Seminoma: Surveillance or radiation?

[Scott]

...a figure we hear over in the UK is that on average, one in three people will get Cancer at some stage in their lives.

Half of all men and a third of all women.

[Fish]

TC2006:

It is confusing when the "experts" don't always agree. However, it actually supports the argument that there is no right or wrong desicion. It ultimately comes down to what level of risk you can live with. I think whatever you decide, you will be OK.

To Johnseed: I would have threatened legal action to have my health records amemded. You did not refuse treatment! Surveillance is a treatment. I'm glad things ultimately worked out for you.

Best wishes to all.

Fish

[tc2006]

Johnseed, it sounds chemo was a pretty rough road for you; I guess radiation could be the lesser evil, although even with radiation, I won't know for sure if I will still need chemo at a later stage.

[tc2006]

UK Mart, your comments make a lot of sense, at least to me. By 'best report possible', do you mean you were described as a low-risk stage I seminoma (no enlarged lymph nodes, tumor size <4cm, etc.) ? What did your radiation therapy look like (dose, radiation field, etc.) ? How often do you need a check-up (CT, blood marker, etc.) now that you have the radiation behind you?

[johnseed]

A rough road?

Hi tc,

Was chemo a rough road? Well I was off of work for six months and chemo weakened me tremendously. Also, my wife filed for divorce halfway through chemo so there were all kinds of difficult emotions. She is a person who needs to be the center of attention, and during chemo all my family and friends rallied around me and oddly enough she just cracked.

But hey, at least chemo was there for me and it sure beats death!

I know that every situation is different when it comes to cancer, but with attention and courage and good doctors it can be beaten.

Being practical, if I had it to do over again I would choose radiation, but even though chemo was difficult I can't complain since I have been clear of cancer for over four years, have a wonderful new marriage, and -- can you believe it -- a second post TC baby due in November.

Re: should I sue to get my medical records changed I have been told that when I have five years clear of cancer I can get a life policy again, so at this point I don't feel the need to take legal measures.

JS

[UK Mart]

UK Mart, your comments make a lot of sense, at least to me. By 'best report possible', do you mean you were described as a low-risk stage I seminoma (no enlarged lymph nodes, tumor size <4cm, etc.) ? What did your radiation therapy look like (dose, radiation field, etc.) ? How often do you need a check-up (CT, blood marker, etc.) now that you have the radiation behind you?

Well, I had my initial consultation today where they marked me up... I have green markings (and a couple of dot tattoos!) that begin about a centimetre above my belly button, is about three inches wide and and six inches high - it's right slap bang in the middle of my chest and is rectangular. I'm due to have 8 blasts of 6MV in strength, starting tomorrow.

In terms of my report, there was no evidence of spread, tumour was 5.0x3.5.x4.0 and the CT scan was clear - also my tumour markers were fine. I really am low risk.
I'm having radiation for the following reasons;
There may be a few cancerous cells remaining that had left the testicle and were en route to the lymph glands (this is the area that they're zapping). Radiation should get rid of these.
The side effects are relatively minor.
With surveillance there's a 20% chance of recurrence.
With radiation there's possibly a 2% chance of recurrence / secondary cancer.
I asked about chemo as an alternative and according to recent studies I believe that the chance of secondary cancers may be quite bit higher.
Radiation is focused whereas chemo is more general.

At the end of the day, follow-up treatment is preventative and precautionary so as long as some sort of follow up is done post IO then we should be fine. Should the worst happen, at least we'll be in a position to notice it and do something about it.

[tc2004]

hope this helps!

I was pretty much in your shoes in 2004. I was diagnosed with stage 1 seminoma, cancer contained to testis, no lymphatic involvement, etc. Follow-up CT-Scan noted two lymph nodes in pelvic region just above normal 1 cm. I decided to follow the recommendation of the drs. and received radiation therapy. Everything was fine for a year then just recently February 2006 routine ct-scan noted two small 1 cm lung nodules. I had a biopsy which confirmed metastizied seminoma. Began chemo in April, will finish in June. My suggestion to you is follow your gut, cancer is out of our control and it is extremely tough to make a desicion without knowing a confirmed outcome. If I would be faced with the diliemma again from the beginning I would probably have opted for the carboplatin chemo regimen as mentioned by another member or even possibly considered surveillence. All in all cancer sucks!

[tc2006]

johnseed, sorry to hear what happened - this sure sounds like no walk in the park for you. well, I went thru simulation yesterday, getting comfortable with the idea to start radiation next week. But then I decided to get another CT scan instead next week - my thinking is that if the sub-centimer nodes are gone then, I may switch to surveillance last minute. It's not that I think radiation is all that bad an idea, but I do have some concerns about my suspicous spots (liver, pancreas) in the last CT, and somehow I feel I should know first whether they really are harmless before hitting them with radiation. Now, it nothing has changed in my CT by next week, I may just follow thru with the radiation and get it behind me. It's kind of weird though: when I did the simulation, the nurses pretended as if it was the most normal thing in the world - to get you ready to be loaded up with radiation. Somehow, I didn't like that, although my brain says: maybe radiation IS the way to go .... anyhow, don't mean to bore you too much with this stuff, that's where I am. By the way, did anybody else have another CT scan taken - after the first after the I/O - about 6weeks later, or am I starting to lose it, b/c this 2nd CT will reveal nothing new (but still add radiation too) ..?

[TSX]

By the way, did anybody else have another CT scan taken - after the first after the I/O - about 6weeks later, or am I starting to lose it, b/c this 2nd CT will reveal nothing new (but still add radiation too) ..?

With seminoma, you're not likely to see much difference with a six-week interval. I don't know the numbers, but I've been told that the radiation from a CT scan is much lower than a single radiation treatment. I was also told that the helical CT scanners have higher resolution and lower radiation than the older style scanners. Can anyone provide numbers to confirm this?

-TSX

Edit: I'm going to answer my own question here. I was misinformed about the relative radiation doses. I'll quote my source below, but the executive summary is that the radiation from a conventional CT scan is 33 times the amount in a X-ray, and a helical CT scan is 4 times greater than a conventional CT scan. For those considering a chest X-ray versus a helical CT scan of the chest, the question to ask is whether the small improvement in diagnostic ability is worth 133 times more radiation.

Note that I added the emphasis in the following quote.

Radiation dose is simply the amount of energy absorbed by a medium, most often the medium being the human body or, more specifically, a particular tissue or organ of the body. The typical units used to quantify absorbed dose are, in international units, the sievert (Sv), which is equivalent to the absorption of 1 Joule of energy per kg of tissue.


Effective dose is another term used to quantify the biological impact of the absorbed dose by taking into account the varying sensitivity of the different tissues and organs of the body to radiation injury. A weighting factor is applied to the individual organ doses to yield a single effective dose number for a particular procedure, like a chest x ray. The International Commission on Radiological Protection (ICRP), reports #60 and #73, explain in great detail the concept and use of effective dose. So there is a difference in the terms and use of dose-organ dose versus effective dose.


Let’s consider the procedures in more detail. Spiral, or helical CT, will result in doses up to four times higher than that for a conventional CT scan, and certainly greater than that incurred in standard x rays. In helical CT, the patient is continuously moved through the scanner as the source and receptor rotate around the patient. To achieve such a detailed and expansive feat, it is necessary to expose the entire thickness of the patient to a greater quantity of x-ray photons. The pitch is the ratio of distance the patient has moved through the scanner per rotation per slice thickness. Usually, the number is between one and two. Higher pitch lowers radiation dose, but at the expense of partial volume effect (loss of detail). Larger patients receive a relatively higher skin dose in order to penetrate their bodies and smaller patients have a relatively higher dose to internal organs. (Since internal organs are more radiosensitive than skin, smaller patients generally incur a higher effective dose for the same CT settings and, hence, higher long-term cancer risk.)


With either a chest x ray (CXR) or a CT scan, the part of the body receiving the greatest exposure is the entrance skin in the field of view. Conventional CT (serial noncontiguous slices) gives a much higher dose than a CXR. The typical CXR effective dose is about 0.06 mSv (6 mrem); a conventional chest CT scan with slice thickness of about 5 mm would give about 2 mSv (200 mrem) and a helical CT of the chest results in about 8 mSv (800 mrem) (Invest Rad, 2000; Pediatric Radiol, 2002; BJR, 1997). These skin doses are well below the levels required to produce any immediate or short-term effects such as reddening of the skin or blistering. Hence, the concern is the long-term risk from such exposure—the development of cancer later in life. Based upon the calculated effective dose, the patient’s theoretical increased fatal cancer risk from a standard CXR is 0.0002%, about 0.008% for conventional CT and about 0.03% for a helical CT of the chest. Hence, the helical CT of the chest delivers an effective dose, and increased cancer risk, that is over 100 times greater than that for a standard CXR. Note that the natural incidence of fatal cancer in the United States is 25%. Therefore, the theoretical total risk of fatal cancer for the group of adult subjects participating in this study in which they receive a helical chest CT is predicted as 25.03 %. Conventional wisdom is to minimize exposure, and risk, as much as possible, unless there is the prospect of a direct benefit to the patient from the exposure.


What is the benefit of receiving a helical CT scan? If a small slice thickness and low pitch is used, it is possible that a very small lesion might be detected that would otherwise not be detected with a CXR. We qualify this comment to say that the utility of this is very suspect. A lesion small enough (less than a centimeter) to escape detection with a standard CXR is so small that its clinical significance is doubtful. Only serial x rays will prove the lesion to be benign or malignant. Hence, more than one helical CT scan would still have to be performed to give the study any meaning. Perhaps the same benefit could be achieved with serial chest x rays with a fraction of the dose. Another combination that might be even more worthwhile would be a standard CXR and follow-up standard CT scan (only in the area of the lesion) with small slices (1-2 mm) to evaluate a suspicious lesion.


The main advantages of helical CT are not germane to the current situation of screening healthy individuals. Often helical CT scans are very useful in emergency rooms where a fussy child needs a critical x ray (or even a delirious or uncooperative adult). The advantage is that the entire helical CT can be done in less than a minute (maybe long enough to keep a child still) whereas conventional CT scans would take ten minutes or so. Furthermore, the speed of helical CT is an advantage in trauma cases where minutes are vital. With the information stored in the computer files, one can even convert serial horizontal slices to vertical slices (without having to repeat the study) in some cases of facial trauma where multiple views are important to assess fractures and soft tissue entrapment. For simply detecting a lesion in a routine outpatient setting, a helical CT scan would be considered excessive.


Regarding your concern with the patient’s understanding of the risks versus benefits of performing helical chest CTs in the absence of symptoms, it is extremely important that the patient is provided full disclosure of the associated radiation dose, increase in potential cancer risk, and alternatives for screening in this indication. Most importantly, it appears that the helical CT scan is not necessary for the patient’s medical care, but rather is indicated to fulfill clinical research objectives. Thus, the patient should be informed that the associated radiation exposure is approximately one hundred times greater than that from a standard chest x ray. Typically, a standard chest x ray is all that is really necessary for screening for most pulmonary disease.


Jamey West, MD
Lisa Coronado, Senior Health Physicist
National Institutes of Health
Bethesda, MD

[rjs]

TC2006-
Your concerns and interest and questioning are all normal. Trust me you will drive yourself crazy trying to find the "right" answer. In the cases of seminoma and the options provided to you, there are actually a few "right" answers. All of them have some risk and all require different steps on your part, but they should all lead you down the same path. It can be frustrating when dealing with all the percentages of risk that are being thrown your way, coupled with the small centimeter nodules the CT or XRAY find then you really can be frustrated with what to do. In the end, you gather all the information you need, ask questions, trust your doctors and move forward with confidence that you will beat this no matter the path chosen.

I suspect that another CT will not show anything dramatically different. Those nodules / cysts have probably been there for some time already and may not even be TC related so the radiation will probably have little affect on them. For the most part, adjuvant radiation treats any cancer cells in the lymph nodes that the CT can not pick up. While the scans show clear and there may have been no vascular invasion, there is a risk that some cells are present and undetected. Radiation should zap those out and lessen the chances of any recurrence in the radiated area. Unfortunately, as the previous poster shows, there is a very small chance that some cells still have made it to the lungs and those could come back later, but that is why we all have to do our regular follow-ups. And in most cases, any recurrence is taken care of with chemo.

You are right about the common approach the techs seem to take at the radiation center. I thought it all seemed so surreal and simple when my simulation was taking place. The actual treatments were fairly routine also, but over time I realized that these are professionals and they do care about their job and your well being. Everyone knows its serious stuff and I don't think any of them are taking the treatment lightly. I found my techs to be very professional, helpful, and encouraging. If you need an indicator for how serious this stuff can be, then notice how quickly they leave the room before turning on the machine! (HA) These techs see lots of patients everyday with varying degrees of the illness and radiation levels. Don't equate the short amount of time you are on the table or the speed with which they do their work as an indicator that they don't care or are not taking the treatment seriously.

Hang in there. Stay positive. It's all moving fast, but you are moving in the right direction!

[tc2006]

B/c of some unexplained stomach (flank) pain on my right side, I did have a sonogram done last week (I haven't started RT yet), and it showed that the "cyst" on my right kidney really is a small "fatty tumor". My GP told me that this is a benign tumor which does not require any treatment, but of course now I am worried again that RT might make this thing worse. - Has anybody else who went on RT (or decided against it) had this diagnosis?

[Eric]

TC2006

I have a cyst on the liver and have done chemo anyway, my doc told me to not worry about because she probably has more cyst than me on the liver and she doesn't know. Almost all of the people have cysts somwhere and they don't know it because they don't have scan. Like i said to you earlier if i had to do it again i would choose surveillance or chemo. I you choose radiation be sure at 100% that is THE best for you and talk to more than 1 doc.

[tc2006]

Thanks to all of you for your continued comments and suggestions; if only I could make a decision ... So far, I have talked to 2 urologists (including the one who did the I/O), 2 radiation oncologists, 1 medical oncologist and of course my GP. While surveillance looks quite attractrive to me, the votes from these doctors are 5:1 in favor of RT in my case. I am considering to talk to one last doctor next week, but then force myself into a decision one way or another as next week will be 7 weeks after I/O and I think IF you choose RT, you should start it no later than 8 weeks (4-6 weeks) after I/O. Have you guys taken more time to make your decision or am I late in the game already if I did decide to go ahead and undergo RT ?

[TSX]

tc2006:

First, you can disregard the urologists' and GP's recommendations. This is not their field and they have no business recommending treatment for TC. I am reminded of a quote by Richard Feynman: "I believe that a scientist looking at nonscientific problems is just as dumb as the next guy."

Second, the preference for surveillance over radiation in stage I cases of TC is a fairly recent trend. My guess is that if you asked a group of oncologists at one of the cancer centers with a lot of experience in treating TC, you would get a very different picture than if you asked a group of oncologists in other centers or in community hospitals.

That being said, where are your second-opinion oncologist(s) practicing? At a minimum, the second opinion should come from outside the group of your first-opinion oncologist. Ideally, the second opinion should come from someone with strong expertise in treating TC, or at least from someone who practices in a center with strong expertise in treating TC (Indiana University, Sloan Kettering, Dana-Farber, M.D. Anderson, etc.).

-TSX

[Eric]

I think that if you already have cancer cell in your blood, 2 or 10 week does not make any difference. It takes only one microcell to go out of the radiation window before you do RT and RT will be useless. In a population of 100 people there is 80 who are cured by radiation alone, the other 20 do radiation and about 3 of them will relapse. This mean 3/20 or 15% but with chemo your are at 5% of relapse so your odds are still better with chemo.