Lymph negative but one marked as 'i+'

[squak]

Hello Dear Board Members,

I am a 39 yo Female, diagnosed with CRC on Jan 12, 2016. Symptoms were rectal bleeding and major discomfort - colonscopy revealed a near obstructing mass in rectosigmoid, adenocarcinoma, invasive. CT showed no distant mets. Open LAR was performed on Feb 10, 2016. 23.5cm of Rectum/Colon were removed along with a 11.5 x 4.2 x 4.0 cm tumor. The scar is big, and is healing slowly. BMs are still irregular and quite frequent (esp at night), but stool is much better formed than before LAR.

While the cancer remains unstaged (am currently waiting for referral to oncology), the depth of invasion is pT3, so into the subserosal/mesorectal fat. Margins were negative, no vascular invasion. 34 lymph nodes were examined, and while none were 'involved', one single lymph node in section A18, a single tiny cluster of malignant cells measuring less than 0.2 mm in diameter is present. This cluster of malignant cells is present but becomes smaller in deeper levels. Lymph node stage was determined as pN0(i+) (pTN stage pT3N0(i+)M0). I think this puts me squarely between stages IIa and stage IIIb, but am not sure.

I am simply looking for someone to share their experience regarding ongoing treatments with a similar diagnosis, what these could look like (i do have an appointment with a radiation oncologist as well as a GI oncologist coming up in a few weeks), and whether they have shown any benefit in really inhibiting recurrence. What specific tests are available, to better understand the real risk of recurrence to me (ie genetic)?

These are very early days in my journey, at this stage I cannot do much other than empower myself with information and positivity. Sending courage, light, and strength to all you on this CRC journey.. thank you!

[Nik Colon]

I could only seem to find the (i+) for breast cancer. Haven't seen it used for colon, maybe someone else has.
https://www.google.com/search?q=i%2B+ca ... e&ie=UTF-8

[squak]

My surgeon seemed not to have much knowledge or experience with it either! He felt that the pathology team had been extremely thorough, and I am grateful for that. He indicated that 34 lymph nodes was a good thing.
He had a fairly binary view of i+ (aka 'isolated tumor cells') though, as in "either it is in/on the lymph or not."

little confused, little worried - but staying positive!

[Jacques]

... Lymph node stage was determined as pN0(i+) (pTN stage pT3N0(i+)M0). I think this puts me squarely between stages IIa and stage IIIb, but am not sure...

I have never seen the (i+) notation before, but apparently it is an abbreviation for "Isolated Tumor Cells" (see reference below)

6.4. Isolated Tumour Cells
....
pN0(i+). No regional lymph node metastasis histologically, positive morphological findings for ITC

http://cancerstaging.blogspot.fr/

There are other people on this board who are in the grey area between Stage II and Stage III. Maybe some of them will chime in.

[macpudd]

Hi Squak, I had something similar I think, my pathology report said tumour deposits on the meso colon, when I asked what these were I was told they were isolated tumour cells, and that I was between stage 2c and 3a, but the surgeon said they were not really classified as lymph nodes. I had adjuavant Folfox x 12.
Regards
Mcpudd

[squak]

Hey Macpudd - thank you, and yes, it does sound very similar. I see from your signature that you had a CEA of 1.6 pre-OP - I was at 1.3 pre-OP, still waiting for a post-OP reading, so maybe that is a further similarity.

[macpudd]

Hey Macpudd - thank you, and yes, it does sound very similar. I see from your signature that you had a CEA of 1.6 pre-OP - I was at 1.3 pre-OP, still waiting for a post-OP reading, so maybe that is a further similarity.

Hi Squak, yes our CEA does seem similar, my surgeon said it would proabably not be a good marker for me as it was within the normal range pre surgery. Like you I also had clear margins and no vascular invasion, my tumour was much higher in the colon than yours (ceacum). I finished chemo last July/August and have some ongoing problems with fatigue, concentration and surgery related pain but overall life is very good and I am just so happy to be eighteen months out from diagnosis and NED. I have every faith that you will have a simillar path and will soon get back to good health.

Regards
Macpudd

[mainelyj]

I would air on the side of caution and get the adjuvant therapy BUT first have a DPD deficiency test. I know Quest does a genetic test that is not expensive and only takes about a week for results. It finds the most common alleles that cause problems with 5 FU which is part of FOLFOX. If you are partially deficient you should not start higher than a 50% dose. If you are totally deficient you should not have adjuvant therapy it will likely kill you quickly and miserably.

https://en.m.wikipedia.org/wiki/Dihydro ... deficiency

[squak]

Macpudd - I am so glad to hear that you are NED after 18 months, that is wonderful. Thank you for sharing, and I will focus on a positive outcome for me too! I think my main issue lies in the fact that with only one of 34 lymphs deemed to contain isolated tumor cells yet not be 'invaded, (and this is sitting in a jar of formaldehyde in a lab somewhere)' and the LAR surgery to remove the tumor having been deemed a 'success' (clean margins etc) - what tangible objective does chemotherapy offer me?

I am at the junction, where I am trying to weigh the pros vs the cons of receiving adjuvant therapy now. With a low pre-OP CEA baseline, and no distant mets as per CT - how will success of possible chemotherapy even be measured? Also, aside from eg DPD deficiency as an issue, I think I recently read an article (sorry, too disorganized to be bookmarking links yet ) that stipulated that adjuvant chemo could limit the effectiveness of its use in case of a recurrence. Anyway, I am just thinking out aloud here, with the pros and cons racing through my mind as I await my date with oncology.

Mainelyj - thank you for this. I knew absolutely nothing about DPD deficiency, and find this information very useful. I have not yet been offered or have even discussed any genetic testing with my care team yet, but will now certainly make an effort. As it so happens, in another topic in this forum (Calling all CANUCKS, http://coloncancersupport.colonclub.com/viewtopic.php?f=1&t=32353) user Steph20021 recently posted information about a company called Contextual Genomics, that was offering some free cancer genomics testing for the first 1,500 applicants in Canada. Armed with this information, I just sent off a message to my oncologist team and the company to see whether I could be referred for this if I qualify. Fingers crossed!

Thank you all for sharing! With so much uncertainty ahead, it has done me a world of good to have discovered The Colon Club and it's wonderful community here, along with all their collective wisdom and positivity!

[macpudd]

Hi Squak,
As regards chemo, as I understand it in my case, I was advised to have chemo because my tumour was t4b and was in contact with the peritoneum, my pathology report said there was strong evidence of peritoneal involvement, also the surgeon and onc said that there might be more of those isolated tumour cells which had not been removed during the surgery. Also I had a family history of colon cancer. They also said that as I was relatively young (49 years) and otherwise healthy they would be as aggressive as possible with it. Statistically the onc said I would have a 70% chance of no recurrence if I had the chemo. My circumstances were probably more clear cut because of the t4 tumour. If there is anything else you want to know dont be afraid to ask . Hope this helps.
Regards
McPudd

[mike1965]

My dx was pt1nc1 where that found two tumors in fat but not lymph nodes. Not sure if same as yours. I was conservative in my treatment and it was not a good decision. I will start chemo in two weeks. I am going to be aggressive in my treatment go forward. I pray all goes well. The choices and decisions are hard .

[squak]

Indeed.. choices and decisions are hard. I suppose I am a little stumped at my surgeon's guidance that he may have not even considered my post-OP referral to oncology had those pesky little isolated tumor cells not been identified.. however, with his black and white attitude (either the node is positive or not) he did, and it is probably a good decision to consult with oncology before determining the path ahead, I do feel better about that vs not seeing an oncologist at all. I am actually surprised that no oncologist has been in the mix so far

Questions:
--how often (or when) is radiation (concurrent with chemo) used as adjuvant therapy for CRC? I wasn't really prepared for meeting with a radiation oncologist, and was surprised when I was given an appointment there for next week, along with one for the med oncologist.
--is there a window that oncology targets, for when adj therapy should be started post-OP? Is it solely dictated by the post-OP healing-time? How significant may the danger be in delaying the start to pursue any alternative or wait&see options?

[macpudd]

As regards radiation it was not applicable in my case. The start of my chemo was delayed as I had abdominal abcesses, and I remember the onc saying that the most effective window for starting chemo was within 8 weeks of surgery but that it tapers off and is not a sudden drop in effectiveness if started after 8 weeks. I started mine 9 weeks after surgery. I am sure the onc will be able to definitively answer your questions when you see him/her. Best of luck.

Regards
Macpudd

[mike1965]

Squak

I am in the same situation not happy that surgeon found a pesky cancer cell outside of rectum but relieved he found it so I can get proper treatment. If the cancer was outside of the area he cut than it would have continue on to grow and move. I would have been Stage 1a l with no chemo and the cancer would have travelled. I feel blessed that it was found and I have a chance to battle. I do not know when is good time to start. I am starting chemo 6 weeks after operation but oncologist wanted 8 weeks but my wife pushed him to 6 weeks.

[squak]

All the best starting out with the chemo, Mike - I pray for all to be well too. Which chemo and what dosages are you starting on?
I'm really fatigued today, that never helps the waiting game.. still, i'm staying confident in my conservative approach - but appreciated your words about you feeling differently later. Difficult thoughts, and difficult decisions indeed.