Pathology a bit unnerving...

[Joe.shupe22]

Multiple tumors, multiple types. Heres a direct copy word for word of the summary, not sure how I feel other than nervous....

There are at least 4 separate tumor nodules: 1) one pure embryonal carcinoma, 2.1 cm in greatest dimension which invades the rete testis and superficial hilar soft tissue associated with hilar vascular invasion, 2) one solid classic type seminoma, 1.0 cm in greatest dimension, in the superior pole, 3) one classic type seminoma, 0.5 cm in greatest dimension, inferior pole hilar predominantly intratubular with interstitial and pagetoid rete infiltration, and 4) one 0.9 cm inferior subcapsular pole nodule composed of intratubular embryonal carcinoma. Multifocal tumors and epididymal cribriform epithelial hyperplasia are associated with an increase risk for contralateral germ cell tumor formation.

[RJKD]

There's nothing unnerving to me when I look at that pathology. It's not uncommon to have multiple tumors in the testicle. Personally, I would do either RPLND or 1 x BEP, but surveillance is still a very viable option here.

[Joe.shupe22]

Thanks for the encouragement. The thought of pure ec just seems a bit scary to me

[RJKD]

Since you have seminoma elements, this is technically not pure EC. Now, one of your tumors is pure EC so I wonder if this should be treated like a pure EC case. That's a question for the great Einhorn. I suspect you'll be given a percentage of EC less than 100% because of all the other tumors there. I had two tumors, but when they did the pathology they gave me 80% EC. I'm not sure how they calculated that though.

[Davepet]

My understanding is that with any percentage of non-seminoma, the entire case is treated as non-seminoma.

Dave

[RJKD]

My understanding is that with any percentage of non-seminoma, the entire case is treated as non-seminoma.

Dave

Yes that's absolutely correct. The question I have is how much of this case would be treated as a pure EC if one tumor was pure EC but other components are non-EC. I suspect this will be treated as a non-pure EC case though.

[Davepet]

I'm unaware of any difference in treatment between a mixed cell case and a pure EC case?

[RJKD]

I'm unaware of any difference in treatment between a mixed cell case and a pure EC case?

The only difference is in trying to determine the relapse rate.

[Davepet]

I always assumed the potential relapse rate was the same if any EC content was present. Why would 1cm of pure EC be any more likely to spread than the equivalent of 1cm of EC in a mixed tumor?

[RJKD]

I always assumed the potential relapse rate was the same if any EC content was present. Why would 1cm of pure EC be any more likely to spread than the equivalent of 1cm of EC in a mixed tumor?

No, percent of EC does change the relapse rate. Now, how they determine percentage of EC is a question I'd ask the pathologist. I would like to know how accurate this is from one pathology reading to the next.

[Joe.shupe22]

Heres my reply from Dr. Einhorn.

"Basically you have several tumors, which is not rare. This is however basically embryonal cell CA with vascular invasion clinical stage I since all studies normal. Cure rate with orchiectomy alone 50% . Three options are RPLND, 1 course of BEP chemo or surveillance. These are very long conversations going over the pros and cons of each approach, but they all lead to an eventual 99-100% cure rate. If you want to be seen here for discussion and review we would be happy to arrange."

Im thinking that this will be treated as pure ec as my tumor was not comprised of anything else. 1 pure seminoma 1 pure ec

[RJKD]

Heres my reply from Dr. Einhorn.

"Basically you have several tumors, which is not rare. This is however basically embryonal cell CA with vascular invasion clinical stage I since all studies normal. Cure rate with orchiectomy alone 50% . Three options are RPLND, 1 course of BEP chemo or surveillance. These are very long conversations going over the pros and cons of each approach, but they all lead to an eventual 99-100% cure rate. If you want to be seen here for discussion and review we would be happy to arrange."

Im thinking that this will be treated as pure ec as my tumor was not comprised of anything else. 1 pure seminoma 1 pure ec

Well, with LVI and non-seminoma the relapse rate is 50%. It didn't actually matter what percentage the EC was. However, a higher percentage EC can more strongly make the case for chemo over RPLND since higher percentage of EC has a higher likelihood of skipping the retroperitoneum. Still, even with 100% EC it's not a common occurrence (approx 5-10%).

If you had been stage 1a, then the percentage of EC makes a much larger difference with respect to relapse rate.

[Joe.shupe22]

Well yesterday was my appointment with the oncologist. Even with the 50% chance of relapse he thinks surveillance is the best option. I also emailed Dr. Einhorn again asking his reccomendation of treatment in my case and he also agreed with surveillance, even though relapsing would mean more chemo than if I were to do a round now. I'm not sure how I feel about surveillance just yet but I'm going to give it a few days. With such a high relapse it seems like I will be waiting for the inevitable, but I see where my oncologist and Dr. Einhorn are coming from. Even with relapse, the cure rate does not change and the risk of chemo related complications short or long term is enough to take the chance on surveillance. Sigh. Cancer is such a waiting game. Part of me likes the thought of surveillance, but part of me likes the very low chance of relapse with a short round of chemo.

[RJKD]

I never thought of surveillance even though I know it is a very viable option. Because I've never liked the coin-flip situation for stage 1b non-seminomas. If you relapse, it's 3 x more chemo. 3 x BEP is NOT the same as 1 x BEP. Unfortunately, we do not know the complications of 1 x BEP. Since we do not know, that may be reason enough to avoid it. I would actually seriously consider RPLND in your situation.

[RJKD]

Also, asking Einhorn over email does not give him the opportunity to go over the pros/cons of each approach (surveillance, 1 x BEP, RPLND). So it's easy for him to say that surveillance is a good choice, but without a thorough conversation with him, it doesn't tell me much. In fact, if I had seen Einhorn, I would've come prepared to challenge his recommendations and I'm sure he would say all options are on the table. One can really make a strong case for each option. The strongest case against surveillance is that if you guess wrong, the complications from 3 x BEP are much greater than with 1 x BEP. This is why I advocate a pre-emptive strike with an RPLND or 1 x BEP, and surveillance for those with guts.