Solitary lymph node metastasis: treatment options

[Dennyp]

I met with my oncologist yesterday and he asked about my openness to strong chemo (FOLFOXIRI) for about three months and follow up with maintenance chemo. I responded that I am open to everything.

He believes that the chemo can kill cancer cells in the lymph node and will provide systemic therapy. He was not an advocate for surgery. He said that removing the lymph node is an extensive surgery with potential complications, you might feel better if you remove it but it does not guarantee that cancer does not come back. If we go for surgery, he would like me to do surgery first , recover from it and then do the chemo. He also talked about potentially adding few doses of radiation to the area but was not sure of someone would be willing to do that for me.
I am being referred to a surgeon to see what options I have. And also a radiologist.

I would like the treatment to start as soon as possible but the oncologist says I have time and I should meet with surgeon and come up with treatment plan. Overall I am uneasy and anxious

Having gone through what you are going through, I understand your anxiety. In retrospect it wasn’t that bad, it certainly wasn’t as difficult as the first surgery. Surgery does have its complications, I experienced a torn vein which a vascular surgeon had to repair. I had FOLFIRI and while more challenging that FOLFOX for me it wasn’t intolerable. The good news is you have options!

[catstaff]

FOLFOXIRI is pretty nasty, though, since it's "throw everything at it." Would bevacizumab be added, did the oncologist say?

[skb]

Hi catstaff, I do not remember if he said that bevacizumab would be added. It was a blur

[rp1954]

The major failing of oncologists concerns their (in)ability to totally eliminate distant, metastatic lymph nodes using 2-3 week chemo cycles, with cyclical chemo's kill - regrow - "hardening" cycle unto eventual failure. Palliative is all that can be usually done for distant LN with Folf- -ox -iri +MAb formulas without surgery - usually they buy time, despite whatever spin. Their usual biases are that this is better than the risk(s) of metastatic spread from surgery, and the big waits between surgery and chemo. Their other bias is that "theirs" is bigger and better than any other chemistry.

Then if a metastatic residue exists after surgery, patients usually miss 6-12 weeks between chemo and surgery and things can spread. A fundamental problem for normal chemo is various forms of damage vs chemo intensity, and chemo continuity.

Our plan included four special elements:
a. eliminate dead space (ahem) in the chemo-surgery-chemo cycle to less than 2-3 days (about 1.3 days actual vs 6-12 wks);
b. reduce/eliminate perioperative metastasis;
c. absolute (immuno)chemo continuity where possible (all 24 hrs, x365); AND
d. to increase chemo intensity with superior QoL, so that chemo restart was not a big ugly decision.

They were stuck on solitary nodes/sites and we were aimed for hell or high water, even if multiple sites and circulating CRC cells, as necessary. My wife has never used -iri, -oxi, MABs or cycles.

[dianetavegia]

May I remind you that oncologists are trained to treat cancers with chemo (poisons) and surgeons remove said cancer. Surgery is the gold standard for cure.

A spread four years out is a good sign. I'd suggest the cells were there at your Stage III dx but that your cancer sounds like a very slow growing variety.

I had a solitary, smaller than a dime met on the back of my liver 3 years post my Stage III dx. My oncologist did suggest major surgery with a famous doctor out of Atlanta. I had 80% of my liver removed but no follow up radiation or chemo. That was spring 2012. No lymph nodes were involved but I had 5 out or 17 (I think) positive for microscopic cells in Jan. 2009 at my first dx.

I'm having my colonoscopy next Thursday. It's been 5 years since my last. The only polyp I ever had was the cancerous one in Jan. 2009.

Have faith and get that node removed!

[skb]

Yeah, we were told they only do surgery on lymph nodes if it's a particular node that is "causing a problem." It's a more difficult surgery than one might think.

But why not SBRT? Is this node in a previous radiation field or is the intestine at risk? Radiation was very effective on my DH's retroperitoneal nodes at diagnosis.

But chemo may be very effective as well, and I would agree that there's a substantial chance of other lymph node involvement at some point.

Hi Catstaff, I stand corrected. When I met with radiation oncology team, they told me that this node falls in a previous radiation field and were nervous about proceeding with radiation. I still dont have a treatment plan, I meet with surgeon today

[Cancercare]

Solitary lymph node (SLN) metastasis is a distinct subset of colon cancer associated with good prognosis. You might want to try Ask-A-Doc, a free service on OncoPower app. They have a panel of US Oncologists help patients manage symptoms or treatment options or virtually any questions absolutely free. It was started by an oncologist.

[skb]

My doctors have arrived at a consensus, a treatment plan.

Surgery to remove metastatic lymph node followed by chemo.

[Dennyp]

My doctors have arrived at a consensus, a treatment plan.

Surgery to remove metastatic lymph node followed by chemo.

I happy to hear you have a plan, I’m sure it’s a great relief knowing what’s next. Best of luck!

[skb]

Solitary lymph node (SLN) metastasis is a distinct subset of colon cancer associated with good prognosis. You might want to try Ask-A-Doc, a free service on OncoPower app. They have a panel of US Oncologists help patients manage symptoms or treatment options or virtually any questions absolutely free. It was started by an oncologist.

This is very useful information that gives me hope, thank you very much

[skb]

I am back on the forum , 9 months after an abdominal surgery to remove retroperitoneal lymph node metastasis. This was followed by FOLFIRI (12 rounds- that is 6 months) during which I lost all hair
I suffered foot drop from the surgery due to nerve damage sustained during the surgery . I limp and use a walking stick. I have physiotherapy sessions. Also my bowel control is less than ideal, I often have to rush to the bathroom.

What is interesting is that the surgery took 10 hours and did not find any lymph node that had metastasis. Out of 6 samples taken, two tissue samples had cancer. I doubt if the procedure that made me kind of disabled was necessary at all. Here is the pathology report. I made complaints to the hospital about nerve damages but they say that I have no case and these are normal risks that manifested itself. i also tried getting some lawyer to represent me but no one out of 10 people I called was willing to take the case.

Are all these things common in pelvic surgery? (losing normal mobility, using a walking stick, reduced bowel control)
I felt very healthy before I went into surgery. Now I am a mess. I started working again this month but still suffering from a bit of chemo brain


--------------Surgical pathology report- Oct 1st, 2021-----

A. RIGHT OBTURATORLYMPH NODES X5, EXCISION:
Negative for metastatic carcinoma (0 /5)

B. RIGHT OBTURATOR LYMPH NODE X1, EXCISION:
Negative for metastatic carcinoma (0 /1)

C. RIGHT OBTURATOR LYMPH NODES X2, EXCISION:
Negative for metastatic carcinoma (0 /2)

D. RIGHT OBTURATOR LYMPH NODE, EXCISION:
Fibroadipose and neural connective tissue:
-No lymph nodes identified; negative for carcinoma

E. PET POSITIVE RIGHT OBTURATOR LYMPH NODE, PART 1, EXCISION:
POSITIVE for carcinoma (intravascular):
-Fibroadipose and skeletal connective tissue only
-No lymph nodes identified (See Comment)

F. PET POSITIVE RIGHT OBTURATOR LYMPH NODE, PART 2, EXCISION:
POSITIVE for carcinoma (perineural and soft tissue):
-Fibroadipose, neural and skeletal connective tissue only
-No lymph nodes identified

[Dennyp]

Wow! I’m sorry to hear that! My oncologist did a biopsy prior to me starting chemo and having surgery I assume your oncologist didn’t order one?

[skb]

Dennyp,
Thanks for your concern, Dennyp.

A biopsy was done on lymph node which was positive. But when lymph nodes were removed during surgery, they were negative for adenocarcinoma.

Something is off. Either the biopsy was wrong. Or the pathology study of lymph nodes removed during surgery was wrong. If lymph nodes had no cancer, why put me on 6 months of Folfiri??

I had a horrible surgery.
Still cant walk properly after 9 months
Still have some brain fog from chemo

I dont know if the surgery was warranted.
I feel wronged

[Dennyp]

That’s awful, I understand why you feel that way.

[rp1954]

I'm working on a long answer of cumulative experiences.

Could you fill in some of the story gaps running up to surgery and chemo?
What kind of direct conversations and outside consults did you have with various surgeons before surgery.
Did you repeat our stories to them in the search for options?
what kind of uncertainties did you have and their changes/resolution in the run up to surgery?
What serial CEA readings (as well as any CBC, ALP, GTTP, LDH and CA199 panels) did you have in 3-4 months before surgery? (and after)
did you ask for (or they used) substitutions on opiates for surgery; cimetidine for proton pump inhibitors, and celecoxib for post surgical pain?
What kind of conversations and consults did you have with various oncologists before chemo actually started?
How many weeks after surgery before chemo?
what was your view of the hospital and doctors' stature and (special) quality before surgery and did you feel like there was much choice (vs work, timing, distance, big city/medical center access, HMO/insurance)?