely metastatic disease. Um, ok. All right. So, one of the last cases that we have here then. So this is going to be a case of rectal cancer now. So we have Mister Lewis, he's 54. Uh He comes in with a rectal mass that's biopsy proven to be an adenocarcinoma. So they present this case at tumor board, um where certain high risk features suggest that proceeding directly to surgery might not be recommended. So remember how I spoke before about uh the MRI being important in the workup of rectal cancer and rectal malignancy. Well, this is why because if we see certain high risk features on the MRI, um going straight to surgery may not be recommended and there actually may be a recommendation for neoadjuvant chemotherapy and radiation before um, going to surgery. Although right now in the rectal cancer world, this is a bit debated as to exactly what order that should be, what drugs that should be. Uh Somebody says infiltration of sphincters. Mortaza has been doing some reading. Uh That's absolutely one of them because the trouble is if you have a cancer invading into the sphincter and the surgeon goes and cuts out the sphincter, um, that individual has lost control of their bowels. Uh, and for many patients that will, or I think most patients actually would say that decreases your quality of life, you'll likely need an ostomy bag. Um And uh, if we can shrink the cancer to the point where the sphincter can be saved, that can be helpful, encasement of a adjacent arterial territory. Um That's something we actually see more in pancreatic cancer than rectal cancer. Although if it were the case, um, certainly that would be problematic uh for surgeons from a surgical perspective. I don't think there's any major arteries that, that typically happens to in the rectal area, but definitely a good thought tumor size. So that's interesting, you know, that makes sense. But in the rectal cancer world, we're actually looking more at tumor depth. So how deep into the uh wall, the rectal wall does it invade if it's very superficial? Um, a lower risk than if it's very deep or even invades through the wall, tumor might be too large with no clear plan of demarcation. Yes. So if you're not able to get good surgical margins, if you go in as a surgeon and you're not sure where the cancer ends and where you're supposed to cut, that's not ideal lymph node involvement. Yes. Yes. You guys are getting all of it. It's actually excellent. So T three T four refers to how deep into the uh rectal wall. The tumor goes sphincter involvement, as someone said, uh node involvement, as Adrian has said, and certain surgical margins as well. Uh those and the infiltration into the muscularis propria. Yeah, that relates to the T three T four. OK. Uh That's all the cases I had actually, but I think we have about 10 minutes. So if anybody's got any questions or anything they'd like to ask, um please feel free. Um We have the chat, we have 10 minutes. Perfect. Perfect. If you want and you can just click on present now again and sharing. That's lovely. There you go. Just start now. So yeah, if anyone has any questions, please do, pop them in the chat. Um I was, I was saying to Beatrice earlier that um backstage that actually we have recently um experienced cancer in our family and, and I know for us it was the doctors who were able to be honest and communicate this, this isn't for my dad because of X, this is what we can do. So for us, it was the communication that was really key. Um I know that's not, you know, obviously maybe doesn't help but it was really helpful for us for someone to just be blunt but caring, you know, and just say, look, this is what has happened and because we can't do XY and Z this is the prognosis for that. So yeah, I don't know. II saw that somebody had put about um communication and palliative care, you know, but II think it is communication is really key, you know, to just say, look, this isn't an option for you, you know, because of. But anyway, so you've got some questions now. I like II normally chat a little bit so they can, they can be typing away. Um Right. OK. Let's have a look. Uh Can you please elaborate on a new delivery methods of chemotherapy example, beads delivered through artery in liver. Me, I just had an argument with this uh about this with somebody uh last week because I said as a medical oncologist, this is not my area of expertise and some surgeon or somebody needs to do this. Um So you, you're right. Um Broadly speaking, there are ways to give chemotherapy locally to scenarios such as a specific liver metastasis and metastasis. Um I can't elaborate reading on that anymore because I don't do it. I don't know much about it. Um But if you want to reach out, you know, I'm happy to look around or ask around and get you some resources to read around that. Uh Can we see the size of fresh? I think this is recorded too if I'm not mistaken. Yeah. So, Lian, you should be able to watch the recording and get the slides that way. Hopefully. Uh do patients often want some kind of treatment despite doctors suggesting palliative care? Yes. Yes. So this is, this is very common and actually I was telling I'm on the inpatient service right now and we see that a lot. Um I think a large part of it is cultural um sometimes um individuals from certain cultures and certain religions um see palliative care sometimes as giving up or um uh giving up on life uh which uh can be quite challenging. Um And also you have some people who simply uh it it's an age to fight, right? Um They want to fight to the end and it's challenging because what fighting means can, can be different, right? Different for different people. And sometimes as I top patients, fighting doesn't mean taking the last drop of drug, um, until you stop breathing, right. Fighting might mean just waking up each day and trying to make the best out of it. And I see what's coming from. That. That's really where the communication comes from and uh just having the ability to, to sit down with folks and say, you know, I'm sorry that this is, you know, the situation. But in my experience, this is what I see. But you know, let's talk about what's important to you, right? Let's talk about what you really want because I think very few people actually really want to have their last breath in a hospital bed or getting the last stroke of chemotherapy. There's other fears or other factors that are applying into that. And I think as physicians, as doctors, it's as oncologists, it's very important to have the skills to try and pull that out and um help a patient make the decision that's best for them. Uh Thank you. Yeah, it wasn't easy to try and compress all this into 50 minutes. Um So what are the prognosis for some of these common cancers with and without treatment? Absolutely. Ok. So, um pancreatic I think would probably be the worst if you have a patient with pancreatic cancer, metastatic untreated uh of months to weeks um have uh patients, you know, they present with their bilirubin quite elevated. There's nothing that can be done about that. From a stenting perspective, um prognosis is probably days to weeks, a treated pancreatic cancer. Uh So a patient who's has pancreatic cancer that is treated and has a good response to chemotherapy with the lines that we have maybe a year and a half on average, um might be what I would expect um versus something like colon cancer. So even in the metastatic setting, if we're looking at oligo metastatic colon cancers that are treated for cure, initially, um Several years, sometimes we can get good control uh before having to go on regular systemic therapy. Uh I think according to the trials, once we start systemic therapy again, 1 to 2 years average, but some people get excellent control uh of their cancer and can have years on the flip side. And that's why um choosing patient populations that we're going to treat is so important because if you give somebody a heavy duty chemotherapy or treatment and they have a bad side effect, you can shorten their life, they can actually die from side effects and that's certainly not something that we ever want to do. Um Yeah, Mohammed, I think this is being recorded. So hopefully you should be able to access that. Um Please, can you elaborate on why lymph node involvement is contraindicated? Ok. So it's not contraindicated necessarily what it tells us is that um, erectile cancer. Uh, it's aggressive, which means it, um, it can spread quickly, but also it's a high likelihood to come back, um, and come back in the future, either localized or metastatic. And in both cases, it's tricky because if you could think about it, if you've already had your rectum cut out and you've had a lot of surgery in that very small area and they have to go in and cut things out again. It can be quite painful and uncomfortable and positive for patients. So, if we see cancer that's spread and involves the lymph nodes that tells us this is a cancer that's already on the move and a higher risk to come back. So, if we treat this with uh chemotherapy and radiation before maybe we can shrink things, maybe we can get better control to try and make surgical resection easier. Um and decrease the risk of the cancer coming back in the future. That's the big reason it's not that lymph nodes themselves contraindicate um uh surgical resection of rectal cancer is that it tells us it's higher risk. And this patient may benefit from more treatments with cholangio. For no, with cholangiocarcinoma with raise bilirubin. What should be the first thing to do upfront surgery or stenting first with E RCP? Uh Yes. So the trouble with uh high bilirubin is that it's a marker for how the liver is working. And I think most surgeons would be hesitant to take somebody with a liver that's not working very well to get rid of all the toxins. It needs to, to the operating theater for a major surgery. Stenting is usually much easier. Um, you just go down, uh, there's no cutting into the belly and all those sorts of things. And I think again, not being a surgeon but my sense is that most surgeons would hesitate to take a patient to the operating theater with an elevated bilirubin when there might be something that could, um optimize uh the patient's situation for that kind of a surgery. Oh, I think it's more questions. Uh Yes. So I have to scroll down. Can you love it? Um, I did, I did that. Ok. All right. Any other questions? Anybody has brilliant, I think, II so from experience bitches, I'm sure you've just seen the message that we're all gonna ignore from Mohammed. Um That from experience also, I know that um um treatment you said about treatment plans can have side effects. Um That's what, unfortunately, my dad passed away from the side effects of radiotherapy. He passed away from the complications that five years later, we didn't even realize that it would be something so far away. Um That's what he eventually died from the complications of that. So, um yeah, I think sometimes you sort of think radiotherapy and maybe it was the best option. I don't know. Um But sometimes there, there are complications to that he wasn't able to have that seed because I think the cancer was a different stage. Um, so he couldn't have the seed in his prostate, so he had to have whatever the other form is. Um, and obviously it's not as precise as we want it to be yet. Um, so I think for prostate cancer, we were told that it just obliterates the bladder, you know, and causes damage to the bladder and that's then um what he suffered from afterwards, it was radiation or something like that. Is that what it's called? I don't really know. Um But anyway, so that's so yeah, I think sometimes it is that explaining everything, you know, that actually even radiation and chemotherapy, there are side effects. It's not a, it's not an absolute, you will be cured and you will be healthy. It is that communication again, it's like inform the patient that these are the consequences of this. Um I think that's just really key coming from a patient perspective and a family perspective that is really, really key. I think so. Anyway, any other questions at all? Um If we have no more, we will say goodbye. I will pop up the um the catch up for you. I will put that up and um like I said, fill out your feedback form um and your certificate will be on your medal account and I'll pass on all the feedback to Beatrice. There is a question in that that says is there anything else you'd like to learn about? So if there's anything else you'd like to learn about and maybe Beatrice might come back again and, and do another chat for us. Um but we can send all the feedback off to Beatrice. Alright. So thank you everyone for joining us. We're gonna, I'm gonna close the call now. Thank you. Take care everyone.