W&W or Surgery Dilemma

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Hopepray
Posts: 14
Joined: Fri Feb 14, 2020 9:48 pm

W&W or Surgery Dilemma

Postby Hopepray » Tue Jun 16, 2020 8:00 am

Hi folks,

My second post here, some background, TL;DR please read my signature.

my mom was DX with a rectal tumor on 8th Feb 2020. Her CT and MRI confirmed it is node +ve(2 perirectal nodes upto 6mm). CT also mentioned a Liver hemangioma and a Ground Glass Nodule (GGN)in Lung. However they both said no mets in lungs or liver. CEA 2.8

She went through a pre-op CRT 28x1.8Gys and Capecitabine 1500mg/day till 28th March 2020
(she was asked to take 3 tabs in a day of 500 mg each, although I am not sure why this is the case in India as looking at posts here it looks like she took only 75% of the dose that is generally taken for her size)

We got an MRI done on 30th Apr 2020 which said "no obvious tumor mass present, rectal wall thickening is consistent with post CRT treatment status. A nubbin of a single lymph node can be seen in the perirectal space. A Liver hemangiaoma can be seen measuring 1.6x1.3cms". We were asked to due a Covid19 test(mandatory now for any contact tests) and then a flex sig.

However Due to covid worries and other familial matter we couldn't get back for a PET/CT and a Flex Sig until 12th June 2020. Which put her at 11 weeks after her CRT.

PET/CT says no nodes detected in rectal area, no detectable mass in rectum and shows good response to CRT. Also nothing about the Ground Glass Nodule in the Lung. Liver Hemangioma remains same. Flex Sig confirmed the tumour response by saying that only a scar can be seen at the initial tumour site and full response to CRT. also CEA now 1.3

A biopsy was done during flex sig, to confirm which came back Negative.


The Surgical onc was thinking whether she would be a candidate for Wait & Watch. So he had a chat with Medical Onc and they both told me that they think getting a surgery with a temp ileo would be still a better approach as it's a standardized one and they will advise us that. However we were told the final decision is with us and either way we would get the follow up Chemo rounds and surveillance.


Now we are totally in dilemma as to get a "not-so-moderate" surgery and the recovery from it plus other things that come with temp ileo etc or watch and wait.

I am worried especially due to the nodes which were present as the surgeon says even the pet/ct cannot pickup any present cancer cells that are smaller than 4mm. Also I am worried if the disappearance of the Ground Glass Nodule was due to the treatment if so then we need to get surgery done to avoid any Lymph Node involvement.

I know nobody can decide it for us, however any inputs on this we would be grateful for. Thank you
Caregiver to mom
54 y, dx 2/20, T3N1B Upper Rectal CA,14 cms from AV
2.5 x 1.3 cm, base 1.5cm
CEA: 2.8 2/10/20;; 2.3 4/20;;1.3 6/20
CT and MRI show the tumour + Ground Glass Nodule Lung + Hemangioma Liver.
Grade 1 Tumor
EMVI absent
Genetics not done
28x/Cap/ CRT 28/Mar/20
MRI- 4/20- no mass seen, a nubbin of a node in peri-rectal space.
Pet/CT 6/20 no nodes or rectal mass, no Glass nodule in lung. Hemangioma.
Flex Sig w/ biopsy: scar tissue remains no obvious mass, biopsy result -ve for active CA cells

boxhill
Posts: 555
Joined: Fri Apr 06, 2018 11:40 am

Re: W&W or Surgery Dilemma

Postby boxhill » Tue Jun 16, 2020 2:04 pm

Why go through the surgery, and more to the point the probability of life-altering after-effects if not necessary?

If it were me I think I'd go for watch and wait in the circumstances.

If she has quarterly scans, and they eventually pick something up, she could opt for surgery then.

This is purely a personal opinion.
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
5/18 FOLFOX
7/18 CT NED
11/18 CT NED
12/18 MRI 5mm liver mass, 2 lymph nodes in porta hepatis
12/31/18 Keytruda
6/19 Multiphasic CT LNs normal, Liver stable
6/28/19 Pause Key, predisone for joint pain
7/31/19 Restart Key
9/19 CT stable
Pain: all fails but Celebrex
12/23/19 CT stable
5/19 MRI stable/NED
Suspend treatment

Hopepray
Posts: 14
Joined: Fri Feb 14, 2020 9:48 pm

Re: W&W or Surgery Dilemma

Postby Hopepray » Tue Jun 16, 2020 10:21 pm

boxhill wrote:Why go through the surgery, and more to the point the probability of life-altering after-effects if not necessary?

If it were me I think I'd go for watch and wait in the circumstances.

If she has quarterly scans, and they eventually pick something up, she could opt for surgery then.

This is purely a personal opinion.


Thx boxhill, we are debating that ourselves and will have a second opinion today from a veteran surgical/medical oncologist near us.
Caregiver to mom
54 y, dx 2/20, T3N1B Upper Rectal CA,14 cms from AV
2.5 x 1.3 cm, base 1.5cm
CEA: 2.8 2/10/20;; 2.3 4/20;;1.3 6/20
CT and MRI show the tumour + Ground Glass Nodule Lung + Hemangioma Liver.
Grade 1 Tumor
EMVI absent
Genetics not done
28x/Cap/ CRT 28/Mar/20
MRI- 4/20- no mass seen, a nubbin of a node in peri-rectal space.
Pet/CT 6/20 no nodes or rectal mass, no Glass nodule in lung. Hemangioma.
Flex Sig w/ biopsy: scar tissue remains no obvious mass, biopsy result -ve for active CA cells

hawkowl
Posts: 127
Joined: Sun Dec 14, 2014 5:29 am
Location: MN/FL

Re: W&W or Surgery Dilemma

Postby hawkowl » Fri Jun 19, 2020 4:09 am

Totally depends on one’s risk tolerance and personality. I was offered w/w, but for me, it would have been more stressful. I opted for APR, have a permanent ostomy that is really no big deal and doesn’t limit or alter my life in any significant way, and 5 years later I am very happy with my decision. Good luck!
Dx 12/2014 T3N2MX (distant LPLN) low rectal
12/2014-4/2015: FOLFOX (8 cycles)
4/2015-6/2015: 28 cycles of chemoradiation with xeloda, SBRT
8/2015: Robotic APR with iliac node dissection; path showed ypT0,ypN0 (complete pathological response).
11/2015 scans clear, CEA 2.1
11/2015 parastomal hernia repair
3/2016 CEA 1.7, scans stable...
6/2020 5 years of normal CEA and stable scans
Now dealing with pyoderma gangrenosum.
Totally disabled due to oxaliplatin induced neuropathy and dysautonomia


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