Mucinous cystadenocarcinoma recurrence

[marie3B]

I have posted before while I was on the Avastin Folfox chemo.  I have mucinous cystadenocarcinoma found at stage 3B/C in June of 2007.  Primary site was originally diagnosed as ovarian, but was questioned as possible GI origin by University of Chicago.  Recurrence was treated with the Avastin/Folfox but had tumor growth after 6 cycles.  Tumor was successfully removed sugically from near the portal vein.  During the surgery samples were taken.  I have a nest of neoplastic cells by the pyloris.  My cancer is a slow growing grade 1.  Would you try chemo again even though grade 1s are not very responsive to it, or wait and see for a while??  If you would treat, what chemo would you try?  Thank you,  Marie

[Kamal S Saini, MD, MRCP (UK), DM]

Dear Marie,

Your immunohistochemistry (IHC) shows CK7 and CK20  to be strongly positive, and CDX2 weakly positive. IHC is often used to distinguish between tumors that may have similar morphological features. For example, metastases from ovary and colon may look similar under the microscope. IHC may help in such situations.

IHC of ovarian cancers usually tests positive for CK7, and negative for CK20. IHC for colon cancer usually tests positive for CK20, and negative for CK7. CDX2 may be positive in colon cancers.

If you have colon cancer, then K-RAS mutation testing is advisable to predict if you will benefit from a monoclonal antibody called cetuximab (Erbitux). This may be given to you in combination with FOLFIRI chemotherapy (similar to FOLFOX, but oxaliplatin is replaced with irinotecan).

I suggest that you should get a PET-CT done, along with histopathological review and additional IHC markers (like CA125, CEA, vimentin, Ca 19-9, HAM56). Discuss with your oncologist if you are a candidate for CyberKnife therapy.


See these links for more info (contain medical jargon):

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1731190&blobtype=pdf
http://www.slideshare.net/aalamaram/80508algorithm?type=powerpoint
http://linkinghub.elsevier.com/retrieve/pii/S004681779890065X

Please ask me any follow-up questions or clarifications, and I will be happy to discuss.

All the best, and God Bless!

Kamal

[Kamal S Saini, MD, MRCP (UK), DM]

Hi Marie,
Thank you for your kind words.
Please enjoy your chemo-holiday, and I hope you recuperate well.
I look forward to your update after you meet your oncologist.
Good Luck,

Dr Saini

[marie3B]

I cannot thank you enough.  The CT is scheduled in September.  The oxaliplatin was hard for me to tolerate.  I hope anything new she tries will not be as bad.  I will ask my onc about the other markers you mentioned.  She did send out my sample for the k-ras test.  Those results are not back yet.  I am ER and PR negative.  Also neg for brca1 & 2.  I will let you know what she decides to do with me next month.  For now I will enjoy being off treatment and finish healing from surgery.  You have helped me so much.  Thank you again.  Marie

[marie3B]

I found more info.  Rectal lesion positive for CK7, CK20, and CDX2.  Ovarian tumors positive strong for CK7, CK20 and weakly positive for CDX2 suggesting possible GI origin.  Marie

[marie3B]

CA125s do not work for me.  Mine was 1.7 at the time my recurrence was diagnosed.  They have also been drawing CEAs, but those have not been out of the normal range either.  I asked about the C19-9, but she hasn't checked that.  Is that what you meant about the immunohistochemistry?  I have tried to learn as much as possible about all this, but have a long way to go yet.  Marie

[marie3B]

Path report says:

Final Pathologic Diagnosis

A.  Peritoneal mass, biopsy:  Extrvasated mucous; no viable tumor cells identified
B.  Pylorus, biopsy:  Extravasated mucous with small nest of neoplastic cells (within the pool of mucous are small aggregates of neoplastic epithelial cells)
C.  Falciform ligament, biopsy:  Extravasated mucous; no viable tumor cells identified.
D.  Portal triad mass, excision:
        1.  Metastatic well differentiated (grade 1) mucinous cystadenocarcinoma (4 x 2.5 x 2 cm)
         2.  Tumor appears to be replacing a lymph node.
E.  Portal lymph node, biopsy:  negative for metastatic carcinoma (0/1)
F.  Gallbladder, excision:
          1.Cholelithiasis
           2.  Mild chronic cholecystitis

This is from the only report I have.  I don't know what the immunohistochemistry is.  I have never been shown anything that has that word on it.

The last scan I had was in June.  It showed the tumor near the liver had grown while on the folfox/avastin.  It also showed the rectal thickening where I had active cancer found by colonoscopy had resolved.  Nothing else showed up.

As far as being symptomatic, I have had nothing new.  I just have the bowel trouble that I have had for years.  I also have left-over seffects from the chemo, but nothing like new pain or bleeding.  I have never has ascites and still don't.

My onc mentioned testing for a Kras mutation (I hope I got that right)  I had never heard of it.  She is scanning me again in September and then trying to figure out what to do next.

I hope I have given enough info.  I appreciate your help.  I don't know what I should be doing now, if anything.  
Marie

[Kamal S Saini, MD, MRCP (UK), DM]

Hi Marie,
Before commenting, I request you to provide the histopathology and the immunohistochemistry report to me.
What does the latest imaging show?
Do you have any symptoms right now?

[marie3B]

My first chemo was Cisplatin and Taxol, I/V and I/P.  I was stable for 10 months after that.  Marie