Right orchiectomy: CT shows mass on left side and right lung

[AZMom]

Hello All,

My 20 yo old son was diagnosed with testicular cancer at college. He came home and we consulted an oncologist who ordered a CT scan, and then he had a urologist perform the orchiectomy on the right side. Tumor markers were all normal before surgery.
We are still waiting on pathology, but the CT scan results indicated metastases. Here is the report.

IMPRESSION:

Abnormal aortocaval lymph nodes which would be in the proper place for metastatic disease
from a right testicular cancer.

2.5 cm right upper lobe nodule noted. This is the only pulmonary nodule. This nodule is
circumscribed. This could be due to metastatic testicular cancer given its appearance.
However, a infectious granuloma is also a possibility.

Large left pelvic sidewall mass measuring up to 5.5 cm which is different in appearance
than the retroperitoneal lymph nodes. The appearance is more suggestive of splenic tissue
based on the enhancement characteristics. This could be a regenerating splenule given the
history of splenectomy. This could be confirmed with a technetium sulfur colloid nuclear
medicine study. A lymph node metastasis is not entirely excluded but would be unlikely in
location for right testicular cancer.


The oncologist indicated that it is unusual for the pelvic mass to be on the opposite side, and that it may be unusual to have a single node for lung metastasis, but that these masses are likely related to the cancer. Is anyone familiar with a pattern of spread like this? Or does the radiologist's impression seem more likely?

Thanks.

[biwi]

Pathology here will be important I think. If it is pure seminoma, it is unlikely to have a lung metastasis without having lymph node metastasis. I think it would be worth looking into if biopsy of the lung nodule is an option, and if that is clear, doing the confirmation test the radiologist mentioned for the pelvic mass. It would be a shame to receive unnecessary chemotherapy in the event that neither is cancerous.

[AZMom]

Thank you, biwi. That is helpful to know about seminoma. We're very anxious to get the pathology results.

BTW, here is the info about the lymph nodes from imaging:

LYMPH NODES: Large hypervascular pelvic mass is seen along the left internal iliac chain
on image 104 of series 8 measuring 5.5 x 3.2 cm. Abnormal aortocaval lymph node is seen
on image 54 of series 8 measuring 1.4 x 1.6 cm. A second abnormal aortocaval lymph node
is seen slightly inferior and image 59 of series 8 measuring 1.3 x 1.5 cm.

[JeskiM69]

How recent was the splenectomy ?

If it was very recent could it be the increased lymph node sizes are related to that.

If it's not recent; I would suspect cancer. However as biwi said; you wouldn't want to jump into chemo unless it's either proven to be cancer or very highly suspect of it.

Maybe a biopsy could be obtained or at least frequent monitoring of those nodes.

- Matt

[biwi]

JetskiM69 has good questions. The other two smaller but visible aortocaval nodes are probably indicative of TC spread unless related to a recent surgery or infection. Lymph nodes normally are <1cm and not visible on CT scans. Those are also the typical landing zone for TC (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3163197/).

[AZMom]

Hi JeskiM69.

The splenectomy was in 2005 when he was in second grade. So, not recent.

We also suspect cancer. My son said he experienced groin pain last summer when he was on tour with his band, but it went away when he went back to school in August. He says he noticed a mass around that time, but didn't see a urologist at school until February. Strangely, the ultrasound showed multiple masses in right testicle, but the radiologist report said it looked like epidermoid cyst and to follow up in six months. Urologist disagreed and performed orchiectomy last Wednesday.

[Mike]

Hi AZMom,

Sorry to hear about your son's diagnosis. The aortocaval nodes as mentioned are a typical landing area for a right-sided TC and are of significant size over 1 cm. Unless, the splenectomy was recent, as mentioned, I think most physicians would look at those as metastatic sites, so that is something to ask the physician. I am not sure how long it takes for splenules to develop to that size so I guess that is something you could ask too. I suppose asking about further imaging is in order as well, just in case it does not respond to chemotherapy (I am not sure if chemotherapy would interfere with the test later on). If it was the TC, which I think as the radiologist mentioned, would be rare, then it should respond to the chemotherapy.

The lung nodule at 2.5 cm is of significant size, did he have a dedicated chest CT that detected this? At this point you would like to know for sure if the pulmonary nodule is TC or not but chat with the doctor, because regardless if it is or not, I do not think that it would change the selected course of chemotherapy. Meaning that regardless if he went through a biopsy procedure that was positive or negative that the treatments would not change. Thus, it is were me, I would want to avoid the biopsy if possible since it would solve the curiosity but not the treatments.

Either way, I believe that with the aortocaval nodes and the possibility of a pulmonary nodule and a slighter possibility of a left pelvic mass that chemotherapy is going to be needed. Response to chemotherapy can help solve the questions too as if the pulmonary nodule disappears then it most likely TC related. I would want to have a conversation with my doctor as the left pelvic mass could very well be a red herring but if it was some kind of visceral metastasis, then I suppose it could dictate a longer course of chemotherapy.

Are you in Arizona by chance? In the Phoenix area if so?

Mike

[AZMom]

Thank you, Mike.

The chest imaging was from a CT thorax, abdomen and pelvis with contrast.

We are in the Phoenix area.

[AZMom]

Hi Everyone.

Here is the preliminary report from pathology. Still waiting on final report.

TESTICLE, RIGHT, RESECTION: MALIGNANT GERM CELL TUMOR, FAVOR EMBRYONAL CARCINOMA
SIZE 1.8X1.6 CM
NECROSIS: PRESENT
RESECTION MARGINS: NEGATIVE
CASE WILL BE SEND OUT TO DR. T FOR EXPERT OPINION AND SPECIAL IMMUNOSTAINS AS NEEDED; A REPORT WILL FOLLOW

Gross Description:
Specimen A: Received in a formalin container, labeled with the patient's name, and designated as "Right Testicle". Is a dark brown testicle measuring 5.0x3.0x2.5 cm and weighing 31.6 g.
The spermatic cord measures 3.5 cm in length. The specimen is inked in black and subsequently fixed in Bouin's solution. The specimen is sectioned longitudinally revealing a normal upper lobe and a fairly circumscribed yellow to red nodule in the lower lobe measuring 1.8x1.6 cm. The nodule is 0.3 cm from the closest capsule. The following sections are submitted in the following cassettes:
A1 - Spermatic cord resection margin
A2 and A3 - Complete cross sections of tumor, Bisected
A4 - Tumor
A5 - Normal tissue
A6 - Fibrotic tissue and tunica albuginea


Still waiting to speak with the oncologist.

[Mike]

So it appears that he has a nonseminoma but they really didn't specify the details as far as percentages of embryonal so not sure if there are other types or if it is 100% embryonal. The details of the pathology report are unfortunately not that helpful as it is the abnormal retroperitoneal lymph nodes and the pelvic mass/lungs that are most likely going to dictate the treatment options, which I would anticipate being full dose chemotherapy. Let us know what the oncologist has to say.

Mike

[AZMom]

Thanks, Mike.

We saw the oncologist today. Here's what it says in the final pathology. There were no percentages.

Embryonal carcinoma with focal teratoma, 1.5 cm
Tumor limited to the testis
No lymphovascular invasion identified
No invasion into the tunica albuginea
Surgical margin free of tumor

The oncologist wants to begin three cycles of BEP starting Monday. I thought he had said earlier that it would be four cycles for non-seminoma. He also seems to now think the left side mass is splenic-maybe that's the reason for the change?

[Mike]

You can ask the doctor, but I would assume that with just the two aortocaval nodes and the questionable lung involvement that he would be considered in the good risk category so BEPx3 or EPx4 would be the usual treatments. If there were concerns with the pelvic mass then perhaps that might change things. But with the markers being normal and no apparent signs of non-pulmonary visceral metastasis then I wouldn't think he would be considered moderate or poor risk and need BEPx4.

Mike

[AZMom]

Hi everyone.

I thought I'd leave an update since we have new info, and I've learned so much from reading about others on this board.

My son is getting ready to start second round of BEP on Monday. The first round went about as well as could be expected. He had a bad reaction to the compazine they gave him for nausea, but that was easily resolved. He was definitely tired, nauseous and had some headaches/body aches on his 5 day week, but it was manageable with nausea meds and tylenol/ibuprofen. He ate well and drank a lot of water- didn't lose any weight. He felt really good on the bleo only weeks. Some hair started falling out around day 16 and he sported a mohawk for a few days. Buzzed the rest of it off yesterday.
He finally had the nuclear study test and the results were what we hoped for- that big pelvic mass is actually a spenule and not mets. So now we just have the two enlarged nodes and lung nodule to contend with. We switched to another oncologist, and he said that the HGC marker that is at 2 should actually be at zero, and he wants to see it drop. His neutrophils are also very low right now on day 18 (300?), but it seems like the doctor does not like to use the neupogen shot.


Gearing up for BEP round 2, which I gather will be rougher than round 1.

[Davepet]

hcg of 2 is nothing to worry over as long as it isn't rising. I'd be more concerned about not using proven meds to raise immunity.

Dave

[Trekga]

Thinking of you and your son as you gear up for round 2. Dr. Lawrence Einhorn concurs that Neupogen shot is NOT needed even for severe Neutropenia. You can email him at [email protected]
I personally reached out to him regarding that last year. Hang in there!