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

[AZMom]

Hello All.

Another quick update:
My son is on Day 6 of cycle 3 now, so he just finished his long week yesterday which went better than expected. Cycle 2 was his worst- he had insomnia and didn't sleep at all on Day 1 into 2, and the nausea was worse too. After his insomnia, he basically stayed in bed for the next 5 days. He bounced back the next week by Tuesday, though, and felt pretty good for his bleo weeks. His Cycle 3 long week was much better- no insomnia and nausea under control. I think it's because for Cycle 2, he was just taking Ativan at home, and for Cycle 3 they added Olanzapine at night which really seemed to help with nausea and knocked him out so he slept through the night.

His neutrophils have stayed above 1,000 so far on the weekly checks after they had dropped to 390 on Cycle 1. Tumor markers for Cycle 2 were AFP 3.9 and LDH 267. The LDH concerns me a little because it has crept up slowly and is over the 111-245 stated range.

LDH:
2/12- 204
3/09- 204
3/30- 222
4/20- 267

No HCG results, but it had dropped to <1 on 3/30.

We will see the oncologist again on the Friday after the final bleo, and I think he wants to do scans two weeks after that.

[Davepet]

I wouldn't be too concerned about the LDH just yet, it is not really a cancer specific marker. It is an indicator of inflammation in many areas of the body, and his numbers are still quite low. Mine have gone over range quite a few times over the years & return to normal at the next test. It needs to be monitored, but unless it starts rising a fair amount higher, I wouldn't be concerned.

Dave

[AZMom]

Hi everyone.

My son had his follow up CT scans on Monday, which was exactly 4 weeks from the day of his final bleo. He had a chest scan for pulmonary embolism on 5/3, so we already knew the lung nodule was shrinking. The new results have posted and we will see the oncologist tomorrow.

CHEST: Slightly ill-defined right upper lobe pulmonary nodule now measures approximately 6
x 11 mm (series 3 image 41), previously 6 x 12 mm on the 5/3/2018 CT and 16 x 24 mm on the
2/16/2018 CT. New small focus of ill-defined atelectasis or consolidation in the anterior
segment of the right upper lobe measuring up to 12 mm (series 3 image 41). Minimal
bibasilar atelectasis versus scar. Lungs are otherwise clear. No enlarged lymph nodes. No
pleural fluid or pericardial fluid. Cardiac size is normal. Thoracic aorta is normal in
caliber. Central pulmonary vessels are normal in caliber. Previously seen bilateral lower
lobe pulmonary emboli are no longer visualized, though sensitivity for pulmonary emboli is
limited as this was not performed as a dedicated pulmonary embolus protocol CT. Right
chest wall port catheter is positioned with the tip in the cephalad aspect of the right
atrium. No suspicious appearing focal osseous lesions.

ABDOMEN: Prior splenectomy. Liver, gallbladder, adrenal glands, kidneys, and pancreas are
unremarkable. Bowel caliber is normal. No bowel obstruction. No abnormal bowel wall
thickening in the upper abdomen. No perigastric, perienteric, or pericolonic inflammatory
changes in the upper abdomen. Abdominal aorta and inferior vena cava are unremarkable.
Aortocaval lymph nodes at the L3 craniocaudal level now measure 6 x 10 mm and 6 x 10 mm
(series 8 images 63, 67), previously 14 x 16 mm and 13 x 15 mm. No enlarging lymph nodes
on the current examination. No free fluid. No suspicious appearing focal osseous lesions.


PELVIS: Splenule along the sigmoid mesocolon measures up to 37 x 57 mm, unchanged compared
to the 2/16/2018 CT. Bowel caliber is normal. No bowel obstruction. No abnormal bowel wall
thickening. No perienteric or pericolonic inflammatory changes. Appendix is visualized and
----- Page Break ----- appears normal. Bladder is incompletely distended but grossly unremarkable. Prostate is
normal in size. Unchanged 5 mm midline prostatic cyst. No enlarged lymph nodes. No free
fluid. Prior right orchiectomy. No suspicious appearing focal osseous lesions.


I'm guessing these results will put him on surveillance rather than surgery? Any thoughts? Thanks.

[biwi]

Yup, surveillance unless at certain institutions where they lean towards RPLND in most situations.

With 1.0cm of those two remaining nodes there is a slight chance for teratoma. In my situation I had one node at 1.0 remaining and on surveillance they grew over the course of 6 months and then I had an RPLND to remove it. It was teratoma and contained within that lymph node. See my signature. below my post.

[AZMom]

Thanks, Biwi.

It sounds like your post chemo nodes were right on the borderline too. I've been trying to research the guidelines and risks/benefits of surgery vs. surveillance and I feel more confused than ever.

Lots of questions for the oncologist tomorrow.

[biwi]

Yeah, I know the feeling. I consulted with two centers and both said go on surveillance. Realistically it was the right choice, since if they didn't grow, I would have been able to avoid RPLND. And since they did grow, it was just a delayed RPLND vs having one right away.

[AZMom]

Yeah, his oncologist today put him on surveillance. When I mentioned the 1 cm guideline for nodes, he said they measure by the short axis and described the 6 x 10 mm nodes as normal, thus surveillance. He recommends a draw for tumor markers every two months and another scan at 6 months.
The 6 months seems like a long time.

[Trekga]

You can look up followup for son's stage and treatment regime at NCCN- they lay out guidelines. I know for most cases Dr. Einhorn at IU they do not recommend post chemo RPLND unless nodes are larger than 1cm. I do not think it should be 6 months, but am unsure of your son's staging & risk group. Onto healing!!!

[Davepet]

It is also possible that they will shrink a bit more by the next scan, my node did.

Dave

[biwi]

In 2015 I had markers every 2 months and scans every 4 for that first year. But guidelines have changed even since then I think.

[AZMom]

Thanks Trekga, Dave and Biwi.

I did check the NCCN guidelines and they recommend 6 month scans for a complete response to chemo. I guess I just thought that complete response meant no residual masses, but his oncologist is satisfied with the results.