Got post-op staging

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Re: Got post-op staging

Postby NHMike » Sat Oct 05, 2019 7:22 am

SilverWedding wrote:Jacques - Thank. This is so helpful. I did find in the report this:

Primary Tumor (pt): ypT3
Regional lymph nodes: (pn) ypN2a
Distant Metastasis (pm): n/a

So - is this T3N2M0 ? Should that be on my signature? *

* But it also says something that seems off according to the N2 with Lymph nodes:
Total lymph nodes examined: 22
Total lymph nodes involved: 6
So - wondering why it doesn’t say N6

This was of the rectosigmoid, it says.

Lots of other data is on thjs pathology report entitled “Final Report.” ... Medium.pdf

Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1-3 regional lymph nodes
N1a Metastasis in one regional lymph node
N1b Metastasis in 2-3 regional lymph nodes
N1c Tumor deposit(s) in the subserosa, mesentery, or non peritonealized pericolic or perirectal tissues without regional nodal metastasis
N2 Metastasis in 4 or more regional lymph nodes
N2a Metastasis in 4-6 regional lymph nodes
N2b Metastasis in 7 or more regional lymph nodes
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
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

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Re: Got post-op staging

Postby Amarie123 » Sat Oct 05, 2019 7:29 am

Just wanted to pop in to say that when you see N2 (or N2a), it means that there where between 4-6 lymph nodes effected, so this looks correct. 7 or more lymph nodes would, I believe be characterized as N2b.

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Re: Got post-op staging

Postby DarknessEmbraced » Sat Oct 05, 2019 9:32 am

I'm sorry it wasn't what you hoped and I hope your chemo goes well!*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! :)

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Facebook Username: Cynthia Harding Marshall

Re: Got post-op staging

Postby SilverWedding » Sat Oct 05, 2019 8:31 pm

Thank you!

I updated my signature with that clarity, NHMike.
DH, 56, Sigmoid & rectum
Adenocarcinoma 2cm
 G2: Moderately differentiated
Stage IIIb
LN 6/22
5/19 Baseline CEA value - 18.9
Lymphovascular invasion (LVI): present
Perineural invasion (PNI): not identified
Surgical margins: proximal -negative; distal - negative 1.5cm; circumferential - negative 1mm)
MSI status: Waiting‬
Lynch status: ?
Open Restorative Proctectomy, J-Pouch Coloanal Anastomosis, Loop Ileo w/Appendectomy
Neo-adjuvant Xeloda/radiation
Adjuvant Chemo: to begin 11/19

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Location: San Francisco

Re: Got post-op staging

Postby jsbsf » Sat Oct 05, 2019 10:19 pm

That sounds like FOLFOX. It’s Oxaliplatin with leucovorin, then a 5fu pump to take home. We just started Monday, 9/30. Wednesday, they showed me how to help disconnect the pump so it saves a trip to the hospital on day 3. It’s not very complicated. They recommend the caregiver take on the responsibility. They stressed keeping things sanitized. We had the port installed a week prior. It has a catheter that goes up toward the neck. There were no complications, but he could feel what he thought was the catheter for a couple days which felt “strange”.

He felt more comfortable sleeping with the 5fu pump during the second night. Supposedly it’s pretty durable. The pump deflates and should be empty when you disconnect. They will show you everything you need to know.

In our case it’s stage IV, and the treatment is “with curative intent”, so we have high hopes. I feel like you should too!

We live in California, and pay into SDI. So, he gets something like 60 or 70% of his pay, and immediately applied for disability after getting diagnosed. His company is maintaining his insurance plan, and he pays them since he had to quit with no notice. Otherwise he would use Cobra or Covered California. I’ll try to get him onto mine during open enrollment, which is coming up, and since we both currently have the same insurance and PCP, he can continue his course of treatment with the same team. Kaiser has a system that did all the disability for us. They’re like a one-stop shop. I understand that SSDI takes about 5 months, so in our case we need to start applying in about 6 months, since SDI runs out after one year. I’m told it’s a bit more complicated to sort out, and to not wait till the last minute. Another thing I understand is that SSDI doesn’t offer medical coverage upfront. There is a 2 year waiting period, but after that waiting period, Medicare kicks in. If he turns 65 beforehand, he can convert to retirement and get Medicare at that time. That’s what my mother did in 2012.

During the infusion, he had an Ensure drink, a small sandwich, and a small bottle of vegetable juice. It was perfect.

Since it’s so fresh for us: they gave him 2 different anti-nausea meds to take for three or four days. He skipped the 3rd day thinking he might not need it, and regretted that decision. His side effect was some mild cold sensitivity on the first day. But today and yesterday were rough with fatigue and constipation. Senokot-s has been really helpful. Hopefully our recent experience might help you prepare. Like others have said on this forum: keep hydrated. This stuff really dries you out.

Best of luck to you both.
DH 61
8/23 C-scopy, 5+cm mass. CEA:4.1
8/26 CT ~1cm lvr met?
9/6 PET: liver spot
9/16 MSS. MRI: 2 liver mets: 2.7 & 7mm
9/23 Port
9/30 Start FOLFOX 1-6
10/4 Lg lvr met ~3.7cm (raised concern), pri tmr stable.
CEA: 10/13,12.5;10/27-12/8 btw 4.7 & 3.1
11/5 both lvr mets ~ 2/3 smaller.
12/17 PET: sm lvr met gone, remaining tmrs @10% of orig sz & actvty
Chemo break
MWA 2/5, Lap resection 2/11
CEA: 3/1-5/31 btw 2.1&2.9
3/2 start FOLFOX 7-12
7/23-29 radiation

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Missing data elements in your signature

Postby Jacques » Sat Oct 05, 2019 11:40 pm

Here is a standard signature template that you can use as a type of checklist of items that probably should be included in your signature.

Your task now is to go through your available prior documents (i.e, colonoscopy procedure report, colonoscopy biopsy report, both pre- and post-treatment scan reports, baseline blood test results, follow-up blood test results, special test results, if any, (e.g., genomic or genetic tests), to search for the important missing data fields.

The overall objective at this point in time is to create a signature that shows your DH's complete risk-factor profile before treatment ever commenced (i.e., before neo-adjuvant therapy, before surgery, and before adjuvant therapy). This defines your husband's risk profile at the time of highest risk, and this is what the doctors focus on when designing a first-line treatment plan.

The items that are most important now are indicated in bold face type. The items that seem to be missing in your current signature are highlighted in red.

This task may be a bit difficult for you because the necessary data points are typically found in a variety of different places and may be phrased in unusual, non-standard vocabulary. And some of them may actually be missing because they were never done.

At the bottom of this post I have put some numbered comments that may help you in locating the required elements for the data points in question (if they in fact exist in your dossier of reports).

You may eventually have to have a special meeting with your oncologist where you bring your dossier of reports and ask him to help you find the specific important missing items that should be in your signature.

O Stoma Mia wrote:
Some items that you could include in your signature are given below:
  1. Age & Sex
  2. DX: Rectal Cancer (RC) or Colon Cancer (CC)
  3. Tumor Location: If RC, then upper, middle or lower rectum, and distance from anal verge (AV). If CC, then cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, or recto-sigmoid junction, etc.
  4. Tumor type: Adenocarcinoma; villous adenoma; signet ring-cell carcinoma, etc.
  5. Tumor size(in mm or cm)
  6. Tumor grade:
      G1: Well differentiated (low grade)
      G2: Moderately differentiated (intermediate grade)
      G3: Poorly differentiated (high grade)
      G4: Undifferentiated (high grade)
  7. TNM code: e,g, T3N0M0, etc
  8. Stage : Stage I, Stage II, Stage III or Stage IV (with subscript, if applicable)
  9. Positive lymph nodes: eg., X positive out of Y sampled.
  10. Mets: Location of remote metastases, if any (e.g., mets to liver, mets to lungs, etc)
  11. Baseline CEA value (if known)
  12. Lymphovascular invasion (LVI) (if known): present vs. absent
  13. Perineural invasion (PNI) (if known): present vs. absent
  14. Surgical margins (proximal, distal, circumferential): clear or involved
  15. MSI status (if known): MSI-H, MSS, etc.
  16. Lynch status (if known)
  17. KRAS/BRAF status (if known)
  18. Primary surgery type:
      LAR, ULAR, TME, EMR, APR, Laparascopic vs. open resection, polypectomy, proctosigmoidectomy, colectomy, hemi-colectomy, sigmoid-colectomy, etc...
  19. Ostomy surgery: Ileostomy, or colostomy, or no ileo surgery
  20. Radiation therapy (if any): Chemo/radiation
  21. Adjuvant Chemotherapy (if any): e.g., XELOX(CAPEOX), FOLFOX, FOLFIRI, Xeloda monotherapy, 5FU/LV, etc.
  22. Immunotherapy, targeted therapy (if any)
  23. Clinical trials (if any)

- - -
Line #1 - OK
Line #2 - OK
Line #3 - It's not clear exactly where the tumor was and how large it was. You say, "5+cm at dentate line extending to rectal vau" but what does 5+cm mean? Is this the size of the tumor? Is this the distance from the AV? It's not clear. Also, what is the reference to "rectosigmoid junction" all about? Why is this mentioned at all in the report? Is that where the tumor was? Is that where the proximal margin was? Is that where the J-pouch was connected? Was the recto-sigmoid junction removed during surgery? It's all very confusing to me
Line #4 - OK
Line #5 - The size of the tumor is not explicitly mentioned as such. We need to know how large it was, how far down it extended and how far up it reached.
Line #6 - OK
Line #7 - Possibly OK. I would prefer to list the TNM stage as T3N2aM0, provided the T value is truly T3. The issue is with the comment "Deep ulcerated 2.0 cm." in your signature which could suggest that the original tumor (before chemo/rad) might have grown deeper into the rectal wall than T3 level and might have been a more risky T4a tumor, not a T3 tumor. I find the "Deep ulcerated 2.0 cm. " comment very puzzling, and I don't see why it was mentioned in the report without explaining its significance for TNM staging. Also, I would prefer not to use the ypT3N2aM0 type of notation since that is reserved for post-treatment pathology, and what we are really interested in is what the risk-factor profile was before any treatment was delivered.
Line #8 - OK
Line #9 - OK
Line #10 - Not applicable
Line #11 - The baseline CEA tumor marker blood test should have been done after the colonoscopy and before the start of chemo/radiation. If it was never done, then your DH is without an important baseline.
Line #12 - Since there were 6 involved lymph nodes, then LVI was probably present, otherwise how would those lymph nodes have become infected, However, the chemo/radiation treatment may have obliterated all evidence of LVI in the vascular network, so LVI might not appear explicitly in the post-surgery pathology report. Check with the oncologist about this.
Line #13 - Similar to comment #12 above: The pathologist might not have been able to see any evidence of PNI, since the evidence for PNI might have disappeared due to heavy chemo/radiation effect. Check with the oncologist about this. In any event the pathologist should have put PNI in the report, if only to check the box "Unable to assess". That's what is required in the CAP standard..
Line #14 - You haven't mentioned margins anywhere in your signature. There are three types of margins. Very Important.
Line #15 - MSI status is missing. This is very important and has been a mandatory reporting element for all CRC pathology reports since January 1, 2018. It should be in the report somewhere, but may be under a different name. Check with the oncologist about this. If it is completely missing, then this is a very serious matter. and should be resolved before first-line chemotherapy is started.
Line #16 - Probably not needed right now, unless there is evidence of family history of CRC
Line #17 - Probably not needed right now. Might be needed in special cases.
Line #18 - OK
Line #19 - OK
Line #20 - OK
Line #21 - The type of adjuvant chemotherapy protocol needs to be specifed more accurately, as well as planned start date / stop date.
Line #22 - Not needed right now
Line #23 - Not needed right now

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