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Investigatory modalities

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

To Jeff, in particular:- your thoughts on the following would be appreciated - interpretation, significance, follow-up etc. and, in particular what types of scan, or other investigation you think might be sensible.

Clinical History:

Right nephrectomy for high grade sarcomatoid T4 renal cell carcinoma. Level 4 follow-up. Single met at first post op CT (3/12) - 1cm. Removed at surgery 4 weeks later measured at 2.5 cm. Histopathologically complete excision. Seroma only at initial CT follow-up. Close follow-up (Level 4) : FOR EARLY SEPTEMBER 2012 PLEASE

CT Thorax & abdo & pelvis with contrast:

Chest: The lungs are clear apart from chronic scarring at the bases. No lymphadenopathy in the chest.

Abdomen and pelvis : Liver, spleen, pancreas and remaining solitary left kidney remain free of metastatic disease.

The previously noted fluid collection at the site of the right nephrectomy is no longer demonstrated although there is some residual soft tissue thickening present. However, there is now a further encapsulated fluid collection with peripheral enhancement, measuring approximately 2.5 cm. x 1.8cm. , lying within the right anterolateral abdominal wall just adjacent to the anterior and inferior aspect of the liver, close to the gallbladder. In retrospect, this was visible before but was indeed hardly measurable.

The retroperitoneal lymphadenopathy has slightly increased with a necrotic appearing aortocaval node measuring at least 1.5 cm. In short axis diameter. Although this may be reactive, metastatic involvement cannot be entirely excluded.

No other evidence of any convincing metastatic disease.

Opinion: Increase In size of a fluid collection in the anterolateral right abdominal wall (differential diagnosis necrotic metastatic lesion) and retroperitoneal lymphadenopathy.

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

So we start with the good part....The CT Chest is normal.
In the Abd and Pelvis CT....If there was a fluid collection which is now showing to be a soft tissue mass which is enhancing, that would mean it is now vascular and as stated at the end of the report using the words differential diagnosis....necrotic metastatic lesion means this is what the Radiologist "thinks" it is. He's not swearing to it, but he's putting it out there as something to be concerned about. I would guess that the best combination of exams needed to rule out everything would be a CT/PET scan. Most centers have these machines now. They look like a Cat Scanner but the gantry is double in length. (the area where you lie). The end result is to be able to superimpose the CT scan on to the PET scan. Very colorful, and very informing. I think this would probably be the best way to go. It's very hard for me to say for sure. A bit out of my league. Depending on the oncologist, possibly an MRI of the Abdomen and Pelvis with and without gadolinium. Hope that helped a little.
Jeff

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

Jeff, thanks so much for your thoughts and for responding so unbelievably swiftly!! I'll be getting the well-considered advice of my MDT at a clinic tomorrow and may well want to trespass further on your good nature when I have their recommendations. The hospital has all types of scanner so they may well be thinking of further scans with different technology. The notion of a superimpose is new to me and sounds fascinating.

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

You know we always joke how wiki has taken the place of the World Book Encyclopedia, but in this case it has a really nice explanation of a PET/CT scanner. Even some understandable images you can click on to see what I mean by the superimposition of the CT scan on to the PET. You might find it interesting. Here's the link

http://en.wikipedia.org/wiki/PET-CT

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

Thanks again Jeff - most interesting. I wonder if we have one of those available and if so whether they'll consider use of it appropriate - I guess I'll find out tomorrow!

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Let me know, and good luck with everything tomorrow

Limelife50's picture
Limelife50
Posts: 411
Joined: Nov 2011

Good luck today

DMike's picture
DMike
Posts: 239
Joined: Nov 2011

TW,
I'll be thinking about you and sending lots of positive thoughts your way. Good luck today!
--David

angec's picture
angec
Posts: 626
Joined: Mar 2012

Hi TW, i am thinking the report doesn't sound too bad. From what I can tell, not an expert, but the node isn't too large at all and the mass shows as fluid. But i am surprised that more people are not given the ct-pet scan. They do a complete whole body scan on mom. I understand quite a bit of time the femur gets involved which is what i was told so thus the whole body ct-petscan with contrast. I know things will go well for you tomorrow. Praying for you and keeping positive, you do the same! Please keep us posted.

alice124's picture
alice124
Posts: 860
Joined: Mar 2012

Will be thinking of you tomorrow. To you and NED. . .

foxhd's picture
foxhd
Posts: 1951
Joined: Oct 2011

Best of luck tomorrow, Wedge man. I'll be checking posts often.

pjune127's picture
pjune127
Posts: 127
Joined: Dec 2011

Thinking of you and sending prayers and light from Atlanta. I (along with many others) will be waiting to hear GOOD news. Rest well tonight.

XO Paula

I am alive
Posts: 224
Joined: Jul 2012

Wedge,
Your steady presence, thoughtful posts and obvious concern for all of us out here in cancer land provides us comfort and a kind of shelter. Oh that we could provide the same for you! Know that we're thinking about you and radiating all kinds of positivity! Feel it?

garym's picture
garym
Posts: 1651
Joined: Nov 2009

Tex,

I can't think of a thing to add to everything above, but know that I am pulling for you today and I know that you are up for any challenges that may lie ahead.

Godspeed,

Gary

adman's picture
adman
Posts: 267
Joined: Jul 2012

God Bless!

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

Thanks everyone for your good wishes - what this forum is all about!

Good discussion today and my Wife and I left relieved that it went exactly as we expected and better than some of the apprehensions at the backs of our minds! Scarring at base of lungs is of unknowable origin, trivial and can be safely ignored. Lymphadenopathy needs to be monitored and so I'm being scheduled for a CT/PET scan, or just a PET scan, as a matter of urgency. (I didn't mention the advice I've received on forums, but the plan accords with what Jeff had suggested and also Susan Poteat and Gautam Sakya on ACOR).

If anything more appears on the next scan, we'll re-appraise the strategy, otherwise we'll proceed at once with a third open surgery to remove the encapsulated fluid accumulation. That will be the third tumour removal in less than a year so I'm thinking of asking for a de-bulk discount :)

I might get the next carve-up on my 70th birthday but I'm still fit and strong enough that the op should be a cinch and I expect to bounce back rapidly. I'm playing golf early tomorrow and told I should continue rowing, weight-lifting etc and keep in good shape. The tumour is becoming a bit uncomfortable but I'm happy that I won't be needing any adjuvant therapy for the foreseeable future, so can keep my immune system up to scratch.

We learnt a little more today. It's known that Chromophobe is reluctant to metastasise but I'd believed that sarcomatoid de-differentiation was a game-changer and all bets would be off on metastasis. However, I'm told that sarcomatous manifestation, in common with actual sarcomas, entails a disinclination for the crab to get around - it tends to stick to base with local, rather than distant recurrences. It will tend to move sideways rather than swim away in the bloodstream or the lymph system.

[Gary, I've always feared I'm abnormal and I guess it's unusual for a bat to be attacked by a crab, isn't it? Also makes me wonder about having a PET scan!]

alice124's picture
alice124
Posts: 860
Joined: Mar 2012

Tex,

Your relief resonates in your posts, and I'm thrilled for you. I know today was just one battle, but you'll win the war. You've got an army on your side.

foxhd's picture
foxhd
Posts: 1951
Joined: Oct 2011

I like all your assessments and plan of care. Particularly surgery. We are like each other in activity levels and also our excellent recovery from medical procedures. I say go for it. I know I would. Go for gold.

angec's picture
angec
Posts: 626
Joined: Mar 2012

Hey TW.. i think all went very well for you today!! The only thing i am wondering, if you don't mind. They are removing fluid or a tumor? Is it cyst like then? Is there no way to drain it other than surgery? Just asking because i remember someone else having that and they actually were able to drain it. But in any case, I am sure the nurses will bring you in a wonderful cupcake for the 70 year mark and you will be out playing golf before long!

I also thought that bit of information about the way your particular cancer travels across is noteworthy. That has to settle you a bit,i know it did me. All in all, I think everything is positive at this point and will continue that route. Looking forward to hearing about the scan, will it be full body?

What is that site you quoted as ACOR? I am not familiar with it, do you have the full URL available? I will check it out.

Sending love and positive thoughts to everyone!

adman's picture
adman
Posts: 267
Joined: Jul 2012

http://www2.acor.org/

angec's picture
angec
Posts: 626
Joined: Mar 2012

Will be looking at that site today....

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

You must drive your doctors crazy walking in with the amount of RCC knowledge you have. I'm sure when you leave they're feeling they owe YOU a co-payment. So glad your plan is in tact. Great news.

Jeff

DMike's picture
DMike
Posts: 239
Joined: Nov 2011

Tex,
I'm very happy to see you have a plan in place. I wish you the best!

Also, thank you for the new (to me anyway) information on sarcomatoid de-differentiation and metastasis. That is very interesting to me. It would be good to add that to the sarcomatoid thread.
--David

Limelife50's picture
Limelife50
Posts: 411
Joined: Nov 2011

i have been promoting PET scans for a little while ,sometimes i get the feeling my opinions are overlooked,anyways good luck Tex

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

True, Mike, and I think we also shouldn't overlook what an icon Fox is for PET scans (and CT and MDX-1106 and exercise and junk food and Harleys and ATTITUDE and ... )

ClaraW
Posts: 64
Joined: Jun 2012

TW, All the best with your scans and your upcoming surgical treatment. You're intelligent, well-learned, obliging and so selflessly helped so many including myself.
I know we cannot thank you enough!
If there is anything i could be of service, please let me know. Although my knowledge is very limited compared to yours, I still remember a thing or two regarding medicine and surgery from my school days.
Kind Regards,
Clara

garym's picture
garym
Posts: 1651
Joined: Nov 2009

TW,

While you may very well be considered as abnormal by most of the "normal" world, you fit right in here and we are far richer for your presence. I dare say your postings rank at or near the top of everyone's favorites, old-timers and newbies alike. What a great excuse you now have for feeling a little "crabby" once in a while, there are days when that will come in handy I should think.

I have used the analogy of Christmas and surgery many times over, and I think it works just as well for birthdays, this may be the greatest gift you ever receive. I pray that it is the last time you are carved upon and that on you 90th you are still golfing, rowing, and continuing to bless this site with your insight, research, and wit.

Godspeed my friend,

Gary

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

Such a nice bloke, that Gary! ;-)

alice124's picture
alice124
Posts: 860
Joined: Mar 2012

Well said Gary. Let me piggyback your words.

ClaraW
Posts: 64
Joined: Jun 2012

Spot on! TW, I will be reading your posts and wishing you happy 99th!
Best wishes. Hope your discomfort will resolve in no time.

Max Power's picture
Max Power
Posts: 60
Joined: Sep 2012

I had a dream the other night where I was gripped by a giant blue-crab claw - couldn't close the claw because there were rocks in the way.

I woke up thinking "What was that all about?" but now I realize I've read your other references to crab and that explains it. Case closed!

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