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Solitary lymph node metastasis : what treatment is available?

sreekanth
Posts: 61
Joined: Apr 2017
Hi,
My latest PET scan lit up ONE lymph node in pelvic region (external iliac lymph node along right obturator chain). The lymph node in question is 1.2 cm x 1.6 cm (SUVmax=5.8 ). There were no other findings in the PET scan. It has been four years since my first rectal cancer diagnosis. The radiologist calls this a recurrence unless proven otherwise. I have no symptoms. How do I know if it is not some infection?

Has anyone been treated for a solitary lymph node metastasis? If yes, please share details.

Online scientific papers do not have a clear recommendation. Some predict poor prognosis. Some predict good prognosis. My oncologist is still evaluating my results with an interdisciplinary team

skb

Disease History:
3/21/17: Dx T3N0M0- distal rectal cancer, 4.5cm tumor, CEA <0.5
4/18 to 5/22/17: chemoradiation
6/28/17: clean biopsy
8/09/17: MRI - no primary tumor, starts wait and watch
8/17/17 to 12/1/17: chemo with Folfox and oxaliplatin
5/19 expanding right lung nodule, 8mm, CEA <0.5
8/19 VATS wedge
9/19, 12/19, 4/20, 7/20, 1/21- Clean CT, MRI, NED
7/17/21- Clean CT, MRI, CEA 15.6 !
7/22/21- CEA 17.3, god, what's up??!
8/02/21- Clean colonoscopy
8/12/21- PET - one hypermetabolic lymph node 1.6cmx1.2 cm (in pelvic region) !
SnapDragon2's picture
SnapDragon2
Posts: 582
Joined: Nov 2019

Find a top surgeon outside your "team" for a second opinion on surgery.

OnTheRoad
Posts: 29
Joined: Jul 2018

I am in a very similar situation at this moment. 2 lymph nodes with around the same size of yours appeared in a control CT I do from time to time. My CT was done last week.

The comments from my oncologist were:

- The "normal" size of a lymph node is around 1cm. Your (and mine) lymph nodes are not much larger than that, which means it could not be cancer, but an infection

- He requested a PET scan to be done 3 weeks from now. This means I will do the PET 4 weeks after the CT that perceived the enlarged lymph nodes. He says if the lymph nodes are currently enlarged due to an infection or other cause not related to the cancer they should have a smaller size when the PET is done. If they light up and are still about the same size (or larger) he will consider them as mets and then we will plan how to get rid of them.

 

sreekanth
Posts: 61
Joined: Apr 2017

I am having biopsy today of the lymph node

Trubrit's picture
Trubrit
Posts: 5509
Joined: Jan 2013

I hope it is a painless procedure, and all comes back negative. 

Tru

sreekanth
Posts: 61
Joined: Apr 2017

Hi Trubrit, the biopsy returned bad results. Positive for metastatic adenocarcinoma. I cried a bit with my wife. Still processing. Worrying. I dont know what treatment if there is available

sreekanth
Posts: 61
Joined: Apr 2017

Thank you OnTheRoad for sharing your story. It helps me understand how other physicians are treating this

sreekanth
Posts: 61
Joined: Apr 2017

 

sreekanth
Posts: 61
Joined: Apr 2017

Hi Wadsdan, the biopsy returned bad results. Positive for metastatic adenocarcinoma. I cried a bit with my wife. Still processing. Worrying. I dont know what treatment if there is available

SnapDragon2's picture
SnapDragon2
Posts: 582
Joined: Nov 2019

I read about your findings earlier and did a search of it.  It came back for different cancers (testicular and ovarian mostly) but surgery has been done for those.  Research more and hunt for a TOP surgeon willing to cut it out is my opinion.

sreekanth
Posts: 61
Joined: Apr 2017

Thank you SnapDragon for your kind advice

sreekanth
Posts: 61
Joined: Apr 2017

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

myAZmountain
Posts: 420
Joined: Apr 2018

I would do the surgery first and foremost. 

SnapDragon2's picture
SnapDragon2
Posts: 582
Joined: Nov 2019

I agree with myAZ.

Sometimes chemo disqualifies you from surgery (big ex: it wears the body down and a factor for surgery is being healthy enough to have surgery) and other times it just doesn't work and cancer spreads.

sreekanth
Posts: 61
Joined: Apr 2017

My oncologist says that cancer is in lymph node which means it could go anywhere from there and is probably circulating in blood stream. He says it is pointless to cut out one lymph node because you dont know where else  it might have gone . It might have gone to nearby lymph nodes, faraway lymph nodes or organs. Surgery will only get out one lymph node and he wonders whether it is worth the complications especially given that it does not guarantee that the cancer wont come back. He is advocating for strong chemo to get rid of as much cancer cells in the body as possible. If there is surgery and  chemo, he would do chemo only after the surgery and recovery from it. If we do the chemo first, he is concerned that the surgeon wont be able to locate the lymph node ( which is already too small, 1.2 cmx1.6cm )  would shrink further and become hard-to-locate. I am concerned that doing the surgery first, further delays chemo allowing cancer cells to circulate and spread :(. 

Real Tar Heel
Posts: 253
Joined: Nov 2019

I am maybe not the best example but on the last recurrence, given the choice to do chemo or surgery I chose surgery only. I was in remission a little longer than I was when I was on adjuvant chemo. The best part about that time was not having chemo. When we are counting the days, I place some importance on being able to experience those days. I don't know about lymph involvement from any personal experience but if they are worried about being able to see what they need to cut out I think that is pretty important.

I don't know why he's bringing in he word "guarantee" because none of us have that, especially those who have spread to distant organs, no matter which path we take. If he means there is a greater likelihood of success with one way or the other, maybe listen to his advice.

There are a lot of "ifs," but if you do chemo first and they can't find what they need to cut you've lost an option. If you do surgery first, you have chemo left to try. With most treatment standard of care, you have option B and C left as well.

sreekanth
Posts: 61
Joined: Apr 2017

Thank you for your perspective Real Tar heel. Chemo needs to happen regardless of whether the surgery happens or not.

beaumontdave's picture
beaumontdave
Posts: 1170
Joined: Aug 2013

I'm inclined to agree with doing the chemo, it's a percentage thing, but it really is the choice if you can handle it, and  the seeds of cancer are circulating. My course of Folfox didn't prevent the mets that popped up in my liver, 1.5 to 3.5cm, 2 1/2 years later, but who knows what was floating around elsewhere. I don't regret trying and dealing with the side effects, as they were relatively mild. Was able to work and function still. I'd at least try it........................................Dave

SnapDragon2's picture
SnapDragon2
Posts: 582
Joined: Nov 2019

He is right.  It's complicated and a gamble for sure.

Have you had the ctDNA testing and CTC?

sreekanth
Posts: 61
Joined: Apr 2017

No, I have not. The oncologist (whom I respect immensely) said I am sending messages to him through the intenet too frequently before he even gets a chance to think. I have heard of CtDNA but forgot to include it in the list of questions when I met him. Dont know CTC. 

SnapDragon2's picture
SnapDragon2
Posts: 582
Joined: Nov 2019

Well I am always up for surgery first over chemo.  Just my opinion.

Research the 2 tests.

OnTheRoad
Posts: 29
Joined: Jul 2018

I do also prefer surgery over chemo. Chemo is good when you have systemic disease, but very little effective when you have few and manageable mets (at least in some organs). I am also in a dire situation now with one suspect node in one lung + 2 suspect Lymph nodes... If the lymph nodes are clear I would surely go for a surgey to remove the "suspect" node in the lung. Just my opinion as well....

sreekanth
Posts: 61
Joined: Apr 2017

It is not a choice between surgery and chemo for me. I definitely plan to get the chemo.

The question is whether it is surgery+chemo or just chemo
If the radiologist says a radiation therapy is possible to that lymph node, I will get that too.

I want everything but my oncologist says it is pointless to remove one lymph node because once it is in one lymph node, it is circulating everywhere. Not just that, my lymph node is very deep in the pelvis and hard to locate. It is a difficult surgery and could leave one with post-surgical complications. I meet the surgeon only on Sep 15 . 

Trubrit's picture
Trubrit
Posts: 5509
Joined: Jan 2013

It is easy to hit the Submit button twice - I have done it so many times. When I do, I just return and hit Report as Inappropriate and let the moderators delete it. 

Another reason you get double posts is if you hit the < button instead of the Colorectal Cancer at the top of the page. 

You probably know all of this, but I thought I would butt in, becasue that's what I do. 

Tru

sreekanth
Posts: 61
Joined: Apr 2017

Thanks, I followed your suggesion regarding this

sreekanth
Posts: 61
Joined: Apr 2017

My treatment plan is set. Surgery first to remove the lymph node, chemo follows

SnapDragon2's picture
SnapDragon2
Posts: 582
Joined: Nov 2019

Wonderful news!!!!

The chemo part sucks but gotta huh.

OnTheRoad
Posts: 29
Joined: Jul 2018

I am glado you now have a plan, Sreekanth. As I might have a similar case that you have, I made some research and Surgery + Chemo look the be the right path moving forward. I hope you success on your surgery.

Do you already know which chemo you are getting moving forward ?

 

sreekanth
Posts: 61
Joined: Apr 2017

Not sure of of my chemo cocktail yet. My oncologist had suggested FOLFOXIRI before my plan for surgery was set. He will see me a month after my surgery to set the specific chemo.

OnTheRoad
Posts: 29
Joined: Jul 2018

Hello, Sreekanth,

I got my surgery booked for next week. They are going to remove the 02 lymph nodes and then I will have chemo again if the biopsy of the lymph nodes comes as positive (as it will probably come). 

Have you removed your lymph node yet ? Are you ok ? How is the recovery doing ?

It looks like my onc will want me to take Folfox again, but I still need to talk with him after surgery is done.

My best wishes for you on your recovery !

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Annabelle41415
Posts: 6722
Joined: Feb 2009

I'm sorry that I've got no knowledge of what you are going through.  It's good to know that you have a path forward and you can see your journey to healing on the way.  Wishing you the best going forward and please let us know how you are doing.

Kim

sreekanth
Posts: 61
Joined: Apr 2017

Thank you Kim for your kind message.

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