polyp-awaiting second opinion-colectomy vs endoscopic submucosal dissection

[nsog]

Hi All!
I recently had a colonoscopy (Feb 20, 2017) due to intermittently blood on tissue after BM. A "pecan" sized flat polyp was found and biopsied. The surgeon was unable to remove it by scope due to it's size. The biopsy came back as "precancerous" . The doctor ordered a CT scan with contrast, liver profile and CEA. All came back normal. No mass seen on CT. The CEA is 1.25 which the doctor said was normal. At that point she said this is all very good news and now all you have to do is get it out. She believed I would have successful removal at a larger endoscopy center that has more advanced equipment. I was referred to the metro area near me, to an endoscopy center. When I inquired prior to the procedure about whether it was ESD or not, the nurse seemed to not know what I was referring to. The 2nd colonoscopy was done Mar 22, 2017 and when I woke from sedation the GI doctor told me he was unable to remove with snare and I would need surgery, laporoscopic of course. After discharge I made an appointment with the surgeon I was referred to by the GI doctor. Meanwhile I received the biopsy results from the 2nd scope.
Rectal polyp, partial removal by hot snare. Multiple fragments of tubulovillous adenoma with at least high grade dysplasia/intramucosal adenocarcinoma, with some areas suspicious for invasive carcinoma. Lynch syndrome negative. The size is 9x7x6 mm.
I then saw the recommended surgeon the next day and had a not so great experience in terms of bedside manner etc. But was told " so we will remove about a foot of your colon and we should be able to put it all back together as it is now". He went on to explain that it was probably high enough that there would be enough to anastomose the colon and rectum. I wasn't comfortable with the way this very serious (to me) procedure was being explained and regarded.
The next day I requested an appointment at a well known cancer treatment and research facility in my state.
I guess my concern is that my polyp is considered large but it is still less than an inch long and the surgeon I saw immediately wanted to cut out a foot long section. No one has mentioned the ESD procedure I've read about and there is no imaging that supports this polyp has moved beyond the colon. Is it possible that this was the easiest or most common way to deal with this rather than the best way for me and this particular polyp?
Also, the first doctor reported the biopsy was precancerous only. The second biopsy has all these other cancer terms thrown in there. 1 month apart, is so much change or advancement possible or is this from a more advanced lab or something else?
I will get to the bottom of all of this soon but the wait is unnerving due to the urgency the surgeon placed on the need for a colectomy. They said it could wait some time but not months. Reading some of the posts on here I think maybe I'm worrying a little too much about this but one doctor said precancerous and it just needs to get out and then another acts as if it needs to be removed in the next month and taking a foot of colon is the only answer.
Sorry so long, I tend to be wordy.

[CRguy]

Having read your very detailed post ... AND not being your doctor with all the other detailed info .....

AS you have mentioned ... there seems to be some disparity between the results of the first procedure and the second.

LESS invasive techniques are often preferred by patients and some Docs.

The PROPER procedure is needed by patients and the best Docs.

ESD may in fact be appropriate for your own situation ... again, it may not = I am not your doc.

Removing 1 foot of gut for a "small" tumor may seem excessive ... BUTT it will depend upon a whole shitload of factors
Having DONE these surgeries for a lotta years ( I am a vet ! ) you need to deal with what you NEED TO DEAL WITH ... when you actually DO the surgery. There are accepted protocols for doing resections which take into consideration "what happens if we don't take enough / leave too much to cause MORE problems..." kind of thing.

If you want touchy feely ... don't talk to a surgeon
IF you want a good surgical result ... talk to a great surgeon
JMO

IF you have conflicting / confusing info ... get yet another opinion

Don't know if that is much help to you ... BUTT it is what I have done in my own situation

Best wishes and please ask more questions as they arise

In Harmony
CRguy

[ozziej]

Hi Shelley,
Sorry you have had to deal with this, but you'll find lots of support on this forum.
My experience was similar to yours. I had a colonoscopy in June 2014 which found a large but supposedly benign polyp that the GI was unable to remove. I was referred to a specialist in endoscopic mucosal resection, who removed the polyp in September 2014 and wished me all the best with a high five. Unfortunately the second lot of pathology on the polyp found adenocarcinoma so after a phone call to tell me I had cancer I was then referred to a colorectal surgeon. As the polyp had already been removed it was too late for radio/chemo so I was given the choice of watch and wait or ultra low anterior resection for rectal cancer. I chose the surgery because there was a chance that the cancer had spread to the lymph nodes and the only accurate way to determine spread was surgery. It appears now that an alternative might have been mop up chemo but that's not always a walk in the park and I was never offered it. Choosing the surgery was probably the hardest decision I've made but I am now NED and so it was worth it for me.
Wishing you all the best whichever choice you make.

[MissMolly]

Shutson:
One thing to keep in mind regarding the surgeon's assessment that he may need to resect 12" of your colon, is that it is not as simple as merely removing the segment of intestine that houses the polyp like snipping a segment of garden hose.

The large intestine is supplied by a vast vascular network that spans out like an opened paper fan that you might otherwise fan to cool yourself on a hot summer's day. An extensive highway system of veins, arteries, capillaries, and lymphatic drainage vessels lie in a mesentery of connective tissue. A given lineage of vein and artery will supply and nourish a given 10-12" segment of colon, followed by another lineage of vein and artery to supply and nourish the next connecting 10-12" segment of colon. It is a series of linking vascular connections that characterize the intestinal terrain - the vascular "tree" embedded in an apron of connective tissue.

A surgeon must be cognizant of the vascular "tree" when deciding on where to make beginning and end points of an intestinal resection. A surgeon must ensure that the distal and proximal segments of remaining intestine each have patent vascular perfusion. The vascular and lympathic "tree" has a deciding impact on the placement of a resection and the length of resection. A surgeon is restricted in being able to simply remove only the affected polyp. The surgeon has to ensure that the vascular "tree" is patent for the entire length of colon that remains.

Bottom Line: Removing 10-12" of colon for a poly is not unusual nor out of place owing to the segmental anatomy of veins and arteries that supply the intestinal tract.
- Karen -

[Cowgirl918]

CRguy and Miss Molly are the best and I always take their advice seriously. All I can offer is a similar experience.

I started in a smaller town with routine colonoscopy, history of polyps. The mass in my ascending colon was too large to remove and they scheduled hemi-colectomy.

I sought second opinion at major medical and university center. Underwent two endoscopic mucosal reductions (EMR) and I am currently NED and on annual surveillance.

You cant make a decision based on my results as there are so may other variables to consider. But it does let you know that you have enough time to check out your options.
Good luck.

[ChiMama]

Hi nsog, since you have concerns and confusion as to the diagnosis and how to proceed, I would get another opinion.

A bit of my story: I had a routine screening colonoscopy, during which the Dr found what he called "an area of inflammation" from which he took 3 biopsies that came back as "high grade dysplasia." He alternately called it "precancerous" "early cancer" and "carcinoma in situ."

CT and PET showed nothing in that area. CEA was 2.8. He recommended surgery.

The second opinion Doctor also recommended surgery, and explained that sometimes when a biopsy is taken, it only gets the top layer of cells, or it's taken from the edge of the mass, and further in it could be more advanced. He also doesn't have super awesome "bedside manner," but is known as a great surgeon. In his pre-surgical talk, he said that he may have to remove as much as a foot of colon, that I may need a bag, and basically told me all the worst-case scenarios.

I went with my second opinion Doctor for the surgery, partly because of his reputation, partly because he was affiliated with a better hospital system, and partly because I was not 100% confident in the first Doctor. After I joined this forum, I learned the importance of getting a Board Certified Colorectal Surgeon which my surgeon of choice was not, but I stayed with him because of the the other factors in his favor and his years of experience in abdominal/colon surgery even without the certification.

Turns out it was a Stage 1, 5.2 x 4.1 cm tumor that went all the way into the muscle - far bigger and deeper than the original diagnosis and pathology indicated. He only removed 8 inches of colon, and got clean margins. He also removed 29 LN that thankfully were all benign. I have no regrets and would make the same choice again. I hope you find a path that gives you confidence and a good outcome.

[DarknessEmbraced]

I'm sorry you are going through this!*hugs* I'm glad you're getting a second opinion!*hugs*