Decision to make: RPLND first or chemo?

[hisaunt]

I was reading this forum for few months and it was very good source of information. I'm very thankfull for finding it. I will try to explain best I can, as english is not my mothers language.
My nephew was diagnosed in september 2013 and had right orchiectomy.
Pathology: Seminoma anaplasticum with scyncytrophoblastic cells 60% Yolk sac tumor 30% Teratoma immaturum 20% , pT3 L1 V1
Tumor markers: AFP 1055, Beta HCG 14,2 Post surgery : AFP 306, Beta HCG 0,5 Ultrasound and CT scan and pulmonary RTG were good. Started chemotherapy on BEP protocol (3 cycles) 18. 10. 2013. His tumor markers on day one: AFP 57.85, Beta HCG < 1.0
Stoped chemotherapy because of acute mononucleosis during first cycle, he didn't got that third week bleomicin. He had very high fever for days and was admited in hospital where they find out he had mono.

That is when I wrote to dr Einhorn, he said same as doctor here: not to give chemo until full recovery from mononucleosis. He also said that he might be cured with one cycle. We all hoped and prayed for this to be the case as markers dropped down to normal. But on his first CT in january there was two new nodes 22x18mm and 12x9mm, with good markers. Dr Einhorn said he needs RPLND ( I did write him again) but it is prefered in Europe in case like this to go with chemo first. He has done chemo (2 cycles of BEP) and nodes shrink but did not completely gone. Doctor said wait to see if they will shrink.

On last CT in august nodes were the same size, so doctor recommended RPLND. Today on ultrasound he find that nodes enlarged and two new nodes : retroperitonal IAC 28 x 13/14mm each, one preaortal 16 x 9mm, and one retrocaval. So in one month they grew and now he must go for chemotherapy again.
There are two options: one is RPLND first with 2 cycles of chemo after and second is 4 cycles of VIP chemo first.
We are so worried about that teratoma immaturum. How responsive is to chemo?
Please, if you have any advice about this?
Thank you, Maria

[eodtech2001]

I would say RPLND first because that might cure him by itself, then if needed follow up with chemo. But thats just my opinion. But routes are a good option its just a matter of deciding what is best for him.

[BenceCali]

I agree with eodtech2001 above. I think with good markers and lymph-node enlargement the RPLND has to be done in this case. I had Immature Teratoma in mine and it is NOT responsive to chemo at all, it has to be surgically removed. With normal markers, it is possible that surgery might be all thats needed and maybe no chemo after because Teratoma doesn't give off markers.

I'm not an expert but I say RPLND for sure! Wish you the best of luck.

[hisaunt]

We can not go to centers with best surgeons. Thank you eodtech and Bencecali for your answers. I also wrote to dr Einhorn again and he said the same :This is an easy decision- he needs RPLND but only by an experienced and skillful urological oncological surgeon, assuming hCG and AFP remain normal. This is probably all teratoma and chemo would not help. Not sure what else to tell you as I realize your country may not have the skill that is available in other countries.
That would be our major concern because doctor here said it would be less risk to do RPLND after 4 cycles VIP. So maybe that is better option. I appreciate any insight on this.

[hisaunt]

I also found this in some older topic (link) and this is even more confusing

As to teratoma, I had a tumor which was nearly all teratoma (70% immature, most of the rest mature). I have looked into it a little, as it is somewhat complicated, and asked my doctor about it, and, from what I gather, seems to be this: mature teratoma and immature teratoma are not the same thing. Immature teratoma is, and behaves like, any other malignant tumour: it will grow, invade tissues and spread through the lymphatic system. It is slower growing and a bit less aggressive than some other types of testicular tumour, but still well capable of spreading Immature teratoma is very susceptible to platinum-based chemotherapy.

Mature teratoma, on the other hand, is not strictly a malignancy at all. Unlike in immature teratoma and other sorts of neoplasm, the cells themselves in a mature teratoma are ordinary body cells - muscle, cartilage, skin, and other such things - just in the wrong place. A mature teratoma will grow (sometimes rapidly) and can cause ill health simply by being large and in the way, but it will not invade tissues or spread through the lymphatic system. Mature teratoma, because its cells are like ordinary body cells, will not respond to chemotherapy or radiotherapy.

The relationship between mature teratoma and immature teratoma is not fully understood, although I think that it is thought that mature teratoma might very often develop from immature teratoma (there is a correlation between instances of the two).

The real risk with teratoma is what is called "teratoma with malignant transformation", which is a malignancy, and will invade and spread. The relationship between this and the other types of teratoma is, I understand, not fully understood, but it is thought that mature teratoma can break down into this type of malignancy, and frequently does if the teratoma is present for some time (although it is not usually a quick process). Teratoma with malignant transformation is both malignant and resistant to chemotherapy and radiotherapy, which makes it difficult to treat and therefore dangerous.

The danger is that, if immature teratoma spreads to a part of the body where surgery is not possible and seeds mature teratoma there, it can eventually become a teratoma with malignant transformation in an inoperable location, which would then be fatal. However, I am told by my doctor that this is not a fast process, and that teratoma tends to spread predictably through the lymph nodes (which are readily operable). This - I think - is why it makes sense in the case of a person with a stage 1 tumour, where there is no clinical sign of spread, to treat with adjuvant chemotherapy and why surgery is unlikely to be necessary now - because, if anything has spread, it will only be in the very early stages of doing so, the only thing that could spread in such early stages would be the immature teratoma, and that is susceptible to chemotherapy. If there is a recurrence, any traces of mature teratoma can be removed surgically with the RPLND.

Incidentally, my doctor put me on surveillance as, in my case, there was no lymph-vascular invasion; even if were to recur, I was told, it would be treatable by chemotherapy, although I should probably also have to have the RPLND at that juncture, too, because of the teratoma element.

I hope that this helps!

[BenceCali]

dr Einhorn again and he said the same :This is an easy decision- he needs RPLND but only by an experienced and skillful urological oncological surgeon, assuming hCG and AFP remain normal. This is probably all teratoma and chemo would not help.

This is the correct answer here. I really hope you will find a qualified surgeon.

As for the teratoma - immature teratoma is dangerous and NEEDS to be removed. it can transform into many cell types - immature teratoma can transform into embryonal carcinoma, yolk sac, seminoma etc.. It can also transform into different families of cancer that aren't testicular cancer anymore (rare but it can happen)

For example - In my case my tumor was 75% immature teratoma, 15% embryonal, 10% yolk sac - i relapsed on surveillance and had the RPLND (where they found teratoma in my lymph nodes) Teratoma needs to be removed no matter what.

[hisaunt]

I really appreciate your answer. And dr Einhorns for sure. But it is very delicate operation as doctor said and must be done perfectly. In Europe it is not so often done as in the USA. So it is decided to go with chemo first and he will be closely monitored by ultrasound. Probably RPLND after chemo. I actually insisted to do RPLND first but it is not easy decision and as safe as in USA.

[Dook]

Hi Maria,

Where are you from ? There is no center of excellence in your country ?

Take a look here :

http://tcrc.acor.org/experts.html

[hisaunt]

Hi Dook, thanks, we are from Serbia. No center of excellence here, but I think he is treated by one of the best doctors.

[Dook]

That's too bad that Serbia is not in the European Union. Because I read somewhere, if you're an European Citizen, you can be treat in any hospital in Europe :

http://ec.europa.eu/social/main.jsp?catId=569&langId=en

[Mike]

I am not of that much assistance but when I was trying to help a guy in Kosovo about a year ago they had mentioned having to go to Macedonia to find proper imaging. I am wondering if that may serve as a potential resource.

[hisaunt]

I appreciate your help. In Europe this is more common approach. He was offered to have RPLND first anyway. Actually we were preparing for it since august, but new nodes that grow in a month changed the situation. It could still be just teratoma and I'm afraid of unnecessary chemo. But it could be needed as well.