Pathological downstaging

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Punky44
Posts: 339
Joined: Mon Oct 01, 2018 4:29 pm

Pathological downstaging

Postby Punky44 » Sat Mar 23, 2019 9:49 am

My mom got a verbal prelim report of her pathology from surgery—with her 8 rounds of FolFox and short course radiation, her tumor shrunk from a T3 at diagnosis to a T2 and her lymph nodes went from “more than 4” suspicious nodes to 0/38 cancerous nodes affected. They told her that her pathological Stage is a Stage 1. I know I’ve seen it said that you’ll always still be the Stage you were at diagnosis (Stage 3 for her) but getting “downstaged” is a good prognostic indicator, correct?
Caregiver to my amazing mom (68)
10/1/18 DX with rectal cancer; CEA 17 at diagnosis
MRI/CT/PET puts staging at T3N2M0
Total neoadjuvant therapy:
8 rounds Folfox 11/5/18 - 2/11/19
Short course radiation 3/14/19 - 3/20/19
Robotically assisted laparoscopic LAR 3/21/19
Pathology report says yT2N0M0 with 0/38 nodes
CEA 4/23: 2.1; 7/24: 1.9
6/28/19 Reversal and port out

Me: 34, first colonoscopy 11/16/18—normal! Come back in 5 years.

dhamptonii
Posts: 8
Joined: Sun Dec 30, 2018 6:58 pm

Re: Pathological downstaging

Postby dhamptonii » Sat Mar 23, 2019 11:52 am

I don't know but interested in hearing what anyone has to say about this. Regardless, it sounds like things are going well for your mom. I hope they continue. Wishing you the very best.

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O Stoma Mia
Posts: 1600
Joined: Sat Jun 22, 2013 6:29 am

Re: Pathological downstaging

Postby O Stoma Mia » Sat Mar 23, 2019 3:49 pm

Punky44 wrote:My mom got a verbal prelim report of her pathology from surgery—with her 8 rounds of FolFox and short course radiation, her tumor shrunk from a T3 at diagnosis to a T2 and her lymph nodes went from “more than 4” suspicious nodes to 0/38 cancerous nodes affected. They told her that her pathological Stage is a Stage 1. I know I’ve seen it said that you’ll always still be the Stage you were at diagnosis (Stage 3 for her) but getting “downstaged” is a good prognostic indicator, correct?

The pathology report that you are referring to is a "yp" pathology report, because it examines a specimen that has already undergone some treatment. This type of pathology report is different from a regular pathology report and needs to be interpreted within a different framework.

The following article provides some clarification on this:
https://onlinelibrary.wiley.com/doi/full/10.1002/cncr.21887

WarriorSpouse
Posts: 196
Joined: Tue Aug 16, 2016 9:02 pm

Re: Pathological downstaging

Postby WarriorSpouse » Sun Mar 24, 2019 11:25 am

It is always good to see NED and better results than last reported, but I am a big believer in not sugar coating the initial staging upon diagnosis.

It is my personal belief that the higher the stage, the more aggressive the treatment. Treatment and surveillance efforts are not cheap, so no insurance plan or government sponsored program would support aggressive treatment plans for lower staged patients as they do for those diagnosed with a higher stages.

I would love if my wife was staged lower at diagnosis. It may have made her feel better initially, but I also know that her Stage IV diagnosis may also be responsible for keeping her alive into her fourth year and now heading toward her fifth year anniversary. She has been on chemotherapy and Avastin treatments throughout it all.

Best wishes to all!
WS
D/H 47 years old, 10/2014, Stage IV M/CRC, nodes 12/15, para-aortic, 5 cm sigmoid resection, positive Virchow. KRAS mut, MSS, Highly Differentiated, Lynch Neg, 5FU/LV and Avastin 1 YR (Oxi for 5 months), Zeloda/Bev since 01/2016. 02/2019 recurrence para-nodes, back to 5FU/LV Oxy/Bev. It is working again. "...Perseverance is not a long race; it is many short races one after the other."-Walter Elliot

hopie
Posts: 90
Joined: Fri Jan 18, 2019 12:15 pm

Re: Pathological downstaging

Postby hopie » Mon Mar 25, 2019 7:05 am

I haven't done much research about stage 3, but my reasoning tells me that it depends on whether those suspected nodes were cancerous before chemo. If that was the case, I think your mom would be a Stage 3, NED. If those nodes were not cancerous, then it would either be Stage 1 or 2--again, depending on whether the shrinkage was a response to treatment or was due to imaging issues. Regardless, it's a great sign! Even if those nodes were indeed cancerous before, 0/38 means a complete pathological response, which is p e r f e c t!

Sending you and your mom hugs!
Caregiver to my super-mom (62), diagnosed Dec 2018
Sigmoid colon, Stage IV
G3, Poorly differentiated adenocarcinoma (5,5 x 4 x 1 cm)
T4N2bM1
13 positive out of 23 lymph nodes, largest one 1,8 cm
4(?) mets in liver, located at Segment 3 & 7, largest one 2 cm
LVI & PNI present
Clear surgical margins
MSS, KRAS G13D mutant
Laparoscopic anterior resection, Jan 2019

First chemo 11 Feb 2019 (Folfox). 25/2/19 Folfox + Avastin.

Punky44
Posts: 339
Joined: Mon Oct 01, 2018 4:29 pm

Re: Pathological downstaging

Postby Punky44 » Mon Mar 25, 2019 11:29 am

Thank you all!

We meet with the Mayo onc on April 24th to discuss next steps—I am so curious to see if she will recommend doing the final 4 rounds of FolFox.
Caregiver to my amazing mom (68)
10/1/18 DX with rectal cancer; CEA 17 at diagnosis
MRI/CT/PET puts staging at T3N2M0
Total neoadjuvant therapy:
8 rounds Folfox 11/5/18 - 2/11/19
Short course radiation 3/14/19 - 3/20/19
Robotically assisted laparoscopic LAR 3/21/19
Pathology report says yT2N0M0 with 0/38 nodes
CEA 4/23: 2.1; 7/24: 1.9
6/28/19 Reversal and port out

Me: 34, first colonoscopy 11/16/18—normal! Come back in 5 years.

weisssoccermom
Posts: 5950
Joined: Thu May 10, 2007 2:32 pm
Location: Pacific NW

Re: Pathological downstaging

Postby weisssoccermom » Mon Mar 25, 2019 9:04 pm

Please, understand that your mother is NOT 'downstaged'. True 'downstaging' happens very rarely and only happens when a mistake or some other such error was made in the initial staging.

When a patient's tumor responds to ANY type of treatment....be that chemo, radiation, a combination of both, immunotherapy, the ensuing pathology report simply shows how well the tumor responded to the neoadjuvant treatment. Your mother will always be a stage 3 and is NOT a stage 1. Think about it for a minute. The doctors WANT the tumor to respond to treatment....otherwise, why undergo that treatment? What would be the purpose of neoadjuvant (before surgery) chemoradiation for a rectal tumor if the medical community didn't believe that the treatment could potentially have a positive effect on the tumor or nearby lymph nodes?

To answer your question, yes it is a good sign that your mom's tumor shrunk.....it's what you want it to do. Please, however, make NO mistake....your mom was and is a stage III and will be (or at least should be) treated as such. Her pathological stage will show the designation of yp .....meaning that the 'y' indicates that there was some neoadjuvant treatment and the 'p' simply indicates a pathological report. IT IS NOT THE SAME AS A PATHOLOGY REPORT PRIOR TO ANY TREATMENT.
Dx 6/22/2006 IIA rectal cancer
6 wks rad/Xeloda -finished 9/06
1st attempt transanal excision 11/06
11/17/06 XELOX 1 cycle
5 months Xeloda only Dec '06 - April '07
10+ blood clots, 1 DVT 1/07
transanal excision 4/20/07 path-NO CANCER CELLS!
NED now and forever!
Perform random acts of kindness

Punky44
Posts: 339
Joined: Mon Oct 01, 2018 4:29 pm

Re: Pathological downstaging

Postby Punky44 » Tue Mar 26, 2019 9:49 am

I understand that. I just wondered if the “y” stage has been shown to have any prognostic significance, for example with recurrence rates? O Stoma Mama’s link said “the anatomic extent of disease as described by the ypTNM classification after preoperative therapy remains of great prognostic significance” and I was just curious what exactly that means. :)

Also wondered if there’s anything to be drawn from the fact that it occurred mostly as a result of the systemic chemo treatment she received neoadjuvantly vs the radiation, which was only short course 5 days prior to surgery and we were told wouldn’t have the time to “take effect” in test results the way the long course treatment could (if that makes sense.) I am hopeful that because systemic chemo seemed to do such a good job on the tumor itself and the lymph nodes that it also likely zapped micromets.
Caregiver to my amazing mom (68)
10/1/18 DX with rectal cancer; CEA 17 at diagnosis
MRI/CT/PET puts staging at T3N2M0
Total neoadjuvant therapy:
8 rounds Folfox 11/5/18 - 2/11/19
Short course radiation 3/14/19 - 3/20/19
Robotically assisted laparoscopic LAR 3/21/19
Pathology report says yT2N0M0 with 0/38 nodes
CEA 4/23: 2.1; 7/24: 1.9
6/28/19 Reversal and port out

Me: 34, first colonoscopy 11/16/18—normal! Come back in 5 years.

weisssoccermom
Posts: 5950
Joined: Thu May 10, 2007 2:32 pm
Location: Pacific NW

Re: Pathological downstaging

Postby weisssoccermom » Tue Mar 26, 2019 9:56 am

Of course it is a good sign that chemo and the radiation (no matter how short the course....that particular treatment works well on nodes) helped clean up nodes/shrink her tumor. What you don't know is exactly the extent of shrinkage. Your signature shows a T3 prior to treatment and a T2 after. So yes, there is some shrinkage but how much??? That's hard to assess. My take.....take whatever good news you can get from cancer and run with it! This is such a non-predictable disease. Good news for your mom.
Dx 6/22/2006 IIA rectal cancer
6 wks rad/Xeloda -finished 9/06
1st attempt transanal excision 11/06
11/17/06 XELOX 1 cycle
5 months Xeloda only Dec '06 - April '07
10+ blood clots, 1 DVT 1/07
transanal excision 4/20/07 path-NO CANCER CELLS!
NED now and forever!
Perform random acts of kindness

Punky44
Posts: 339
Joined: Mon Oct 01, 2018 4:29 pm

Re: Pathological downstaging

Postby Punky44 » Tue Mar 26, 2019 10:11 am

Thank you!
Caregiver to my amazing mom (68)
10/1/18 DX with rectal cancer; CEA 17 at diagnosis
MRI/CT/PET puts staging at T3N2M0
Total neoadjuvant therapy:
8 rounds Folfox 11/5/18 - 2/11/19
Short course radiation 3/14/19 - 3/20/19
Robotically assisted laparoscopic LAR 3/21/19
Pathology report says yT2N0M0 with 0/38 nodes
CEA 4/23: 2.1; 7/24: 1.9
6/28/19 Reversal and port out

Me: 34, first colonoscopy 11/16/18—normal! Come back in 5 years.

Nohogirl
Posts: 114
Joined: Sun Oct 14, 2018 12:15 am

Re: Pathological downstaging

Postby Nohogirl » Tue Mar 26, 2019 9:07 pm

My husband's tumor was also downgraded from T3 to T2 with the only difference that he didn't have any lymph involvements prior to chemoradiation. On his post surgery pathology report it was indicated T2NOM0, however the final stage was still indicated as stage 2. Considering my husband's young age and the fact that his tumor was moderate to poorly differentiated, his doctors took the aggressive approach and treated him as if he was stage 3. Chemo was decided before surgery and remained so after.
04/18 DH 49 Stage 2A T3N0M0 rectal cancer moderately differentiated.
05/18 chemorad. (Xeloda) 28 days
08/18 Surgery- 24 cm, including entire rectum out
Path -Stage II T2N0M0 moderate to poorly diff. adenocarcinoma
0 of 15 lymph nodes
No PNI
No LVI
Clear margins
10/18-02/19 8 cycles of Folfox
02/19 Pet Scan. NED
07/18 Pet Scan NED

Punky44
Posts: 339
Joined: Mon Oct 01, 2018 4:29 pm

Re: Pathological downstaging

Postby Punky44 » Tue Mar 26, 2019 11:32 pm

Nohogirl, I remember your story! How have you been? I see that he did 8 cycles of FolFox? My mom did 8 as well so I’m curious to see if we will be advised to do 4 more? (Since she didn’t have the chemo alongside the radiation like your husband did.)
Caregiver to my amazing mom (68)
10/1/18 DX with rectal cancer; CEA 17 at diagnosis
MRI/CT/PET puts staging at T3N2M0
Total neoadjuvant therapy:
8 rounds Folfox 11/5/18 - 2/11/19
Short course radiation 3/14/19 - 3/20/19
Robotically assisted laparoscopic LAR 3/21/19
Pathology report says yT2N0M0 with 0/38 nodes
CEA 4/23: 2.1; 7/24: 1.9
6/28/19 Reversal and port out

Me: 34, first colonoscopy 11/16/18—normal! Come back in 5 years.


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