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No alternative to chemo?

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  • No alternative to chemo?

    So I had the right orchiectomy on 10/26. Pathology report:
    Mixed malignant seminomatous and non-seminomatous germ cell tumor, composed of 60% yolk sac tumor, 30% embryonal carcinoma, and 10% seminoma, with scattered syncytiotrophoblasts.
    The tumor measures 4.2 x 3.2 x 2.7 cm, invades into the rete testes and tunica aluginea but not beyond these structures
    Lymphovascular invasion is present (PT2).
    Surgical resection margin is negative for tumor
    Germ cell neoplasia in situ (formerly intratubular germ cell neoplasia) is identified
    Macroscopic extent of tumor: confined to the testis
    pT2 ([primary tumor]): Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis

    Tumor markers before orchiectomy:
    LDH 277
    AFP 52.1
    bHCG 573

    4 weeks later (November 21):
    LDH 286
    AFP 42.4
    bHCG 15

    CT scan lymph nodes:
    Abnormal enlarged retroperitoneal lymph nodes, largest lymph node as follows: Para-aortic lymph node measuring 1.4 x 1.0 cm ... Precaval lymph ode measuring 1.4 x 2.2 cm

    I guess my question is:

    Is 4 weeks enough to wait to know that tumor markers aren't going to fall back to normal without chemo? I was heartened that bHCG went down so dramatically from 573 to 15, but still not normal. Is having a CT scan post-surgery advised? I was told that on its own without the testicular cancer the enlarged lymph node wouldn't have been worrying.

    But given: lymphovascular invasion, 2 somewhat enlarged lymph nodes, and the tumor markers posted above at the 4 week mark, is chemo the only real option?

    They have scheduled 3xEP (I'm 50 years old so no B with my EP). I'm not particularly looking forward to short and long-term effects of chemo. I sent off a sample of my sperm to bank this week but no word yet on what shape it was in...

    Thanks for help and advice!

  • #2

    Sorry to welcome you.

    Not a doctor just offering my input based on my experience -- please consult your doctors.

    I believe the positive nodes and tumor markers make you a Clinical Stage IIA (marker positive) or just CS IIA.

    From: Stage IIA/B non-seminoma
    "There is a general consensus that treatment should start with initial chemotherapy in all advanced cases of NSGCT except for stage IIa NSGCT disease and pure teratoma without elevated tumour markers, which can be managed by primary RPLND or surveillance to clarify stage [111, 129].

    If surveillance is chosen, one follow-up evaluation after 6 weeks is indicated to document whether the lesion is growing, remaining stable or shrinking. A shrinking lesion is probably non-malignant in origin and should be observed further. A stable or growing lesion indicates either teratoma or an undifferentiated malignant tumour. If the lesion is growing without a corresponding increase in the tumour markers AFP or beta-hCG, RPLND represents the first treatment option and should be performed by an experienced surgeon because of suspected viable disease or teratoma [129]. Patients with a growing lesion and a concomitant increase in the tumour markers AFP or beta-hCG require primary chemotherapy with BEP according to the treatment algorithm for patients with metastatic disease and IGCCCG recommendations (Figure 2). An alternative to the surveillance strategy in marker-negative II A/B non-seminoma with suspicion of an undifferentiated malignant tumour is a CT-guided biopsy, if technically possible. There is insufficient published data on PET scans in this situation. When primary chemotherapy is refused by the patient or when it has some contraindications, primary nerve-sparing RPLND represents a viable option. Primary chemotherapy and primary RPLND are comparable options in terms of outcome, but side-effects and toxicity are different, allowing for involvement of the patient in selecting the treatment of choice [130]. The cure rate with either approach will be close to 98% [131-133]. In patients with marker negative CS IIA follow up is only recommended, if teratoma is more likely than marker negative embryonal carcinoma. If possible, a biopsy is recommended to exclude marker negative embryonal carcinoma."

    These guidelines suggest that marker positive CS IIA should be best treated by initial chemotherapy (3xBEP).

    With marker negative CSIIA (not your case I believe), RPLND is another option but only if done in a regional referral center by an expert. One advantage of RPLND is that it doesn't preclude chemotherapy later, if a relapse were to occur. The other way around is more tricky surgically (post-chemo RPLND). If you are philosophically opposed to chemotherapy, RPLND might be an option -- but not the recommended one.

    Did you ask your docs if a biopsy is possible on the lymph nodes?

    I think the doubling time for germ cell tumors is on order of 1 month -- so delays of that magnitude can have those effects. I was also hearing delays to orchiectomy of 1 month are approximately corresponding to stage 1, stage 2, stage 3.

    Also, my understanding was that 4xEP is indicated when there are contraindications to 3xBEP (your age in this case).

    Regarding the tumor markers and the drop in them:
    The serum half-life of AFP is about 7 days, so in 4 weeks it should have dropped considerably.
    "These patients should not be treated with chemotherapy, including salvage chemotherapy, when the AFP remains stable and minimally elevated at levels of 8 to 25 ng/mL"

    Where are you located? Perhaps folks on the forum can suggest excellent docs that are near you.
    Last edited by mcintoda; 12-09-17, 12:21 PM.
    Age 31 - Portland, OR
    01NOV16- Pain in right testicle, palpable mass
    13NOV16- R I/O. Markers normal
    27NOV16- Stage Ia non-seminoma, 1.3cm, 100% EC, no LVI
    06DEC16 - CT scan clear
    09DEC16 - Started 1xBEP. Neutropenic at day 15; Worst part for me was bleo (allergic).
    03JAN17- Ended 1xBEP; start surveillance
    18MAR17-2nd pathology report shows 90% EC , 10% seminoma


    • #3
      Mcintoda is right, your AFP should have dropped to single digits by now. I personally would not consider anything but chemo in your situation. Chemo will destroy any TC in your body, pretty much wherever it's spread to, even cells too small to image right now.

      Also he is correct that you should either get 3xBEP or 4xEP. I had 3xBEP at age 55, so there is no hard & fast age cutoff that I know of.

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


      • #4
        Yup, you need 3xBEP or 4xEP. I 3rd the above posters.
        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!
        9/27/2018 all clears up to this date!