Staging and treatment options.

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camicom
Posts: 22
Joined: Thu Jun 27, 2019 1:39 pm
Facebook Username: david galloway

Staging and treatment options.

Postby camicom » Sun Jul 28, 2019 7:48 pm

Hello all, its been a while since I posted. I had an extended right hemicolectomy on 7/19 to remove a 5cm mass from my TC. It was originally supposed to be done by robot, but they had to convert because of its locations. They took 2/3 of my colon. The surgery lasted approx 2 hours and everything went well. The mass was only 2.6cm and all margins were clear. My hospital stay was 3 days, and just had my first firm bm. Got the path report back as follows

PT3PN1A

Stage 3a with only one the primary lymph node involved

They took a total of 48 LN.

The surgeon recommended a 3 month chemo. He told me my 5 year DF would go from 40-80% with chemo. Those statistics are incorrect.


Here are my thoughts after much research. I have put some much time researching this over the last couple months and in the last 7 days I have found many studies that say, Stage 3a with only the primary LN involved is different that regualr Stage 3a's. I found found at least 2 studies that show curative surgery is just as succesful in 5 year DF as 2 chemo options. Not only that but I have used the different cancer survival calculators by the CLeveland Clinic, Sloan, and MD ANderson that show 5 y rates with or with chemo and it shocked me with the below results. The calculators are very specific age, location CEA level, pos LN, total taken lymph nodes etc

https://www.mskcc.org/nomograms/colorec ... robability

5 year disease free after surgery with no chemo 79%

5 year disease free after surgery with chemo 78%



Cleveland Clinic Calc confirms Sloans numbers

http://riskcalc.org/ColorectalCancer5an ... eSurvival/

No Chemo 81%

Chemo 80%



I think the total amount of nodes taken play into these numbers.

At this point I am leaning against doing chemo, and staying with a anti inflammatory diet that I have successfully for the last 2 months. I would very much like you thoughts and suggestions, and your experience with short similar chemo cycles.



Dave
5/13 Blood in stool CT and Bloodwork Clean
6/17 Colonoscopy 5cm Malignant Neoplasm in Transverse Colon
CEA 1.2 Lung CT clear
6/19 Confirmed Adenocarcinoma Mod Diff
7/19 Extended Right Hemicolectomy
Stage 3A with only Primary node affected 48 total nodes taken
BRAF Neg
Recommended 3 month Folfax
Decided no chemo
5 year DF ration is 81% w/o chemo 80% with

michelle c
Posts: 1885
Joined: Wed Dec 02, 2009 3:58 am

Re: Staging and treatment options.

Postby michelle c » Mon Jul 29, 2019 5:11 am

I was diagnosed with CC 10 years ago and had 3 lymph nodes affected. I did chemo - then it was 12 cycles over 6 months! My onc advised to do chemo to give me the best possible chance of survival. He said it was to kill off any rogue cells that might be floating around. Was I cured from surgery alone? I don’t know, possibly. I went with the chemo, to me it was a no brainer. Was I scared of chemo? Most definitely. I hated chemo, I won’t lie to you but I would do it again. I trusted my onc and his recommendation was enough for me. I didn’t research it as I knew it was standard care for stage III. It is totally up to you what you decide to do, only you can make that decision. Best wishes to you.
25 May 09 Dx with CC (sigmoid colon) 2 days after my 44th b'day
CEA prior to surgery 4.7
3 Jun 09 LAR - Stage III 3/10 lymph nodes
6 Jul - 10 Dec 09 12 cycles FOLFIRI
Genetic testing - inconclusive for Lynch
Jul 12 port removed & hernia repair

Beckster
Posts: 399
Joined: Thu Jan 12, 2017 3:01 pm
Location: New Jersey

Re: Staging and treatment options.

Postby Beckster » Mon Jul 29, 2019 6:03 am

camicom wrote:Hello all, its been a while since I posted. I had an extended right hemicolectomy on 7/19 to remove a 5cm mass from my TC. It was originally supposed to be done by robot, but they had to convert because of its locations. They took 2/3 of my colon. The surgery lasted approx 2 hours and everything went well. The mass was only 2.6cm and all margins were clear. My hospital stay was 3 days, and just had my first firm bm. Got the path report back as follows

PT3PN1A

Stage 3a with only one the primary lymph node involved

They took a total of 48 LN.

The surgeon recommended a 3 month chemo. He told me my 5 year DF would go from 40-80% with chemo. Those statistics are incorrect.


Here are my thoughts after much research. I have put some much time researching this over the last couple months and in the last 7 days I have found many studies that say, Stage 3a with only the primary LN involved is different that regualr Stage 3a's. I found found at least 2 studies that show curative surgery is just as succesful in 5 year DF as 2 chemo options. Not only that but I have used the different cancer survival calculators by the CLeveland Clinic, Sloan, and MD ANderson that show 5 y rates with or with chemo and it shocked me with the below results. The calculators are very specific age, location CEA level, pos LN, total taken lymph nodes etc

https://www.mskcc.org/nomograms/colorec ... robability

5 year disease free after surgery with no chemo 79%

5 year disease free after surgery with chemo 78%



Cleveland Clinic Calc confirms Sloans numbers

http://riskcalc.org/ColorectalCancer5an ... eSurvival/

No Chemo 81%

Chemo 80%



I think the total amount of nodes taken play into these numbers.

At this point I am leaning against doing chemo, and staying with a anti inflammatory diet that I have successfully for the last 2 months. I would very much like you thoughts and suggestions, and your experience with short similar chemo cycles.



Dave


Hi Dave...

As you can see from my signature, I had a right hemicolectomy with Stage IIA. I researched the same nomograms as you and found the same results. In fact my results showed a 5% decrease when doing chemo. I discussed this with my onc, who is affiliated with MD Anderson, and he felt it would be the opposite. After much discussion, I did 6 months of Xeloda. As he said, some chemo is better than none. Xeloda is the pill form of 5FU and it was quite doable. You are given the opportunity to do 3 months instead of 6....I would personally consider taking the chemo. He said there is 3 scenarios... surgery got it all and chemo would be useless, micro cancer cells are still present and chemo would eradicate it or micro cells are present and chemo would not work. I wanted to do everything possible to make sure that I dd not have a recurrence. Here is another 2017 nomogram that you can use... https://qcancer.org/colorectal-survival/. One other suggestion would be to get a second opinion from as major cancer center if you onc is a local community dr.
57/F
DX:(CC) 10/19/16
11/4/16- Lap right hemi(cecum)
CEA- Pre Op (1.9), Pre Chemo (2.5)
Type: Adenocarcinoma
Tumor size:3.5 cm x 2.5 x 0.7 cm
Grade: G3 (path) G2 (pre-op)
TNM: T3N0M0/IIA
LN: 0/24
LVI present
Surgical margins: clear
MSS
12/27/2016 - Capeox, anaphylactic reaction
1/2/17 to 6/9/17- Xeloda monotherapy
6/17,12/17,6/18,12/18 6/19 CT Scan NED :D
CEA- 6/17- 3.6, 9/17- 2.8 12/17-2.8, 3/18-3.1, 6/18-3.0, 9/18 2.8, 12/18 2.5 3/19 3.1 6/19 3.1 9/19 2.6 12/19 2.8
Clear Colonoscopy 10/17, 11/19 :D

Rock_Robster
Posts: 399
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Staging and treatment options.

Postby Rock_Robster » Mon Jul 29, 2019 6:11 am

Hi Dave,

Definitely a dilemma. I think the challenge here is that you’re trying to take population medians and apply it prognostically to an individual case. Unfortunately of course that doesn’t work. I’m probably saying things you already know, but an increase in 5-year survival from 80% to 81% does not mean that your risk is improved by 1%. Of course your outcome will be binary - you’re either alive in 5 years, or you aren’t. The only question I think is whether the downsides/risks of chemo outweighs any potential benefit.

FOLFOX is not messing about in terms of short- and long-term side effects, but if an option to manage these was on the table (eg 6 cycles, dose reduction, etc.) then I’d seriously be considering it.

Good luck either way mate.
Rob
Male 37; Melbourne, Australia
10/2018 Dx 3.5cm RC adenocarcinoma, 12cm from AV
Mod diff, EMVI+ LVI+ PNI-
3 LN; 4 liver mets
pT3pN1aM1a; Stage IVa. MSS, NRAS (G13R)
CEA: Oct-18= 12; Nov-18= 14, Mar-19= 2.4, Aug-19 <2.0
11/18 - FOLFOX x 6
3/19 - Liver resection
4-5/19 - 25 x pelvic radiation; complete met. response
07/19 - ULAR (robot), temp ileo, 1/27 LN
08/19 - Missed liver spot
08-11/19 - FOLFOX x 1, FOLFOXIRI x 1, FOLFIRI x 5
12/19 - Planned liver resection #2 & (01/20) stoma reversal

AmyG
Posts: 304
Joined: Tue Dec 25, 2018 8:08 pm

Re: Staging and treatment options.

Postby AmyG » Mon Jul 29, 2019 9:54 am

If it were me, I'd do the chemo. Mostly just to be sure there wasn't any cancer cells hiding somewhere. Folfox and Avastin have worked wonders for me. As much as I hate the side effects, I know they're temporary. I'd hate the what if scenario if I choose not to do chemo and had a recurrence. Know what I mean?

Good luck with whatever you choose!
42 dx @ 9wks pregnant w/baby #8 8/18
Sigmoid colon resection 9/18
Adenocarcinoma, G2, T3N0M0..or so we thought
KRAS/BRAF wild
Liver biopsy is malignant, stage iv now boys!
Delivered healthy baby 3/19
FOLFOX + Avastin 5/19
CEA 167 to 24 after 4 rounds
Liver resection 8/28/19
NED!! CEA 2.3
CEA 5.8 idk wtf is up with that, but everything else is clear!

mariane
Posts: 676
Joined: Sun Sep 13, 2015 6:16 pm

Re: Staging and treatment options.

Postby mariane » Mon Jul 29, 2019 2:07 pm

I would look at the pathology and genetics of the tumor. Type of cells? Mutations? They can help to predict how aggressive the tumor was. I had stage 4 cancer and agressive chemo saved my life.
Good luck!
mom of now 10 years old twins, dx @ 40 in 6/2015 with upper rectal cancer, 10+ liver mets, CEA 140
chemo: 8/2015 - 10/2016 - 4xFOLFIRINOX, 2xFOLFOX, 8xFOLFIRI, 10x5FU, HAI pump -12xFUDR
4 surgeries, complete pathological response
CEA<2 since 10/2015
NED since May 2016

I praise God for every day with my family!

jmn
Posts: 48
Joined: Sat Aug 11, 2018 8:20 pm
Location: New York/Philadelphia

Re: Staging and treatment options.

Postby jmn » Tue Jul 30, 2019 3:00 am

Dave,

My signature will give you a sense of my journey to date, but I want to emphasize the need for a pathology second opinion.

After my right hemicolectomy with Stage IIA, pathologists at my community hospital identified no high-risk factors (pT3N0), which is why my local oncologist recommended surveillance and no further treatment. After doing my due diligence, I learned that pathology reports are subjective—they are the interpretation of the pathologist viewing the tissue samples—and there can be serious errors in pathologic diagnosis. A wrong diagnosis can have devastating consequences. Beckster, in a post on this board, said that she knows a few Stage II folks who “had a second pathology done on their tumor and the results changed.”

I ultimately decided to get a second opinion at Memorial Sloan Kettering—and I am so glad I did! MSK pathologists analyzed my tumor specimen and identified several high-risk factors, including extensive tumor budding, small vessel lymphovascular invasion, perineural invasion, and pT4a stage. Given my high-risk Stage IIB status, Dr. Leonard Saltz, my MSK oncologist, started me on chemotherapy right away—eight cycles (six months) of Xeloda (6,000 MG of capecitabine daily). I experienced some side effects but, all in all, it was quite manageable.

The good news is that I finished chemo in April, had my NED status confirmed in May, and had a clear colonoscopy two weeks ago. I’ll never really know what if any impact chemo has had on my risk of recurrence and survival, but I have peace of mind knowing that I did everything possible to prevent a recurrence.

As I have said before, I believe everyone confronting cancer should get a second opinion. The goal is to prevent diagnostic and staging errors and to obtain accurate and complete information to determine the best course of treatment.
DX: CC, 7-9-18 @ age 61, male
Severe anemia (4.5 g/dl), 5-11-18; colonoscopy, 6-29-18
Lap-assisted right hemicolectomy, 7-16-18
G2, moderately differentiated adenocarcinoma in cecum, 4.2 x 3.7 x 0.7 cm
Stage IIB, pT4aN0 (first pathology DX: pT3N0)
0/24 lymph nodes, LVI present, PNI present, surgical margins clear, MSS
CEA: 3.0 (pre-op, 7-10-18); 0.7 (post-op, 8-8-18)
TX: Xeloda (capecitabine) monotherapy, 10-16-18 to 4-21-19
CEA: 4-19, 3.4; 5-19, 3.0; 7-19, 3.0
NED: 5-28-19 :D
Clear colonoscopy, 7-15-19 :D

boxhill
Posts: 405
Joined: Fri Apr 06, 2018 11:40 am

Re: Staging and treatment options.

Postby boxhill » Thu Aug 01, 2019 3:31 pm

Personally, if it's in a lymph node, I'd do the chemo. Definitely.

The question may be: which chemo? What are your tumor genetics? I'd be discussing what regimen and why with my oncologist. Ask him/her if you are a type known to be poor responders to certain basic drugs.

BTW, I noted this language on the MSK site "Note: Results produced by this tool are based on data from patients treated from 1990 to 2000, when fluorouracil was the only active agent in adjuvant chemotherapy for colon cancer."
F, 64 at DX CRC Stage IV
3/17/18 blockage, r hemi
11 of 25 nodes,5 mesentery nodes
5mm liver met out
pT3 pN2b pM1
BRAF wild, KRAS G12D
dMMR, MSI-H
5/4/18 FOLFOX
Neulasta 6/28
7/9/18 CT NED
11/20/18 CT NED. Enlarged spleen.
12/20/18 Liver MRI 5mm liver met? and 2 lymph nodes in porta hepatis
12/31/18 Keytruda
6/5/19 Triphasic CT LN and spleen normal, Liver node stable
6/28/19 Pause Keytruda, predisone for joint pain
7/31/19 Restart Keytruda
9/10/19 CT stable

camicom
Posts: 22
Joined: Thu Jun 27, 2019 1:39 pm
Facebook Username: david galloway

Re: Staging and treatment options.

Postby camicom » Thu Aug 01, 2019 7:24 pm

boxhill wrote:Personally, if it's in a lymph node, I'd do the chemo. Definitely.

The question may be: which chemo? What are your tumor genetics? I'd be discussing what regimen and why with my oncologist. Ask him/her if you are a type known to be poor responders to certain basic drugs.

BTW, I noted this language on the MSK site "Note: Results produced by this tool are based on data from patients treated from 1990 to 2000, when fluorouracil was the only active agent in adjuvant chemotherapy for colon cancer."


Thank you for the response. I haven't met with the oncologist yet, but my surgeon says it would probably be FOLFOX. Just got the news that its BRAG neg, which makes me happy. I will definitely give the oncologist a chance to make his case, but I also want him to be receptive to my information I have acrued with my specific diagnosis.

I think mine is a bit unusual due to the total amount of nodes taken 48, from my research, that amount raises the DF chances. My issue with chemo in this circumstance, is that I would worry the exact same amount whether I did chemo or not.

Thank you again
5/13 Blood in stool CT and Bloodwork Clean
6/17 Colonoscopy 5cm Malignant Neoplasm in Transverse Colon
CEA 1.2 Lung CT clear
6/19 Confirmed Adenocarcinoma Mod Diff
7/19 Extended Right Hemicolectomy
Stage 3A with only Primary node affected 48 total nodes taken
BRAF Neg
Recommended 3 month Folfax
Decided no chemo
5 year DF ration is 81% w/o chemo 80% with

kaloy85
Posts: 5
Joined: Sun Nov 04, 2018 8:41 pm
Facebook Username: carlo angelo pagulayan

Re: Staging and treatment options.

Postby kaloy85 » Thu Aug 01, 2019 8:09 pm

isn't it T3N1 is stage 3B, not 3A (T1-T2/N1, T1/N2a)?
03/2018 Diag. RectoSig Adenocarcinoma w/ mucin features Stage 3A (T2N1M0), 33M, Philippines
Pre Surgery CT: 3mm nonenhancing liver lesion, cyst?
04/2018 LAR; No LVI/PNI, mod. diff. 2/12 LN clean marg, 4.2cm, surgery on my bday.
05-09/2018: 4 rounds Xelox, 2 rounds Xeloda
10/2018: CT clean, stable 3mm cyst, Bone scan clean
01/2019: Scope clean
05/2019:CT clean
CEA's: 03/2018: 0.5, 05/2018: 0.47, 02/2019: 0.30, 05/2019: 0.27

Rock_Robster
Posts: 399
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Staging and treatment options.

Postby Rock_Robster » Thu Aug 01, 2019 10:42 pm

I’m not sure I’d be relying on those calculators for this decision - the Cleveland Clinic tool also uses a dataset from 1990-2000; ie from up to almost 30 years ago!

This paper released in Feb this year suggests a 20-25% improved 5-year survival from chemo for Stage III patients; I realise there is still stratification within this group of course.

https://link.springer.com/chapter/10.10 ... 01165-9_33

Great news that you don’t have to worry about a BRAF mutation. Another other question to consider in this - did your primary tumour have any higher risk factors such as EMVI+, LVI or PNI?
Male 37; Melbourne, Australia
10/2018 Dx 3.5cm RC adenocarcinoma, 12cm from AV
Mod diff, EMVI+ LVI+ PNI-
3 LN; 4 liver mets
pT3pN1aM1a; Stage IVa. MSS, NRAS (G13R)
CEA: Oct-18= 12; Nov-18= 14, Mar-19= 2.4, Aug-19 <2.0
11/18 - FOLFOX x 6
3/19 - Liver resection
4-5/19 - 25 x pelvic radiation; complete met. response
07/19 - ULAR (robot), temp ileo, 1/27 LN
08/19 - Missed liver spot
08-11/19 - FOLFOX x 1, FOLFOXIRI x 1, FOLFIRI x 5
12/19 - Planned liver resection #2 & (01/20) stoma reversal

camicom
Posts: 22
Joined: Thu Jun 27, 2019 1:39 pm
Facebook Username: david galloway

Re: Staging and treatment options.

Postby camicom » Fri Aug 02, 2019 8:13 am

kaloy85 wrote:isn't it T3N1 is stage 3B, not 3A (T1-T2/N1, T1/N2a)?


pT3pn1a is on the report.

I think its broker down like this. Mine had broken through the mucosa and muscularis but not the subserosa or serosa. It only affected the closest lymph. Stage 3a would be what I described up to 3 LN. 4-7 LN would be Stage 3B
5/13 Blood in stool CT and Bloodwork Clean
6/17 Colonoscopy 5cm Malignant Neoplasm in Transverse Colon
CEA 1.2 Lung CT clear
6/19 Confirmed Adenocarcinoma Mod Diff
7/19 Extended Right Hemicolectomy
Stage 3A with only Primary node affected 48 total nodes taken
BRAF Neg
Recommended 3 month Folfax
Decided no chemo
5 year DF ration is 81% w/o chemo 80% with

Rock_Robster
Posts: 399
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Staging and treatment options.

Postby Rock_Robster » Fri Aug 02, 2019 8:22 am

camicom wrote:
kaloy85 wrote:isn't it T3N1 is stage 3B, not 3A (T1-T2/N1, T1/N2a)?

pT3pn1a is on the report.

For this one I would agree with Kaloy; I believe T3 with any lymph node involvement would be stage 3b.
Male 37; Melbourne, Australia
10/2018 Dx 3.5cm RC adenocarcinoma, 12cm from AV
Mod diff, EMVI+ LVI+ PNI-
3 LN; 4 liver mets
pT3pN1aM1a; Stage IVa. MSS, NRAS (G13R)
CEA: Oct-18= 12; Nov-18= 14, Mar-19= 2.4, Aug-19 <2.0
11/18 - FOLFOX x 6
3/19 - Liver resection
4-5/19 - 25 x pelvic radiation; complete met. response
07/19 - ULAR (robot), temp ileo, 1/27 LN
08/19 - Missed liver spot
08-11/19 - FOLFOX x 1, FOLFOXIRI x 1, FOLFIRI x 5
12/19 - Planned liver resection #2 & (01/20) stoma reversal

camicom
Posts: 22
Joined: Thu Jun 27, 2019 1:39 pm
Facebook Username: david galloway

Re: Staging and treatment options.

Postby camicom » Fri Aug 02, 2019 8:23 am

Rock_Robster wrote:I’m not sure I’d be relying on those calculators for this decision - the Cleveland Clinic tool also uses a dataset from 1990-2000; ie from up to almost 30 years ago!

This paper released in Feb this year suggests a 20-25% improved 5-year survival from chemo for Stage III patients; I realise there is still stratification within this group of course.

https://link.springer.com/chapter/10.10 ... 01165-9_33

Great news that you don’t have to worry about a BRAF mutation. Another other question to consider in this - did your primary tumour have any higher risk factors such as EMVI+, LVI or PNI?


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4575069/

Here is another Stage 3 single lymph node study/report from 2015 that compares 5FU, oxaliplatin-based regimen, and jsut curative surgery. Once again they point out single lymph node involvement, with a high lymph node harvest as big factors in 5 yr DF. They are include low CEA levels. Once again the numbers are surprising.

The median 42-month follow-up period included 363 eligible patients. Among them, 230 (63.3%) received only 5-flurouracil (5-FU) adjuvant chemotherapy; 76 (20.9%) underwent oxaliplatin-based regimens; and 57 (15.7%) chose surgery alone. The 5-year survival rate of these evaluated patients was 75%, 63%, and 77%, respectively (P = 0.823). Multivariate analysis revealed that normal preoperative CEA level (≦5 ng/mL) and adequate LN sampling (LN ≧ 12) were significant predictors for higher 5-year OS (P < 0.001; P = 0.007, respectively). However, the use of postoperative adjuvant chemotherapy in these N1a colon cancer patients did not significantly affect their 5-year OS.


Surprisingly, in my specific circumstance, survival rates are better with surgery alone. Here are the conclusions.

In conclusion, stage III colon cancer patients in our study with only one LN metastasis are a unique group of patients, and differ from those with more advanced stage III disease. We documented that a preoperative CEA level ≤ 5 ng/mL and curative surgery with adequate lymphadenectomy (LN ≧ 12) are favorable prognostic indicators for OS in stage III colon cancer patients who had only one LN (N1a) metastasis. Using postoperative adjuvant chemotherapy in this unique group of patients does not appear to result in different outcomes.
Last edited by camicom on Sat Aug 03, 2019 3:27 pm, edited 1 time in total.
5/13 Blood in stool CT and Bloodwork Clean
6/17 Colonoscopy 5cm Malignant Neoplasm in Transverse Colon
CEA 1.2 Lung CT clear
6/19 Confirmed Adenocarcinoma Mod Diff
7/19 Extended Right Hemicolectomy
Stage 3A with only Primary node affected 48 total nodes taken
BRAF Neg
Recommended 3 month Folfax
Decided no chemo
5 year DF ration is 81% w/o chemo 80% with

Rock_Robster
Posts: 399
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Staging and treatment options.

Postby Rock_Robster » Fri Aug 02, 2019 8:32 am

Fascinating article camicom, thanks for sharing. I note that the overall survival being better for the non-chemo group failed to achieve statistical significance; but nonetheless it still doesn’t appear to demonstrate superiority of chemo in this trial design.
Male 37; Melbourne, Australia
10/2018 Dx 3.5cm RC adenocarcinoma, 12cm from AV
Mod diff, EMVI+ LVI+ PNI-
3 LN; 4 liver mets
pT3pN1aM1a; Stage IVa. MSS, NRAS (G13R)
CEA: Oct-18= 12; Nov-18= 14, Mar-19= 2.4, Aug-19 <2.0
11/18 - FOLFOX x 6
3/19 - Liver resection
4-5/19 - 25 x pelvic radiation; complete met. response
07/19 - ULAR (robot), temp ileo, 1/27 LN
08/19 - Missed liver spot
08-11/19 - FOLFOX x 1, FOLFOXIRI x 1, FOLFIRI x 5
12/19 - Planned liver resection #2 & (01/20) stoma reversal


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