New Member : Stage 2

[Dlroadruck]

6 week stalker, 1st time poster. It's been a bit of a roller coaster ride since my first screening colonoscopy on march 31. A largish tumor was found, surgery scheduled for April 19. Had a left colectomy. Surgeon called and said it was stage 2 and referred me to an oncologist. I scheduled with the referred one and one that is closer to home. They both said only surveillance needed because it was stage 1. I was like yayyyy, but what??? Surgeon said stage 2. Long story short the pathology report was incorrect it was stage 2 and since has been amended ( t2 to t3). I'm currently supposed to be deciding if in"want" chemo or not Now, I FINALLY got my pathology and it says "on section this mass extends through the wall into the surrounding fat (ouch lol) and approaches to within .6 cm of the closest serosal surface. Is it possible they made TWO freaking errors! I thought going beyond the wall is t4??? Help! So far there have been no additional risk factors noted.

Thanks for any input!
deanna

[Jacques]

6 week stalker, 1st time poster. It's been a bit of a roller coaster ride since my first screening colonoscopy on march 31. A largish tumor was found, surgery scheduled for April 19. Had a left colectomy. Surgeon called and said it was stage 2 and referred me to an oncologist. I scheduled with the referred one and one that is closer to home. They both said only surveillance needed because it was stage 1. I was like yayyyy, but what??? Surgeon said stage 2. Long story short the pathology report was incorrect it was stage 2 and since has been amended ( t2 to t3). I'm currently supposed to be deciding if in"want" chemo or not Now, I FINALLY got my pathology and it says "on section this mass extends through the wall into the surrounding fat (ouch lol) and approaches to within .6 cm of the closest serosal surface. Is it possible they made TWO freaking errors! I thought going beyond the wall is t4??? Help! So far there have been no additional risk factors noted.

Thanks for any input!
deanna

Diroadruck - My input is that your case is complex enough that it deserves its own topic thread so that you can get comments from others that are focused on your particular situation.

You can start a new thread just for yourself by using the NewTopic button, and introduce yourself as a new member so that people will notice that you are here.

In my opinion it would help to know your MSI status and your oncotypeDX results. From there, you can add in any other risk factors in decidibg what to do about further treatment.

Here is a link to the "Post a NewTopic" page:

posting.php?mode=post&f=1

[CRguy]

Ask and ye shall receive !!!!

Welcome Dlroadruck to your own topic

Cheers and best wishes
CRguy

[Beckster]

6 week stalker, 1st time poster. It's been a bit of a roller coaster ride since my first screening colonoscopy on march 31. A largish tumor was found, surgery scheduled for April 19. Had a left colectomy. Surgeon called and said it was stage 2 and referred me to an oncologist. I scheduled with the referred one and one that is closer to home. They both said only surveillance needed because it was stage 1. I was like yayyyy, but what??? Surgeon said stage 2. Long story short the pathology report was incorrect it was stage 2 and since has been amended ( t2 to t3). I'm currently supposed to be deciding if in"want" chemo or not Now, I FINALLY got my pathology and it says "on section this mass extends through the wall into the surrounding fat (ouch lol) and approaches to within .6 cm of the closest serosal surface. Is it possible they made TWO freaking errors! I thought going beyond the wall is t4??? Help! So far there have been no additional risk factors noted.

Thanks for any input!
deanna

I think it is a great idea to start a thread for Stage II colon cancer. Stage II is difficult because a decision needs to be made for chemotherapy. There is no clear cut answers.

I was the opposite...surgeon thought stage I, but pathology came back stage II. My report staged that a "tongue of invasive tumor invaded the subserosa layer of tissues but did not penetrate the serosa." It is still contained to the colon, but invaded the outer tissues. T4 tumors penetrate the serosa level and sometimes adjacent organs, but does not affect the lymph nodes.

I was diagnosed with stage 2A colon cancer of the cecum (right sided). I had LAP surgery in November with pathology of T3N0M0. You will have to wait until your pathology report comes back to see if you have any of the following risk factors for recurrence (T4, less than 12 lymph nodes, lymphovascular and/or perineural invasion, high grade tumor, perforation, obstruction). This will determine if adjunct chemo is needed after surgery. I had 2 high risk factor; high grade and lymphovascular invasion. Because of this, my MD Anderson oncologist suggested chemo. It was up to me, but I decided to do whatever was needed to be disease free. He originally gave me Capox (5/FU in pill form and Oxaliplatin) every 3 weeks for 8 cycles. I went for my first infusion of Oxaliplatin, but had an allergic reaction. No more Oxi! I am now only on the pill, which is Xeloda (5/FU in pill). He was ok doing this because it was my decision to receive the chemo. Xeloda will allow you to take pills wearing a pump for 48 hours and getting a port. I just finished cycle 7 and will be finished June 9th! This treatment fit my lifestyle and people do not even know I am on chemo. Another treatment for stage II if chemo is suggested, is Folfox, which is 5/FU and Oxaliplatin every other week for 12 weeks. You will need a port because they send you home with a 48 hour pump for the 5/FU.

If you have no high risk factors, you will probably go on surveillance (observation). CT scans twice a year with blood work every 3 months for the first 2 years. I hope this helps...if you need any additional info, just let me know.

[Dlroadruck]

Thanks, Beckster and CRguy, and Jacques!
All of my information is from the pathology report. It seems to me that saying it is T3 contradicts saying the tumor goes through the serosa wall...???

Oncotype DX results are expected by May 29.

[Beckster]

By saying "on section this mass extends through the wall into the surrounding fat (ouch lol) and approaches to within .6 cm of the closest serosal surface,"
it means it is outside the muscular layer, but did not go to the outmost layer, which is the serosal layer. Mine was .01cm to the closest serosal surface.

[SurvivorsSpouse]

You pathology report is consistent with T3, into the fat but within the serosa.

Your circumferential margins look clean as the tumor is 6mm from the serosal layer. Concern comes when they are within 1mm of the serosa. This is one less risk factor for you.

At the risk of too much information, here are a couple of nomograms showing the numbers for chemo vs no chemo.

http://www3.mdanderson.org/app/medcalc/ ... ctumcancer

https://www.mskcc.org/nomograms

[Dlroadruck]

My surgeon drew me a diagram indicating that the tumor was beyond the serosal wall by .6 cm. This is why I'm really confused. Ack!!!! I'll be making MORE phone calls tomorrow. A day in the life I suppose...

[SurvivorsSpouse]

It would be odd for them to get T stage incorrect on the path report. That is cut and dry and they would err on the overstaging side if the microscopic examination was questionable.

What does the microscopic section say? This is where the meat of the report is with the gross examination being just looking at it on the bench. Does it say "extends x cm beyond the muscularis propia into the perirectal/pericolonic/subserosal layer?"

Your surgeon would most likely draw two concentric circles to describe penetration of the serosal layer, the first wall/ circle is the muscularis propia.

[Deb m]

My husband was a stage IIbt4a. We did 6 months/12 hits of folfox. If you are indeed a t4, then in my opinion you should do chemo. T4 puts you in a high risk category. Also if less than 12nodes were removed, LVI, poor differentiated /high grade all put you in a high risk category. You need to have a very serious discussion with you oncologist and have him explain the pathology report with you. If none of these high risk features are present, than chemo my not be recommended, but I would still do it!

deb

[Dlroadruck]

Thanks everyone : ) I think i finally got the attention of a nurse on the phone this morning and the doc is supposed to call me back. My pathology report doesn't mention LVI or any of those other risk factors. I'm not sure where else that info might be located. Frustrating

[Deb m]

All of those high risk features should be on the pathology report. Get a copy of it and have them explain it to you! If it's not written on the report, then you need to ask if any of those risk features were present. They should know and need to know. It's important information to have while making your treatment decisions.
deb

[Jacques]

... I'm not sure where else that info might be located...

According to the NCCN Guidelines on Colon Cancer, Stage 2 patients can be divided into three categories for purposes of determining appropriate subsequent treatment.

This information is shown on page 9 of the NCCN Colon Cancer Guidelines:
https://www.tri-kobe.org/nccn/guideline/colorectal/english/colon.pdf

You can see the three categories near the top of page 9, They can be summarized as,

• 1. T3N0M0 with MSH-H or dMMR
• 2. T3N0M0 with MSH-L or MSS, and no high risk features
• 3. T3N0M0 with high risk features.

Thus, the two main factors that determine which category you are in are (a) your MSI status, and (b) the number of high risk factors from the pathology report

You can see from Footnote m how they define the seven high risk factors that they use:

• Poorly differentiated histology
• Lymphatic/ vascular invasion
• Bowel obstruction
• < 12 lymph nodes examined
• Perineural invasion
• Localized perforation
• Close, indeterminate or positive margins

In the diagram on page 9, the horizontal arrow to the right of each category points to the type of adjuvant treatment (if any) recommended for that particular category of Stage 2.

You can ask your doctors if they are using the NCCN Guidelines, or if they are using some other system for staging. You need to have both your MSI results and your pathology report to use the NCCN system.

If you want to see how some of these terms are defined, you can read the article below. Table 2 on page S350 has a summary checklist of a typical pathology report.
http://www.siapec.it/content/file/2873/colorectal%20tumours%20the%20histology%20report%20G%20Lanza%20et%20al.pdf

Here's another article:

Understanding Your Pathology Report: Colon Cancer
https://www.oncolink.org/cancers/gastrointestinal/colon-cancer/treatments/understanding-your-pathology-report-colon-cancer

Here's a typical path report template:

Path Report Template

Table 2
Surgically resected specimens of colorectal cancer – Checklist

Tumor site:
Cecum
Ascending colon
Hepatic flexure
Transverse colon
Splenic flexure
Descending colon
Sigmoid colon
Rectosigmoid junction
Rectum

Tumor size
Maximum tumor diameter: cm

Histologic type
Adenocarcinoma
Mucinous adenocarcinoma
Signet-ring cell carcinoma
Small cell carcinoma
Squamous cell carcinoma
Adenosquamous carcinoma
Medullary carcinoma
Undifferentiated carcinoma
Other (specify):

Grade of differentiation
Low grade (well or moderately differentiated)
High grade (poorly differentiated or undifferentiated)
High grade component (%):

Depth of tumor invasion
No evidence of primary tumor
Tumor invades submucosa (pT1)
Tumor invades muscularis propria (pT2)
Tumor invades through the muscularis propria into the subserosal adipose
tissue or the nonperitonealized pericolic or perirectal soft tissues (pT3)
Tumor penetrates to the surface of the visceral peritoneum (serosa)
(pT4a)
Tumor directly invades other organs or structures
(specify:) (pT4b)
Tumor penetrates to the surface of the visceral peritoneum (serosa) and
directly invades other organs or structures
(specify: ) (pT4b)

Margins of resection
Proximal/distal margin
Cannot be assessed
Invasive carcinoma present
Invasive carcinoma absent
Distance of invasive carcinoma from closest margin:
mm
Circumferential (radial) margin
Not applicable
Cannot be assessed
Invasive carcinoma present
Invasive carcinoma absent
Distance of invasive carcinoma from non-peritonealised margin:
mm

Regional lymph nodes
Number examined:
Number involved:

Tumor deposits
Not identified
Present (number: )

Response to neoadjuvant therapy
Not applicable (no prior treatment)
Complete regression
Minimal residual tumor
No marked regression

Extramural venous invasion
Not identified
Present

Pathologic staging (pTNM)
TNM descriptors
(required only if applicable)
m (multiple primary tumors)
r (recurrent)
y (posttreatment)

Primary tumor (pT)
pTX: Cannot be assessed
pT0: No evidence of primary tumor
pTis: Carcinoma in situ, intraepithelial or invasion of lamina propria
pT1: Tumor invades submucosa
pT2: Tumor invades muscularis propria
pT3: Tumor invades through the muscularis propria into pericolorectal
tissues
pT4a: Tumor penetrates the visceral peritoneum
pT4b: Tumor directly invades other organs or structures

Regional lymph nodes (pN)
pNX: Cannot be assessed
pN0: No regional lymph node metastasis
pN1a: Metastasis in 1 regional lymph node
pN1b: Metastasis in 2 to 3 regional lymph nodes
pN1c: Tumor deposit(s) in the subserosa, or nonperitonealized pericolic
or perirectal tissues without regional lymph node metastasis
pN2a: Metastasis in 4 to 6 regional lymph nodes
pN2b: Metastasis in 7 or more regional lymph nodes

Distant metastasis (pM)
Not applicable
pM1: Distant metastasis
Specify site(s):
pM1a: Metastasis to single organ or site (e.g., liver, lung, ovary,
nonregional lymph node)
pM1b: Metastasis to more than one organ/site or to the peritoneum

Additional pathologic findings
None identified
Diverticular disease, ulcerative colitis, Crohn’s disease, familial
adenomatous polyposis, other forms of polyposis, synchronous
carcinoma(s) (complete a separate form for each cancer), etc.
Specify:
Polyps present (specify type and number):

Comments

Reference:
" Recommendations for the Reporting of Surgically Resected Specimens of Colorectal Carcinoma" ASCPJournal

[Dlroadruck]

Deb M,
I got the chance to ask my doc yesterday about the information that is NOT on the report. He said that the pathologist told him verbally the information that is not on the report (LVI AND PNI). He said he thought the info was going to be added to the amended report but it's not. He said the path must have forgotten. I am incensed and have very little faith in the report at this point. Grrrrr...I'm trying to stay calm about all this but it gets harder EVERY day!

[justin case]

Ah, my favorite topic! As of 2/3 /2012 after chemo, surgery and some radiation as I had rectal and colon cancer, I am surviving well. It's not a cakewalk, nor anything I would wish on others, but you're damn lucky to catch this early. I had a friend, who had stage 1, and decided to refuse chemo. Notice I HAD a friend. Light chemo in any form, I would recommend, and if an Oncologist would like you to do a different regimen, I would suggest you take that doctors advice. I hope you stick around for many years to come !
Michael