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Which one first Chemo or rplnd ?

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  • Which one first Chemo or rplnd ?

    Hello everyone,
    I want your opinions about my situations, I briefly summarized my situation in the half. thanks to all.

    6/2014-right orchiectomy was made and the diagnostic was testis mix-nonseminoma carcinoma(embryonal carcinoma and yolk sac tumor);tumor size 4.5cm and LVI Invasion, AFP:2068.
    Pet/Bt results: 2cm lenf node with FDG(Suvmaks:10.8). 21mm(Suvmaks:10) and 33mm(Suvmaks:16.6) lenf node with FDG and Suvmaks:5.6 with FDG. The doctor planned the 4 BEP.
    8/2014-Before 3th BEP, AFP:37.Start the 3th BEP and end of the 3th BEP AFP:111. AFP starts to increase and the doctor stopped the 4th BEP. Pet/Bt results: lenf node with FDG(Suvmaks:4.1)and Suvmaks:2.9 with FDG and Suvmaks:1.6 with FDG
    9/2014-Acute Hepatitis B occurred and according to blood results(ALT:3352;AST:3609,HBV DNA:170000000;HBV DNA(copy):989400000).Stayed 1 month hospital.
    10/2014-Liver start to return normal.(ALT:92;AST:60;HBV DNA:3650;HBV DNA(copy):21243;AFP:150,21).The doctor said that liver can produce AFP and the reason why AFP increase during chemotherapy is liver diseases.
    11/2014-Survialence and AFP:100,86
    12/2014-The results came to AFP:199,37 ALT:65;AST:34.Pet/Bt results: Lenf node 2cm(Suvmaks:6.2) with FDG and Lenf nodes 2 cm and 3 cm without FDG

    So, AFP starts to increase and now the doctor planned that 4 TIP chemotherapy and after chemotherapy rplnd surgery.

    Now I think that if I first rplnd surgery and then chemotherapy what will the advantages and disadvantages? what you recommend to me? or any different suggestion?

    Do you have any suggestion for rplnd ? open or with daVinci rplnd. I'm in Turkey and Do you suggest that surgery should I make in UK or US? and which centers?

    Can you share your experience ?

    Thank you so much.

  • #2
    My guess is that they will want to do chemo before RPLND. The reason why is because your tumors are actively growing and they will want to get them under control some before they do some surgery. I may ne wrong and you should ask the question to your Oncologist for better clarification/understanding.

    If you are considering RPLND in the UK I believe that Royal Marsden is one place to look into. I am in the US but I know I've heard of this hospital from someone else on this board.

    If you are considering RPLND in the US then I would recommend the following:

    1: Indiana University
    2: Memorial Sloan-Kettering

    Also, my advice would be to reach out to Dr. Lawrence Einhorn at the Indian University.

    You can email him individually or ask you Oncologist to reach out to him.

    Keep us posted as you go because we are now part of your extended family. Welcome brother !

    - Matt

    March 4th 2014: [AFP = 2.5; bHCG = 6; LDH = 618]
    March 13th: Left IO 100% Classic Seminoma
    6.3 x 5.1 x 3.8 cm, no invasion of anything
    LDH never fully normalized
    Stage: IS
    Watchful Waiting
    May 1st: promoted to Stage IIB with two PET active tumors in the para-aortic lymph nodes 2.5 & 2.4 cm
    May 12th: started 3xBEP
    Neupogen during Cycle 2 and 3
    July 8th: Last Bleo shot of Cycle 3 -- chemo completed !
    August 4th: Post Chemo CT/PET scan
    September 4th: Port removed
    January 2020: 5.5 YEARS ALL CLEAR !


    • #3
      My understanding is that most surgeons do not feel that robotic RPLND gives enough access to do a proper job. I would lean towards an open procedure & try to find a surgeon who has as much experience as possible, whether that is in your country or some other.

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


      • #4
        Hi there, i have described my experience on other threads but i can offer them here in summary. If your planning to go to UK then Royal Marsden and Prof David Nicol is the man to see. I had my lap-RPLND there on october. No side effects. For US vs UK i believe that in US they do the rplnd more easily/frequently wheareas in europe the prefer the chemo way more. But that depends also on your insurance coverage as the cost might be bigger. You dont really need to use the davinci for the rplnd as i understood that the doctor doesnt really earn something from the robot in this specific surgery. My lap -rplnd was done without the robot. bare in mind that using the robot will most likely increase the cost of the surgery. On the question on chemo first or not, you will have to consult the oncologist. There is a case that if you do chemo ,no residual masses will be left and no rplnd will be required. On the other hand if you do rplnd first, then the doctor might suggest having less chemo cycles (like my case). I believe though that in most hospitals they go for chemo 1st, rplnd 2nd. On the open vs lap-rplnd its a major topic of discussion and diffrent people will offer diffrent opinions. Personally im really happy i did the lap-rplnd and not the open one and thankfully the biopsy proved me right but thats what happened in my specific case.
        -02/2015 ct scan clear now on surveillance
        -January 2015 end of chemo
        -01-12-2014 2xBep start
        -biopsy said classic seminoma in 2/22 nodes
        -10-2014 lap rplnd
        -06-2014 lymph node increased to 12 mm
        -01-2014 10mm lymph node in the paraortic left region
        -2 years surveillance clear with ct scans and blood work
        -2 biopsies performed(1st said teratoma, embryonal and seminoma element, 2nd said teratoma and seminoma)
        -12-2011 cancer diagnozed NSGCT left orchiectomy


        • #5
          In a recurrent situation such as yours, I would not go with anything but open RPLND at the hands of a skilled and practiced surgeon (if possible).

          The oncologist should help you decide, but with your findings they would likely want to do chemo first.