Lymph negative but one marked as 'i+'

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squak
Posts: 12
Joined: Sat Apr 02, 2016 8:33 am

Lymph negative but one marked as 'i+'

Postby squak » Sat Apr 02, 2016 9:01 am

Hello Dear Board Members,

I am a 39 yo Female, diagnosed with CRC on Jan 12, 2016. Symptoms were rectal bleeding and major discomfort - colonscopy revealed a near obstructing mass in rectosigmoid, adenocarcinoma, invasive. CT showed no distant mets. Open LAR was performed on Feb 10, 2016. 23.5cm of Rectum/Colon were removed along with a 11.5 x 4.2 x 4.0 cm tumor. The scar is big, and is healing slowly. BMs are still irregular and quite frequent (esp at night), but stool is much better formed than before LAR.

While the cancer remains unstaged (am currently waiting for referral to oncology), the depth of invasion is pT3, so into the subserosal/mesorectal fat. Margins were negative, no vascular invasion. 34 lymph nodes were examined, and while none were 'involved', one single lymph node in section A18, a single tiny cluster of malignant cells measuring less than 0.2 mm in diameter is present. This cluster of malignant cells is present but becomes smaller in deeper levels. Lymph node stage was determined as pN0(i+) (pTN stage pT3N0(i+)M0). I think this puts me squarely between stages IIa and stage IIIb, but am not sure.

I am simply looking for someone to share their experience regarding ongoing treatments with a similar diagnosis, what these could look like (i do have an appointment with a radiation oncologist as well as a GI oncologist coming up in a few weeks), and whether they have shown any benefit in really inhibiting recurrence. What specific tests are available, to better understand the real risk of recurrence to me (ie genetic)?

These are very early days in my journey, at this stage I cannot do much other than empower myself with information and positivity. Sending courage, light, and strength to all you on this CRC journey.. thank you!
01-12-2016: colonoscopy- large rectosigmoid mass
01-14-2016: path- CRC, adenocarcinoma, invasive, low grade, well diff. (39 yo @ DX)
01-25-2016: CT scan- no mets (pM0?)
02-20-2016: open LAR (pre-OP CEA 1.3)
03-01-2016: path- pT3 (11.5x4.2x4cm), pN0(i+) ie 1/34 lymph w/ isol.tum.cell)
04-20-2016: It was CRC Stage IIa. I'm NED!! (CEA is <1.0) :D
04-2016: 12-15% chance of relapse within 5 years
04-2016: No adjuvant therapy ie no chemo, no radiation. Follow-up in 6 mos.

Nik Colon

Re: Lymph negative but one marked as 'i+'

Postby Nik Colon » Sat Apr 02, 2016 10:03 am

I could only seem to find the (i+) for breast cancer. Haven't seen it used for colon, maybe someone else has.
https://www.google.com/search?q=i%2B+ca ... e&ie=UTF-8

squak
Posts: 12
Joined: Sat Apr 02, 2016 8:33 am

Re: Lymph negative but one marked as 'i+'

Postby squak » Sat Apr 02, 2016 10:26 am

My surgeon seemed not to have much knowledge or experience with it either! He felt that the pathology team had been extremely thorough, and I am grateful for that. He indicated that 34 lymph nodes was a good thing.
He had a fairly binary view of i+ (aka 'isolated tumor cells') though, as in "either it is in/on the lymph or not."
:?
little confused, little worried - but staying positive!
01-12-2016: colonoscopy- large rectosigmoid mass
01-14-2016: path- CRC, adenocarcinoma, invasive, low grade, well diff. (39 yo @ DX)
01-25-2016: CT scan- no mets (pM0?)
02-20-2016: open LAR (pre-OP CEA 1.3)
03-01-2016: path- pT3 (11.5x4.2x4cm), pN0(i+) ie 1/34 lymph w/ isol.tum.cell)
04-20-2016: It was CRC Stage IIa. I'm NED!! (CEA is <1.0) :D
04-2016: 12-15% chance of relapse within 5 years
04-2016: No adjuvant therapy ie no chemo, no radiation. Follow-up in 6 mos.

User avatar
Jacques
Posts: 579
Joined: Sun Dec 28, 2014 10:38 am
Location: Occitanie

Re: Lymph negative but one marked as 'i+'

Postby Jacques » Sat Apr 02, 2016 10:52 am

squak wrote:... Lymph node stage was determined as pN0(i+) (pTN stage pT3N0(i+)M0). I think this puts me squarely between stages IIa and stage IIIb, but am not sure...

I have never seen the (i+) notation before, but apparently it is an abbreviation for "Isolated Tumor Cells" (see reference below)
6.4. Isolated Tumour Cells
....
pN0(i+). No regional lymph node metastasis histologically, positive morphological findings for ITC

http://cancerstaging.blogspot.fr/


There are other people on this board who are in the grey area between Stage II and Stage III. Maybe some of them will chime in.

macpudd
Posts: 120
Joined: Tue Jul 21, 2015 7:00 pm

Re: Lymph negative but one marked as 'i+'

Postby macpudd » Sat Apr 02, 2016 1:51 pm

Hi Squak, I had something similar I think, my pathology report said tumour deposits on the meso colon, when I asked what these were I was told they were isolated tumour cells, and that I was between stage 2c and 3a, but the surgeon said they were not really classified as lymph nodes. I had adjuavant Folfox x 12.
Regards
Mcpudd
Dx 10/13/2014 right hemicolectomy 10/15/2014 pT4b N0 M0
Folfox x12 from Dec 2014 to July 2015
01/16/18 tonic seizure hospital admission
01/17/18 ct and mri 2cm tumor on left side of brain
commenced anti epileptic and steroids and
insulin.
01/25/18 brain craniotomy 80% of tumour removed pathology says gbm4
6 weeks of rad and Temodar chemo and then 6 monthly cycles of Temodar
MRI in Oct no tumor
Mri Jan 2019 tumour growth Feb Pet scan tumour 6cm, no surgery, starting Avastin also Lomustine

squak
Posts: 12
Joined: Sat Apr 02, 2016 8:33 am

Re: Lymph negative but one marked as 'i+'

Postby squak » Sat Apr 02, 2016 4:23 pm

Hey Macpudd - thank you, and yes, it does sound very similar. I see from your signature that you had a CEA of 1.6 pre-OP - I was at 1.3 pre-OP, still waiting for a post-OP reading, so maybe that is a further similarity.
01-12-2016: colonoscopy- large rectosigmoid mass
01-14-2016: path- CRC, adenocarcinoma, invasive, low grade, well diff. (39 yo @ DX)
01-25-2016: CT scan- no mets (pM0?)
02-20-2016: open LAR (pre-OP CEA 1.3)
03-01-2016: path- pT3 (11.5x4.2x4cm), pN0(i+) ie 1/34 lymph w/ isol.tum.cell)
04-20-2016: It was CRC Stage IIa. I'm NED!! (CEA is <1.0) :D
04-2016: 12-15% chance of relapse within 5 years
04-2016: No adjuvant therapy ie no chemo, no radiation. Follow-up in 6 mos.

macpudd
Posts: 120
Joined: Tue Jul 21, 2015 7:00 pm

Re: Lymph negative but one marked as 'i+'

Postby macpudd » Sun Apr 03, 2016 9:25 am

squak wrote:Hey Macpudd - thank you, and yes, it does sound very similar. I see from your signature that you had a CEA of 1.6 pre-OP - I was at 1.3 pre-OP, still waiting for a post-OP reading, so maybe that is a further similarity.

Hi Squak, yes our CEA does seem similar, my surgeon said it would proabably not be a good marker for me as it was within the normal range pre surgery. Like you I also had clear margins and no vascular invasion, my tumour was much higher in the colon than yours (ceacum). I finished chemo last July/August and have some ongoing problems with fatigue, concentration and surgery related pain but overall life is very good and I am just so happy to be eighteen months out from diagnosis and NED. I have every faith that you will have a simillar path and will soon get back to good health.

Regards
Macpudd
Dx 10/13/2014 right hemicolectomy 10/15/2014 pT4b N0 M0
Folfox x12 from Dec 2014 to July 2015
01/16/18 tonic seizure hospital admission
01/17/18 ct and mri 2cm tumor on left side of brain
commenced anti epileptic and steroids and
insulin.
01/25/18 brain craniotomy 80% of tumour removed pathology says gbm4
6 weeks of rad and Temodar chemo and then 6 monthly cycles of Temodar
MRI in Oct no tumor
Mri Jan 2019 tumour growth Feb Pet scan tumour 6cm, no surgery, starting Avastin also Lomustine

mainelyj
Posts: 8
Joined: Tue Apr 15, 2014 10:21 pm

Re: Lymph negative but one marked as 'i+'

Postby mainelyj » Sun Apr 03, 2016 4:01 pm

I would air on the side of caution and get the adjuvant therapy BUT first have a DPD deficiency test. I know Quest does a genetic test that is not expensive and only takes about a week for results. It finds the most common alleles that cause problems with 5 FU which is part of FOLFOX. If you are partially deficient you should not start higher than a 50% dose. If you are totally deficient you should not have adjuvant therapy it will likely kill you quickly and miserably.

https://en.m.wikipedia.org/wiki/Dihydro ... deficiency
Stage 3 1a March 2014
Adjuvant Therapy Stopped due to Partial DPD deficiency
lymph node mets to para aortic area CEA at 25 Dec 2015
Folfox 50% 5 FU -doing Ok- CEA 14 - lymph nodes shrinking - 3/16
Oxaliplatin dropped - CT scan clear - CEA 7- 6/16
Superclavicular + pelvic nodes + para aortic nodes CEA 58 10/16
Folfiri 10/16
Nodes shrinking Chemo Break 2/17

squak
Posts: 12
Joined: Sat Apr 02, 2016 8:33 am

Re: Lymph negative but one marked as 'i+'

Postby squak » Mon Apr 04, 2016 9:02 am

Macpudd - I am so glad to hear that you are NED after 18 months, that is wonderful. Thank you for sharing, and I will focus on a positive outcome for me too! I think my main issue lies in the fact that with only one of 34 lymphs deemed to contain isolated tumor cells yet not be 'invaded, (and this is sitting in a jar of formaldehyde in a lab somewhere)' and the LAR surgery to remove the tumor having been deemed a 'success' (clean margins etc) - what tangible objective does chemotherapy offer me?

I am at the junction, where I am trying to weigh the pros vs the cons of receiving adjuvant therapy now. With a low pre-OP CEA baseline, and no distant mets as per CT - how will success of possible chemotherapy even be measured? Also, aside from eg DPD deficiency as an issue, I think I recently read an article (sorry, too disorganized to be bookmarking links yet :wink: ) that stipulated that adjuvant chemo could limit the effectiveness of its use in case of a recurrence. Anyway, I am just thinking out aloud here, with the pros and cons racing through my mind as I await my date with oncology.

Mainelyj - thank you for this. I knew absolutely nothing about DPD deficiency, and find this information very useful. I have not yet been offered or have even discussed any genetic testing with my care team yet, but will now certainly make an effort. As it so happens, in another topic in this forum (Calling all CANUCKS, http://coloncancersupport.colonclub.com/viewtopic.php?f=1&t=32353) user Steph20021 recently posted information about a company called Contextual Genomics, that was offering some free cancer genomics testing for the first 1,500 applicants in Canada. Armed with this information, I just sent off a message to my oncologist team and the company to see whether I could be referred for this if I qualify. Fingers crossed!

Thank you all for sharing! With so much uncertainty ahead, it has done me a world of good to have discovered The Colon Club and it's wonderful community here, along with all their collective wisdom and positivity!

macpudd
Posts: 120
Joined: Tue Jul 21, 2015 7:00 pm

Re: Lymph negative but one marked as 'i+'

Postby macpudd » Mon Apr 04, 2016 11:16 am

Hi Squak,
As regards chemo, as I understand it in my case, I was advised to have chemo because my tumour was t4b and was in contact with the peritoneum, my pathology report said there was strong evidence of peritoneal involvement, also the surgeon and onc said that there might be more of those isolated tumour cells which had not been removed during the surgery. Also I had a family history of colon cancer. They also said that as I was relatively young (49 years) and otherwise healthy they would be as aggressive as possible with it. Statistically the onc said I would have a 70% chance of no recurrence if I had the chemo. My circumstances were probably more clear cut because of the t4 tumour. If there is anything else you want to know dont be afraid to ask :D . Hope this helps.
Regards
McPudd
Dx 10/13/2014 right hemicolectomy 10/15/2014 pT4b N0 M0
Folfox x12 from Dec 2014 to July 2015
01/16/18 tonic seizure hospital admission
01/17/18 ct and mri 2cm tumor on left side of brain
commenced anti epileptic and steroids and
insulin.
01/25/18 brain craniotomy 80% of tumour removed pathology says gbm4
6 weeks of rad and Temodar chemo and then 6 monthly cycles of Temodar
MRI in Oct no tumor
Mri Jan 2019 tumour growth Feb Pet scan tumour 6cm, no surgery, starting Avastin also Lomustine

mike1965
Posts: 118
Joined: Mon Jan 25, 2016 11:07 pm

Re: Lymph negative but one marked as 'i+'

Postby mike1965 » Tue Apr 05, 2016 1:15 am

My dx was pt1nc1 where that found two tumors in fat but not lymph nodes. Not sure if same as yours. I was conservative in my treatment and it was not a good decision. I will start chemo in two weeks. I am going to be aggressive in my treatment go forward. I pray all goes well. The choices and decisions are hard .
Colonoscopy 09/06/15 Doctor removed polyp
DX - Rectal cancer 09/10/2015 T1M0N0
Surgeon recommended wait and see approach 09/2015
Tumor board recommended LARs Surgery 10/2015
Oncologist and PCP recommended LARs Surgery 11/2015
Seeking 2nd opinion from another Surgeon 01/2016
Having Sigmoidscopy on 02/01/16.
Figured out treatment 02/2016
LARS Surgery 03/2016
Stage 3A T1 N1C M0
Chemo Folfox to begin 04/18/16

squak
Posts: 12
Joined: Sat Apr 02, 2016 8:33 am

Re: Lymph negative but one marked as 'i+'

Postby squak » Tue Apr 05, 2016 9:55 am

Indeed.. choices and decisions are hard. I suppose I am a little stumped at my surgeon's guidance that he may have not even considered my post-OP referral to oncology had those pesky little isolated tumor cells not been identified.. however, with his black and white attitude (either the node is positive or not) he did, and it is probably a good decision to consult with oncology before determining the path ahead, I do feel better about that vs not seeing an oncologist at all. I am actually surprised that no oncologist has been in the mix so far :o

Questions:
--how often (or when) is radiation (concurrent with chemo) used as adjuvant therapy for CRC? I wasn't really prepared for meeting with a radiation oncologist, and was surprised when I was given an appointment there for next week, along with one for the med oncologist.
--is there a window that oncology targets, for when adj therapy should be started post-OP? Is it solely dictated by the post-OP healing-time? How significant may the danger be in delaying the start to pursue any alternative or wait&see options?
01-12-2016: colonoscopy- large rectosigmoid mass
01-14-2016: path- CRC, adenocarcinoma, invasive, low grade, well diff. (39 yo @ DX)
01-25-2016: CT scan- no mets (pM0?)
02-20-2016: open LAR (pre-OP CEA 1.3)
03-01-2016: path- pT3 (11.5x4.2x4cm), pN0(i+) ie 1/34 lymph w/ isol.tum.cell)
04-20-2016: It was CRC Stage IIa. I'm NED!! (CEA is <1.0) :D
04-2016: 12-15% chance of relapse within 5 years
04-2016: No adjuvant therapy ie no chemo, no radiation. Follow-up in 6 mos.

macpudd
Posts: 120
Joined: Tue Jul 21, 2015 7:00 pm

Re: Lymph negative but one marked as 'i+'

Postby macpudd » Tue Apr 05, 2016 11:05 am

As regards radiation it was not applicable in my case. The start of my chemo was delayed as I had abdominal abcesses, and I remember the onc saying that the most effective window for starting chemo was within 8 weeks of surgery but that it tapers off and is not a sudden drop in effectiveness if started after 8 weeks. I started mine 9 weeks after surgery. I am sure the onc will be able to definitively answer your questions when you see him/her. Best of luck.

Regards
Macpudd
Dx 10/13/2014 right hemicolectomy 10/15/2014 pT4b N0 M0
Folfox x12 from Dec 2014 to July 2015
01/16/18 tonic seizure hospital admission
01/17/18 ct and mri 2cm tumor on left side of brain
commenced anti epileptic and steroids and
insulin.
01/25/18 brain craniotomy 80% of tumour removed pathology says gbm4
6 weeks of rad and Temodar chemo and then 6 monthly cycles of Temodar
MRI in Oct no tumor
Mri Jan 2019 tumour growth Feb Pet scan tumour 6cm, no surgery, starting Avastin also Lomustine

mike1965
Posts: 118
Joined: Mon Jan 25, 2016 11:07 pm

Re: Lymph negative but one marked as 'i+'

Postby mike1965 » Wed Apr 06, 2016 3:58 pm

Squak

I am in the same situation not happy that surgeon found a pesky cancer cell outside of rectum but relieved he found it so I can get proper treatment. If the cancer was outside of the area he cut than it would have continue on to grow and move. I would have been Stage 1a l with no chemo and the cancer would have travelled. I feel blessed that it was found and I have a chance to battle. I do not know when is good time to start. I am starting chemo 6 weeks after operation but oncologist wanted 8 weeks but my wife pushed him to 6 weeks.
Colonoscopy 09/06/15 Doctor removed polyp
DX - Rectal cancer 09/10/2015 T1M0N0
Surgeon recommended wait and see approach 09/2015
Tumor board recommended LARs Surgery 10/2015
Oncologist and PCP recommended LARs Surgery 11/2015
Seeking 2nd opinion from another Surgeon 01/2016
Having Sigmoidscopy on 02/01/16.
Figured out treatment 02/2016
LARS Surgery 03/2016
Stage 3A T1 N1C M0
Chemo Folfox to begin 04/18/16

squak
Posts: 12
Joined: Sat Apr 02, 2016 8:33 am

Re: Lymph negative but one marked as 'i+'

Postby squak » Wed Apr 06, 2016 9:31 pm

All the best starting out with the chemo, Mike - I pray for all to be well too. Which chemo and what dosages are you starting on?
I'm really fatigued today, that never helps the waiting game.. still, i'm staying confident in my conservative approach - but appreciated your words about you feeling differently later. Difficult thoughts, and difficult decisions indeed.
01-12-2016: colonoscopy- large rectosigmoid mass
01-14-2016: path- CRC, adenocarcinoma, invasive, low grade, well diff. (39 yo @ DX)
01-25-2016: CT scan- no mets (pM0?)
02-20-2016: open LAR (pre-OP CEA 1.3)
03-01-2016: path- pT3 (11.5x4.2x4cm), pN0(i+) ie 1/34 lymph w/ isol.tum.cell)
04-20-2016: It was CRC Stage IIa. I'm NED!! (CEA is <1.0) :D
04-2016: 12-15% chance of relapse within 5 years
04-2016: No adjuvant therapy ie no chemo, no radiation. Follow-up in 6 mos.


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