Scars vs local recurrence

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jts
Posts: 66
Joined: Sat Aug 24, 2019 3:07 pm

Scars vs local recurrence

Postby jts » Tue Jun 11, 2024 10:41 am

It has been a long time since I posted. I do read the board, but have not been logging in. My CRC story has been, thankfully, boring the last two years. My expectation is that they will eventually find another lung met, and hopefully cut it out. Or maybe not find anything, but that's the area that has everyone's attention.

Then with my most recent CT scan (have been getting them every 6 months or so) the people running the machine immediately got animated as they were rolling me out of the CT machine, and wanted to know if I had had any other operation done since my last scan. No, I had not. Do you see anything different? Oh it's nothing... etc. Wait, are you sure ... Why are you asking? Nope, nothing to see here!

Then the radiologist's report a couple days later said there was a new 1.5 cm mass in the presacral area, suspect for local recurrence. The prognosis for something like that is actually quite bad.

This coincided with my annual appointment with the Gastro-oncology clinic, so I gave them the scan data and the report. After having their people look at it, they concluded it was most likely scar tissue. Why would there be a big new scar tissue 4 years after the surgery? I don't know. Part of their reasoning seems to be that a lot of research has found that something like 90% of local recurrences show up within 4 years of the initial surgery. This seems almost reasonable, but also sounds like the logical fallacy where people ignore evidence of improbable events. Improbable things still do happen. And if it is a local recurrence, the survival plots I've seen say that waiting 6 months to scan it again would be disastrous.

So I met with my oncologist. He suggested taking the scan to their tumor conference. They would then suggest doing a PET scan, or some other followup action. But they would want better images, so he set me to get an MRI of the area. The conclusion of the MRI was, based on stuff I don't understand about how the contrast medium diffuses, that it's most likely scar tissue. Not a recurrence.

Also my CEA has been going down, so evidence-wise it's basically 3:1 against this being a local recurrence.

An annoying part of this is that I can't see what the heck they are talking about. With the lung met, I could scroll through the CT scan and it was obvious. With the liver cyst I could scroll through the MRI and it was obvious. In this case, the radiologist pointed out the exact sequence of images in the report. Of course I spent a LOT of time scrolling through those images in the days after getting the first report, but It is all just a bunch of grey fuzz to me. And the presacral area is really quite thin. How can I not see something that is 1.5cm? In the MRI, the grey fuzz is much clearer, but which of the blobs caused this commotion, I have no idea.
Male 42 — stage IV RC
NRAS mutant - KRAS, BRAF wt
08/2019 DX 6 cm long tumor
09-10/2019 Chemo-radiation
12/2019 TME Surgery, clear margins, 7/16 nodes positive
Pathology: ypT3 ypN2b M0
01-06/2020 - FOLFOX
CEA only goes up during chemo: 2.4 --> 6.2
07/2020 6 mm tumor in lung, was growing fast during chemo
09/2020 VATS
01/2021 new 5mm cyst in liver, CEA continues to increase --> 8
06/2021 CEA down to 6. Cyst not visible anymore.
05/2023 CEA fluctuates between 4 and 6. Scans have been clear.

deha50
Posts: 33
Joined: Fri Nov 20, 2020 8:24 pm

Re: Scars vs local recurrence

Postby deha50 » Tue Jun 11, 2024 2:45 pm

I would ask your oncologist to show you the scar tissue!

Nor Cal
Posts: 92
Joined: Sun Dec 06, 2020 8:18 pm

Re: Scars vs local recurrence

Postby Nor Cal » Tue Jun 11, 2024 4:34 pm

Did you have symptoms with your original diagnosis? Something on blood tests? Are those things repeating themselves? In my experience every time I've had three or four things pointing one way, and one thing pointing the other way, the side with the greater evidence has always been right.
Dx June 2020, stage IV, w liver mets in both lobes. M, age 50. Right-sided colon tumor. CEA 120.
BRAF+ TMB 5% MSS TDL1-1%
July 2020 - Present: 57 cycles chemo (All the various 5-FU regimens)
December 2020 - February 2021 Y90 Radioembolization, Chemoembolization x2

roadrunner
Posts: 483
Joined: Sun Jan 12, 2020 8:46 pm

Re: Scars vs local recurrence

Postby roadrunner » Tue Jun 11, 2024 8:31 pm

MRI is very sensitive for locoregional recurrence, so it sounds like you are in good shape. CEA suggests the same. These things are always worth following up, of course, since nothing is 100%, and particularly because these days many local recurrences are salvageable if caught early. I attached a 2011 study on MRI below.

https://link.springer.com/article/10.10 ... 010-2052-8
7/19: RC: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/19-10/19 4 rds.FOLFOX neoadjuvant, 3 w/Oxiplatin (reduced 70-75%)
neoadjuvant chemorad 11/19
4 rounds FOLFOX July-August 2020
ncCR 10/20; biopsies neg
TAE 11/20, tumor cells removed
Chest CT 3/30/21 growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
6/20/22 TAE rectal polyp benign)
NED from 3/22 - 3/23
4 cycles FOLFIRI
LUL VATS lobectomy for radio resistant met 7/7/23

User avatar
Green Tea
Posts: 491
Joined: Mon Oct 24, 2016 10:48 am

Re: Scars vs local recurrence

Postby Green Tea » Wed Jun 12, 2024 12:08 am

Do you have any information on which particular part of the sacrum is involved with a "1.5 cm mass"?

https://www.researchgate.net/profile/Rafael-De-La-Garza-Ramos/publication/263585186/figure/fig1/AS:614391611412486@1523493783554/Anatomy-of-the-sacrum-in-anterior-A-posterior-B-lateral-C-sagittal-D-and.png

And do you have information on which part of the rectum (upper, middle, lower) your resected rectal tumor was located? Was the tumor close to the sacrum, and did the pathology report say that the resection margins were clear?

jts
Posts: 66
Joined: Sat Aug 24, 2019 3:07 pm

Re: Scars vs local recurrence

Postby jts » Wed Jun 12, 2024 4:48 pm

deha50 wrote:I would ask your oncologist to show you the scar tissue!


I did! Do other peoples' oncologists look at scans with them? Mine does not. He says the radiologists have special software and displays that let them distinguish things that we can't from the DICOMs alone. Just trust their reports. Still I wish someone would draw a red circle around this supposed scar tissue.
Male 42 — stage IV RC
NRAS mutant - KRAS, BRAF wt
08/2019 DX 6 cm long tumor
09-10/2019 Chemo-radiation
12/2019 TME Surgery, clear margins, 7/16 nodes positive
Pathology: ypT3 ypN2b M0
01-06/2020 - FOLFOX
CEA only goes up during chemo: 2.4 --> 6.2
07/2020 6 mm tumor in lung, was growing fast during chemo
09/2020 VATS
01/2021 new 5mm cyst in liver, CEA continues to increase --> 8
06/2021 CEA down to 6. Cyst not visible anymore.
05/2023 CEA fluctuates between 4 and 6. Scans have been clear.

jts
Posts: 66
Joined: Sat Aug 24, 2019 3:07 pm

Re: Scars vs local recurrence

Postby jts » Wed Jun 12, 2024 4:55 pm

Green Tea wrote:Do you have any information on which particular part of the sacrum is involved with a "1.5 cm mass"?

https://www.researchgate.net/profile/Rafael-De-La-Garza-Ramos/publication/263585186/figure/fig1/AS:614391611412486@1523493783554/Anatomy-of-the-sacrum-in-anterior-A-posterior-B-lateral-C-sagittal-D-and.png

And do you have information on which part of the rectum (upper, middle, lower) your resected rectal tumor was located? Was the tumor close to the sacrum, and did the pathology report say that the resection margins were clear?


I know which slices in the axial view it is supposed to be in. The original tumor was very low in the rectum. They did a TME with clear margins.
Male 42 — stage IV RC
NRAS mutant - KRAS, BRAF wt
08/2019 DX 6 cm long tumor
09-10/2019 Chemo-radiation
12/2019 TME Surgery, clear margins, 7/16 nodes positive
Pathology: ypT3 ypN2b M0
01-06/2020 - FOLFOX
CEA only goes up during chemo: 2.4 --> 6.2
07/2020 6 mm tumor in lung, was growing fast during chemo
09/2020 VATS
01/2021 new 5mm cyst in liver, CEA continues to increase --> 8
06/2021 CEA down to 6. Cyst not visible anymore.
05/2023 CEA fluctuates between 4 and 6. Scans have been clear.

jts
Posts: 66
Joined: Sat Aug 24, 2019 3:07 pm

Re: Scars vs local recurrence

Postby jts » Wed Jun 12, 2024 4:58 pm

roadrunner wrote:MRI is very sensitive for locoregional recurrence, so it sounds like you are in good shape. CEA suggests the same. These things are always worth following up, of course, since nothing is 100%, and particularly because these days many local recurrences are salvageable if caught early. I attached a 2011 study on MRI below.

https://link.springer.com/article/10.10 ... 010-2052-8


Thanks. That is exactly my line of thinking right now. Will be following up in early fall.
Male 42 — stage IV RC
NRAS mutant - KRAS, BRAF wt
08/2019 DX 6 cm long tumor
09-10/2019 Chemo-radiation
12/2019 TME Surgery, clear margins, 7/16 nodes positive
Pathology: ypT3 ypN2b M0
01-06/2020 - FOLFOX
CEA only goes up during chemo: 2.4 --> 6.2
07/2020 6 mm tumor in lung, was growing fast during chemo
09/2020 VATS
01/2021 new 5mm cyst in liver, CEA continues to increase --> 8
06/2021 CEA down to 6. Cyst not visible anymore.
05/2023 CEA fluctuates between 4 and 6. Scans have been clear.


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