Our new pathology from Dr Ulbright at IU

[mercyriver]

OK, today I recieved in the mail the results from Dr. Ulbright, I may be doing some research on all this, but please help with any of this that you can.

And it is not 100% Embryonal Carcinoma and I don't know how this changes things.

Here is the report

Testis, right, radical orchiectomy:
Mixed germ cell tumor (embryonal carcinoma-70%;teratoma-20%;yolk sac tumor-10%), with lymphovascular space invasion; no extra-testicular extension identified.
Maximum tumor dimension by gross examination, 3.0cm.
Spermatic cord negative.

Pathologic Stage: T2, NX, MX



Microscopic Description:
In our opinion, this right testicular tumor represents a mixed germ cell tumor. The predominat element is embryonal carcinoma, and this is arranged in mostly papillary and glandular configurations. These tumor cells have the characteristic pleomorphic appearance with crowded, overlapping nuclei. Additionally, we feel that there is a neoplastic stromal component often seen paralleling the embryonal carcinomatous cells. While it is controversial, in our opinion, this component should be regarded as teratoma. Additionally, there are myxoid foci that contain stellate cells and occasional glands and this, in our opinion, represents yolk sac tumor. The tubules peripheral to the tumor show intratubular germ cell neoplasia of the unclassified type. There is lymphovascular space invasion by tumor; we do not identify extra-testicular extension in these sections. The spermatic cord sections are negative for tumor.

End of report.

[djmac]

OK, today I recieved in the mail the results from Dr. Ulbright, I may be doing some research on all this, but please help with any of this that you can.

And it is not 100% Embryonal Carcinoma and I don't know how this changes things.

Here is the report

Testis, right, radical orchiectomy:
Mixed germ cell tumor (embryonal carcinoma-70%;teratoma-20%;yolk sac tumor-10%), with lymphovascular space invasion; no extra-testicular extension identified.
Maximum tumor dimension by gross examination, 3.0cm.
Spermatic cord negative.

Pathologic Stage: T2, NX, MX



Microscopic Description:
In our opinion, this right testicular tumor represents a mixed germ cell tumor. The predominat element is embryonal carcinoma, and this is arranged in mostly papillary and glandular configurations. These tumor cells have the characteristic pleomorphic appearance with crowded, overlapping nuclei. Additionally, we feel that there is a neoplastic stromal component often seen paralleling the embryonal carcinomatous cells. While it is controversial, in our opinion, this component should be regarded as teratoma. Additionally, there are myxoid foci that contain stellate cells and occasional glands and this, in our opinion, represents yolk sac tumor. The tubules peripheral to the tumor show intratubular germ cell neoplasia of the unclassified type. There is lymphovascular space invasion by tumor; we do not identify extra-testicular extension in these sections. The spermatic cord sections are negative for tumor.

End of report.

Hey Congrats!

I've read somewhere that yolk sac elements and teratomatous elements in the primary tumor are prognostic indicators for unlikely spread... Armed with this path report, I'd pick Einhorn's brain on surveillance as an option for your husband (then of course, there are the lymph nodes)...

Best of luck to you and your stubborn hubby!

djm

[dadmo]

mercyriver:
Good job getting that report. Who would ever think you could be relieved by a report on cancer. Yor husbands tumor is similar in composition to what my son had except my guy was stage III. It was a long road but after 4EP and an RPLND he is cured, and there is no reason to expect anything different for your husband.

[willgetoverit]

Good job.

I must say I am so relieved that its not adenocarcinoma. I did not contribute to your other thread, but I did go through the whole thread.

My tumor composition is very similar to your hubby's. Embryonal - 70%, teratoma 20%, Yolk sac 5%, and chorio 5%. IMO, the only major difference was that I did not have lymphovascular invasion and your hubby's path report says he does have LVI.

Anyway, from here on, I'd imagine it's pretty much you/your hubby's choice.
Surveillance(??), RPLND and/or adjuvant chemo, 3xBEP, depending on your comfort level and mindset.
And of course, I cannot stress enough on the importance and advantages of a TC specialist or, if possible, getting it done at one of the Centers of Excellence.

And here is my treatment thread...hope it helps.

http://www.tc-cancer.com/forum/showthread.php?t=4583&highlight=willgetoverit

[mercyriver]

Yes, I can't even say how nice it was to see that the adenocarcinoma was exactly what I thought it to be, bad lab practice.

I also discovered that our hospital that did the pathology only sees 5-10 cases of testicular cancer a year. It makes me wonder why there isn't a more standard way for testicular cancer pathology to be done. Why isn't every tumor sent out to a expert facility?

It is very comforting to read all the great sucess with all of your cases. Gives me less to worry about. Of course I do still have to worry over the enlarged lymph nodes and the fact that something has been growing in my husbands abdomen for at least 3 months now.

We are still waiting to hear from the oncologsit as to what Dr Einhorn had to say, but of course, adding to how annoying all of this, his oncologist was out sick yesterday.

My only question now is about Teratoma. I know there are three basic types of teratoma, but all I can tell from the pathology report is they found neoplastic stromal components with the embryonal carcinoma , that while controversial, they are calling teratoma. Does that tell me what kind of teratoma it is, or can they not tell that from the slides?

Thanks for all the posts, it has really helped to make me feel better about the new pathology.

Becki

[dadmo]

From reading your signature I now see that according to the PET scan your husband has some activity in the lymph nodes so for him it's not just a matter of lymph node size. Make sure this information is given to Dr. Einhorn, it will be a big factor in determining a treatment plan.

[mercyriver]

Yes, there were at least 3 enlarged lymph nodes on the CT scan from November, but the September CT showed at least 5, so who's to say exactly how many are in there. But when they did the PET scan the activity did line up with where the enlarged lymph nodes were on the CT scan.

And I finally updated the signature to reflect as much info as I could, it makes it easier on people, then having to go back and read all the posts.

We will be certain that Dr. Einhorn gets ALL the information in my husbands file.

Becki

[willgetoverit]

mercyriver,

Maybe I missed it, but, from the bloodwork, what were the AFP counts like?

[mercyriver]

New Twist in the story

OK, newest twist, the oncologist is now saying that this is clearly not in his arena and has given it back to my husbands urologist.

It was almost to much.

But then my husband asked me what needed to be done to get the 2nd opinion from Dr. Einhorn.

He wants to avoid surgery IF ALL POSSIBLE. He said he is OK with larpascopic, but is not certain that is what would be offered.

At first he said he would wait to see what the urologist had to say but in the end I convinced him to just get the 2nd opinion started, after all, it is just an opinion, he doesn't have to follow it. Of course once he sees how great Dr. Einhorn is I know he will know who to be following in this.

So I called the oncolgist office for him, left a message telling them we want his files sent off to Dr Einhorn for a 2nd opinon. Hopefully we will get a response from them.

Question though, what if by some reason the Dr's officedelays and takes forever. Is there a way for me to get the Dr Einhorn to look at his files via me or better yet, request them from the oncologist.

I know you all have a wealth of information when it comes to contacting IU.

Oh, and Willgetoverit-All of his tumor markers are normal, AFP has been normal since it did it's drop after surgery. The only tumor markers we have dealt with are the strange Beta Hcg thing, but even it is normal now!

Becki

[willgetoverit]

Becki,
I am sure experts on this forum will tell you how to go about the process of getting in touch with "The" Dr. Einhorn.

In the meantime, AFP normal, Bhcg a bit elavated, hmmm...all point in the direction of teratoma in the abdomen.

In my case, I chose RPLND(laparoscopic way) over surveillance specifically to make sure there is no left over teratoma in my retroperitoneum.

I am sure Dr. Einhorn will suggest the best course of action, but just wanted
to give you an heads-up that it's quite likely to be teratoma, especially with no elevation of the AFP.

No matter which way you go, odds are very very high that your hubby is gonna be just fine...

[Lori]

Becki, I would suggest one of two ways: have your doctor call Dr. Einhorn and ask him to review your information. Or you can call his office directly at 317-274-3515. I set up an appointment through his secretary Ann and we took all the reports with us. If you simply want him to review the reports but not see him right away you may want to have your oncologist start the process.

[mercyriver]

Well the good news on that is that I trust our urologist. He has been great from the start and I also know he will consulte with anyone at anytime to make sure he is doing the right thing.

Question though, will Dr. Einhorn work with my husband's urologist? I have a feeling this will all move faster through him and since it has been handed back over to him I am wondering if Dr. Einhorn will work with the urologist.

Guess I will have to ask!

And Chris, just so there is no confusion, my husband started out on surviellence, the first CT showed slightly enlarged lymph nodes none bigger then 1.3 cm. The second CT showed continued enlargment. This all was done with blood work as well. And once a chest xray. I know proper protocol has not been followed for surviellence, but surviellence is what we did pick originally.

And we here in Denver have once again been hit by yet another snow storm, 4-10 inches this time, hopefully it doesn't slow things down, yet again.

Becki

[boyce]

Laproscopic RPLND

Hi Mercy,

I felt just like your husband wanting to avoid big surgery. The problem is that the lap procedure is SO new. The best in the country do 6-8 per year. We found 1 Dr. in St. Louis, 1 at Johns Hopkins and 1 in NJ that even attempt it. Ther mortality rate during procedure is 600% higher than classic RPLND and there is a much higher rate of losing a kidney as well.

I went to Sheinfeld in NY who does 100+ per year and had the big one. Healing time is similar, big surgery generally has more post-surgical pain, but mine lasted about 3 weeks or so. Lap procedure has different healing complication.

In my case, the 3 lap surgeons looked at my info and agreed that even if they went in for lap procedure, a 70% chance existed that they would have to convert to a full RPLND anyway. So I went to Sheinfeld, recognized as 1 of the 3 best in the world.

That's just my story, but I was VERY pro laproscope and had my mind changed...am glad I did it the way I did

[Davie]

I had a postchemo RPLND done in the UK, for resection of all my right-sided lymph nodes, including some residual mass.

I had an open procedure, but my surgeon did the procedure through a 5 inch mid-line abdominal incision (2.5 inch either side of my belly button). I was his 389th, so he'd practised a bit before he got to me. Like any other RPLND my abdominal muscles were separated and then stiched together. I'm sure the small size of the incision really helped me get back on my feet very quickly.

The same surgeon did this guys www.timstollery.com. Click on gallery and scroll to page 3, to see what is a relatively small scar. If anything my scar is slightly smaller.

I've seen pictures of guys with 14"+ scars for a primary RPLND, which seems excessive to me, and I'm sure must be more uncomfortable and lead to longer recovery times.

If your husband has to have an RPLND, maybe you could quiz the surgeon on incision length.

Davie

[dadmo]

Becki:
IU is a center of excellence in the treatment of tc so don't focus too much on who exactly does the treatment. Dr. Einhorn will be the primary contact and he will hand the work off to whom ever he feels is best for the job. Many of the procedures can be done by several people at centers of excellence.
My son had his RPLND at Sloan I know Dr. Sheinfeld was there but to this day I don't know if he participated or directed. We met with Sheinfeld at 6:30am and he was still involved with surgeries at 11pm. It's hard to picture him doing all of the actual work.