We just found out that P53 and Ki-67 are two gene expressions that my mom has. So it appears that notwithstanding her MSI suggestive and lymphocytic response as well as no lymph nodes, she will probably need to proceed with chemotheraphy (due to P53 and perforation). Dr. Lenz had mentioned that the standard of care is FOLFOX? – Is that the same as 5-FU?

Thanks.

Thanks and you are right. It is time to wait and see. We actually found one or two hospitals here which can perform MSI determination test. Also, I mistook the perforation indication to be tumor not colon – my mom’s perforation seems to be in the tumor itself (macroscopic tumor perforation) and not in the colon? Does that make a difference? In any case this is not going to be an easy decision. My mom now seems to recall that my grandma (her mother) had adverse result from her chemotherapy about 11/12 years ago; she was almost 80 when it was diagnosed and it was terminal stage colon cancer. And if she had not had the treatment her prognosis was not too bad given the stage. But then she received chemotherapy which was not good right after the first session. That may be another fact we need to take into consideration.

But yes, it is a tough one.

This is a complex combination of high and low risks. There probably isn’t one simple solution.

Do the doctors have a recommendation?

They seem to be looking further right now.

Let’s wait for the tests and then mask decisions when all the evidence is in.

I know it is hard.

Thanks for your message again. I really appreciate all your time and input. I am living in Taiwan now and unfortunately (although we will keep checking) we cannot seem to find a hospital that would perform the immunohistochemical testing. I am not sure what other test they are doing to my mom now it could be another genetic testing, so maybe that will provide some other clue. I will also keep checking to see if anywhere can do a test for loss of MLH2, MSH2 and MSH6 for her or blood test for mutations of these genes.

If that is affirmative – which would mean she has Lynch colon cancer, what would your recommendation be? I believe her report says the perforation is low /partial(?) (which is still a yes I think) and which would still put her in the high risk group right? Gosh, there is just no sure win-win situation here. If she is MSI and has lymphocytic response (and/or also Lynch) yet her tumor is perforating and partially obstructing, which would make her tumor high risk, I would imagine most people may still proceed with chemotherapy?

Thanks.

One more clue! Intratumoral lymphocytic response is a good thing.

It means that the immune system reacted to the tumor and moved into the tumor itself, ideally to destroy cells.

Immune system response is not common in cancer. While the immune system recognizes bacteria or viruses as “bad outsiders” and mounts a response to destroy them, it is puzzled by cancer. Cancer isn’t exactly an outsider, so it takes something extra to get an immune response.

MSI cancers and, particularly those related to inherited Lynch syndrome, more often exhibit immune response by having lymphocytes (white blood cells) inside the tumor.

I strongly suggest that you find someone who can do some genetic testing of the tumor for loss of MLH2, MSH2, or MSH6 expression. Or you could have your mother’s blood tested for inherited mutations in these genes.

Was there actual perforation of the colon — a hole that allowed feces and possibly cancer cells to spill into the abdomen? That would make a difference and make the tumor high risk.

Otherwise, the MSI and lymphocytic invasion move it toward low-risk, with the possible risk that 5-FU might lower survival.

A tough call.

In what country are you?

Good luck.

Sorry for my confusing question. The testing done here does not determine the amount of MSI it only says “histologic features suggestive of microsatellite instability” and that she has mild to moderate intratumoral lymphocytic response (0-2 per high-power field). But her tumor was 4 cm, not 4.5, but perforating and partially obstructing. They are doing one more test for her but it seems that her stage is so conflicting from everyone we hear from. I know you cannot make the decision for us – but if you would recommend one thing, do you think we should have her perform the immunohistochemical testing somewhere that renders it? Thanks again for all your advice/comments.

It is really hard to know what is meant by genes that are “antibodies”. Genes are usually not talked about in that way.

So I am puzzled.

So I can’t really answer your question. It is one that her doctor should explain further to you.

There appears to be nowhere to perform the immunohistochemical testing you mentioned last week in my country. In the absence of that information, given her MSI – H and no lymphnodes but slighly obstructing tumor (about 4.5cm), based on Dr. Marshall’s webinar, it still appears that chemotherapy may not be recommended. My mom has some genes that are in fact supposed “antibodies” of her colon tumor. However, given that she has one of the high risk factors, we may still proceed with generic chemotherapy (adjuvant) (without the targeted therapy). Is there any possibility that the chemotherapy could potentially kill those antibodies and make her even more vulnerable to recurrence?

That is good to know really…and thank you for sharing your own experience. Thank you…..although nothing is certain and everyone is different, just to know that you lived for 28 years after made me feel so much better….my grandma (on my mom’s side) had colon cancer and died of colon cancer b/c it was terminal stage. I would imagine it is hereditary and probably likely Lynch. But I cannot seem to find in the pathology report anything about the missing protein expression of MLH1, MSH2 or MSH6. Is it a very problematic or invasive test to do? Will it be doable given that she is still recovering from surgery slowly?

Thanks.

An obstruction is one of the high risk features that may call for chemotherapy.

So your mom’s case is a little more complicated.

However, one more test (which already might have been done when they determined that the tumor was MSI-H) can give you some important information.

Some MSI cancers are caused by an inherited mutation. These can be very large and obstruct the colon because they grow quickly. The pathologist can look for missing protein expression of MLH1,MSH2,or MSH6.

These are a clue to an inherited cancer called Lynch syndrome. Although there is usually a family history of uterine or colon cancers in Lynch families, there does not need to be.

If your mother’s tumor lacks expression of one of these genes, she should get some genetic testing to see if her tumor is an inherited one.

If so, she’ll need closer follow-up and you and any other children should be tested for that gene too.

Check the pathology report to see if there was immunohistochemical testing for MLH1,MSH2,or MSH6. If not, arrange for it. It’s important.

While this is scary, Lynch syndrome cancers have excellent prognosis. I’ve lived 28 years since my own first Lynch colon cancer (which did obstruct!)