Post Chemo RPLND vs Surveillance

[TheyCallMeLefty]

I was diagnosed w/ testicular cancer on 9/29/2017. On 10/5 I had my right radical orchiectomy. Since then, my serum marker levels have returned to normal. There was one 1.1cm lymphnode visable near my Vena Cava on the cat scans. Thus, T2N1M0S0 (Stage 2A) Non-Seminoma (55% Seminoma, 20% Embrynol, 15% Yolk Sack, 10% Teratoma).

My Medical Oncologist recommended 3X BEP or 4EP. I got a second opinion from a surgical oncologist who recommended RPLND.

I'm 24 years old and don't want the side effects of surgery (retrograde ejaculation). I have already froze sperm and decided I'm going to go the chemo route (set to begin 11/27).

My question comes here: My surgical oncologist from the Cancer Institute of NJ said that he always recommends the RPLND even if there are no visible lymphnodes (or lymphnodes <1cm) after chemo therapy (PC-RPLND). I asked my medical oncologist and he said there are two schools of thought on this. Most of the time (~95%) the PC-RPLND doesn't come back with any viable cancer if there are no lymphnodes or LN <1cm. If I have LN <1cm the medical oncologist said surveillance is an option.

Has anyone been in this situation? If truly the right call was to have the RPLND after chemo regardless of lymphnode size, wouldn't everyone just get the RPLND prior to chemo if it could spare them the chemo potentially? I just don't want to make the wrong decision.

Thank you for your help in advance.

[unotesticulo]

Iirc, somewhere around 20% will require RPLND after chemo. Honestly, if you get there RPLND with an experienced surgeon, your chances of retrograde ejaculation are pretty low. And the side effects of chemo are pretty serious. Also, post chemo RPLND is a much worse surgery.

I'd recommend you give some serious consideration to the RPLND route. That's probably what I'd do, not because you might have to do an RPLND after chemo, but because chemo is much scarier than an RPLND.

[Ann]

I'm scared about PC- RPLND. Stage 2A. My Son is on cycle 3 of 3XBEP which he should finish up on 11.21.17. His AFP is down to 5.9. With being in the ER last weekend twice with blood clots in the lungs and trouble breathing a scan was done. The lymph node that was infected is under a cm. They advised yesterday that they will wait 2-3 weeks after chemo is done and repeat blood work and scans. Then will bring us all back together to talk

[biwi]

I'm scared about PC- RPLND. Stage 2A. My Son is on cycle 3 of 3XBEP which he should finish up on 11.21.17. His AFP is down to 5.9. With being in the ER last weekend twice with blood clots in the lungs and trouble breathing a scan was done. The lymph node that was infected is under a cm. They advised yesterday that they will wait 2-3 weeks after chemo is done and repeat blood work and scans. Then will bring us all back together to talk

If all lymph nodes are < 1cm post chemo, most centers will not recommend a PC-RPLND. There are a few that will.

[Joe.shupe22]

I would absolutely not reccomend chemo that this point! First off you have a single lymph node that is .1cm outside of normal. If your tumor markers are normal I think you be do SURVEILLANCE for now and do a ct in a month. If tymph node has grown, then you know you need treatment.

As far as treatment goes I would absolutely hands down go for rplnd before chemo. Nerve sparing surgery methods can be used and you'll like be fine. Rplnd after chemo? No promises, PLUS chemo could make you sterile, so retrograde would be the least of the worries.

I had the rplnd and 3xbep after. I can say hands down rplnd was a walk in the park compared to 3xbep. Chemo SUCKS. It will take you a long time too get back to 100% (if you ever do), much longer than Rplnd.

[Joe.shupe22]

I'd be willing to bet einhorn would give the option of check for growth in a month or 6 weeks. He told me that was an option for me and i had multiple nodes enlarged, some over 2.0 cm. His wording was "redo ct in 6 weeks, if those nodes double in size cure rate would still be 99-100% with chemotherapy (preferably 3x bep)

[Joe.shupe22]

Think about it. Waiting would literally not change your chances for cure and you could get lucky and that node could be the same size or smaller and you would avoid ANY treatment!

[Joe.shupe22]

Oh and only pre chemo rplnd if ct scan still showed stage 2A.

[Mike]

If it were me, I would have the conversation with my doctor about the option of watching and re-doing the CT is the node is only 1.1 cm. Especially if I was favoring chemotherapy over primary RPLND anyway and even more so if the CT scan was done after the orchiectomy (due to any possible reactive lymph node issues from surgery). I personally would want to know for sure that I needed chemotherapy instead f rushing into it. You very well may need it but then again there is always the possibility you may not. If indeed you do the outcomes should be the same regardless of a short follow up period.

Mike

[biwi]

If it were me, I would have the conversation with my doctor about the option of watching and re-doing the CT is the node is only 1.1 cm. Especially if I was favoring chemotherapy over primary RPLND anyway and even more so if the CT scan was done after the orchiectomy (due to any possible reactive lymph node issues from surgery). I personally would want to know for sure that I needed chemotherapy instead f rushing into it. You very well may need it but then again there is always the possibility you may not. If indeed you do the outcomes should be the same regardless of a short follow up period.

Mike

Mike has very good advice here. 1.1cm has the possibility of not being cancer, especially post-orchiectomy. If it is cancer, allowing it to grow to 1.5-2.0cm by watching it for the next month won't change the effectiveness of chemotherapy. If you were set on RPLND over chemo though, now would be the time to do an RPLND while potential disease is small and still likely contained in that and nearby lymph nodes (if there is disease).