Need advice: Margins were not clear

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jsbsf
Posts: 105
Joined: Sat Aug 24, 2019 6:01 am
Location: San Francisco

Need advice: Margins were not clear

Postby jsbsf » Fri Jun 03, 2022 11:50 am

DH is recovering from his APR.

The pathology reports showed that although the bulk of the tumor was removed, cancer cells were found in the margins. The oncologist won’t be back until later this month.

Does anyone have an experience with surgery where the margins were not clear? How do you go about getting rid of the remaining cancer?

The location is in the tissue very close to the prostate.

Thank you
DH 61
2019 4A t3 n2 m1a
8/23 C-scopy, 5+cm mass. CEA:4.1
9/16 MSS. MRI: 2 lvr mets: 2.7 & 7mm
9/30 Start FOLFOX 1-6
10/4 Lg lvr met ~3.7cm, pri tmr stable.
CEA: 10/13,12.5;10/27-12/8 btw 4.7 & 3.1
11/5 both lvr mets ~ 2/3 smaller.
12/17 PET: sm lvr met gone, remaining tmrs @10% of orig sz & actvty
2020
MWA 2/5, Lap resection 2/11
CEA: 3/1-5/31 btw 2.1&2.9
3/2 start FOLFOX 7-12
7/23-29 EBRT
10/2/2020 NED/W&W
4/2022 EUS-FNA,MRI: recur.;
5/2022:CT scan no mets

roadrunner
Posts: 271
Joined: Sun Jan 12, 2020 8:46 pm

Re: Need advice: Margins were not clear

Postby roadrunner » Fri Jun 03, 2022 4:36 pm

I haven’t seen too much on this, but the question appears complicated and at least somewhat unsettled. Re-resection and systemic therapies (chemo) may be options, and I think should be discussed with your team. Given the complexity, I think a second opinion from a major, high-volume cancer center (even if remote) would be ideal.
7/19: Rectal cancer: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (side effects/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 small growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
CT 3/22: Clear
Thoracic CT 5/19/22 Clear
6/20/22 TAE rectal polyp benign

jsbsf
Posts: 105
Joined: Sat Aug 24, 2019 6:01 am
Location: San Francisco

Re: Need advice: Margins were not clear

Postby jsbsf » Fri Jun 03, 2022 6:03 pm

Thanks roadrunner. I’m setting up a consultation right now for a second opinion (top cancer hospital) we might even consider switching during enrollment depending on how it goes. Right now we know the bulk was removed and that most likely a tiny amount remains.
DH 61
2019 4A t3 n2 m1a
8/23 C-scopy, 5+cm mass. CEA:4.1
9/16 MSS. MRI: 2 lvr mets: 2.7 & 7mm
9/30 Start FOLFOX 1-6
10/4 Lg lvr met ~3.7cm, pri tmr stable.
CEA: 10/13,12.5;10/27-12/8 btw 4.7 & 3.1
11/5 both lvr mets ~ 2/3 smaller.
12/17 PET: sm lvr met gone, remaining tmrs @10% of orig sz & actvty
2020
MWA 2/5, Lap resection 2/11
CEA: 3/1-5/31 btw 2.1&2.9
3/2 start FOLFOX 7-12
7/23-29 EBRT
10/2/2020 NED/W&W
4/2022 EUS-FNA,MRI: recur.;
5/2022:CT scan no mets

Rock_Robster
Posts: 694
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Need advice: Margins were not clear

Postby Rock_Robster » Fri Jun 03, 2022 8:31 pm

Sorry to hear this - not what you were hoping to hear. I agree with roadrunner about a multidisciplinary consult; preferably at a major centre. Where did you get to on radiation? I wonder if some adjuvant radiotherapy may be of benefit - or possibly even SBRT depending on the location.

Given it’s close to the prostate I’m assuming the primary was rectal? You may want to consider a consult with a specialist rectal/pelvic surgeon who specialises in re-resection and salvage surgery. There are sometimes other options available there too.

Best of luck, as always.
40M Australia
2018 Dx RC, 12cm high
G2, EMVI, LVI. 4 liver mets
pT3N1aM1a Stage IVa. MSS NRAS G13R
CEA: Nov-18= 14; then <2. Jun-22: 5
11/18 FOLFOX x6
3/19 Liver resection
5/19 25x pelvic IMRT radiation
7/19 ULAR & ileo (reversed)
8/19 Liver lesion
8/19 FOLFOX, FOLFOXIRI, FOLFIRI x7
12/19 Liver resection
NED
11/21 Liver met & celiac node; 2-3 tiny lung things
12/21 PVE
3/22 Nodal spread & 3 liver mets. Lymphadenectomy
4/22 Liver SBRT
6/22 Liver looks good. Still some small lung things

jsbsf
Posts: 105
Joined: Sat Aug 24, 2019 6:01 am
Location: San Francisco

Re: Need advice: Margins were not clear

Postby jsbsf » Sat Jun 04, 2022 1:16 am

Thank you.

Yes this was lower rectal and DH is recovering from an APR surgery, robotic. The surgeon removed the primary tumor that had been treated with radiation almost 2 years ago. It didn’t show on CT scans, and was flat, so didn’t show on physical exams. His CEA has been normal. So it’s been under the radar.

A biopsy proved cancer was present, and an MRI showed possible prostate invasion. The ultrasound ruled out prostate invasion.

He was given 3 options:chemo, a TME (sphincter preserving), or an APR. APR was recommended since a TME would end up with a poor quality of life.

The APR would possibly include a prostatectomy, and so a urologist was on standby. 4 hour surgery removed the rectum and tissue up to, not including, the prostate. The surgeon said she felt confident she removed all the cancer.

The pathology report showed that all the lymph nodes were indeed clear of cancer, but the cancer cells appeared very close to the margin, enough so we have to assume there may be some cancer cells left behind.

The surgeon felt optimistic with his prognosis, despite the strong possibility that there might still be a (small) amount of cancer cells.

She feels that radiation might be in order, but we have yet to hear from the oncologist who may recommend chemo. She feels there is a chance any remaining cancer cells might die off, and that there is little to no chance of it spreading.

I have contacted a reputable cancer center for a consultation with them, and they have already downloaded all his medical records. I expect to hear back from their oncologist early next week.

It seems as though the lymph nodes being removed will drastically minimize, if not prevent, the risk of spreading.

It’s possible there’s nothing to worry about, but there’s a good chance that there is.

It would take a long time for the cancer to form a tumor that could invade the prostate, whereby he would likely need to move forward with the prostate surgery that was just averted.

So it’s good that he still has his prostate, but the trade-off is that there’s a new type of watch and wait where it might need to be removed at a later date.

Personally, I feel like since he did so well on chemo the first time around, that he should try that, and then radiation if that doesn’t do the trick. Ultimately, he could do the prostate surgery, but it might quite likely never come to that in this lifetime.

He’s almost 65 years old, so we’re thinking if it takes 20 years to be problematic then screw it/ we can just go on with life. But we just don’t know.
DH 61
2019 4A t3 n2 m1a
8/23 C-scopy, 5+cm mass. CEA:4.1
9/16 MSS. MRI: 2 lvr mets: 2.7 & 7mm
9/30 Start FOLFOX 1-6
10/4 Lg lvr met ~3.7cm, pri tmr stable.
CEA: 10/13,12.5;10/27-12/8 btw 4.7 & 3.1
11/5 both lvr mets ~ 2/3 smaller.
12/17 PET: sm lvr met gone, remaining tmrs @10% of orig sz & actvty
2020
MWA 2/5, Lap resection 2/11
CEA: 3/1-5/31 btw 2.1&2.9
3/2 start FOLFOX 7-12
7/23-29 EBRT
10/2/2020 NED/W&W
4/2022 EUS-FNA,MRI: recur.;
5/2022:CT scan no mets

jsbsf
Posts: 105
Joined: Sat Aug 24, 2019 6:01 am
Location: San Francisco

Re: Need advice: Margins were not clear

Postby jsbsf » Sat Jun 04, 2022 1:18 am

I should also add that DH is in very good spirits after his APR. I can see he is going to adjust very well. We are both very optimistic and confident that the worst part of this journey is behind us.
DH 61
2019 4A t3 n2 m1a
8/23 C-scopy, 5+cm mass. CEA:4.1
9/16 MSS. MRI: 2 lvr mets: 2.7 & 7mm
9/30 Start FOLFOX 1-6
10/4 Lg lvr met ~3.7cm, pri tmr stable.
CEA: 10/13,12.5;10/27-12/8 btw 4.7 & 3.1
11/5 both lvr mets ~ 2/3 smaller.
12/17 PET: sm lvr met gone, remaining tmrs @10% of orig sz & actvty
2020
MWA 2/5, Lap resection 2/11
CEA: 3/1-5/31 btw 2.1&2.9
3/2 start FOLFOX 7-12
7/23-29 EBRT
10/2/2020 NED/W&W
4/2022 EUS-FNA,MRI: recur.;
5/2022:CT scan no mets

Rock_Robster
Posts: 694
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Need advice: Margins were not clear

Postby Rock_Robster » Sat Jun 04, 2022 2:58 am

Glad to hear he’s feeling better and in good spirits!

Certainly a tough situation. The trouble of course is that a subsequent local rectal recurrence can be potentially very challenging to deal with, so if there’s any way to further reduce the risk of this now then it’s certainly worth considering. I’m not sure how effective chemo would be in this setting - I suspect no-one could really say for sure as it’s such a unique set of circumstances. Re-resection is a big call, and indeed would potentially have QoL impacts (particularly if TME). I would definitely be considering radiation if the rad onc thinks they could target the region and it would potentially have an effect on recurrence risk given the potential involved margin. Hopefully given he has an ostomy now regardless, some targeted radiation might be quite tolerable and over fairly quickly. I’m sure there’ll be other opinions here though too!
40M Australia
2018 Dx RC, 12cm high
G2, EMVI, LVI. 4 liver mets
pT3N1aM1a Stage IVa. MSS NRAS G13R
CEA: Nov-18= 14; then <2. Jun-22: 5
11/18 FOLFOX x6
3/19 Liver resection
5/19 25x pelvic IMRT radiation
7/19 ULAR & ileo (reversed)
8/19 Liver lesion
8/19 FOLFOX, FOLFOXIRI, FOLFIRI x7
12/19 Liver resection
NED
11/21 Liver met & celiac node; 2-3 tiny lung things
12/21 PVE
3/22 Nodal spread & 3 liver mets. Lymphadenectomy
4/22 Liver SBRT
6/22 Liver looks good. Still some small lung things

Rikimaroo
Posts: 420
Joined: Tue Dec 20, 2016 8:48 pm
Location: Florida

Re: Need advice: Margins were not clear

Postby Rikimaroo » Sat Jun 04, 2022 11:12 am

Hi,

After my LAR (lower anterior resection) the margins came back positive. Unfortunately for me 4 years later I am still fighting. After my surgery in 4/2018, about a 1.5 month break and they put me on FolFiri to see if they can kill any small tumors in the positive CRM. This was my results from surgery:

"A tumor deposit is present at the circumferential margin of resection. Proximal and distal margins of resection are free of tumor. Tumor is approximately 2 cm from the distal margin of resection. 8 lymph nodes negative"

Having positive margins after resection is not a good thing, but still everyone is different, for me the cancer continues to be a problem and I am on chemo for life. Hoping for some trials after a 2nd opinion with Univ of Miami/Sylvester Cancer Institute.

I hope your husband has better experience, but from my understand if there is positive margins chemo is necessary (adjuvant).

Riki
RC T3N1M0 12/16
MSS - NRAS Mutation
Chemo Rad, CCR - W&W 5/2017
Recurrence 11/2017
CT Scan 11/2017 Liver Met 5.5cm Stable, Stage IV
LAR/Liver Resect 4/2018
Reversal 10/18
CEA highest 500, lowest .8 throughout process, waiting for latest
Recurrence left vesical/pelvic sidewall - 10/7/2019 resect perm bag,
CEA rise Feb/May 3.7, 8.8, 30, Recurrence in Pelvic
CEA 40 right now, but was 57, so folfiri to beat it back down.
Lots of chemo for the past 4 years.

User avatar
Peregrine
Posts: 100
Joined: Tue Mar 01, 2022 1:18 am

Re: Need advice: Margins were not clear

Postby Peregrine » Sat Jun 04, 2022 12:13 pm

jsbsf wrote:...
So it’s good that he still has his prostate, but the trade-off is that there’s a new type of watch and wait where it might need to be removed at a later date
...

My comments/questions pertain primarily to prostate watch-and-wait:

  1. What would be used for prostate monitoring during the watch-and-wait?

    • CEA, or PSA, or both CEA and PSA as tumor markers?
    • CT-scan, MRI, or Ultrasound? Which would be best?
  2. Does the oncologist see any risk for prostate cancer? Or is it the urologist who is the one who normally deals with prostate cancer screening?
  3. If cancer cells invade the prostate, will this be prostate cancer, or will it be colorectal cancer (local recurrence), or does it matter?
  4. If cancer is eventually suspected, then how are they going to confirm it? Normally, confirmation would done with an ultrasound-guided 12- or 18-core needle biopsy with access through the rectum wall, but since DH no longer has a rectum, how would they manage to do a competent prostate biopsy?

roadrunner
Posts: 271
Joined: Sun Jan 12, 2020 8:46 pm

Re: Need advice: Margins were not clear

Postby roadrunner » Sat Jun 04, 2022 12:24 pm

Your husband’s case is obviously quite complex. As Riki and RR said, and as you know, positive margins increase the likelihood of local and distant recurrence. (I’m not qualified to express an opinion, but if it were me I’d ask how to minimize *both* of these related but somewhat independent risks.) That said, as Riki also said, everyone is different. Your husband has already experienced metastasis, so that’s an additional challenge. I salute you for getting the second look. The only thing I’d add at this point (perhaps obvious) is that it would be ideal for you and your husband to do any consults jointly and have a focused list of questions for the second oncologist going in. If you get a bad vibe or leave confused, I’d seek a third opinion. This may well be, as they say in the corporate world at the moment, a high-rigor point.
7/19: Rectal cancer: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (side effects/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 small growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
CT 3/22: Clear
Thoracic CT 5/19/22 Clear
6/20/22 TAE rectal polyp benign

jsbsf
Posts: 105
Joined: Sat Aug 24, 2019 6:01 am
Location: San Francisco

Re: Need advice: Margins were not clear

Postby jsbsf » Sat Jun 04, 2022 12:46 pm

Thanks everyone for the great feedback.

Peregrine, it is only CEA. His recent PSA was 1.1 which seems really good. The concern would be the colorectal cancer invading his prostate.

The oncologist who originally gave a second opinion back in 2019 is the same oncologist who we will be consulting with. It’s considered a follow-up. DH and I were talking last night about contacting yet a different cancer center such as MSK or City of Hope to get an opinion from them since we wonder if it’s even possible to get a prostate surgery which isn’t so intense should it come to that. We want to hear as many opinions and options as possible.

After almost 2 years he hasn’t had any distant metastases, and with the most recent scans and tests he was (downstaged?) to a more local tumor that had not spread. We have to wait to hear back from the team to get a more definite diagnosis / prognosis. According to the surgeon, he’s in really good shape. But I guess a surgeon won’t want to tell him he’s in bad shape after they were responsible for the surgery that likely left cancer cells behind.
DH 61
2019 4A t3 n2 m1a
8/23 C-scopy, 5+cm mass. CEA:4.1
9/16 MSS. MRI: 2 lvr mets: 2.7 & 7mm
9/30 Start FOLFOX 1-6
10/4 Lg lvr met ~3.7cm, pri tmr stable.
CEA: 10/13,12.5;10/27-12/8 btw 4.7 & 3.1
11/5 both lvr mets ~ 2/3 smaller.
12/17 PET: sm lvr met gone, remaining tmrs @10% of orig sz & actvty
2020
MWA 2/5, Lap resection 2/11
CEA: 3/1-5/31 btw 2.1&2.9
3/2 start FOLFOX 7-12
7/23-29 EBRT
10/2/2020 NED/W&W
4/2022 EUS-FNA,MRI: recur.;
5/2022:CT scan no mets

jsbsf
Posts: 105
Joined: Sat Aug 24, 2019 6:01 am
Location: San Francisco

Re: Need advice: Margins were not clear

Postby jsbsf » Sat Jun 04, 2022 2:17 pm

Riki,

I have followed your story over the years.

Was it suspected that the cancer that remained in the margin is the cause of the metastasis? Were they able to eliminate all the local cancer? I wasn’t sure if the chemo was successful at removing those cells or if you had another surgery to address that.

I am feeling like his case could be very similar to yours. DH responded very well to his initial FOLFOX. Unfortunately, it didn’t eliminate the primary tumor, nor did the follow up radiation. Without any feedback from the oncologist or other teams, we are trying to understand what we are dealing with so we can participate more in the decision.

Thank you
DH 61
2019 4A t3 n2 m1a
8/23 C-scopy, 5+cm mass. CEA:4.1
9/16 MSS. MRI: 2 lvr mets: 2.7 & 7mm
9/30 Start FOLFOX 1-6
10/4 Lg lvr met ~3.7cm, pri tmr stable.
CEA: 10/13,12.5;10/27-12/8 btw 4.7 & 3.1
11/5 both lvr mets ~ 2/3 smaller.
12/17 PET: sm lvr met gone, remaining tmrs @10% of orig sz & actvty
2020
MWA 2/5, Lap resection 2/11
CEA: 3/1-5/31 btw 2.1&2.9
3/2 start FOLFOX 7-12
7/23-29 EBRT
10/2/2020 NED/W&W
4/2022 EUS-FNA,MRI: recur.;
5/2022:CT scan no mets

Rikimaroo
Posts: 420
Joined: Tue Dec 20, 2016 8:48 pm
Location: Florida

Re: Need advice: Margins were not clear

Postby Rikimaroo » Sat Jun 04, 2022 2:27 pm

I have distant metastasis, but there not a concern. The local cancer is the concern, mine is currently invading bladder/prostate which is causing some pain with peeing, so I am on flomax right now. The distant mets can be managed but the primary is the real problem.

The cancer that was initially there in rectum was removed, but because of the positive CRM, cancer grew back in the area which is the biggest cause for concern. They were not able to eliminate all local cancer even after a second surgery with intraoperative radiation, the chemo did not work to remove all the cells unfortunately.

It has been an uphill battle and very tiring at that and I am 43. Everyday I wonder what is next, am I going to survive or can I be cured. Right now I am going back on Folfiri starting June 22nd to knock it back down because I have always been responsive to it. It is just tough to do because of weight loss and other side effects of the treatment. They have clinical trials for me as well and hopefully for your husband if it gets to that point.

Rikimaroo
RC T3N1M0 12/16
MSS - NRAS Mutation
Chemo Rad, CCR - W&W 5/2017
Recurrence 11/2017
CT Scan 11/2017 Liver Met 5.5cm Stable, Stage IV
LAR/Liver Resect 4/2018
Reversal 10/18
CEA highest 500, lowest .8 throughout process, waiting for latest
Recurrence left vesical/pelvic sidewall - 10/7/2019 resect perm bag,
CEA rise Feb/May 3.7, 8.8, 30, Recurrence in Pelvic
CEA 40 right now, but was 57, so folfiri to beat it back down.
Lots of chemo for the past 4 years.

roadrunner
Posts: 271
Joined: Sun Jan 12, 2020 8:46 pm

Re: Need advice: Margins were not clear

Postby roadrunner » Sat Jun 04, 2022 3:15 pm

Two things I’d add to this discussion: (1) I think it would be important to know why the surgeon got positive margins. Was there something about the site or tissue that was confusing or difficult? You reported that there were cells in the margin, but what do the specific features and details mean for local and distant recurrence risk/treatment? (2) I have seen that aggressive thoracic scanning is often recommended in this situation (positive margin upon rectal resection). Might be worth exploring.
7/19: Rectal cancer: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (side effects/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 small growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
CT 3/22: Clear
Thoracic CT 5/19/22 Clear
6/20/22 TAE rectal polyp benign

User avatar
Peregrine
Posts: 100
Joined: Tue Mar 01, 2022 1:18 am

Re: Need advice: Margins were not clear

Postby Peregrine » Sun Jun 05, 2022 9:26 pm

roadrunner wrote:...
I think it would be important to know why the surgeon got positive margins. Was there something about the site or tissue that was confusing or difficult? ...

I tend to agree with roadrunner's insightful comment above. In my opinion, the problem may have been the difficulty of doing a robotic surgery less than two years after DH's July 2020 EBRT course of radiation -- which may have structurally damaged the tissue in this area to such an extent that a clear incision with good margins couldn't be made.

Here is an article that briefly mentions this kind of problem:



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