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Question on Staging?

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Question on Staging?

Postby sandrichelle » Wed Mar 07, 2012 6:19 pm

Now I may just be grasping for straws and in the entire scheme of things...not sure that it really matters however I have been diagnosed with Stage IV colon cancer that apparently started in my upper rectum region, spread thru the wall, entered 1/9 lymph nodes that we know of and went ahead and attached itself to my uterus, cervix and top of my vagina (all of which were removed in surgery). So my question is, I thought that you needed distant spread (liver/lung) to be considered stage IV? Also, I know that there are different types of staging so what stage would I be in the dukes staging or the other TNM staging? Any info on this would be great.

Thanks All!!
Dx Stage IV CC 02/12-56.1 CEA
Resection/Bye Bye Uterus 02/12
Folfox 03/12-08/12
05/01/12 3 TX CEA-6.5
07/23/12 10 TX CEA-5.0
09/18/12 PET shows 3 suspicious spots CEA -15.5
09/25/12 CEA- 23.8
10/23/12 CEA-51.8 1st of 6 FOLOFIRI
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Re: Question on Staging?

Postby SkiFletch » Wed Mar 07, 2012 7:17 pm

Well, not having performed the operation, none of us can answer this for certain. Technically you would fall into one of two staging categories from the AJCC scale, Stage IIIC or IVA. For IIIC:

T4b, N1-N2, M0: The cancer has grown through the wall of the colon or rectum and is attached to or has grown into other nearby tissues or organs (T4b). It has spread to at least one nearby lymph node or into areas of fat near the lymph nodes (N1 or N2). It has not spread to distant sites.


And for IVA:

Any T, Any N, M1a: The cancer may or may not have grown through the wall of the colon or rectum, and it may or may not have spread to nearby lymph nodes. It has spread to 1 distant organ (such as the liver or lung) or set of lymph nodes (M1a).


The distinction which is not entirely apparent in the definitions is whether the cancer was physically attached/adhered to each of your specific organs in a single unit, or if one or more of your affected organs were not adhered to the primary (this of course assumes you have no distant organ/lymph mets). If it's one continuous tumor (ie all attached/adhered) then it's IIIC, but if it's multiple separate tumors, then it's IVA. The difference in prognosis and treatment of IIIC or IVA resectable is dubious at best (IVA resectable is significantly better than IVB and/or non-resectable patients). The main difference between the two will be the clinical trials available to you at certain points if that were something you chose to participate in. Some trials only recruit stage III or less, and some only IV or more.
11/13/09 5cm Stage IV 9/25 lymph nodes w/2cm peritoneal met at 29 YoA
12/15/09 LA right hemi-colectomy
6/16/10 Folfox FINISHED
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Re: Question on Staging?

Postby Patience » Wed Mar 07, 2012 8:09 pm

Indeed this is such a confusing topic for many of us. Here are two sites that might help:

National Cancer Institute http://www.cancer.gov/cancertopics/factsheet/detection/staging
The TNM staging system is based on the extent of the tumor (T), whether cancer cells have spread to nearby (regional) lymph nodes (N), and whether distant (to other parts of the body) metastasis (M) has occurred.

ACS http://www.cancer.org/Cancer/ColonandRectumCancer/DetailedGuide/colorectal-cancer-staged
T categories for colorectal cancer
T categories of colorectal cancer describe the extent of spread through the layers that form the wall of the colon and rectum.
[T4b: The cancer has grown through the wall of the colon or rectum and is attached to or invades into nearby tissues or organs.]

N categories for colorectal cancer
N categories indicate whether or not the cancer has spread to nearby lymph nodes and, if so, how many lymph nodes are involved.

M categories for colorectal cancer
M categories indicate whether or not the cancer has spread (metastasized) to distant organs, such as the liver, lungs, or distant lymph nodes.


You also asked about different types of staging. That same ACS site (towards the bottom) gives a comparison chart, Comparison of AJCC, Dukes, and Astler-Coller stages. According to that chart, the term Stage "IV" is only used with the AJCC (TNM) system.
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Re: Question on Staging?

Postby Toby57 » Thu Mar 08, 2012 9:08 pm

This website is pretty good explaining the stages, hope it helps.

http://www.cancer.gov/cancertopics/pdq/ ... ient/page2
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Re: Question on Staging?

Postby Buckwirth » Fri Mar 09, 2012 2:24 am

SkiFletch wrote:Well, not having performed the operation, none of us can answer this for certain. Technically you would fall into one of two staging categories from the AJCC scale, Stage IIIC or IVA. For IIIC:

T4b, N1-N2, M0: The cancer has grown through the wall of the colon or rectum and is attached to or has grown into other nearby tissues or organs (T4b). It has spread to at least one nearby lymph node or into areas of fat near the lymph nodes (N1 or N2). It has not spread to distant sites.


And for IVA:

Any T, Any N, M1a: The cancer may or may not have grown through the wall of the colon or rectum, and it may or may not have spread to nearby lymph nodes. It has spread to 1 distant organ (such as the liver or lung) or set of lymph nodes (M1a).




Sorry Skifletch, but distant here is a relative term. Any organ, other than the primary, is considered distant. As an example, the bladder and the prostate are very close, but cancer that has spread from one to the other (and discovered at diagnosis) would be stage 4.
Dx April 2010
Stage IV
Mets to distant lymph
Colostomy 1/2011
Folfox w Avastin 4/2010 to 9/2010
Radiation 10/2010
Erbitux/Irinotecan 6/2011 to 12/2011
Currently out of treatment options? 12/2011
Back on Folfox 2/2012
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Re: Question on Staging?

Postby weisssoccermom » Fri Mar 09, 2012 2:39 am

Buckwirth,
Sorry but that's not necessarily true. For example, a T4 tumor in a woman with rectal cancer can be attached to the vagina - not the same organ as the primary, but....depending on the doc, is NOT necessarily considered a stage IV. In her situation, with the tumor being quite extensive in her pelvis, it's easy to see how the staging came about. Just another FYI to the original poster. Distant mets don't have to be confined to an organ. If, for example, you had positive lymph nodes in your chest but nothing in your lung/liver, that would also qualify as a stage IV.

I think the original poster is quite correct. In her situation, the staging isn't as important as getting the treatments and honestly, whether this is a stage IIIC or a stage IV is irrelevant at this point....as the treatments will be the same either way.

Good luck to you.

Jaynee
Dx 2006 IIA rectal cancer
6 wks rad/Xeloda
1st attempt transanal excision 11/06
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Re: Question on Staging?

Postby Gaelen » Fri Mar 09, 2012 6:21 am

This graphic from the most recent 7th edition AJCC (American Joint Committee on Cancer) might clear some things up in this conversation. It also compares the TNM staging directly to other methods. FWIW, there is no comparable Dukes staging classification for TNM Stages IVa or IVb.

If you were dx'd with "Stage IV colon cancer that apparently started in my upper rectum region, spread thru the wall, entered 1/9 lymph nodes that we know of and went ahead and attached itself to my uterus, cervix and top of my vagina", then you are:
- ANY T
- ANY N
- M1b (Metastases in more than one organ/site or the peritoneum)
For a T4b, "Tumor directly invades or is adherent to other organs or structures." Everything counts as another "organ or structure."

Cancer adherent to or present in the uterus, cervix and vagina is considered "more than one organ or site." And as someone else mentioned, "distant" is a relative term. They are all adjacent to the colon, but they are considered multiple "distant" sites.

Your clinical staging (scans, etc.) if it confirmed tumor attachment to uterus, cervix and vagina, would put you at Stage IVb. It's not up to "the doctor" and s/he has no discretion in staging if s/he's working according to the AJCC guidelines.

And yeah - accurate evaluation of your staging makes a difference. For one thing, it determines which drugs you're eligible for as first and second line treatments, and what kind of medical follow-ups your insurance company will authorize.
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4/04: dx'd @48 StageIV RectalCA w/9 liver mets. 8 chemos, 4 surgeries, last remission 34 mos.
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Re: Question on Staging?

Postby Buckwirth » Sat Mar 10, 2012 6:23 pm

weisssoccermom wrote:Buckwirth,
Sorry but that's not necessarily true. For example, a T4 tumor in a woman with rectal cancer can be attached to the vagina - not the same organ as the primary, but....depending on the doc, is NOT necessarily considered a stage IV. In her situation, with the tumor being quite extensive in her pelvis, it's easy to see how the staging came about. Just another FYI to the original poster. Distant mets don't have to be confined to an organ. If, for example, you had positive lymph nodes in your chest but nothing in your lung/liver, that would also qualify as a stage IV.

I think the original poster is quite correct. In her situation, the staging isn't as important as getting the treatments and honestly, whether this is a stage IIIC or a stage IV is irrelevant at this point....as the treatments will be the same either way.

Good luck to you.

Jaynee


Thanks Jaynee,

I'll stick with Gaelen's explanation. For the record, my rectal cancer spread to my inguenal lymph node, and my first reaction was that this was not distant, so I must be stage III. I am painfully aware that "organ" is not limited to the lungs, liver or most anything a layperson might consider an organ. It was my oncologist at the Norris Cancer Center who first set me straight on the difference between local and distant, a lecture that is forever seared into my memory.

Also, while there are similarities in the treatment for stage III and stage IV they are not quite the same. As Gaelen says
Gaelen wrote: It's not up to "the doctor" and s/he has no discretion in staging if s/he's working according to the AJCC guidelines.

And yeah - accurate evaluation of your staging makes a difference. For one thing, it determines which drugs you're eligible for as first and second line treatments, and what kind of medical follow-ups your insurance company will authorize.
Dx April 2010
Stage IV
Mets to distant lymph
Colostomy 1/2011
Folfox w Avastin 4/2010 to 9/2010
Radiation 10/2010
Erbitux/Irinotecan 6/2011 to 12/2011
Currently out of treatment options? 12/2011
Back on Folfox 2/2012
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Re: Question on Staging?

Postby sandrichelle » Sun Mar 11, 2012 12:49 pm

Well, like I said before, really doesn't make a difference at this point..in my minds eye, the surgery removed all of the tumor and the fact that they did not find anything in my liver / lungs is only a good thing. I also like the fact that it was one single tumor..not more and that my doc saw clear margins on removal. Now time for the cleanup chemo.
Dx Stage IV CC 02/12-56.1 CEA
Resection/Bye Bye Uterus 02/12
Folfox 03/12-08/12
05/01/12 3 TX CEA-6.5
07/23/12 10 TX CEA-5.0
09/18/12 PET shows 3 suspicious spots CEA -15.5
09/25/12 CEA- 23.8
10/23/12 CEA-51.8 1st of 6 FOLOFIRI
http://www.yeswecansir.com
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Re: Question on Staging?

Postby sandrichelle » Mon Mar 19, 2012 10:05 am

Just an update:

Received my official Clinical Diagnosis from Sloan and it states:

It is unclear from the outside reports whether tumor involves vagina and cervix by direct extension or not. In the case of direct extension the tumor is best staged at T4bN1a. If not, the tumor is best staged as T3N1aM1.

Again, not that it really matters at this point but found this comment interesting.
Dx Stage IV CC 02/12-56.1 CEA
Resection/Bye Bye Uterus 02/12
Folfox 03/12-08/12
05/01/12 3 TX CEA-6.5
07/23/12 10 TX CEA-5.0
09/18/12 PET shows 3 suspicious spots CEA -15.5
09/25/12 CEA- 23.8
10/23/12 CEA-51.8 1st of 6 FOLOFIRI
http://www.yeswecansir.com
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Re: Question on Staging?

Postby SkiFletch » Mon Mar 19, 2012 12:53 pm

Well then I'm flatly confused. Why the distinction between the descriptions of IIIc and IVb that I quoted? Why do they go through the bother of distinguishing "...and is attached to or has grown into other nearby organs or tissues (T4b)" in the description of stage IIIc if ANY involvment of another organ is automatically Mx and therefore stage IVa? The distinction in the description is pointless, confusing, or just plain wrong then...

It seems to me that the distinction is there for some specific reason. Attempting to say that the mechanisms involved in tumors with deep penetration are not the same as those which metastasize via blood/lymph system.
11/13/09 5cm Stage IV 9/25 lymph nodes w/2cm peritoneal met at 29 YoA
12/15/09 LA right hemi-colectomy
6/16/10 Folfox FINISHED
8/10/10 Prophylactic HIPEC
10/9/10 got Married :D

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Re: Question on Staging?

Postby sandrichelle » Mon Mar 19, 2012 12:58 pm

I have no clue....took right from my report?
Dx Stage IV CC 02/12-56.1 CEA
Resection/Bye Bye Uterus 02/12
Folfox 03/12-08/12
05/01/12 3 TX CEA-6.5
07/23/12 10 TX CEA-5.0
09/18/12 PET shows 3 suspicious spots CEA -15.5
09/25/12 CEA- 23.8
10/23/12 CEA-51.8 1st of 6 FOLOFIRI
http://www.yeswecansir.com
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Re: Question on Staging?

Postby Kathryn in MN » Mon Mar 19, 2012 1:32 pm

sandrichelle wrote:Well, like I said before, really doesn't make a difference at this point..in my minds eye, the surgery removed all of the tumor and the fact that they did not find anything in my liver / lungs is only a good thing. I also like the fact that it was one single tumor..not more and that my doc saw clear margins on removal. Now time for the cleanup chemo.


It actually does make a difference for you. If staged at III, insurance will not pay for Avastin, which you have listed you will receive. It is for stage IV patients, and has been shown to be of no benefit to stage III (thus the problem with getting insurance to cover it). I do not know of any insurance that does not have to pre-approve Avastin. If you did start Asvastin already, then they staged you at IV to get it for you.
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Re: Question on Staging?

Postby nbrandt » Mon Mar 19, 2012 2:02 pm

I had no symtoms, went in September, 2010 because Health Care Reform and had a colonoscopy with my annual Pap and Mamo and found cancer in both the appendix and right colon with 5 of 20 lymph nodes and was dx late stage IIIC. The surgeon thought the tumor originated in the Appendix, but Mayo agreed with the Fargo DX Colon Cancer Stage IIIC. Now I understand why when I arrived in Arizona I was asked why I was not on Avastin to prevent recurrence. It also explains why someone on this board when I explained earlier having cancer in both the appendix and the right colon as well as 5 lymph nodes asked why I was not Stage 4. I thank Health Care Reform for being here today. Hoping and Praying next scan is OK
NBrandt
DXCCT3N2aMx 5/20LN
Folfox10/2010 4/2011
Scan 10-13-10,4-4-11,7-4-11,9-22-11,4-9-12,9-24-12,10-1-13,4-9-14,9-17-14NED
CEA 1. PreChem .6 7-4-11 .7 9-22-11 .6
1-13-12 .9 4-9-12 .7 9-24-12 .6 1-4-13 .8 10-1-13 .8 4-9-14 .7 9-17-14 .8
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