cauliflower stalk/ mushroom mass, 5cm: How to proceed?

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Lee
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby Lee » Mon Mar 19, 2018 7:30 pm

dallasdog wrote: . . . . Later that same day I received the path of the biopsy. Margins were clear but the GI specialist and Colo surgeon still think it has cancer in it. This is the path that they have laid out for me:


I have no idea what I am doing here, so any advice/recommendations would be helpful. I guess it is possible that it is just a huge uncancerous growth?


GI doc(s) are pretty good at diagnosing cancer when they see it. Sometimes a mushroom will be clean on the outside (ie no cancer found), butt once pathology gets a hold of what was removed, they "can" find cancer cells inside the mushroom.

Chrissyrice laid out a VERY good reason for getting a CAT scan. Again get that 2nd opinion from a place that deals with cancer everyday.

Yes it could still be non cancerous. It takes about 10 years for a polyp to turn cancerous.

Good luck,

Lee
rectal cancer - April 2004
46 yrs old at diagnoses
stage III C - 6/13 lymph positive
radiation - 6 weeks
surgery - August 2004/hernia repair 2014
permanent colostomy
chemo - FOLFOX
NED - 16 years and counting!

Utwo
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby Utwo » Mon Mar 19, 2018 8:19 pm

dallasdog wrote:
Utwo wrote:Depending on your histology report after this colonoscopy/polypectomy you may not even need a real surgery.
Just keep your finders crossed.
You mean depending on the histology report that I get after it is totally removed and biopsied?

Yes

Theoretically speaking you may have two outcomes:
1. benign polyp
In case of such report you just need to have a party and forget about it.
2. malignant polyp
In this case you need to look for "Margins" and "T" staging
2.1 In case of magical "T0" cancer (cancer is present only in a head of a polyp with large "Clear Margins"), you also need to have a party and forget about it.
2.2 Starting with "T1" picture is getting "more interesting".
However (based on what you have already reported) you have a high likelihood of getting options #1 or #2.1

My personal advice: get this polyp removed (preferably by full time colonoscopist) and forget about it until you have a histology report.
Start reading all the links provided above only if you have stages T1, T2 etc.

When reading responses on this forum please pay attention to diagnosis/stage of a person.
If diagnosis/stage are different from yours, such advice may not be applicable for your situation.
58 yo male at diagnosis: T1bN0M0, 0/15 nodes, low grade/moderately differentiated adenocarcinoma
03/2016 colonoscopy: 2 small polyps removed in left colon; CEA = 1.3
04/2016 colonoscopy: caecum sessile 3.5 cm polyp piecemeal removed with kind of clear margins
05/2016 "prophylactic" laparoscopic right hemicolectomy - bleeding, leak, infection
06/2017 CT scan, colonoscopy OK; CEA = 1.6
A lot of funny stuff discovered by CT scans in liver, kidney, lungs, arteries, gallbladder, lymph node, pancreas

Utwo
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby Utwo » Mon Mar 19, 2018 8:36 pm

dallasdog wrote: Gastroentologist is the best person to "snare" (the word he used) the cauliflower stalk polyp and remove it
In addition to a camera, a scope also has a wire snare that is used to cut polyps.
Then they would place polyp or its pieces into a special pouch to get it outside.
I am not sure how many snares are there.

dallasdog wrote:I tried to get an idea of risks and whether the gi would be able to deal with any issues/problem should they occur during the surgery ...
Two main risks are "perforation" and "bleeding".
In case of perforation you will be handed over to real surgeon.
Risk of perforation is rather minimal when full time colonoscopist is removing pedunculated polyp.
At the same time this colonoscopist should be able to stop excessive bleeding him/herself.
To do this they would use a wire that is heated by electric current.
After my colonoscopy #2 I was shown a nice color photo that had some black charred spots (where bleeding happened).
58 yo male at diagnosis: T1bN0M0, 0/15 nodes, low grade/moderately differentiated adenocarcinoma
03/2016 colonoscopy: 2 small polyps removed in left colon; CEA = 1.3
04/2016 colonoscopy: caecum sessile 3.5 cm polyp piecemeal removed with kind of clear margins
05/2016 "prophylactic" laparoscopic right hemicolectomy - bleeding, leak, infection
06/2017 CT scan, colonoscopy OK; CEA = 1.6
A lot of funny stuff discovered by CT scans in liver, kidney, lungs, arteries, gallbladder, lymph node, pancreas

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O Stoma Mia
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby O Stoma Mia » Tue Mar 20, 2018 2:43 am

If you are considering Duke for a polypectomy for a large polyp, you might want to consider the Duke Triangle Endoscopy Center. They have 9 highly rated gastroenterologists to choose from, and they no doubt have someone there who knows how to deal with the removal of large, difficult polyps. In addition, they probably have a full line of endoscopy equipment and tools, probably including the type of colonoscope that has multiple size snares that can be adapted for large polyps.

Duke Triangle Endoscopy Center
https://www.dukehealth.org/locations/duke-triangle-endoscopy-center?utm_source=google&utm_medium=organic&utm_campaign=Directory+Management

If you are going to go directly for a polypectomy now, I think it is probably best to look for gastroenterologists who do nothing but endoscope/colonoscope procedures all day. These would be the ones who have the range of experience that you want for handling whatever might occur in a difficult polyp removal procedure.

Lee
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Joined: Sun Apr 16, 2006 4:09 pm

Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby Lee » Tue Mar 20, 2018 5:24 pm

Utwo wrote:When reading responses on this forum please pay attention to diagnosis/stage of a person.
If diagnosis/stage are different from yours, such advice may not be applicable for your situation.


Interesting comment . . .

Maybe I should add more info to my signature line.

During my first colonoscopy, GI doc found a mass in my rectum, less than 5cm. Per GI doc, "Good news, we caught this early, stage 1, surgery for sure, maybe some chemo lite". Days later, after further testing, including a CAT scan. I went from a stage 1 to a stage 3. The mass outside my rectum was 8cm by 11cm. 4 lymph nodes were positive for cancer (surgery would confirm 6 nodes positive).

Because of my over all youth (46 yrs old) and good health, they threw the kitchen sink at me. FOLFOX was experimental during that time, butt my Onc got me on board with it. For 3 month, I was her only patient on it. There was always the talk of me possibility going to stage 4.

Count your lucky stars, you clearly were one of the lucky ones. Not all of us are that lucky, and there are other people like me. You might want to reread what ChrissyRice wrote on this thread and her journey.

In my opinion, giving that type of advice was not good advice.

Ever see that picture of an iceberg, above and below the water line. Low profile above the water, butt beneath the water, it is 5X the size. Sometimes cancer works that way. Just my personal experience.

Lee
Last edited by Lee on Tue Mar 20, 2018 9:30 pm, edited 1 time in total.
rectal cancer - April 2004
46 yrs old at diagnoses
stage III C - 6/13 lymph positive
radiation - 6 weeks
surgery - August 2004/hernia repair 2014
permanent colostomy
chemo - FOLFOX
NED - 16 years and counting!

DarknessEmbraced
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Facebook Username: Riann Fletcher
Location: New Brunswick, Canada

Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby DarknessEmbraced » Tue Mar 20, 2018 5:41 pm

I agree best to get a second opinion.*hugs* I'm sorry you're going through this!*hugs*
Diagnosed 10/28/14, age 36
Colon Resection 11/20/14, LAR (no illeo)
Stage 2a colon cancer, T3NOMO
Lymph-vascular invasion undetermined
0/22 lymph nodes
No chemo, no radiation
Clear Colonoscopy 04/29/15
NED 10/20/15
Ischemic Colitis 01/21/16
NED 11/10/16
CT Scan moved up due to high CEA 08/21/17
NED 09/25/17
NED 12/21/18
Clear colonoscopy 09/23/19
Clear 5 year scans 11/21/19- Considered cured! :)

dallasdog
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby dallasdog » Thu Mar 22, 2018 2:12 pm

Utwo wrote:
dallasdog wrote:
Utwo wrote:Depending on your histology report after this colonoscopy/polypectomy you may not even need a real surgery.
Just keep your finders crossed.
You mean depending on the histology report that I get after it is totally removed and biopsied?

Yes

Theoretically speaking you may have two outcomes:
1. benign polyp
In case of such report you just need to have a party and forget about it.
2. malignant polyp
In this case you need to look for "Margins" and "T" staging
2.1 In case of magical "T0" cancer (cancer is present only in a head of a polyp with large "Clear Margins"), you also need to have a party and forget about it.
2.2 Starting with "T1" picture is getting "more interesting".
However (based on what you have already reported) you have a high likelihood of getting options #1 or #2.1

My personal advice: get this polyp removed (preferably by full time colonoscopist) and forget about it until you have a histology report.
Start reading all the links provided above only if you have stages T1, T2 etc.

When reading responses on this forum please pay attention to diagnosis/stage of a person.
If diagnosis/stage are different from yours, such advice may not be applicable for your situation.


This does make me feel a bit better about having the GI do the procedure. I spoke with both the GI and Colorectal surgeon once more and they are on the same page-- the GI needs to do it. I will see what Duke has to say next week when I have an appointment there. If their general thoughts are in line, I will move forward. Thanks.

dallasdog
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Joined: Sun Mar 18, 2018 9:18 am

Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby dallasdog » Sun Mar 25, 2018 7:54 am

Here is the Pathology for colonoscopy. Any thoughts on what this means?

3. COLON, SIGMOID, BIOPSIES:
FRAGMENTS OF TUBULOVILLOUS ADENOMA
(WGR)

COMMENT
COMMENT: THE BIOPSIES IN SPECIMEN #3 (SIGMOID) APPEAR TO HAVE BEEN TAKEN
FROM THE SURFACE OF A LESION. THE BIOPSIES ARE FRAGMENTED, BUT ARE
COMPOSED OF TUBULOVILLOUS ADENOMA. IN PLACES, THE DYSPLASIA IS MORE
PRONOUNCED THAN THAT TYPICALLY SEEN IN AN ADENOMA, BUT IN THESE
BIOPSIES, DYSPLASIA IS NOT SEVERE ENOUGH TO WARRANT A DIAGNOSIS OF HIGH
GRADE DYSPLASIA. NO DEFINITE CARCINOMA IS IDENTIFIED IN THESE BIOPSIES.

dallasdog
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby dallasdog » Sun Mar 25, 2018 2:32 pm

chrissyrice wrote:I disagree on the need for a CT Scan first and get a second opinion.

Had I done what your CRC surgeon suggested... never would have seen the lymph nodes that already had cancer and the stalk had grew through the colon already.

Since you are so close to Duke I really would go there for a second opinion.

Good Luck,
Chrissy


In your case did they also discover a sigmoid pedunculated polyp during colonoscopy? Once discovered, did they remove it first, or get a CT first?

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O Stoma Mia
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby O Stoma Mia » Sun Mar 25, 2018 4:23 pm

dallasdog wrote:Here is the Pathology for colonoscopy....

What else was in the pathologist's report. You only cited the finding from SPECIMEN #3. Where was this specimen taken from? From the stalk of the polyp? From the head of the polyp? From the outside surface only, or from the interior of the polyp? What did the GI's colonosvopy repott say about the number and location of the biopsy samples?

dallasdog
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby dallasdog » Sun Mar 25, 2018 7:59 pm

O Stoma Mia wrote:
dallasdog wrote:Here is the Pathology for colonoscopy....

What else was in the pathologist's report. You only cited the finding from SPECIMEN #3. Where was this specimen taken from? From the stalk of the polyp? From the head of the polyp? From the outside surface only, or from the interior of the polyp? What did the GI's colonosvopy repott say about the number and location of the biopsy samples?


This is the whole thing:

SMALL BOWEL, TERMINAL ILEUM, BIOPSY:
BENIGN SMALL BOWEL MUCOSA WITH BENIGN REACTIVE LYMPHOID FOLLICLES

2. COLON, RANDOM BIOPSIES:
FRAGMENTS OF COLONIC MUCOSA; NO SIGNIFICANT INFLAMMATION; NEGATIVE FOR
LYMPHOCYTIC OR COLLAGENOUS COLITIS

3. COLON, SIGMOID, BIOPSIES:
FRAGMENTS OF TUBULOVILLOUS ADENOMA
(WGR)

COMMENT
COMMENT: THE BIOPSIES IN SPECIMEN #3 (SIGMOID) APPEAR TO HAVE BEEN TAKEN
FROM THE SURFACE OF A LESION. THE BIOPSIES ARE FRAGMENTED, BUT ARE
COMPOSED OF TUBULOVILLOUS ADENOMA. IN PLACES, THE DYSPLASIA IS MORE
PRONOUNCED THAN THAT TYPICALLY SEEN IN AN ADENOMA, BUT IN THESE
BIOPSIES, DYSPLASIA IS NOT SEVERE ENOUGH TO WARRANT A DIAGNOSIS OF HIGH
GRADE DYSPLASIA. NO DEFINITE CARCINOMA IS IDENTIFIED IN THESE BIOPSIES.

DR. AHMAD HAS REVIEWED. #3 AND IS IN AGREEMENT.

CLINICAL INFORMATION


IMPRESSIONS: THE EXAMINED PORTION OF ILEUM WAS NORMAL. LIKELY MALIGNANT
PARTIALLY OBSTRUCTING TUMOR IN THE SIGMOID COLON AND AT 30 CM PROXIMAL
TO THE ANUS. THE DISTAL RECTUM AND ANAL VERGE ARE NORMAL RETROFLEXION
VIEW.

SPECIMEN
1. TERMINAL ILEUM-BIOPSY
2. COLON-RANDOM BIOPSY
3. COLON, SIGMOID-BIOPSY

GROSS DESCRIPTION
1. RECEIVED IN FORMALIN LABELED WITH THE PATIENT'S NAME AND DOB, AND
ALSO LABELED AS TERMINAL ILEUM. ARE 2 TAN SOFT TISSUE FRAGMENT
MEASURING 0.3 CM, ALL IN ONE. ES
2. RECEIVED IN FORMALIN LABELED WITH THE PATIENT'S NAME AND DOB, AND
ALSO LABELED AS RANDOM COLON. ARE MULTIPLE TAN SOFT TISSUE FRAGMENTS
MEASURING UP TO 0.3 CM, ALL IN ONE. ES
3. DESTROYED IN THERECEIVED IN FORMALIN LABELED WITH THE PATIENT'S NAME
AND DOB, AND ALSO LABELED AS SIGMOID. ARE MULTIPLE TAN SOFT TISSUE
FRAGMENTS MEASURING UP TO 0.3 CM, ALL IN ONE. ES
(CAT/ELS)

THE ABOVE DIAGNOSIS IS BASED ON PERFORMANCE OF THOROUGH GROSS AND/OR
MICROSCOPIC EVALUATIONS. IMMUNOPEROXIDASE PROCEDURES WERE DEVELOPED AND
PERFORMANCE CHARACTERISTICS DETERMINED BY PATHOLOGISTS DIAGNOSTIC
LABORATORY. NOT ALL HAVE BEEN CLEARED OR APPROVED BY THE U.S. FOOD AND
DRUG ADMINISTRATION.

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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby O Stoma Mia » Sun Mar 25, 2018 10:23 pm

On March 18, dallasdog wrote:Last week I had a colonoscopy and .... This is the path that they have laid out for me:
in Two weeks I will have another colonoscopy at which point the GI specialist with perform the procedure to remove the 5 cm mass. That mass will then be biopsied..

Are you still planning to have the polypectomy done two weeks from March 18? If so, will it be done by the same GI doctor who did the original colonoscopy? Are you now satisfied that she will do a good job, or are you looking for another GI specialist instead?

The beginning of April is not that far away. Do you have a definite date set for the polypectomy?

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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby O Stoma Mia » Mon Mar 26, 2018 6:18 am

dallasdog wrote:Here is the Pathology for colonoscopy. Any thoughts on what this means?

... FRAGMENTS OF TUBULOVILLOUS ADENOMA...

    ...It is well known that colorectal cancers arise from adenomatous polyps, which have three histologic variants: tubular, tubulovillous, and villous adenomas. Tubular adenomas represent ~75% to 85% of adenomatous polyps and have < 5% chance of harboring a malignancy. Tubulovillous adenomas represent 10% to 15% of polyps and usually 20% to 25% harbor a malignancy. Villous adenomas constitute 5% to 10% of the remaining polyps and 35% to 40% of the polyps are malignant.
    The size and degree of villous features are also predictive of the risk of malignancy within the polyp. Polyps larger that 2 cm have > 40% chance of being malignant...

    Reference:
    Colorectal Cancer: Epidemiology, Risk Factors, and Health Services (2005)
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780097/


dallasdog
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby dallasdog » Mon Mar 26, 2018 10:25 am

O Stoma Mia wrote:
On March 18, dallasdog wrote:Last week I had a colonoscopy and .... This is the path that they have laid out for me:
in Two weeks I will have another colonoscopy at which point the GI specialist with perform the procedure to remove the 5 cm mass. That mass will then be biopsied..

Are you still planning to have the polypectomy done two weeks from March 18? If so, will it be done by the same GI doctor who did the original colonoscopy? Are you now satisfied that she will do a good job, or are you looking for another GI specialist instead?

The beginning of April is not that far away. Do you have a definite date set for the polypectomy?


It is currently scheduled for Thursday with the same GI. Still have concerns about whether a GI should be doing it vs. a colorectal surgeon. Also have concerns about whether I need a CT before or not? I am hoping to squeeze in a second opinion before doing the polypectomy on THursday. Thanks.

dallasdog
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Re: cauliflower stalk/ mushroom mass, 5cm: How to proceed?

Postby dallasdog » Mon Mar 26, 2018 10:26 am

O Stoma Mia wrote:
dallasdog wrote:Here is the Pathology for colonoscopy. Any thoughts on what this means?

... FRAGMENTS OF TUBULOVILLOUS ADENOMA...

    ...It is well known that colorectal cancers arise from adenomatous polyps, which have three histologic variants: tubular, tubulovillous, and villous adenomas. Tubular adenomas represent ~75% to 85% of adenomatous polyps and have < 5% chance of harboring a malignancy. Tubulovillous adenomas represent 10% to 15% of polyps and usually 20% to 25% harbor a malignancy. Villous adenomas constitute 5% to 10% of the remaining polyps and 35% to 40% of the polyps are malignant.
    The size and degree of villous features are also predictive of the risk of malignancy within the polyp. Polyps larger that 2 cm have > 40% chance of being malignant...

    Reference:
    Colorectal Cancer: Epidemiology, Risk Factors, and Health Services (2005)
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780097/



This is a very helpful breakdown. So, it would seem that it has a 20-40% chance of being malignant based on the size and fact that it is tubulovillous.


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