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  • Biopsy Opinion

    Hello all!

    I have recently joined the TC club (as of December 2017) and have found this site a few weeks ago. I've seen a lot of great info posted from some of you and was hoping you could help me wade through some of it with me.

    I was diagnosed at an annual physical appointment at the end of November and quickly had an ultrasound and inguinal orchiectomy (12/7/17) to remove the left testicle. Pathology of the testicle reviewed pure seminoma. I had no tumor markers in the bloodwork at any time.

    After CT scan, an enlarged (4cm) L iliac lymph node was discovered and a follow-up PET scan indicated cancer. I had a lymph node biopsy completed on 1/24/18, with a diagnosis of metastatic malignant germ cell tumor. The biopsy report states, however, "We cannot further sub-classify the metastatic germ cell tumor, and based on the immunohistochemical findings, cannot rule out the possibility of a non-seminomatous germ cell component"

    I am scheduled for 3xBEP chemotherapy on 2/26/18, as I believe this would be the standard treatment for nearly all of TC tumor types. My concern, however, is that my doctor was not able to really communicate what about the immunohistochemical findings point toward non-seminoma, how likely is it that it is non-seminoma or what types of these TC tumors are indicated. How important is it that we know these things and if the biopsy was inconclusive, is there anything else to be done to find out?

    My immunohistochemical results are below. Does anyone who has done research on these markers know what tumor types might be indicated? If I have a Stage 2b non-seminoma cancer, are any of the treatment plans different from standard 3xBEP?

    OCT 3/4 - positive
    Sall4 - positive
    PLAP - focal positive
    Pancytokeratin - focal positive
    CD30 - positive, week to moderate
    CD117 - negative

    Thank you all for listening. For me, making these decisions is the most difficult part of this entire process.

    Dave


  • #2
    3xBEP for non seminoma is the normal and correct course of action. The cell type isnít all too important at this time since the treatment is pretty much the same no matter what unless it was all teratoma. Teratomas just need removed surgically.
    3/29/17 Diagnosed 100% Embryonal 4/10/17 Left I/O CT scan shows a few suspicious lymph (biggest 1.9 cm) 5/8/17 - 7/3/17 3xBEP 7/20/17 CT Scan Clear, AFP has uptick to 19 8/16/17 AFP Drops in half to 10, ALL CLEAR! 11/16/17 All Clear! AFP continues to drop! 3/19/18 All clear!

    Comment


    • #3
      Ditto, without any tumor makers 1 would assume seminoma. However, if they are unsure then the treatment should default to non seminoma either BEP or in some cases where lung issues would hinder you. Say world class marathon runner or professional scuba diver then its EP. But yes BEP is the 1st line chemo per say.
      Last edited by eodtech2001; 02-12-18, 08:44 PM.
      Jan 2012- U/S mass in Left testicle
      Feb 2012- I/O performed to remove cancer
      Mar 1,2012- pathology pure seminoma
      Mar 7, 2012 PET SCAN stage IIa
      April 2012 Mayo clinic carbolite.
      May 2012 carbolite failed, started BEP x3
      August 7th 2012- BEP complete
      April 2013 CT/PET show relapse
      May 2013 RPLND
      Aug 2013 Relapse again Started VIeP x2
      Oct 2013 HDC AUTOLOGOUS
      Dec 2013 HDC completed CT/PETSCAN 1.1 cm x .8 cm right lower lung lobe
      Feb 2014 confirmed false positive all clear FINALLY !
      Jan 2015 1 year cancer free Pet/CT scan
      Jan 2016 2 years cancer free "Pet/CT scan
      Jan 2017 3 years cancer free "Pet/CT scan
      Jab 2018 4 years cancer free "Pet/CT scan, labs, xrays

      Comment


      • #4
        What makes them think your cancer went from Seminoma to non seminoma? I don't know the exact statistic but from what I understand cancer doesnt change from seminom to non seminoma almost ever (if ever).

        Comment


        • #5
          Originally posted by DaveMan View Post
          OCT 3/4 - positive
          Sall4 - positive
          PLAP - focal positive
          Pancytokeratin - focal positive
          CD30 - positive, week to moderate
          CD117 - negative


          I can't say I've ever heard of any of those tests, & certainly not in conjunction with TC I'm 100% positive I've never had one of those tests. That said, you have an enlarged node. If it is seminoma the only other option besides 3xBEP would be radiation (seems to be falling out of favor most places). RPLND is sometimes an option, but I wouldn't choose it personally. I'd be paranoid they missed a micro-met somewhere.
          3xBEP will cure you, doesn't matter what type of TC it is.

          Dave
          Jan, 1975: Right I/O, followed by RPLND
          Dec, 2009: Left I/O, followed by 3xBEP

          Comment


          • #6
            Originally posted by StaticX View Post
            What makes them think your cancer went from Seminoma to non seminoma? I don't know the exact statistic but from what I understand cancer doesnt change from seminom to non seminoma almost ever (if ever).
            Thank you all for the quick replies!

            The uncertainty comes from the biopsy of the lymph node. I believe the sample was too small for them to get a good read on the specific cancer cell type, but the chemical staining they do (listed above) must have some indicator that it MAY not be entirely consistent with pure seminoma, but my doctor was not able to elaborate. The pathology of the testicle was pure seminoma, however. From some of the research I have done, several of these indicators strongly indicate a germ cell tumor as opposed to other cancers, but both seminoma and embryonal carcinoma may be indicated. My "research" is simply reading various test studies of these indicators, but sample sizes are small and its hard to know if any of those specific tests are the consensus opinion.

            That's where I was hoping some of you had more experience with those chemical stainings. I know we're not doctors, but many of us are taking crash courses in our free time now.

            Comment


            • #7
              As Dave said 3xBEP will cure you. I donít really recall anyone on this forum not be cured from original stage 2. (Some have needed more than others) just keep in mind after these next two months youíll be cured and can move on from this experience.
              3/29/17 Diagnosed 100% Embryonal 4/10/17 Left I/O CT scan shows a few suspicious lymph (biggest 1.9 cm) 5/8/17 - 7/3/17 3xBEP 7/20/17 CT Scan Clear, AFP has uptick to 19 8/16/17 AFP Drops in half to 10, ALL CLEAR! 11/16/17 All Clear! AFP continues to drop! 3/19/18 All clear!

              Comment


              • #8
                Typically a biopsy of an enlarged lymph node is not taken due to the fact that it is more than likely the same type of tumor that was in the testicle. That's where I got confused, more as to why they would even take a biopsy in the first place.

                Comment


                • #9
                  Hi DaveMan,

                  Welcome to your TC PhD program!
                  What I know about immunohistochemistry could fit in a thimble, with enough space left over for a thumb. I've seen a few references to these immunostains here and there (especially PLAP) but didn't pay much attention because I'm more of a population science guy than a cell guy.

                  This article may help:
                  https://www.ncbi.nlm.nih.gov/pubmed/24832161
                  Ulbright et al. (2014). Best practices recommendations in the application of immunohistochemistry in testicular tumors: report from the International Society of Urological Pathology consensus conference. American Journal of Surgical Pathology 38:e50-59.

                  I'm intrigued by the term "immunoconfusion" in the abstract.
                  I'll have to read more, but I suspect that "immunoconfusion" is when the immunostains don't unambiguously identify which type of tumor you have, that may be why there's not a definitive answer.

                  In any event, I'm a rank amateur, and you deserve a better explanation from your doctor.
                  Painless lump 5/18/2017
                  Orchidectomy June 2017 (4.5cm, rete testis involvement)
                  Chemo Summer 2017 (2x7AUC carboplatin)
                  No evidence of relapse since, but plenty of anxiety about it.

                  I'm also an epidemiologist, and a professor at a medical school (with NO training in oncology), oh, and gay, too.

                  Comment


                  • #10
                    It is my understanding that an iliac node is rather uncommon unless you have had previous scrotal surgery so I suppose I could see the desire to do a biopsy. The chemotherapy treatments, whether is is seminoma or nonseminoma for stage II disease are not any different as others have noted. As long as they are sure that it is a germ cell then perhaps I would not be too worried. However, you do have a few weeks before chemotherapy starts and could always ask for a second opinion of the biopsy (I don't know where you are being treated or how experienced the pathologists are with testis cancer). An option for a second opinion would be Dr. Ulbright at IU and his contact number is on our friends at the TCRC page at: http://tcrc.acor.org/experts.html

                    Mike
                    Oct. 2005 felt lump but waited over 7 months.
                    06.15.06 "You have Cancer"
                    06.26.06 Left I/O
                    06.29.06 Personal Cancer Diagnosis Date: Got my own pathology report from medical records.
                    06.30.06 It's Official - Stage I Seminoma
                    Surveillance...
                    Founded the Testicular Cancer Society
                    6.29.13 Summited Mt. Kilimanjaro for 7th Cancerversary

                    For some reason I do not get notices of private messages on here so please feel free to email me directly at mike@tc-cancer.com if you would like to chat privately so as to avoid any delays.

                    Comment


                    • #11
                      I was torn about doing the biopsy myself. My doctor said there was a 98% chance that it was cancer and very likely TC, so my initial thought was "then why bother with the delay and risk?" I finally asked him what he would do, and he said he'd have the biopsy so I agreed. I think the fact that the iliac node is a bit uncommon did weigh in on the desire for confirmation, as with Stage 1 seminoma they would probably just observe if it was found to be something other than cancer or perhaps a different treatment if a different cancer was found.

                      I appreciate all of your responses as it does help put me at ease a little more.

                      Comment


                      • #12
                        If you need to get a 2nd read of pathology as Mike suggest from IU. Include both orchitecomy and lymph node.
                        Son Grant
                        dx 12/21/16 at age 17

                        BEP x3
                        Post Chemo CT Scan on 3/28/17 still showed a few nodes over 2 cm
                        2nd Post Chemo CT Scan on 4/27/17 showed all nodes still over 2cm
                        Post Chemo RPLND 5/8/17: Periaortic Teratoma, Intraaorticaval Teratoma, and Paracaval Teratoma found.

                        Comment

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