Chances of Surgery after Chemo?

[ghjones]

Three months since diagnosis and I find this site by accident - think I'll have to work on my net searching skills from now on! A number of posts have proved to be a great help already, so thanks all for making this such a great site.

Since this is my first post, i'll give you a little background to where I'm at on the TC journey. I was diagnosed 6th Jan'06 with 1cm testicular mass in my right buddy. Getting this diagnosis proved to be a challenge on the UK NHS - I was told it would be a six-week minimum waiting time for the scan even as an 'urgent' case (makes you wonder what the annual £90bn of tax payers money gets spent on) - so I decided had to go private and was scanned the next day at a private hospital.

Had the little guy removed on 13th Jan and pathologist diagnosed non-seminoma/seminoma mix. CT scan showed Stage IIA 1.4cm RP mass in lymph nodes and Oncologist recommended 3xBEP chemo. Tumour markers all normal - so good risk prognosis given.

Chemo not exactly a barrel of laughs - I likened it to a 9 week hangover but without the fun night-out beforehand. I do feel lucky though as I had completely no complications nor any nausea. NHS food was something else - I'd feel cruel giving some of the food to my dog, who regularly enjoys eating cat crap as part of his diet. Particularly liked the "celebrity chef special" of........beans and toast...must have taken the chef a long time to come up with such a soggy culinary masterpiece.

I'm now a week out of chemo and feeling half-healthy for the first time this year. Still have more than a passing resemblance to Dr. Evil but i woke up this morning with a pre-pubescent "bum-fluff" moustache, its like being 13 all over again!

Which leads me onto my question - I'm having my post-chemo CT scan results in four weeks. My oncologist says that there are three potential results - i) all clear ii) residual mass iii) enlarged mass - which will almost certainly be a fluid-filled cyst. Scenarios ii) & iii) are likely to result in RPLND. Does anyone know what the likelihood of each scenario is? Am thinking that the chances of an 'all clear' result must be pretty high considering my RP tumour is only 1.4cm (and the surgeons refuse to operate on anything less than 1cm in the UK) - but really have no idea of the % of people that need the RPLND after chemo. If anyone has any idea of the split it would be greatly appreciated.

Thanks to all in advance,
Gareth

[petep]

I just finished my chemo...and had my CT scan last monday - all clear...the one enlarged node I had is gone...you could see a slight dot where it was...but the doc said it is nothing - he said it is all gone. My markers were all returned to normal about haalfway thru chemo.

i do not know the percentages...but I think the real issue is the type tumor - the teratomas from what I have read, do not tend to shrink...and although they may not be cancerous, a doc will typically opt to have them/it removed post chemo, as they can quickly turn cancerous.

my mix was 95% embryonal and 5% seminoma...which tend to respond well to chemo...both in terms of ability to kill cancer and ability to shrink solid mass tumors.

I suppose what I'm saying is it's like the stat sometimes you will see...90% cure rate overall w/testicular cancer...within that, you may have the cure rates that approach 100% with stage I diagnosis versus a lower cure rate with stage III...

You may just need to wait it out...which is the tough part.

[Mom]

I think your chances of not needing it are very good. My son did not need the RPLND after chemo. He had lymph invasion with only one node involved and that didn't even show up on the CT scan. The reason for the chemo was that his markers did not go down. He is in his second year of surveillance and so far so good. Hopefully, you will be in the "all clear" category. Good luck and keep posting. Dianne

[dadmo]

With no teratoma you should be able to avoid the RPLND. The continued enlargement might be simple scar tissue. Congratulations on your successful treatment.

[Davie]

ghjones,

Here's an abstract from some literature I found delving deep into the web. According to this research you've got an average of a 17% chance of an RPLND. Two of the authors are actually treating me at present with 3 x BEP for a 3 cm RP mass.

I also talked this over with my consultant, because I didn't much fancy an RPLND, but will do whatever is necessary. There appears to be no exact rules, but the amount of mature teratoma (teratoma differentiated) in the primary tumour can effect the chance of a RPLND because it is more likely to be in the secondary tumour. Mature teratoma is unaffected by BEP, because it is not cancerous, but can become so later in life - hence the need to get rid of it.

p.s. I had the same experience with NHS food, but can't say I ate much through my BEP sessions. Otherwise I couldn't falt them for all my treatment so far.

Primary chemotherapy for stage II nonseminomatous germ cell tumors of the testis.

Horwich A, Norman A, Fisher C, Hendry WF, Nicholls J, Dearnaley DP.

Department of Histopathology and Computing, Royal Marsden Hospital, Surrey, United Kingdom.

Between 1979 and 1989, 122 patients with clinical stage II testicular nonseminoma were treated with primary platinum-based combination chemotherapy following orchiectomy. Of the patients 58 had Royal Marsden Hospital stage IIA (nodes less than 2 cm. in diameter) and the other 64 had stage IIB (nodes 2 to 5 cm. diameter) disease. With a median followup after chemotherapy of 5.5 years, 118 patients (97%) were disease-free. Two patients died of progressive germ cell tumors, 1 of bleomycin toxicity and 1 of coincidental disease. The 5-year actuarial survival probability was 95% (95% confidence intervals 91 to 99%) and the 5-year failure-free survival probability was 92% (95% confidence intervals 88 to 97%). Tumor substage was not predictive of relapse but did indicate the probability of lymphadenectomy for a post-chemotherapy residual mass since this was performed in 17% of the patients with stage IIA disease and 39% with stage IIB disease (p < 0.05). Resected specimens contained mature teratoma (29), necrosis alone (5) or embryonal carcinoma (1). We conclude that for these clinical stages primary chemotherapy was as effective as primary lymph node dissection and a major operation was avoided in 68% of the cases.

[Rune]

In addition to the good information already posted, it's worth noting that embryonal carcinoma can turn into teratoma during chemo (teratoma meaning the type unaffected by chemo.. there's some difference in the terms between the US and UK).

Which elements did the non-seminoma part of the tumor contain?

Also, welcome to the forums, Gareth! The same goes for Pete and Davie.. don't think I've "met" you yet

[ghjones]

A big thank you for all of the above replies. I do feel a lot more confident now going into my results next month. Congrats Pete for your clear scan results and good luck Davie for the rest of your chemo treatment.

Thanks for your reply Rune. In answer to your question, I am not 100% sure of the exact mix of my primary tumour but I do remember my consultant saying that there was some teratoma. So I guess that I'll have to hope that the teratoma did not form too much of my secondary tumour.

Only three and a half weeks of waiting to go! Is it usual to have to wait four weeks for CT scan results post-chemo or is this another quirk of the UK health system!?

[dadmo]

A four week wait post chemo is ok. That's about the same amount of time my son had to wait. Those scans will probably be the determining factor for the RPLND.

[ghjones]

Got my post-chemo results through this morning.....the doc says I'm "all-clear".....so i'm now in remission/surveillance Glad to add another notch onto the statistics of not needing a post-chemo RPLND.

Am so happy, not sure I could say it in words, but thanks to everyone for their support. Am desperate to go out and celebrate but cleverly I decided to put myself into a professional exam on Thurs Funny how unimportant it seems now though!

My doc has said that it is very unlikely I will need a CT scan during my surveillance process as there is "no need, because we can pick up any problems from the CXR, Blood Tests". I've been thinking this over and as I have never had raised cancer markers in my blood, I would not be 100% sure how exactly they would pick up any problems, unless the relapse is in the lungs. The doc said there are other things they look for in the blood apart from the markers, any ideas exactly what? It is apparently a 'UK-standard' surveillance process - so has anyone else gone through a similar non-CT scan surveillance succesfully? It seems strange, seeing that in the US, CT scans are part of the course.

[MRM]

The Testicular Cancer Resource Center's preferred protocols are here, and they generally don't require CTs after chemo, just blood and X-rays, unless there was a lot of teratoma in the tumor:

http://tcrc.acor.org/whatnow.html

[Jason]

Isnt that a bit odd though? I mean doing a CT Scan on the abdominals would be more sensible. So if there is any enlargement of the nodes, they can get onto it right away.