Quick question - chemo and reversal surgery

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Rock_Robster
Posts: 184
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Quick question - chemo and reversal surgery

Postby Rock_Robster » Mon Aug 05, 2019 10:50 pm

Hi all,

My colorectal surgeon is saying he can reverse my temporary ileostomy after I’ve been off adjuvant chemo for only a week, but my oncologist said he wouldn’t recommend considering it sooner than a month after last chemo. He suggested you really don’t want to be dealing with reversal recovery and chemo recovery at the same time.

I’m normally inclined to trust my surgeon more on surgical matters... So for those who have done this - how long were you instructed to wait? (Assuming most folk are keen to reverse as soon as possible!)

Thanks,
Rob
Male 37 yr; Melbourne, Australia. BMI 24
10/2018 Dx 3.5 cm RC adenocarcinoma, 12cm from AV
Mod diff (G2), EMVI+, LVI+, PNI-
3 local LN; 4 liver mets, resectable
pT3 pN1a pM1a; 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
12/18 - DVT
3/19 - Liver resection (open); R0
4-5/19 - 25 x pelvic radiation w Xeloda; complete metabolic response (TRG 3)
07/19 - ULAR (robotic), temp ileo. R0; 1/27 LN positive
08/19 - FOLFOX x 2-4

NHMike
Posts: 2078
Joined: Fri Jul 21, 2017 3:43 am

Re: Quick question - chemo and reversal surgery

Postby NHMike » Tue Aug 06, 2019 4:26 am

The end of chemo was about mid-June and my surgery was at the end of July so about six weeks for me. I also wanted some time between the end of chemo and reversal as I had stuff to do that I had put off while going through chemo. The surgery is a lot easier on you than the LAR unless you're bowels don't wake up. I walked five miles after the surgery and nine miles the day after. I didn't get out of bed the day of my surgery, without assistance and walked maybe 67 steps.
6/17: ER rectal bleeding; Colonoscopy
7/17: 3B rectal. T3N1bM0. 5.2 4.5 4.3 cm. Lymphs: 6 x 4 mm, 8 x 6, 5 x 5
7/17-9/17: Xeloda radiation
7/5: CEA 2.7; 8/16: 1.9; 11/30: 0.6; 12/20 1.4; 1/10 1.8; 1/31 2.2; 2/28 2.6; 4/10 2.8; 5/1 2.8; 5/29 3.2; 7/13 4.5; 8/9 2.8, 2/12 1.2
MSS, KRAS G12D
10/17: 2.7 2.2 1.6 cm (-90%). Lymphs: 3 x 3 mm (-62.5%), 4 x 3 (-75%), 5 x 3 (-40%). 5.1 CM from AV
10/17: LAR, Temp Ileostomy, Path Complete Response
CapeOx (8) 12/17-6/18
7/18: Reversal, Port Removal
2/19: Clean CT

User avatar
CRguy
Posts: 9956
Joined: Sun Feb 10, 2008 6:00 pm

Re: Quick question - chemo and reversal surgery

Postby CRguy » Tue Aug 06, 2019 12:24 pm

I waited 2 months after finishing adjuvant Xeloda, before the temp ileostomy takedown surgery.

I would also be slightly concerned about any residual immunosuppressive effects of the chemo
interfering with wound healing after just a week ?????
Seems a bit too soon IMO.

Best wishes
CRguy
Caregiver x 4
Stage IV A rectal cancer/lung met
12 Year survivor
my life is an ongoing totally randomized UNcontrolled experiment with N=1 !
Review of my Journey so far

Rock_Robster
Posts: 184
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Quick question - chemo and reversal surgery

Postby Rock_Robster » Tue Aug 06, 2019 11:59 pm

Thanks for the replies guys! CRguy I think you’re on the money - I questioned my onc and he said his main concern would be going into surgery with low WBCs/neutrophils. I think I might give it the month - last thing I need now would be a bout of febrile neutropenia and sepsis.

Cheers
Rob
Male 37 yr; Melbourne, Australia. BMI 24
10/2018 Dx 3.5 cm RC adenocarcinoma, 12cm from AV
Mod diff (G2), EMVI+, LVI+, PNI-
3 local LN; 4 liver mets, resectable
pT3 pN1a pM1a; 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
12/18 - DVT
3/19 - Liver resection (open); R0
4-5/19 - 25 x pelvic radiation w Xeloda; complete metabolic response (TRG 3)
07/19 - ULAR (robotic), temp ileo. R0; 1/27 LN positive
08/19 - FOLFOX x 2-4

TinaFish
Posts: 107
Joined: Sun Jul 21, 2019 10:11 am

Re: Quick question - chemo and reversal surgery

Postby TinaFish » Wed Aug 07, 2019 12:15 am

Not that I'm in any way qualified to answer your question, but I think that it's always best to err on the side of safety.
F 45, single mother to son, 7 and daughter, 3
DX: stage 4 Rectal Cancer June 2019
Tumor Location: ? cm above anal verge
Tumor type: Adenocarcinoma
Tumor size: 5 cm
Tumor grade: ?
TNM code: ?
Stage : Stage IV-B
# of cancerous lymph nodes: ?
Mets: Numerous mets to liver, lungs
CEA: 22 in July; 11 as of August 15
MSI status: MSS
KRAS/BRAF status: KRAS mutation
surgery: TBD
Ostomy surgery: TBD
Radiation therapy: TBD
Chemotherapy : CAPEOX+Avastin, 6 cycles, with CT scans after 3rd and 6th cycle.

Rock_Robster
Posts: 184
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Quick question - chemo and reversal surgery

Postby Rock_Robster » Wed Aug 07, 2019 12:16 am

TinaFish wrote:Not that I'm in any way qualified to answer your question, but I think that it's always best to err on the side of safety.

Thanks TinaFish, good advice! For one more month I think I can be patient :)
Male 37 yr; Melbourne, Australia. BMI 24
10/2018 Dx 3.5 cm RC adenocarcinoma, 12cm from AV
Mod diff (G2), EMVI+, LVI+, PNI-
3 local LN; 4 liver mets, resectable
pT3 pN1a pM1a; 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
12/18 - DVT
3/19 - Liver resection (open); R0
4-5/19 - 25 x pelvic radiation w Xeloda; complete metabolic response (TRG 3)
07/19 - ULAR (robotic), temp ileo. R0; 1/27 LN positive
08/19 - FOLFOX x 2-4

User avatar
LeonW
Posts: 358
Joined: Sun May 03, 2015 4:59 pm
Location: Amsterdam, Netherlands

Re: Quick question - chemo and reversal surgery

Postby LeonW » Wed Aug 07, 2019 7:57 am

Rock_Robster wrote: . . . my oncologist said he wouldn’t recommend considering it sooner than a month after last chemo . . .

Hi Rob,

FWIW, my onco-liver-surgeon also wanted to allow for at least a month of recovery between the end-of-chemo and anyfollowing surgery. I did CAPOX, but would be surprised things are different for FOLFOX / other chemo regiments.

Best wishes, Leon
Dec 2012 - CC, 2 unresect liver mets, CEA 41.8 (MM 65yrs)
Jan 2013 - colectomy @ spleen, 2/26 nodes, IVa T3N1bM1a MSI-low
Feb-Aug - 1x Xelox-7x Xelox/Avastin, shrinkage from #3
Sept - 2 failed PV embolizations
Oct 2013 - R liver resect 28d hosp (liver failure/delirium, lung emboli, encephalopathy), cancer dead (pCR)
2014/15 - recovery, scopy: 2 polyps
2016 - new town, new life
June 2018 - 5 yr mark, scopy: 2 new polyps
1.3-1.4 CEA/clean CT: 4x2014, 6x2015-17, 2x2018-19 :D, next June 2020

NHMike
Posts: 2078
Joined: Fri Jul 21, 2017 3:43 am

Re: Quick question - chemo and reversal surgery

Postby NHMike » Wed Aug 07, 2019 8:03 am

One other aspect is preparation for life after reversal. I didn't really prepare for it and it was very rough on the other side. It may be helpful to have various supplies, knowledge and even foods to make the adjustments on the other side.
6/17: ER rectal bleeding; Colonoscopy
7/17: 3B rectal. T3N1bM0. 5.2 4.5 4.3 cm. Lymphs: 6 x 4 mm, 8 x 6, 5 x 5
7/17-9/17: Xeloda radiation
7/5: CEA 2.7; 8/16: 1.9; 11/30: 0.6; 12/20 1.4; 1/10 1.8; 1/31 2.2; 2/28 2.6; 4/10 2.8; 5/1 2.8; 5/29 3.2; 7/13 4.5; 8/9 2.8, 2/12 1.2
MSS, KRAS G12D
10/17: 2.7 2.2 1.6 cm (-90%). Lymphs: 3 x 3 mm (-62.5%), 4 x 3 (-75%), 5 x 3 (-40%). 5.1 CM from AV
10/17: LAR, Temp Ileostomy, Path Complete Response
CapeOx (8) 12/17-6/18
7/18: Reversal, Port Removal
2/19: Clean CT

Rock_Robster
Posts: 184
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Quick question - chemo and reversal surgery

Postby Rock_Robster » Wed Aug 07, 2019 8:03 am

LeonW wrote:
Rock_Robster wrote: . . . my oncologist said he wouldn’t recommend considering it sooner than a month after last chemo . . .

FWIW, my onco-liver-surgeon also wanted to allow for at least a month of recovery between the end-of-chemo and anyfollowing surgery. I did CAPOX, but would be surprised things are different for FOLFOX / other chemo regiments.

Thanks Leon, and indeed - I waited a month after both the liver resection and the rectal surgery (well 3 weeks, close enough), hence my surprise when the surgeon said he only needed a week.
Male 37 yr; Melbourne, Australia. BMI 24
10/2018 Dx 3.5 cm RC adenocarcinoma, 12cm from AV
Mod diff (G2), EMVI+, LVI+, PNI-
3 local LN; 4 liver mets, resectable
pT3 pN1a pM1a; 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
12/18 - DVT
3/19 - Liver resection (open); R0
4-5/19 - 25 x pelvic radiation w Xeloda; complete metabolic response (TRG 3)
07/19 - ULAR (robotic), temp ileo. R0; 1/27 LN positive
08/19 - FOLFOX x 2-4

Maelleous
Posts: 116
Joined: Tue Nov 01, 2016 8:13 am
Location: FL

Re: Quick question - chemo and reversal surgery

Postby Maelleous » Thu Aug 08, 2019 8:53 am

I had a jpouch due to rectal cancer, but I can tell you that waiting a month is what I would recommend. I know with regular colon cancer it is a lot easier, but that was one of the most difficult month's of my life. I know you want to get rid of that bag ASAP, but your body really will be a lot happier waiting.
M 35 yr
DX Rectal Cancer, 10/16 (symptoms Feb 2016)
Dx stage 2 - Surgery Oct 25 201 Loop ileo w/ j-pouch
Close margins within 1mm
9/38 lymph nodes involved on path / Stg IIIc,pT4, pN2 B, p.M0. MSS, K‐ras, NRAS, no mutation
Started Folfox - 3rd Treament, Dec 30th 2016 Cardiac Arrest - Lucky to be part of the 6% to survive!
S-ICD installed / Port Removed
Vaccine Clinical trial at UPMC - last shot June 2017
Reversal 8/1/17 - Praying this is it!
Still NED

Rikimaroo
Posts: 238
Joined: Tue Dec 20, 2016 8:48 pm

Re: Quick question - chemo and reversal surgery

Postby Rikimaroo » Thu Aug 08, 2019 3:54 pm

Rock,

I waited a month after chemo for surgery. CRguy hit the nail on the head. Risk of infection is very high with low WBC/Neutrophils. Also healing is an issue. Your surgeon is tripping if he thinks a week out of chemo is a good time to do surgery very surprised he said that, but he is not an oncologist, but typically they all know this if they been doing this a long time.

Anyways good luck, reversal does suck with the new normal/pooping issues, but it gets better. Some days are bad, most days are good. Don't be afraid the first week is hell, or 2....You might be going 25-40 times. It gets better and quickly you will be going 10-25 times, then 1-10 times. Sometimes once a day, those are godsends LOL...

I think me and you are very close on the same thing. I had one metastasis to my liver which they did both surgery at the same time, rectum and liver resection.
RC T3N1M0
MSS - NRAS Mutation
Chemo Rad, CCR - W&W 5/2017
Recurrence 11/2017
CT Scan 11/2017 Liver Met 5.5cm Stable, Stage IV
Port Scheduled for 12/2017, folfox - avastin 12/2017
Blood Clot in Neck 1/2018, stop avastin, continue FolFox
LAR/Liver Resect 4/2018
Chemo Finish 8/2018
Reversal 10/18
CEA - 12/16 26.1, 1/17 32.2, 3/17 6.6, 11/17 500.5, 12/17 638.5, 1/3/18 424.8, 1/16/18 163.5, 1/31/18 62.2, 2/18 21.1, 3/18 14, 4/18 .8, 10/18 1.2, 12/18 3.2, 2/8 11.4, 3/6 22

Rock_Robster
Posts: 184
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Quick question - chemo and reversal surgery

Postby Rock_Robster » Thu Aug 08, 2019 8:34 pm

Thanks Rikimaroo! Indeed we are walking a very similar path, albeit you’re a bit ahead of me. Even down to being in the modest NRAS group, and the DVT club. How are you doing these days?

Thanks for the feedback re surgery. Indeed my surgeon really confuses me sometimes. He is very capable -
Director of Cancer Surgery at the only integrated cancer hospital in Australia, chair of their Lower GI Tumour Board, US & UK board-certified colorectal surgeon, trained at St Marks & the Cleveland Clinic, currently supervising 4 PhD candidates... then he comes out with something like that! I have to think either he knows something hardly anyone else does (unlikely?), or maybe I’ve misunderstood...

Rob
Male 37 yr; Melbourne, Australia. BMI 24
10/2018 Dx 3.5 cm RC adenocarcinoma, 12cm from AV
Mod diff (G2), EMVI+, LVI+, PNI-
3 local LN; 4 liver mets, resectable
pT3 pN1a pM1a; 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
12/18 - DVT
3/19 - Liver resection (open); R0
4-5/19 - 25 x pelvic radiation w Xeloda; complete metabolic response (TRG 3)
07/19 - ULAR (robotic), temp ileo. R0; 1/27 LN positive
08/19 - FOLFOX x 2-4

Rikimaroo
Posts: 238
Joined: Tue Dec 20, 2016 8:48 pm

Re: Quick question - chemo and reversal surgery

Postby Rikimaroo » Thu Aug 08, 2019 10:33 pm

Wow that's quite a surgeon. My surgeon is Dr. Steven Wexner Clevenald Clinic. He is the director of the Colorectal Surgery Dept here in South Florida Weston, Cleveland Clinic brand. He is world renowned. Glad you have a capable surgeon.

You know I am doing good mostly, have the recurrence MRI scheduled for tomorrow to see exactly specifically how close to pelvic wall it is. If its not on it or close at all my current surgeon will remove it, its 2cm x .9 I think. If it is on or too close to wall, then he thinks I should go to MSK, MD Andersen or Cleveland Clinic OHIO, where they have intraoperative radiation for highest chance of cure.

He doesn't do surgery unless he sees it as curative intent, which we will determine tomorrow I really hope it looks good for him to do it. Because my insurance don't cover out of state I think, its an HMO....But once of the best in Florida.

Still dealing with pooping but things have been better the last few days, getting more of a blowout which is what you like, because then your mostly done. I think the Imodium prescription Loperamide is much better then lomotil, but everyone is different.
RC T3N1M0
MSS - NRAS Mutation
Chemo Rad, CCR - W&W 5/2017
Recurrence 11/2017
CT Scan 11/2017 Liver Met 5.5cm Stable, Stage IV
Port Scheduled for 12/2017, folfox - avastin 12/2017
Blood Clot in Neck 1/2018, stop avastin, continue FolFox
LAR/Liver Resect 4/2018
Chemo Finish 8/2018
Reversal 10/18
CEA - 12/16 26.1, 1/17 32.2, 3/17 6.6, 11/17 500.5, 12/17 638.5, 1/3/18 424.8, 1/16/18 163.5, 1/31/18 62.2, 2/18 21.1, 3/18 14, 4/18 .8, 10/18 1.2, 12/18 3.2, 2/8 11.4, 3/6 22

Rock_Robster
Posts: 184
Joined: Thu Oct 25, 2018 5:27 am
Location: Melbourne, Australia

Re: Quick question - chemo and reversal surgery

Postby Rock_Robster » Thu Aug 08, 2019 11:26 pm

Thanks Rikimaroo, indeed it sounds like an extremely capable surgeon you have there. Sorry to hear of the recurrence but glad you have a plan to tackle it: including heading to MSK if necessary. Best wishes for a good result.

Interesting re loperamide. Is the prescription version different? Loperamide 2mg is OTC here, and usual first line for diarrhea. Lomotil is prescription-only and usually only used if loperamide is inadequate.

Cheers
Rob
Male 37 yr; Melbourne, Australia. BMI 24
10/2018 Dx 3.5 cm RC adenocarcinoma, 12cm from AV
Mod diff (G2), EMVI+, LVI+, PNI-
3 local LN; 4 liver mets, resectable
pT3 pN1a pM1a; 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
12/18 - DVT
3/19 - Liver resection (open); R0
4-5/19 - 25 x pelvic radiation w Xeloda; complete metabolic response (TRG 3)
07/19 - ULAR (robotic), temp ileo. R0; 1/27 LN positive
08/19 - FOLFOX x 2-4

Rikimaroo
Posts: 238
Joined: Tue Dec 20, 2016 8:48 pm

Re: Quick question - chemo and reversal surgery

Postby Rikimaroo » Sat Aug 10, 2019 1:20 pm

Yeah its the 2mg but prescribed, I will take a look and let you know.
RC T3N1M0
MSS - NRAS Mutation
Chemo Rad, CCR - W&W 5/2017
Recurrence 11/2017
CT Scan 11/2017 Liver Met 5.5cm Stable, Stage IV
Port Scheduled for 12/2017, folfox - avastin 12/2017
Blood Clot in Neck 1/2018, stop avastin, continue FolFox
LAR/Liver Resect 4/2018
Chemo Finish 8/2018
Reversal 10/18
CEA - 12/16 26.1, 1/17 32.2, 3/17 6.6, 11/17 500.5, 12/17 638.5, 1/3/18 424.8, 1/16/18 163.5, 1/31/18 62.2, 2/18 21.1, 3/18 14, 4/18 .8, 10/18 1.2, 12/18 3.2, 2/8 11.4, 3/6 22


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