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RPLND as Primary Treatment for my 2A EC?

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  • RPLND as Primary Treatment for my 2A EC?

    Backstory:

    23 years old. Two tumors in my right testicle. Primary tumor was 2.1cm, secondary .8cm. Tunica Albuginea and vascular invasion. Pathology found 100% Embryonal Carcinoma. Serum on July 21, 2017 read

    AFP 6.0
    HCG 1 cm. 1 was 2.0cm and 1 was 1.8cm. Others existed around 1cm. Chest CT was clear

    Met with the oncologist who took more serum on 8/23. New readings were

    AFP 5.9
    HCG 1.4
    LDH 187

    Oncologist gave a clinical staging of 2A (T1(should this be T2? I know it doesn't change the final staging once in 2) N1 S0) and reccomends RPLND as a primary course of treatment.

    I understand the preference for surgery and lower or possibly no chemo given the long term implications of chemotherapy, but I'm a little concerned about treating EC with lymph surgery given the possibility of jumps and it's aggression.

    ​Does this course sound reasonable to you all?
    Last edited by SchoolOnHold; 08-25-17, 03:09 PM.

  • #2
    I think the NCCN for TC supports RPNLD for 2A if your markers are not elevated. Hopefully, someone else can chime in since I am not a Dr. I concur that the vascular invasion would make me pause, but maybe follow tumor markers some more, request it if it has not been planned while you are waiting to decide. Please keep us updated.
    17 year old son Grant dx 12/21/16
    pre/o markers 12/21/16- HCG:1065.15,AFP:298.8,LDH:1119
    pre/o CT Scan 12/22/16 normal
    r/o 12/22/16
    Post r/o Elevated Markers with INCREASE 4 weeks post r/o;
    PATHLOGY: mixed maligent germ cell 8.6 x 6.2 x 5.9 cm

    -80% Embryonal, 10% Yolk Sac, 5% Teratoma, 5% Choriocarcinoma w/LVI within Spermatic Cord and invasion into Rete Testis
    2nd CT scan on 1/24/17 3 nodes 2 over 2.5, one over 3.5
    BEP x 3 1/27/17
    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


    • #3
      I should note that it's focal invasion of the TA and V. Not sure if that changes anything from a prognosis standpoint. In my limited research it seems the invasion is mostly a concern in stage 1 EC patients considering observation, and since I definitely know it has spread and will need some form of follow up treatment, maybe I shouldn't be that concerned (relatively speaking)?

      Comment


      • #4
        If I'm reading your post correctly, you have 2 enlarged lymph nodes. Is that in the retroperitoneum? If you indeed have clinical stage 2A disease, then RPLND is generally the preferred treatment as long as your tumor markers are normal. A second choice is 3 x BEP.

        This is a no-brainer. You do the RPLND, preferably open and bilateral. Even though you have 100% EC, this is still the recommended choice by most advanced centers.
        Diagnosed at age 31. Treated in NYC. Now living in Ottawa, ON, Canada.

        7/1/2015: felt tiny lump on side of R testicle
        7/30/2015: Ultrasound shows 2 intra-testicular masses.
        7/31/2015: tumor markers normal, CXR clear
        8/5/2015: R orchiectomy
        8/11/2015: Pathology: 1.2 x 1.0 x 1.0 cm, embryonal 80%, seminoma 20%, with LVI and rete testis invasion
        8/14/2015: CT abdomen/pelvis clear, Stage 1b
        8/24/2015: started 1 x BEP

        Comment


        • #5
          Yeah I have 2 retro nodes that are enlarged, nothing else on the ct. It's good to know have the consensus, I was trusting of the oncologist and urologic oncologist, but was just freaking out about it

          Comment


          • #6
            I was in the same position and went the chemo route. There's no real wrong choice I feel. I can see both sides of the argument and they both make sense. Personal choice. I wanted to go the chemo route because I had read of some relapses for pure embryonal post surgery and wanted to avoid both. Einhorn told me if I went chemo that the cure rate was almost 100%. That was enough for me to decide on it.
            Last edited by dcalandrelli; 08-25-17, 08:03 PM.
            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 was 19. 8/16/17 AFP drops to 10. Doctor pleased ALL CLEAR!

            Comment


            • #7
              Einhorn tends to favor RPLND in these cases. I've seen this with many of his patients. If you can achieve an 80% chance of cure (20% relapse rate) with an RPLND, and have chemo on the back-burner, then do it. 3 x BEP should be a last resort until all other options have been exhausted.
              Diagnosed at age 31. Treated in NYC. Now living in Ottawa, ON, Canada.

              7/1/2015: felt tiny lump on side of R testicle
              7/30/2015: Ultrasound shows 2 intra-testicular masses.
              7/31/2015: tumor markers normal, CXR clear
              8/5/2015: R orchiectomy
              8/11/2015: Pathology: 1.2 x 1.0 x 1.0 cm, embryonal 80%, seminoma 20%, with LVI and rete testis invasion
              8/14/2015: CT abdomen/pelvis clear, Stage 1b
              8/24/2015: started 1 x BEP

              Comment


              • #8
                Tough call for sure. I was staged at IIA, however, my markers were a lot higher than yours and I ended up at IIB. If I had the choice I think I'd do RPLND because chemo sucks. Obviously, retrograde ejaculation is a big concern so get your sperm tested and bank if you want to have kids in the future.

                Comment


                • #9
                  I had a robotic rplnd for stage 2A 100% embryona. Ended up having 2 nodes positive for EC, everything else clear. I relapsed in 4 months and needed 3x bep. If I could do it all oover I would have done an open procedure. I have no side effects from the surgery. My reccomendation would be to do the rplnd first. It can be a very curative procedure and has way less chance of long term complications than chemo does. If you relapse, you get the chemo and are cured. If not, you've avoided chemo which is awesome! Just make sure you get the surgery at a center of excellence.

                  3x bep is a much more difficult treatment than RPLND in my opinion.
                  11/16- Pain/lump in R testicle 11/16- US finds multiple masses 11/16- Right I/O path multifocal largest nodule 2.1cm 100% EC with LVI/rete testis invasion. 12/16- Ct/markers normal stage 1b 12/16- Ct/markers normal 1/17- rplnd pN1 2 nodes 1.8/1.4 cm EC Stage IIA 2/20 ct/markers clear! 3/1/17 started androgel for low T 4/27/17 Relapsed. Multiple lymph nodes in mesentary and few nodes in retriperitoneum. Start 3x bep. Ct after 2nd cycle revealed all masses already resolved! Continue last cycle! 6/26/17 Finished 3x bep!

                  Comment


                  • #10
                    Glad you chimed in Joe, hope you are doing well.
                    Schoolonhold~ Have you had your markers done again?
                    17 year old son Grant dx 12/21/16
                    pre/o markers 12/21/16- HCG:1065.15,AFP:298.8,LDH:1119
                    pre/o CT Scan 12/22/16 normal
                    r/o 12/22/16
                    Post r/o Elevated Markers with INCREASE 4 weeks post r/o;
                    PATHLOGY: mixed maligent germ cell 8.6 x 6.2 x 5.9 cm

                    -80% Embryonal, 10% Yolk Sac, 5% Teratoma, 5% Choriocarcinoma w/LVI within Spermatic Cord and invasion into Rete Testis
                    2nd CT scan on 1/24/17 3 nodes 2 over 2.5, one over 3.5
                    BEP x 3 1/27/17
                    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


                    • #11
                      Not yet, what is the half life on serum? My second markers were taken on 8/23 and thought they took a while to change?

                      Comment


                      • #12
                        The long term health effects of RPLND are less severe than chemo (assuming you don't have any surgery complications). I Think it would be worth primary RPLND here if you fit the criteria that the experts say. full open bilateral though I'd say though if you want the best chance at avoiding chemo.
                        6/5/15: bHCG 27,AFP 8.66, LDH 361, 5.6cm lymph node - Stage IIC
                        6/16/15: Left I/O 85% EC, 10% chorio, 5% yolk sac opinion 2 (mayo) 90% EC, 10% yolk sac
                        7/7/15: bHCG 56, AFP 42, LDH 322
                        7/13/15 - 9/18/15: 4xEP
                        10/1/15: bloodwork normal, ct scan shows 2 lymph nodes 1.0cm
                        10/26/15: 2nd opinion on CT results - lymph nodes normal. Surveillance!
                        4/6/16: 1.7cm X 1.5cm lymph node found with markers normal.
                        4/20/16: RPLND @ IU - teratoma only!
                        9/18/2017 all clears up to this date!

                        Comment


                        • #13
                          Ugh, so I met with the urologist today and he has reservations about rplnd as primary treatment given the speed of embryonal. I have another CT scan and blood work before we make a final decision but it really does not feel great to have the two people on my "team" seemingly playing hot potato with my treatment

                          Comment


                          • #14
                            It is good to see what CT Scan shows and blood work shows a few weeks post orchietcomy.
                            17 year old son Grant dx 12/21/16
                            pre/o markers 12/21/16- HCG:1065.15,AFP:298.8,LDH:1119
                            pre/o CT Scan 12/22/16 normal
                            r/o 12/22/16
                            Post r/o Elevated Markers with INCREASE 4 weeks post r/o;
                            PATHLOGY: mixed maligent germ cell 8.6 x 6.2 x 5.9 cm

                            -80% Embryonal, 10% Yolk Sac, 5% Teratoma, 5% Choriocarcinoma w/LVI within Spermatic Cord and invasion into Rete Testis
                            2nd CT scan on 1/24/17 3 nodes 2 over 2.5, one over 3.5
                            BEP x 3 1/27/17
                            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


                            • #15
                              I get that, but oncology seemed happy enough with clean serums. I just wish I could have gotten the CT before waiting two weeks to meet with urology. Now it's another week for a CT and then who knows how long before whichever treatment begins

                              Comment

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