Announcement

Announcement Module
Collapse
No announcement yet.

High Risk/Low Risk

Page Title Module
Move Remove Collapse
X
Conversation Detail Module
Collapse
  • Filter
  • Time
  • Show
Clear All
new posts

  • High Risk/Low Risk

    Hi,

    It appears my treatment course will be deciding between high risk low risk surveillance.

    I’m gettin ahead of myself but theoretically I can’t have node involvement since my pathology was with clear margins and no LVI. Dr Einhorn echoed in this, however still pending the imaging.

    However, I have a 1.2cm 100%EC contained to the testes, clear margins, LVI -. Hcg 21 and afp43 with LDH 114. Hopefully this will be a stage 1 and all I’ll have to do is chose between surveillance or treatment BEPx1.

    I’m a doctor in first year of residency so I have access to a lot of literature but, I’ve been lurking here and there is a lot of knowledge here that is invaluable and trumps everything I know.

    Do you guys have any input towards this?
    Have any literature that talks about risk stratisficaton? I find a lot of conflicting info, most say LVI alone as a risk factor, others use EC as well. Einhorn said I have a 70% cure rates instead of 80% due to EC.

    I’m just asking this because I’m leaning towards BEPx1. I cannot deal with the anxiety of having a close to 40% relapse rate, yet alone 50.
    Do you guys know anything about the side effect profile (CIPN or tinnitus) with 1 cycle? Also, do you Guys know any objective data about chemo resistance after 1 cycle and reoccurrence?

  • #2
    I was where you were when I first got diagnosed with TC - I had LVI however, making me stage 1B right away. At the time, I had pored over lots of literature, and most concluded that LVI was the highest contributor to an increased probability of recurrence (~45%). Pure embroynal also contributed, but they didn’t provide a breakdown of that specifically. For you, I’d say the probability was about 20%, in line with what Einhorn has said.

    I too contemplated adjuvant, but my oncologist had a good point against it - if you want to kill cancer, you don’t go for a half hearted attempt. Not only might it be a waste, it can potentially risk causing resistance, making it possible that a subsequent 3/4xBEP ineffectual (not sure what the protocol actually is for recurrence after adjuvant).

    He recommended to me to wait till it came, to really fight it hard. Till then, it didn’t make sense going through the pain of 1x either.

    For me, my recurrence occurred within a week or so of this advice, so all of this was moot, but for you, I’d recommend the surveillance path.

    I tend to be a conservative person, so after we finished chemo, a tighter surveillance schedule than was recommended. If that makes you more assured, I’d recommend you do the same.
    2018:
    1/10 - Felt mass in right testicle.
    1/11 - LDH: 287 (max = 246), AFP: 16, HCG: 87
    1/18 - Orcheictomy. Non-sem, 80% EC, 15% Teratoma, 5% Yolk. LVI present. pT2, Tentative stage 1B.
    1/29 - Chest CT, Brain MRI, all clear
    2/19: HCG = 5.6, AFP = 13, LDH = 187 (ref = 340)
    2/20: Abdomen CT, 3 large lymph nodes, 0.8, 1.0 and 1.3. Stage 2A
    2/22: 3x BEP start
    2/22 - 4/26:
    AFP: 13, {11, 9, 5}, {4, 4, 3}, {3, 2, 2}
    HCG: 5.6, {2.7, <0.6, <0.6}, {<0.6, <0.6, <0.6}, {<0.6, <0.6, <0.6}
    LDH: 187, {208, 149, 196}, {215, 197, 222}, {277, 270, 240}
    5/3: CT scan, all clear. Lymph nodes <1cm (largest 0.8cm)
    7/5: Repeat MRI, lymph nodes unchanged. Markers still normal
    9/1: Repeat MRI, unchanged

    Comment


    • #3
      I’ll add that I got severe tummy issues and ringing in my ears right away after the first cycle of chemo. So while it may seem like it’s going to be a stroll compared to 3x, it still extracts a toll on your body (my tummy eventually recovered, no problems today, but my ringing is still there, mild however).
      2018:
      1/10 - Felt mass in right testicle.
      1/11 - LDH: 287 (max = 246), AFP: 16, HCG: 87
      1/18 - Orcheictomy. Non-sem, 80% EC, 15% Teratoma, 5% Yolk. LVI present. pT2, Tentative stage 1B.
      1/29 - Chest CT, Brain MRI, all clear
      2/19: HCG = 5.6, AFP = 13, LDH = 187 (ref = 340)
      2/20: Abdomen CT, 3 large lymph nodes, 0.8, 1.0 and 1.3. Stage 2A
      2/22: 3x BEP start
      2/22 - 4/26:
      AFP: 13, {11, 9, 5}, {4, 4, 3}, {3, 2, 2}
      HCG: 5.6, {2.7, <0.6, <0.6}, {<0.6, <0.6, <0.6}, {<0.6, <0.6, <0.6}
      LDH: 187, {208, 149, 196}, {215, 197, 222}, {277, 270, 240}
      5/3: CT scan, all clear. Lymph nodes <1cm (largest 0.8cm)
      7/5: Repeat MRI, lymph nodes unchanged. Markers still normal
      9/1: Repeat MRI, unchanged

      Comment


      • #4
        What was your tumor size? If you don’t mind me asking.

        Comment


        • #5
          I will preface this by saying "I AM NOT A DOCTOR".

          That said, I've seen very little information that says adjuvent chemo really is worth the risk. certainly there are studies showing those that had it had a lower recurrence rate in some situations, but how many were over treated & never would have had a recurrence? We can never know that. With the state of the art of currant treatments, it seems to me to be prudent to avoid treatments that might not be needed, knowing that if needed, further treatment s will get the job done. JMHO.
          Jan, 1975: Right I/O, followed by RPLND
          Dec, 2009: Left I/O, followed by 3xBEP

          Comment


          • #6
            I agree with davepet. Peace of mind is great but chemo is hard on the body, even just one round. Especially since most of us are young when it comes to cancer, it can have a detriment on your quality of life for a very long time.

            As long as you are going to all your follow Ups and getting ct scans and blood work regularly, they can usually blast a recurrence away with a couple rounds of bep. For sure adjuvant therapy lowers risk of recurrence, so it really depends on the person. Every case is different and you'll never really know if it helped or not.

            Personally I chose survellience and would every time if it is a viable option. But again, it's not one size fits all and you have to do what's best for you.

            Comment


            • #7
              I think it was 3cm on all dimensions.

              I would caution against extrapolating your risk relative to mine from size though
              2018:
              1/10 - Felt mass in right testicle.
              1/11 - LDH: 287 (max = 246), AFP: 16, HCG: 87
              1/18 - Orcheictomy. Non-sem, 80% EC, 15% Teratoma, 5% Yolk. LVI present. pT2, Tentative stage 1B.
              1/29 - Chest CT, Brain MRI, all clear
              2/19: HCG = 5.6, AFP = 13, LDH = 187 (ref = 340)
              2/20: Abdomen CT, 3 large lymph nodes, 0.8, 1.0 and 1.3. Stage 2A
              2/22: 3x BEP start
              2/22 - 4/26:
              AFP: 13, {11, 9, 5}, {4, 4, 3}, {3, 2, 2}
              HCG: 5.6, {2.7, <0.6, <0.6}, {<0.6, <0.6, <0.6}, {<0.6, <0.6, <0.6}
              LDH: 187, {208, 149, 196}, {215, 197, 222}, {277, 270, 240}
              5/3: CT scan, all clear. Lymph nodes <1cm (largest 0.8cm)
              7/5: Repeat MRI, lymph nodes unchanged. Markers still normal
              9/1: Repeat MRI, unchanged

              Comment


              • #8
                I had another thought on this: while statistics say adjuvent treatment improves risk of recurrence, you don't get offered adjuvent treatment unless the risk is already very low. I know proper studies try to take this into account, I have to wonder how well they do that. I'm guessing most guys getting adjuvent treatment would have been better off without it. JMHO.
                Last edited by Davepet; 02-12-20, 12:35 AM.
                Jan, 1975: Right I/O, followed by RPLND
                Dec, 2009: Left I/O, followed by 3xBEP

                Comment


                • #9
                  The issues with interpreting risk of relapse with LVI+ (the most recognized risk factor) and embryonal content is that they very often go hand-in-hand and often time in analysis data is missing.

                  There was a poster presentation at the ASCO Genitourinary Cancer Symposium 2019 https://ascopubs.org/doi/abs/10.1200...37.7_suppl.510 that may help. There was a Tweet of it as well https://twitter.com/i/web/status/1096434110224949248

                  The 111 Trial was just published from the UK which may help too: https://www.europeanurology.com/arti...895-4/fulltext

                  I will actually be at the GU20 tomorrow through Saturday and can ask around too. Dr. Craig Nichols, et al have an upcoming letter to JCO about the 111 Trial and I can ask him and see if he has any ideas about publication date.

                  MIke
                  Oct. 2005 felt lump but waited over 7 months.
                  06.15.06 "You have Cancer"
                  06.26.06 Left I/O
                  06.29.06 Personal Cancer Diagnosis Date: Got my own pathology report from medical records.
                  06.30.06 It's Official - Stage I Seminoma
                  Surveillance...
                  Founded the Testicular Cancer Society
                  6.29.13 Summited Mt. Kilimanjaro for 7th Cancerversary

                  For some reason I do not get notices of private messages on here so please feel free to email me directly at mike@tc-cancer.com if you would like to chat privately so as to avoid any delays.

                  Comment


                  • #10
                    Hi, Mike..Stage 2. 3bep where to find current articles about Rplnd..Relapse rates?

                    Comment


                    • #11
                      [QUOTE=Mike;n320654]The issues with interpreting risk of relapse with LVI+ (the most recognized risk factor) and embryonal content is that they very often go hand-in-hand and often time in analysis data is missing.

                      There was a poster presentation at the ASCO Genitourinary Cancer Symposium 2019 https://ascopubs.org/doi/abs/10.1200...37.7_suppl.510 that may help. There was a Tweet of it as well https://twitter.com/i/web/status/1096434110224949248

                      The 111 Trial was just published from the UK which may help too: https://www.europeanurology.com/arti...895-4/fulltext

                      I will actually be at the GU20 tomorrow through Saturday and can ask around too. Dr. Craig Nichols, et al have an upcoming letter to JCO about the 111 Trial and I can ask him and see if he has any ideas about publication date.

                      MIke[/Hi, Mike..Stage 2. 3bep where to find current articles about Rplnd..Relapse rates?

                      Comment


                      • #12
                        Originally posted by omerkulum View Post
                        Hi, Mike..Stage 2. 3bep where to find current articles about Rplnd..Relapse rates?

                        I think the rates are very much going to depend on details that the surgeon would be more privy to, such as completeness of the resection, if there was any viable cancer/teratoma removed during the RPLND, the prognosis of the patient prior to the RPLND and if there was use of any post RPLND chemotherapy. I would expect most patients for the risk of relapse to be less than 10% but it can vary significantly given the different patient variables. It is certainly a discussion to have with the surgeon.

                        Mike
                        Oct. 2005 felt lump but waited over 7 months.
                        06.15.06 "You have Cancer"
                        06.26.06 Left I/O
                        06.29.06 Personal Cancer Diagnosis Date: Got my own pathology report from medical records.
                        06.30.06 It's Official - Stage I Seminoma
                        Surveillance...
                        Founded the Testicular Cancer Society
                        6.29.13 Summited Mt. Kilimanjaro for 7th Cancerversary

                        For some reason I do not get notices of private messages on here so please feel free to email me directly at mike@tc-cancer.com if you would like to chat privately so as to avoid any delays.

                        Comment


                        • #13
                          Originally posted by Mike View Post


                          I think the rates are very much going to depend on details that the surgeon would be more privy to, such as completeness of the resection, if there was any viable cancer/teratoma removed during the RPLND, the prognosis of the patient prior to the RPLND and if there was use of any post RPLND chemotherapy. I would expect most patients for the risk of relapse to be less than 10% but it can vary significantly given the different patient variables. It is certainly a discussion to have with the surgeon.

                          Mike
                          Thank you Mike.RPLND pathology matur teratom. Good prognosis.Full template.Testicular pathology 50% matur teratoma.Anyone in similar situation?

                          Comment


                          • #14
                            I'm also a doctor (Internal Medicine) who had TC in residency. I had stage 1b predominant EC, did 1 x BEP. I have made many friends along the way that have received the same treatment. None have any peripheral neuropathy (which was a concern of yours in another post). None have permanent tinnitus, but some had it for a few weeks.

                            If you have 100% EC stage 1a, according to the Princess Margaret studies your relapse risk is close to 40%, certainly not as low as 15%.

                            Surveillance is a very good option for you though. 1 x BEP is not an easy treatment. RPLND is also a good option.
                            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


                            • #15
                              Originally posted by RJKD View Post
                              I'm also a doctor (Internal Medicine) who had TC in residency. I had stage 1b predominant EC, did 1 x BEP. I have made many friends along the way that have received the same treatment. None have any peripheral neuropathy (which was a concern of yours in another post). None have permanent tinnitus, but some had it for a few weeks.

                              If you have 100% EC stage 1a, according to the Princess Margaret studies your relapse risk is close to 40%, certainly not as low as 15%.

                              Surveillance is a very good option for you though. 1 x BEP is not an easy treatment. RPLND is also a good option.
                              Hey RJKD.
                              Is there any way we could talk? Maybe through email.
                              Idk if this forum has messaging services. I would like a personal input from yourself since I think we are in the same boat. I'm a first year resident in IM going through this.

                              Comment

                              Working...
                              X