chemoradiation therapy for rectosigmoid

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aam7.00
Posts: 14
Joined: Tue Dec 17, 2019 10:44 am

chemoradiation therapy for rectosigmoid

Postby aam7.00 » Tue Jan 21, 2020 5:25 am

Hello folks, I was recently diagnosed with adenocarcinoma of rectosigmoid. The tumor starts at 17 cm and goes till 24 cm

I visited a couple of doctors, one suggested chemoradiation and sounded logical and went through the entire 5-week course of CRT, which ended last December.

However, it feels like I may have been misdiagnosed. I have a surgery coming up in a couple of weeks and the surgeon says this isn't rectal but colon cancer and I should have had upfront surgery. He feels I have been over-diagnosed

I have been reading a lot of literature on this subject and it seems that there are very few doctors who consider rectosigmoid cancer as rectal instead of the colon.
Looks like any tumour under 15cm is considered rectal and mine starting at 17 cm should have qualified as the colon.

I am worried about distant metastasis and I am wondering if I may have given cancer the chance to spread.

I look forward to your inputs
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine

JJH
Posts: 290
Joined: Mon Apr 24, 2017 7:26 am

Re: chemoradiation therapy for rectosigmoid

Postby JJH » Tue Jan 21, 2020 10:26 pm

aam7.00 wrote:... I am worried about distant metastasis and I am wondering if I may have given cancer the chance to spread. ...

Here are my thoughts: If the cancer did in fact spread during the 5-week CRT, it would be in the form of a circulating tumor cell or a micro-metastasis and would not show up on a scan anytime soon. In addition, there is the possibility that the reduced-dose Capecitabine used during CRT may have served to stabilize or kill off the emerging distant mets. In any event, by April or so they will be putting you on a regimen of adjuvant chemotherapy (probably FOLFOX or Capeox), and that regimen should serve to mop up whatever small distant mets might still be around.

If they do another CT scan next month and find something suspicious in the liver or lungs, they then might decide to use a stronger form of adjuvant therapy (e.g., FOLFOX + Avastin) starting in April.

In my opinion, there is not much point in worrying right now because they have no way of confirming/disconfirming the presence of small remote metastases at this point in time.

-
P.S. It would help to know your tumor's "T" value in the TNM staging system. Also, your tumor's MSI status from the colonoscopy pathology report.
"The darkest hour is just before the dawn" - Thomas Fuller (1650)

CF_69
Posts: 109
Joined: Sat Dec 22, 2018 9:44 pm

Re: chemoradiation therapy for rectosigmoid

Postby CF_69 » Wed Jan 22, 2020 11:32 pm

My tumour was also rectosigmoid. I was about 15 cm from anal verge, depending on who measured.

I was also treated as rectal.

If you had suspicious nodes, that could be why they wanted to hit you with chemoradiation before surgery.

There’s a saying I like. I used to use it when it came to beers, but it’s applicable in many areas.

It’s better to have too many than not enough.
47 at diagnosis
Rectosigmoid junction
Adenocarcinoma
2.8 x 1.8 x 3.5 cm
G2
T3N0M0
CEA:
December 2018 - 1.9
September 2019 - 2.5
March 2020 - 2.3
September 2020 - 2.5
Xeloda / radiation x 25
Laparoscopic LAR April 2019
0 of 12 nodes
Stage 2A
4 cycles of adjuvant Xeloda
MRI on liver for 2mm hypodensity not suspicious.
Clear CT - September 2019

JJH
Posts: 290
Joined: Mon Apr 24, 2017 7:26 am

Re: chemoradiation therapy for rectosigmoid

Postby JJH » Thu Jan 23, 2020 2:18 am

aam7.00 wrote:... I have been reading a lot of literature on this subject and it seems that there are very few doctors who consider rectosigmoid cancer as rectal instead of the colon...

Just a few more thoughts ... Although your tumor is technically in the colon area, to remove it they may need to make the lower cut in the upper or middle rectum in order to insure clear margins. If this is the case, then your surgery might be more like a rectal cancer surgery than like a simple colon cancer surgery, and it might mean that a temporary ileostomy will be necessary and that you may later experience some LAR Syndrome symptoms due to missing rectal functions.

What you might want to do now is to talk to the surgeon and see what his current plans are for type of surgery, e.g., Low Anterior Resection vs. Left Hemicolectomy; and Open Surgery vs. Laparoscopic Surgery, etc. The type of surgery chosen could make a big difference in long-term recovery and quality-of-life considerations.
"The darkest hour is just before the dawn" - Thomas Fuller (1650)

boxhill
Posts: 608
Joined: Fri Apr 06, 2018 11:40 am

Re: chemoradiation therapy for rectosigmoid

Postby boxhill » Thu Jan 23, 2020 8:44 pm

I think JJH makes excellent points about the type of surgery being very important for future quality of life.

I just want to throw one thing out there: laparascopic surgery can sound awfully appealing in terms of quicker recovery and so on, but there is a lot to be said for open surgery with a good, experienced surgeon who is thus afforded the opportunity to take a good look around. When I had an emergency hemicolectomy, my surgeon found and removed a subcapsular liver met that was too small to show on the ct scan. He *felt* it when thoroughly examining my liver. Would not have happened with laparascopic surgery.

I also think that it would be important to discuss with your surgeon in advance the issue of preserving the rectum and avoiding LARS if at all possible, if that is your preference. I think it is important to establish your priorities and come to an understanding in advance with your surgeon how various contingencies will be addressed. Nothing is 100%, of course, and ultimately you have to rely on your surgeon's professional opinion, but you needn't be passive, either.
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 and 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
Stop Key
8/20 MRI NED

JJH
Posts: 290
Joined: Mon Apr 24, 2017 7:26 am

Re: chemoradiation therapy for rectosigmoid

Postby JJH » Fri Jan 24, 2020 1:33 am

boxhill wrote:... I also think that it would be important to discuss with your surgeon in advance the issue of preserving the rectum and avoiding LARS if at all possible, if that is your preference. I think it is important to establish your priorities and come to an understanding in advance with your surgeon how various contingencies will be addressed. Nothing is 100%, of course, and ultimately you have to rely on your surgeon's professional opinion, but you needn't be passive, either.

What boxhill suggests is very, very important. Before your surgery is finalized and before you sign the Informed Consent form, you need to have a discussion with the surgeon to agree on what kinds of surgical options will be considered.

Some of the options are very easy for a surgeon to apply but are actually devastating in term of long-term quality of life for the surviving patient after the cancer is successfully removed:


galee
Posts: 23
Joined: Sat Aug 24, 2019 2:44 pm
Facebook Username: galeehardin@cox.net

Re: chemoradiation therapy for rectosigmoid

Postby galee » Fri Jan 24, 2020 9:17 am

My adenocarcinoma was about 12cm from the anal verge. It was not recommended that I have treatment prior to LAR. I consulted with two surgeons. I chose a surgeon who specializes in colorectal procedures - That is all he does day in and day out. He did a flexible sigmoid procedure three days prior to my resection to make a personal determination of location, decide on laparoscopic surgery and to tattoo parameters. He stated there was about a 10% chance of temporary ileostomy. He did document as rectal cancer in my records. Resection was successful. No ileostomy was needed. He removed about 8 inches of colon. Leaving me with 6-7cm of rectum. Post surgery my bowels are a real challenge, but I’ve been told it’s still early. I have numerous symptoms of LARS but I am hopeful I will find a new normal.

I know it’s almost impossible, but try not to look back. Move forward with hope and positivity. I wish you all of the best in the days to come! If you are able to do so, meet with a couple of surgeons. Ask all your questions. When I met with the surgeon I chose, I felt the first sense of peace since my diagnosis. Prayerfully, surgery will be soon to remove your cancer. At that point your pathology will be thorough and you will gain a better understanding of the beast.
47 year old, Female
8/15/2019 Colonoscopy due to blood in bowels
8/20/2019 Pathology 3cm Adenocarcinoma
Recto-Sigmoid junction, 12 cm from anal verge
G2
MSS
BRAF, KRAS, NRAS Not Detected
CEA 1.8
9/23/2019 sigmoid & rectum colectomy plus left salpingo-oophorectomy, small intestine resection & appendectomy
9/30/2019 Pathology: T2N0M0, moderately differentiated adenocarcinoma (2.8cm), margins uninvolved

aam7.00
Posts: 14
Joined: Tue Dec 17, 2019 10:44 am

Re: chemoradiation therapy for rectosigmoid

Postby aam7.00 » Fri Jan 24, 2020 10:09 am

JJH wrote:
aam7.00 wrote:... I am worried about distant metastasis and I am wondering if I may have given cancer the chance to spread. ...

Here are my thoughts: If the cancer did in fact spread during the 5-week CRT, it would be in the form of a circulating tumor cell or a micro-metastasis and would not show up on a scan anytime soon. In addition, there is the possibility that the reduced-dose Capecitabine used during CRT may have served to stabilize or kill off the emerging distant mets. In any event, by April or so they will be putting you on a regimen of adjuvant chemotherapy (probably FOLFOX or Capeox), and that regimen should serve to mop up whatever small distant mets might still be around.

If they do another CT scan next month and find something suspicious in the liver or lungs, they then might decide to use a stronger form of adjuvant therapy (e.g., FOLFOX + Avastin) starting in April.

In my opinion, there is not much point in worrying right now because they have no way of confirming/disconfirming the presence of small remote metastases at this point in time.

-
P.S. It would help to know your tumor's "T" value in the TNM staging system. Also, your tumor's MSI status from the colonoscopy pathology report.


To be honest I haven't come across anyone in the forum or in any paper/studies that cancer spreads during the waiting period. wouldnt that defeat the whole purpose though ? Thanks for the information
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine

aam7.00
Posts: 14
Joined: Tue Dec 17, 2019 10:44 am

Re: chemoradiation therapy for rectosigmoid

Postby aam7.00 » Fri Jan 24, 2020 10:13 am

CF_69 wrote:My tumour was also rectosigmoid. I was about 15 cm from anal verge, depending on who measured.

I was also treated as rectal.

If you had suspicious nodes, that could be why they wanted to hit you with chemoradiation before surgery.

There’s a saying I like. I used to use it when it came to beers, but it’s applicable in many areas.

It’s better to have too many than not enough.


I spoke to the surgeon today and he says the chemo during radiation is like a catalyst /activator that assists radiation, and that's it. He didnt say if it will prevent any metastasis if that were to happen. He isn't too happy with the chemo-radiation. Just so you know, I am having at a different hospital
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine

aam7.00
Posts: 14
Joined: Tue Dec 17, 2019 10:44 am

Re: chemoradiation therapy for rectosigmoid

Postby aam7.00 » Fri Jan 24, 2020 10:17 am

JJH wrote:
aam7.00 wrote:... I have been reading a lot of literature on this subject and it seems that there are very few doctors who consider rectosigmoid cancer as rectal instead of the colon...

Just a few more thoughts ... Although your tumor is technically in the colon area, to remove it they may need to make the lower cut in the upper or middle rectum in order to insure clear margins. If this is the case, then your surgery might be more like a rectal cancer surgery than like a simple colon cancer surgery, and it might mean that a temporary ileostomy will be necessary and that you may later experience some LAR Syndrome symptoms due to missing rectal functions.

What you might want to do now is to talk to the surgeon and see what his current plans are for type of surgery, e.g., Low Anterior Resection vs. Left Hemicolectomy; and Open Surgery vs. Laparoscopic Surgery, etc. The type of surgery chosen could make a big difference in long-term recovery and quality-of-life considerations.


I spoke to the doctor today at length. He was quite surprised that i have all these questions, but he was quite cordial and answered all my questions.

He says, it's not going to be a Low anterior resection but an anterior resection. He also added, even though some rectum will be removed, he is not looking at any LARS syndrome. As regards to a "temporary ileostomy" he says, there is a low chance but he hasnt ruled it out. If i had not gone for radiation, he would have ruled out ileostomy
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine

aam7.00
Posts: 14
Joined: Tue Dec 17, 2019 10:44 am

Re: chemoradiation therapy for rectosigmoid

Postby aam7.00 » Fri Jan 24, 2020 10:24 am

boxhill wrote:I think JJH makes excellent points about the type of surgery being very important for future quality of life.

I just want to throw one thing out there: laparoscopic surgery can sound awfully appealing in terms of quicker recovery and so on, but there is a lot to be said for open surgery with a good, experienced surgeon who is thus afforded the opportunity to take a good look around. When I had an emergency hemicolectomy, my surgeon found and removed a subcapsular liver met that was too small to show on the ct scan. He *felt* it when thoroughly examining my liver. Would not have happened with laparascopic surgery.

I also think that it would be important to discuss with your surgeon in advance the issue of preserving the rectum and avoiding LARS if at all possible, if that is your preference. I think it is important to establish your priorities and come to an understanding in advance with your surgeon how various contingencies will be addressed. Nothing is 100%, of course, and ultimately you have to rely on your surgeon's professional opinion, but you needn't be passive, either.


I am glad to hear your liver met was taken care of, the surgeon seems to be very skilled. I discussed your case with my surgeon, and he says, CT scan is mostly accurate and this is a rare case. However, he is of the opinion that laparoscopic surgery is better overall especially since my tumor is higher up at 17 cm and he also says that laparoscope will give a magnified view of the insides, especially the nerves, so he seems pretty confident and he also cited that many studies have been done on this topic and laparoscopic has come out on top
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine

boxhill
Posts: 608
Joined: Fri Apr 06, 2018 11:40 am

Re: chemoradiation therapy for rectosigmoid

Postby boxhill » Fri Jan 24, 2020 9:22 pm

CT scans are only accurate down to a certain size. I don't think it is rare for regular CTs to fail to pick up 5mm liver masses and smaller. That's why the MRI is preferred.
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 and 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
Stop Key
8/20 MRI NED

CF_69
Posts: 109
Joined: Sat Dec 22, 2018 9:44 pm

Re: chemoradiation therapy for rectosigmoid

Postby CF_69 » Sat Jan 25, 2020 1:50 am

aam7.00 wrote:
CF_69 wrote:My tumour was also rectosigmoid. I was about 15 cm from anal verge, depending on who measured.

I was also treated as rectal.

If you had suspicious nodes, that could be why they wanted to hit you with chemoradiation before surgery.

There’s a saying I like. I used to use it when it came to beers, but it’s applicable in many areas.

It’s better to have too many than not enough.


I spoke to the surgeon today and he says the chemo during radiation is like a catalyst /activator that assists radiation, and that's it. He didnt say if it will prevent any metastasis if that were to happen. He isn't too happy with the chemo-radiation. Just so you know, I am having at a different hospital


My medical oncologist, radiation oncologist and surgeon were all on the same page.

They did say the intent was to shrink the tumor and I only took the chemo pills on radiation days.

I may be wrong but I would guess that while the chemo is to assist with the radiation, that it is still chemo and would attack any other rapidly dividing cells that it finds, ie: potential mets, even though that was not the primary intention.
47 at diagnosis
Rectosigmoid junction
Adenocarcinoma
2.8 x 1.8 x 3.5 cm
G2
T3N0M0
CEA:
December 2018 - 1.9
September 2019 - 2.5
March 2020 - 2.3
September 2020 - 2.5
Xeloda / radiation x 25
Laparoscopic LAR April 2019
0 of 12 nodes
Stage 2A
4 cycles of adjuvant Xeloda
MRI on liver for 2mm hypodensity not suspicious.
Clear CT - September 2019

CF_69
Posts: 109
Joined: Sat Dec 22, 2018 9:44 pm

Re: chemoradiation therapy for rectosigmoid

Postby CF_69 » Sat Jan 25, 2020 2:02 am

galee wrote:My adenocarcinoma was about 12cm from the anal verge. It was not recommended that I have treatment prior to LAR. I consulted with two surgeons. I chose a surgeon who specializes in colorectal procedures - That is all he does day in and day out. He did a flexible sigmoid procedure three days prior to my resection to make a personal determination of location, decide on laparoscopic surgery and to tattoo parameters. He stated there was about a 10% chance of temporary ileostomy. He did document as rectal cancer in my records. Resection was successful. No ileostomy was needed. He removed about 8 inches of colon. Leaving me with 6-7cm of rectum. Post surgery my bowels are a real challenge, but I’ve been told it’s still early. I have numerous symptoms of LARS but I am hopeful I will find a new normal.

I know it’s almost impossible, but try not to look back. Move forward with hope and positivity. I wish you all of the best in the days to come! If you are able to do so, meet with a couple of surgeons. Ask all your questions. When I met with the surgeon I chose, I felt the first sense of peace since my diagnosis. Prayerfully, surgery will be soon to remove your cancer. At that point your pathology will be thorough and you will gain a better understanding of the beast.


Sounds like we had very similar surgeries. My surgeon took out my sigmoid and a little less than half my rectum, about 12 inches total.

I also did not have an ileostomy.

I think we will fare better than most due to the remaining rectum. I’m not “normal” but then I wasn’t “normal” before either.

It’s definitely a challenge to hit the sweet spot in terms of getting things moving smoothly.

Lately I’ve found that having a small glass of kefir every 3 days or so seems to really help. Any more than that and it slows things down too much.

I’ve also been able to identify a few foods that are trouble.

When I do have a movement, my main complaint now is that it is almost always a one log event that quite often breaks off so it feels like there is more to come, but it won’t come out until later.

I’m about 10 months post surgery now. With some planning ahead I’m able to live a pretty normal life, at the moment.
47 at diagnosis
Rectosigmoid junction
Adenocarcinoma
2.8 x 1.8 x 3.5 cm
G2
T3N0M0
CEA:
December 2018 - 1.9
September 2019 - 2.5
March 2020 - 2.3
September 2020 - 2.5
Xeloda / radiation x 25
Laparoscopic LAR April 2019
0 of 12 nodes
Stage 2A
4 cycles of adjuvant Xeloda
MRI on liver for 2mm hypodensity not suspicious.
Clear CT - September 2019

aam7.00
Posts: 14
Joined: Tue Dec 17, 2019 10:44 am

Re: chemoradiation therapy for rectosigmoid

Postby aam7.00 » Sat Jan 25, 2020 4:19 am

CF_69 wrote:
aam7.00 wrote:
CF_69 wrote:My tumour was also rectosigmoid. I was about 15 cm from anal verge, depending on who measured.

I was also treated as rectal.

If you had suspicious nodes, that could be why they wanted to hit you with chemoradiation before surgery.

There’s a saying I like. I used to use it when it came to beers, but it’s applicable in many areas.

It’s better to have too many than not enough.


I spoke to the surgeon today and he says the chemo during radiation is like a catalyst /activator that assists radiation, and that's it. He didnt say if it will prevent any metastasis if that were to happen. He isn't too happy with the chemo-radiation. Just so you know, I am having at a different hospital


My medical oncologist, radiation oncologist and surgeon were all on the same page.

They did say the intent was to shrink the tumor and I only took the chemo pills on radiation days.

I may be wrong but I would guess that while the chemo is to assist with the radiation, that it is still chemo and would attack any other rapidly dividing cells that it finds, ie: potential mets, even though that was not the primary intention.


You know what , the norm is to do surgery + adjuvant ( no radiation) chemo for tumours at rectosigmoid, however there is a new study that says, chemoradiation before surgery is beneficial for overall OS atleast by 5 percent. It basically all boils down to rectum vs colon and it's a controversial debate. I have a CT scan today and surgery next Tuesday , so hoping for the best .
M 33 smoker
Diagnosed with rectosigmoid cancer
MRI & CT SCAN- suggests regional lymph node metastasis
11\5\2019 to 12\12\2019 - 28 sessions (fractions) of Radiation therapy with Capecitabine


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