PET Scan Results - More Cancer???

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mpbser
Posts: 251
Joined: Wed Apr 19, 2017 11:52 am

PET Scan Results - More Cancer???

Postby mpbser » Sun Jun 18, 2017 5:48 am

We just received husband's PET scan results from the hospital portal. The report states that "there is a hypermetabolic focus within the proximal transverse colon. This is worrisome for an additional colon carcinoma." The surgeon had stated that he had scoped the entire colon when he was doing the surgery (removed 35 cm long, 6 cm diameter plus 8 inches wide 5 cm thick mesenteric fat at the left-transverse juncture) and that it was all clear. We are very confused and don't understand what this PET scan result means.

We don't see his oncologist until Thursday so until then we can only consult google and this forum to ask if anyone has any idea. Thoughts?
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

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Maia
Posts: 2414
Joined: Fri Aug 24, 2012 8:00 am

Re: PET Scan Results - More Cancer???

Postby Maia » Sun Jun 18, 2017 7:29 am

Is he taking metformin or any other substance/supplement that might intervene on the glucose uptake? I have seen people having spots with high uptake/SUV in PETs, because metformin, and there is literature about it.

mpbser
Posts: 251
Joined: Wed Apr 19, 2017 11:52 am

Re: PET Scan Results - More Cancer???

Postby mpbser » Sun Jun 18, 2017 7:38 am

Thanks for the question, Maia. He doesn't take metformin and is controlling his diabetes with diet. He takes supplements that possibly could intervene on glucose uptake. I will definitely look into this as a potential cause.

I did some reading on the term hypermetabolic focus and it appears that it could simply just be inflammation. I am wondering if the proximal transverse colon can become inflamed as a result of the surgery which was only 4 week ago. I am hoping this is just a part of the healing process.
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

User avatar
Maia
Posts: 2414
Joined: Fri Aug 24, 2012 8:00 am

Re: PET Scan Results - More Cancer???

Postby Maia » Sun Jun 18, 2017 8:41 am

Hoping for the same, just inflammation --which, not being chronic but as in this case, part of the reaction to surgery, it is a very good thing, something immunogenic!
Edited to add, just in case someone is looking for this in the future: Eur J Nucl Med Mol Imaging. 2008 Jan;35(1):95-9. Epub 2007 Sep 5.
High and typical 18F-FDG bowel uptake in patients treated with metformin https://www.ncbi.nlm.nih.gov/pubmed/17786437
Last edited by Maia on Sun Jun 18, 2017 8:44 am, edited 1 time in total.

Jacques
Posts: 408
Joined: Sun Dec 28, 2014 10:38 am

Re: PET Scan Results - More Cancer???

Postby Jacques » Mon Jun 19, 2017 12:14 am

mpbser wrote:We just received husband's PET scan results from the hospital portal. The report states that "there is a hypermetabolic focus within the proximal transverse colon. This is worrisome for an additional colon carcinoma." The surgeon had stated that he had scoped the entire colon when he was doing the surgery (removed 35 cm long, 6 cm diameter plus 8 inches wide 5 cm thick mesenteric fat at the left-transverse juncture) and that it was all clear. We are very confused and don't understand what this PET scan result means.

We don't see his oncologist until Thursday so until then we can only consult google and this forum to ask if anyone has any idea. Thoughts?

Yes, I have some thoughts on this issue ...

My thoughts are:

It looks like the quote that you gave came from the INTERPRETATION section of the PET scan report. Normally, a PET scan report will have two main sections: At the top will be the FINDINGS section where the objective facts are presented, then at the bottom of the report there will be an INTERPRETATION section where the radiologist will give his/her evaluation of the objective facts. The phrase "hypermetabolic focus within the proximal transverse colon" would be an objective fact that presumably could be confirmed by any other competent viewer of the scan CD, but the sentence,"This is worrisome for an additional colon carcinoma", is an evaluative comment that may or may not be made by another radiologist viewing the very same PET scan CD.

In my opinion, this particular evaluative comment is a bit out-of-place because it is forcing the reader to accept the radiologist's interpretation. A better way to state this kind of reality would be to say something like: "This suggests the possible existence of a new neoplasm in the transverse colon, but it does not exclude the possibility that the increased uptake is due to a benign inflammatory condition linked to the recent hemi-colectomy surgery".

In my opinion, it would be up to the surgeon and the oncologist to look at the range of objective findings from the PET scan and to make their own subjective evaluations of what the increased metabolic activity might mean. I would imagine that there would be a number of possible explanations for this. My own laymen's view of the situation is that the left hemi-colectomy must have produced some degree of trauma in the area of the transverse colon, since the surgery would have required the transverse colon to be moved away from its anchored position in the upper abdomen so that the distal part of the transverse colon could be stretched enough to reach and join the rectum in the lower pelvic area. Thus, prior to surgery the transverse colon was more-or-less horizontal in orientation in the upper abdomen, but now it is probably oriented at an angle in such a way to span the 35 cm where the resected section of colon used to be. All of this would presumably produce some degree of injury to the transverse colon and some degree of persistent inflammation during the recovery period, especially if there is any persistent tension in the segment of the colon that now leads down to the anastomosis.
DX(2012): RC
Stage IIc,T4b N0 M0 L0 PN1 H0 D0 P0 I1
LAR
MSI: not tested
Chimio-radiothérapie
Chimiothérapie adjuvante : capécitabine + oxaliplatine
CEA < 1.0,
5 years NED,
End of 6-month follow-ups: 7/2017
----
Info links:
Create Your Signature
How to Select a Surgeon
List of Forum Features
Colorectal Cancer Stages (TNM)

mpbser
Posts: 251
Joined: Wed Apr 19, 2017 11:52 am

Re: PET Scan Results - More Cancer???

Postby mpbser » Mon Jun 19, 2017 5:45 am

Thank you, Jacques, for your input. It is much appreciated!
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

mpbser
Posts: 251
Joined: Wed Apr 19, 2017 11:52 am

Re: PET Scan Results - More Cancer???

Postby mpbser » Tue Jun 20, 2017 7:06 am

I spoke with my husband's surgeon yesterday after faxing this letter to him:

I hope this letter finds you well. I have some post-surgical follow-up questions, if you don’t mind.

I am faxing you the safety sheet for the 40-80 TLC75 staples that are present in M----’s abdomen. Last week, we sent requests for clarification to the SVMC Radiology Department and to Dr. Ives regarding the conditional safety of performing an MRI on a patient with implanted TLC75 staples. Since we have not received responses from either the Radiology Department or Dr. Ives, we are hoping that you might be able to advise us regarding the following requirements for M-----’s liver MRI:

• Static magnetic field of 3 Tesla.
• Spatial gradient field of 720 Gauss/cm.
• Maximum whole body averaged specific absorption rate (SAR) of 2.7 W/kg for 15 minutes of scanning.

If not, then he cannot have an MRI.

Also, M----'s PET/CT scan report states that there are “multiple small surgical clips within the central abdominal mesentery.” I just want to make sure that these are the aforementioned TLC75 staples that you used to create the anastomosis and not something else. This information would be greatly appreciated.

Next, M----'s PET/CT scan report states that "there is a hypermetabolic focus within the proximal transverse colon. This is worrisome for an additional colon carcinoma." The phrase "hypermetabolic focus within the proximal transverse colon" would be an objective fact that presumably could be confirmed by any other competent viewer of the scan CD, but the sentence, "This is worrisome for an additional colon carcinoma", is an evaluative comment that may or may not be made by another radiologist viewing the very same PET scan CD.

In my opinion, this particular evaluative comment is a bit out-of-place because it is forcing the reader to accept the radiologist's interpretation. A better way to state this kind of reality would be to say something like: "This suggests the possible existence of a new neoplasm in the transverse colon, but it does not exclude the possibility that the increased uptake is due to a benign inflammatory condition linked to the recent hemi-colectomy surgery".

From what I understand, it should be up to the surgeon and the oncologist to look at the range of objective findings from the PET scan and to make their own subjective evaluations of what the increased metabolic activity might mean. M---- has an appointment with Dr. Ives this Thursday.

My own laymen's view of the situation is that the left hemi-colectomy must have produced some degree of trauma in the area of the transverse colon, since the surgery required the transverse colon to be moved away from its anchored position in the upper abdomen so that the distal part of the transverse colon could be stretched enough to reach and join the rectum in the lower pelvic area. Thus, prior to surgery the transverse colon was more-or-less horizontal in orientation in the upper abdomen, but now it is probably oriented at an angle in such a way to span the 35 cm where the resected section of colon used to be.

We know this to be the case from our discussions. All of this would presumably produce some degree of injury to the transverse colon and some degree of persistent inflammation during the recovery period, especially if there is any persistent tension in the segment of the colon that now leads down to the anastomosis.

Further, M---- had just recently finished the course of antibiotics you had prescribed for him. The side effects of the cephalexin have only just begun to diminish. Also, M---- had not had a bowel movement for nearly 18-22 hours at the time of the PET/CT scan. Since peristalsis can increase uptake of 18F-FDG and create “hot spots,” his digestive activity in the transverse colon could also have caused this hypermetabolic focus, particularly because of its location as precursor to the anastomosis. We hope that the above very benign conditions are the case.

However, there are other, more serious, non-cancerous conditions that could cause the hypermetabolic focus that I believe could be consequences of the surgery. These include, but are not limited to: suture granuloma, abscess, mesenteric fibrosis, reactive lymphoid hyperplasia, histiocytosis, and a reaction to foreign bodies such as staples. His surgical incisions are still healing and the central one at the navel has not yet scabbed. However, from what we understand, that process can take 6-8 weeks to complete.

At Dr. Seyferth’s appointment approximately 10 days ago, he asked us when M----'s next post-surgical follow-up appointment with you was. He appeared to have the impression that one was needed, so I stopped at the General Surgery office to inquire. We never heard back about that.

In sum, to recap, we would greatly appreciate your input as to the following:

1. Will the MRI at SVMC meet the three listed conditions?
2. Will it be safe for M---- to have an MRI June 30th, five weeks post-surgery?
3. What would be your impression of the PET/CT scan finding?
4. Are those "clips" on the PET scan the staples, or does M--- have clips in him?
5. Should M---- have another surgical follow-up appointment? If so, we would greatly appreciate it.

As always, we are deeply thankful for your care and attention.

CV

Dr. Surgeon kindly reviewed the PET scan for us (he's awesome!). He clarified that he had examined the transverse colon externally with his eyes and hands, squeezing it to feel for any masses. He did not feel anything but equivocated about the possibility that there could be more cancer, saying that just because he did not feel anything it does not mean that something isn't there. He emphatically advised further testing for confirmation and said that the upcoming MRI (scheduled for June 30th) might give us enough information to form an opinion.

I explained that my husband refuses any procedure that will require him to have a ileostomy/colostomy "bag for life." Dr. Surgeon assured me that if he was to have another surgery on this area of the colon, which is apparently in the region of the gall bladder, that he would require a "J pouch" but no lifelong stomy. Dr. Surgeon would not be performing this additional surgery as it is beyond his expertise and would be referring us to a CR surgeon.

Apparently, M---- has some clips that we had not been informed of, so I looked up their safety profile. They are the same as the staples. He avoided saying anything about the safety of the MRI at exactly 6 weeks post surgery. Since he is not the doctor ordering the test, this is understandable.
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

jep
Posts: 24
Joined: Sun Jun 11, 2017 7:45 pm

Re: PET Scan Results - More Cancer???

Postby jep » Tue Jun 20, 2017 12:25 pm

I hope you get some definitive answers soon . . . I will add that my husband had surgery (LAR) on May 16 and his oncologist has pushed his PET scan to mid July . . . the Dr. is worried that if we do the scan too soon, inflammation may light up. Maybe that's what's happening with your husband's scan (?).
Husband DX Stage IV CC on May 16, 2017
47 years old
Tumor Location: recto-sigmoid
Tumor type: Adenocarcinoma
Tumor size: 7.4 cm
Tumor grade: G3
TNM code: T3N2M1
Positive lymph nodes: 8 out of 20
Baseline CEA value: .9
LVI: present
Perineural invasion: present
Surgical margins: clear (w/in microns)
Primary surgery type: LAR

Jacques
Posts: 408
Joined: Sun Dec 28, 2014 10:38 am

Re: PET Scan Results - More Cancer???

Postby Jacques » Tue Jun 20, 2017 11:41 pm

Before your meeting on Thursday you may want to read a few of the articles on "brown fat" and PET scan mis-interpretation, e.g. :

http://pubs.rsna.org/doi/full/10.1148/radiol.12100683
DX(2012): RC
Stage IIc,T4b N0 M0 L0 PN1 H0 D0 P0 I1
LAR
MSI: not tested
Chimio-radiothérapie
Chimiothérapie adjuvante : capécitabine + oxaliplatine
CEA < 1.0,
5 years NED,
End of 6-month follow-ups: 7/2017
----
Info links:
Create Your Signature
How to Select a Surgeon
List of Forum Features
Colorectal Cancer Stages (TNM)

mpbser
Posts: 251
Joined: Wed Apr 19, 2017 11:52 am

Re: PET Scan Results - More Cancer???

Postby mpbser » Wed Jun 21, 2017 7:43 am

Thanks, everyone.

We definitely aren't jumping to conclusions. Thankfully, we were able to get back-to-back appointments at Dana Farber and Mass General in Boston July 6th. So, we will get getting second and third opinions.

I got a call from the local hospital's Advocate yesterday per request of my husband's oncologist. I wonder why she made the request. Could it be the numerous little screw ups her office has made from the beginning?
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

rp1954
Posts: 1174
Joined: Mon Jun 13, 2011 1:13 am

Re: PET Scan Results - More Cancer???

Postby rp1954 » Wed Jun 21, 2017 4:13 pm

In our previous situations with hypermetabolic activity, adding blood tests for CEA, CA19-9 and LDH have been useful, controlled for sugar levels with HgbA1C and inflammation levels with ESR and/or hsCRP.

The difference being that we had earlier blood tests and more consistent anti-inflammatory supplements e.g. the frequent vitamin C infusions, aligned 8 - 24 hr before blood tests, and higher dose supplements. At a high enough combined treatment intensity, we could see the persistent exponential of CA19-9 finally turn off with multiple anti-Kras adjuncts, and drop back to a flat line, nearly to the CA199 baseline. This left some surviving non mutant cells (the Kras tissue assay). We would have missed this using CEA alone. Likewise we can see LDH, partially a reflection of anaerobic sugar metabolism, respond to diet, exercise and treatments.

Levels and any large changes to panels and markers were important information.
watchful, active caregiver for stage IVb CC since early 2010. immuno"Chemo forever," for mCRC

mpbser
Posts: 251
Joined: Wed Apr 19, 2017 11:52 am

Re: PET Scan Results - More Cancer???

Postby mpbser » Fri Jun 23, 2017 7:44 am

Husband and I met with his oncologist yesterday. She spoke with his surgeon and gastroenterologist and they all agree that he needs another colonoscopy asap to get definitive answers about whether or not there is additional adenocarcinoma in the colon. Since we have appointments for 2nd and 3rd opinions in Boston on June 6th, time is of the essence to get this done. Husband wants to have the results prior to the June 6th appointments, for obvious reasons.

Oncologist discussed the possible need for additional colon surgery and suggested that if he also needs liver surgery that both procedures could be done simultaneously, killing two birds with one stone. The abdominal MRI that will be done June 30th will give further guidance as to whether invasive liver treatment is needed. The tentative plan, depending on what his gastroenterologist can do with her schedule, is to have the colonoscopy on the same day as the MRI. What a day he will have, if so: cardiologist appointment, bloodwork, MRI, colonoscopy, an entire day at the hospital.
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53

behconsult
Posts: 217
Joined: Fri Jul 04, 2014 4:53 pm

Re: PET Scan Results - More Cancer???

Postby behconsult » Fri Jun 23, 2017 11:17 pm

mpbser wrote:Thanks for the question, Maia. He doesn't take metformin and is controlling his diabetes with diet. He takes supplements that possibly could intervene on glucose uptake. I will definitely look into this as a potential cause.

I did some reading on the term hypermetabolic focus and it appears that it could simply just be inflammation. I am wondering if the proximal transverse colon can become inflamed as a result of the surgery which was only 4 week ago. I am hoping this is just a part of the healing process.



My thought is surgery was just four weeks ago. It will be months before inflammation is reduced. Surgery triggers a massive cascade of cytokine and molecular responses. When I had my surgery a lymph node was swollen up after. They were unsure in the ct write up if it was the result of surgery or more cancer. Three years later..it was the surgery........
Stage 3B Age 52
T4; 2/16; spot on perit
Resctn 6/9/2014
Folfox strt 7/2014. 6 of 12 tx
Chemo induced DM2
Pet 4 mets to lung (1 cm, 6 mm) Xeloda/Avastin 9/16 to present.
Cryo-ablation to three spots- Collapsed lung/chest tube 5/17. One more spot to go.

Jacques
Posts: 408
Joined: Sun Dec 28, 2014 10:38 am

Re: PET Scan Results - More Cancer???

Postby Jacques » Sat Jun 24, 2017 1:05 am

mpbser wrote:Husband and I met with his oncologist yesterday. She spoke with his surgeon and gastroenterologist and they all agree that he needs another colonoscopy asap to get definitive answers about whether or not there is additional adenocarcinoma in the colon. Since we have appointments for 2nd and 3rd opinions in Boston on June 6th, time is of the essence to get this done. Husband wants to have the results prior to the June 6th appointments, for obvious reasons.

Oncologist discussed the possible need for additional colon surgery and suggested that if he also needs liver surgery that both procedures could be done simultaneously, killing two birds with one stone. The abdominal MRI that will be done June 30th will give further guidance as to whether invasive liver treatment is needed. The tentative plan, depending on what his gastroenterologist can do with her schedule, is to have the colonoscopy on the same day as the MRI. What a day he will have, if so: cardiologist appointment, bloodwork, MRI, colonoscopy, an entire day at the hospital.

You have about one week before your MRI/colonoscopy procedure and almost two weeks before your back-to-back appointments for 2nd and 3rd opinions. From my viewpoint as a layman, I think you could use this time to good advantage by reading the relevant sections of the current NCCN Guideline for Colon Cancer. You won't know exactly which section is the relevant one until you have the results from the June 30th MRI/colonoscopy procedures, but you can do some preliminary reading of the guideline assuming different scenarios that the MRI/colonoscopy might suggest, namely scenarios that would require transverse colon resection, liver resection, both resections, or neither resection. To do this you will eventually need to know whether your liver mets are deemed resectable or non-resectable, but this information should become available after your MRI report is in. You might also need to know your KRAS mutant status, and you would need to have your tentative staging (T3 N2b M1a, Stage IV A) confirmed.

This would seem to be a complicated issue because the choice of appropriate therapy regimen for you would also need to take into account your several co-morbid conditions. Some of the interventions mentioned in the guidelines may not be advisable for some reason given your co-morbid conditions. Thus, right now I think that what you should try to do is to lay out all of the different possible scenarios on your own and try to link each one of them up with a recommended treatment regimen from the NCCN Guidelines. In this way, you will be prepared to follow the discussions that will take place when you have your 2nd and 3rd opinion meetings regardless of which direction these discussions might take.
DX(2012): RC
Stage IIc,T4b N0 M0 L0 PN1 H0 D0 P0 I1
LAR
MSI: not tested
Chimio-radiothérapie
Chimiothérapie adjuvante : capécitabine + oxaliplatine
CEA < 1.0,
5 years NED,
End of 6-month follow-ups: 7/2017
----
Info links:
Create Your Signature
How to Select a Surgeon
List of Forum Features
Colorectal Cancer Stages (TNM)

mpbser
Posts: 251
Joined: Wed Apr 19, 2017 11:52 am

Re: PET Scan Results - More Cancer???

Postby mpbser » Sat Jun 24, 2017 6:43 am

Thanks Jacques. I will be studying up diligently.

behconsult, yes, definitely no rush to any conclusions but a colonoscopy will tell us for sure. I am going to start another thread about having a colonoscopy so soon after colon surgery. That's another concern of mine.
Wife 4/17 Dx age 45
5/17 - Lap left hemi
Adenocarcinoma
5 x 4 x 1 cm
low grade
T3 N2b M1a
Stage IV A
lymph nodes: 9 of 54
8/17 Sub-total colectomy
2nd tumor 5.5 cm width T1 N0
CEA: 1.4 Pre-op; 2.1 2 days Post-op
MSS/MSI-L
Lynch no; KRAS wild
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2
Tumor DNA variants: MTOR, APC, TP53


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