Chemo, RPLND, More chemo?

[MROSE]

Hello everyone! Before I ask my question, I just want to thank everyone for posting their stories, questions, and answers in the forum. This has been the most helpful source of information in the last month thanks to all of you great members!

My loved one, John, is 23 years old and was diagnosed with TC in November, 2005. Following the orchiectomy (tumor was nonseminoma) he was on survaillience until his blood markers were elevated in March 2006. He has since completed 4x EP. Doing moderately well with chemo, he moved on to the RPLND last Wednesday as the tumor in the lymph shrunk pretty much in 1/2 after chemo (1cm). The surgeon's immediate resopnse after the RPLND was that the remaining tumor in the lymph is teratoma. Other than anemia-related issues, he is doing very well in the hospital with his recovery and we expect him home this Wednesday. He is being treated at Sloan-Kettering in NYC and is seeing Dr. George Bosl (great Oncologist!). He mentioned 1 out of 8 people in John's position will need 2 more rounds of EP post-surgery. I have met many people in this forum and haven't come across anyone who needed 2 extra chemo rounds after receiving chemo 1st, surgery 2nd. Is there anyone out there who has experienced this, and if so, what was your pathology before/after the RPLND? We should get the pathology report back in just a few more days, but of course I'm anxious and would love to talk about what we might expect should the news not be so great.

Thanks for all your help!

[Davie]

MROSE,

Given that I may need a postchemo RPLND also, I did a bit of research on this. I spoke to the surgeon who does these in the UK, and of the 350 he has done, 15% (about 1 in 7) had residual cancer, hence the need for further chemotherapy. This compares well with the 1 in 8 you have been told.

However, when I delved a bit deeper, the 1 in 7 is across the board, and will include patients across the whole risk spectrum. Therefore, if you are a good risk patient with prechemotherapy low tumour markers and RP mass, then you are likely to have lower odds of further chemotherapy after RPLND than a patient with very high markers and a very large RP mass.

I've posted below a summary of two articles where remaining cancer after postchemo RPLND was much lower than what you've been quoted. The first one found only 1 in 35 residual cancer after postchemo RPLND for stage IIa/IIb disease. The second found 6 in 87 with residual cancer after postchemo RPLND (and 3 of those used carboplatin which is less effective than cisplatinum).

First Article

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.

Second Article

Purpose: To determine preoperative parameters that predict the histology of specimens obtained by retroperitoneal lymph node dissection (RPLND) in patients with nonseminomatous germ cell cancer (NSGCT) whose residual mass was 20 mm in diameter after modern cisplatin-based induction chemotherapy.

Patients and Methods: Eighty-seven patients with metastatic NSGCT underwent RPLND after having received cisplatin- or carboplatin-based induction chemotherapy. In all patients, the largest diameter of the residual mass on the transaxial plane was 20 mm, as assessed by abdominal computed tomography (CT) immediately before RPLND.

Results: Complete fibrosis or necrosis was found in 58 patients (67%), teratoma was found in 23 patients (26%), and vital malignant germ cell tumor was found in six patients (7%), including one patient with rhabdomyosarcoma in the RPLND specimen. In five of the six latter patients, the residual lesion was 10 mm at pre-RPLND CT. No pre- or postchemotherapy clinical or radiologic parameter was identified that significantly predicted the histology of the residual mass.

Davie.

[Scott]

If the residual mass was teratoma, I don't know why more chemotherapy would be warranted.

Is it possible he was talking about men who have RPLND surgery and who have not already had chemotherapy?

[mk6439]

I think she said the surgeon's feeling was that it was teratoma, but they're waiting for the labs to confirm

[MROSE]

Thank you Scott, Davie, and MK for your response - I was so happy to see you all read the post. You know, I knew there had to be something that set apart the 1 from the 8 that do not need further chemotherapy. John's oncologist was reluctant to go into detail pre-surgery - he is the kind of doctor who keeps everyone focused on the present issue, and right now that is the RPLND. I asked the fellow of John's surgeon what separates the 1 from the 8 who do not need chemo, and it sounds like even if there is a small trace of live cancer (I am sure there is an exact size/number), chemo may not be neccessary. I was under the impression that ANY indication of live cancer would result in chemo. To answer your question Scott, I thought he might have grouped all TC patients together with the stat he told us, because that makes sense - I can think of a handfull of people I've crossed paths with that had the RPLND first and needed 2 rounds of chemo. The fellow I spoke with today made it seem as if it's not too great of a chance in John's case, being that his tumor was very small when removed and nothing larger was found. I am guessing if the surgeon told us on his preliminary viewing that what they removed appeared to be a teratoma, then hopefully that is enough to give us all confidence until we hear the official news. Apparently, at Sloan the surgeon's preliminary viewing can be up to 80% accurate. Don't quote me on that, but that came up in discussion not too long ago (but I'm sure you ALL know how conversations can become a huge blur when you are hearing stinky news).

As of now, John's pretty much ready for discharge tomorrow. He's about to get the staples out of his stitching (which I'm sure will suck) so he won't get the pathology until he's home. Another thing I'd like to mention while I'm at it - John has chemo-related anemia and did not lose much blood at all after the surgery, but his red blood count wasn't really replenishing. So, after feeling symptomatic (major fatigue) he had a transfusion today. He was getting his second blood bad when I left the hospital tonight. I think it's helping him feel better, but I am nervous that this is something rare - blood transfusions just sound scary, you know? So, if anyone knows anything about that - I'd love to hear it.

Davie - AMAZING research/articles, thanks for sharing with me. I am a huge fan of research-based information (I'm a research assistant in the mental health field )

Hope all of you are healthy and well! Thanks again.
Melissa

[MROSE]

Had to post the good news - John's pathology report is negative!! 14 lymph nodes were removed, all clear. Thanks for your support and help - it would be pretty much impossible to get through the days without your guidance

[Davie]

That's wonderful news.

Was the residual mass necrotic tissue or teratoma?

Davie

[MROSE]

The mass removed post-chemo was teratoma. There was teratoma present in his original testicle tumor, so it looks like chemo/RPLND was the perfect combination. Thanks for checking in!