Is it a relapse? Is it a TC2?

[MT.]

Hi All,

Excuse my long blog as I need to give the full history for the experts to give their view.


History:

- I was diagnosed with TC in March 2017 and had my IO Left side on the same month.
- Pathology result was pure seminoma with two nodules measuring 3x1.5 cm and 2.5 x 1.5 cm, Free cordal margins, No LVI and No extra testicular extension.
- Tumor Markers were normal before and after IO.
- Stage PT1N0M0
- CT scan before and after operation showed no evidence of matestic spread, but prominent sub-cm para-aortic lymph nodes.

* Surveillance was recommended at this point due to good prognosis. Every 4 months for the first 2 years, then every 6 months for another 2 years, then yearly.


First Follow Up (Aug 2017):

- CT Scan : Para-aortic lymph node largest measuring 1.45 x 0.51 cm.
- PET Scan followed and there was no evidence of cancer, and para-aortic lymph node shrunk.
- Tumor Markers : Normal
- Chest X-Ray : Normal


Second Follow Up (Nov 2017):

- CT Scan : Para-aortic lymph node largest measuring 1.40 x 0.70 cm.
- Tumor Markers : Normal
- Chest X-Ray : Normal

* No PET was requested, but follow up with another CT Scan in 3 months.


Additional scans (Nov 2017):

Pain was felt in the Right testicle and Ultra Sound was requested:

- Ultra Sound results :
1- Inhomogeneous texture with multiple ill-defined hypo echoic focal areas (was not there in pre IO Ultra Sound)
2- Microlithiasis (that was there before IO)


* Follow up with another Ultra Sound in 3 months was recommended.


Testosterone Levels review:

- Total Testosterone level : 3.06 ng/ml (range 2.49 - 8.36 ng/ml)
- Free Testosterone level : 5.85 pg/ml (range 1 - 28.28 pg/ml)

* Natural Korean Gensing (Tongkat Ali) was prescribed for 6 months. Dr does not want to start T therapy now as the testicle will stop working if we do so. He believes it can by an after IO effect.


Third Follow Up (Feb 2018):

- CT Scan : Small Para-aortic lymph nodes biggest have short axis of 0.6 cm. Fatty Hilum is intact (which I was told is good news).
- Tumor Markers : Normal
- Chest X-Ray : Normal

* No Clarity so far on an action to be taken. Urologist needs to get an oncologist view if I need to go for Carboplatin now as an adjuvant therapy. No reply yet.


Right Testicle Ultra Sound Follow Up:

- Ultra Sound Results :
1- Multiple ill defined hypo echoic focal areas notes, no wall seen, no pre-lesional halo and no mass effect. Same size and indication as previous scan
2- Microlithiasis

* Follow up with another Ultra Sound in 2 months is recommended by the urologist , however surgeon recommends frozen biopsy that can be followed by IO.


Questions And Confusion:

1- Are the Para-aortic lymph nodes of normal size or not? Should Carboplatin be an option now after a year from IO? Is surveillance good enough for now?

2- Is the hypo echoic ill-shaped texture in the right testicle an indication of TC2 , or is it too early to know as it is not a mass, no wall and pre-lesional wall. Dr believes many reasons can lead to the coarse texture including trauma from the initial IO, poor blood supply ... etc. Meanwhile if it grows it can be TC2. Does this make sense?

3- Are T levels an indication of an underlying issue? Is Korean Gensing an adequate therapy? Should I seek for T replacement therapy?


Sorry again for the long blog, but I believe there must be a lot of experts who can give their view.

Thanks, MT

[Davepet]

1- I'm not 100% certain. I'm pretty sure that anything over 1cm is considered to be TC with non-seminoma, but they allow up to 2 cm for pure seminoma. Hopefully someone with a better memory will chime in.

2- Hypo echoic usually means TC, but I am sure there are other factors that you doc is looking at. Are you seeing a Urologist or an oncologist?

3-Your T levels are at the low end of normal, but do not necessarily indicate any problems otherwise. How are you feeling? If you do not have low T symptoms, there is no need to consider TRT.

Dave

[Trekga]

I would suggest another opinion.

[MT.]

Hi Davepet,

1- The largest node size was 5.1mm in August 17, followed by PET scan that turned out negative; 7mm in November 17 and 6mm in February 18. Is it possible for nodes size to go down in case of cancer?

The report also mentioned "fatty hilum intact". The urologist explained that in case of cancer the "fatty hilum" would not be intact.

Two opinions are on the table 1- to wait for the next follow up in three months and see what happens to the lymph nodes. or 2- To go for Carboplatin to reduce the risk of relapse.

Not sure which opinion to go with ...



2- I have seen a urologist as well as two oncologists.

The urologist and first oncologist suggested waiting for two months then another ultra sound as there is no mass, no pre-lesion halo and no wall seen. Also the size did not change from November.

The second oncologist advised a frozen biopsy through IO operation.

Not sure which opinion to go with ...


3- There is no signs so far for low T levels. I think I would wait to see what happens with the Korean Gensing.

The whole thing is so confusing, would be great if you can give your view ...