3xBEP or surveillance

[erap]

25.10.2022 - testicular cancer diagnosis (left side testicle) 26.10.2022 - blood test: S-HCG-m <0.2, S-AFP 3.66
27.10.2022 - performed left-sided radical orchiectomy
08.11.2022 - blood test: S-HCG-m <0.2, S-AFP 2.9
11.11.2022 - histology results: seminoma (max. size 18mm), pT2, limited lymphovascular invasion of tumor structures in the area of the rete testis and into the stroma of the rete testis, resection line of the spermatic cord free
14.11.2022 - CT examination of the chest, abdomen and small pelvis with the administration of a contrast agent - Conclusion: Retroperitoneum due to the absence of visceral fat less clear - infrarenal para-aortic l.sin. susp., lymph node 15mm in the short axis, aortocaval 11mm in the short axis. Susp. infrarenal retroperitoneal lymphadenopathy.
15.11.2022 - due to the presence of a risk factor (invasion of the rete testis, pT2 stage) and the borderline size of the lymph nodes of the retroperitoneum. To consider adjuvant chemotherapy with carboplatin is recommended by onkourorogist.
17.11.2022 - Chemoterapist recommended 3xBEP because she thinks this is IIa stage and not I. stage.

I was shocked by recommendation of 3xBEP because I am really scared of late effects of chemotherapy so I "pushed" chemotherapist to recommend PET to confirm there is cancer in the lymph nodes. If PET will be negative she will recommend surveillance. But now I am worried if I have pushed chemotherapist to do the wrong decision because I read that PET is not very useful in this case and it can show false negative if tumor is small.

Do you think I should cancel PET and start 3xBEP asap or there is real chance that all cancer was removed by orchiectomy and no chemo will be ever needed?

[SamanthaS]

Dear ERAP: I am sorry that you are here and this is certainly the community with many well-informed folks. I am not one of the well-informed, but I thought PET is able to tell whether the node is cancerous or not for seminoma? If PET is negative, what about 1 round of adjuvent BEP instead of all three rounds? Certainly something you can ask your doctor perhaps? After one round, perhaps do a CT again to find out whether the node has shrunk? Anyway, just a lay-woman's two cents here.

[Mike]

With the Ct scan after the orchiectomy, there can be surgical changes that can be detected in the lymph nodes that can mimic early metastasis. Thus, when there are questionable, borderline nodes it is sometimes reasonable to re-do a CT in 4-6 weeks, as per the NCCN Guidelines. There typically is no role for PET in the staging process. If they are PET positive then I think that it would more authenticate the spread, but what if they are PET negative, then is another short-interval CT going to be used anyway?

I would guess that more than one node the likelihood of it being nothing is probably lower as well.

Either way, unless the nodes are ruled out as being a possible metastasis, I think carboplatin AUC7 dosing would be an under-treatment and best avoided. Carboplatin AUC7 dosing x 1 or 2 doses is used to prevent the spread if it was indeed contained to the testicle but not potent enough to treat the spread effectively. There is a regimen of carboplatin AUC10 dose used for seminoma in some areas of the United Kingdom but I am assuming this is not where you are located.

Mike

[erap]

I was on PET/CT and it showed no PET activity.

Do you have some reference to "With the Ct scan after the orchiectomy, there can be surgical changes that can be detected in the lymph nodes that can mimic early metastasis."
??

Now they recommend me 3xBEP chemotherapy even though PET was negative and I need to decide if I accept chemo now or not.

Please what do you think? I would rather avoid chemo if not necessarily...

[Mike]

I was on PET/CT and it showed no PET activity.

Do you have some reference to "With the Ct scan after the orchiectomy, there can be surgical changes that can be detected in the lymph nodes that can mimic early metastasis."
??

Here is an abstract, for example, https://www.auajournals.org/doi/full...o.2018.02.1212

I basically copied and pasted the line from the NCCN guidelines in the previous post, but they are located at: https://www.nccn.org/guidelines/guid...gory=1&id=1468

Did the nodes change by CT criterion between the CT and PET/CT and how much time was in between the two imaging studies? Was it 4-6 weeks, in order to give the nodes time to grow, if they were to do so or was it within a short period of time?

Mike

[erap]

Orchiectomy was done on 27th of October
CT was done on 14th of November
PET/CT was done on 21th of November

Size of nodes did not change but it was just 1 week.

[SamanthaS]

My son was in a different but slightly similar situation in that his post-chemo lymph node was at 1.2cm, and I wrote to Dr. Einhorn who said to take another CT in 2 months to see if anything changed. His case is non-seminoma, so not applicable to you perhaps. Somehow I thought with seminoma and no rising markers, even up to 3cm is okay for surveillance, from some academic articles I have read. It might be prudent that you seek a second opinion perhaps? Or write to Dr. Einhorn?

[SamanthaS]

In this video, Dr. Daneshmand talks about surgery for stage IIA seminoma, but he does mention that the cut-off is 3 cm for surgery consideration. I am not sure how helpful this is to you ERAP:

https://www.urotoday.com/video-lectures/testicular-cancer/video/2062-surgery-in-early-metastatic-seminoma-siamak-daneshmand.html

[Mike]

OK, so unfortunately, the negative PET may not help give much additional information and with the short-interval of a week, it probably isn't enough time to see any changes in size. To have a more clear idea of what is going on perhaps a CT in 6-week from the first post-op CT would be reasonable and something that you could ask your doctor.

As mentioned RPLND is becoming more of an option for early stage II seminoma, but if not in the hands of an experienced RPLND surgeon, I personally would not take it into consideration. The mention of Dr. Daneshmand, his study had minimum requirements of the surgeons to do at least 8 RPLNDs a year or 24 in 3 years and most have much higher volumes. So, it is not your inexperienced surgeons procedure. Also, with two locations of possible metastasis, I am not sure RPLND would apply anyway.

The mention for 3 cm nodes for seminoma is in a post-chemotherapy residual mass setting and thus would not apply in your situation.

Keep us posted and let us know if you have additional questions. You are certainly in a bit of muddy waters and that is a tough situation as exactly what is going on just isn't that clear. Sometimes taking the time to make the proper decision as the view of the situation clears up is advantageous.

Mike

[erap]

Thank you all. It is really nice to have here so well informed people willing to help.

I decided today that I wait with chemotherapy until I have some "proof" that it is really metastasis. So I wait some time and have another CT to evaluate LN sizes.

Doctor told me that I should not have another CT at least for 3 months because of the cumulative radiation exposure. I convinced him to have it in 2 months.
Do you think that MRI could be used to evaluate LN sizes in the meantime?

Do you think that there is high risk that it will spread to other testicle or organs while waiting?

[Mike]

Where about do you live/are you being treated?

I don't think the risk of the other testicle developing cancer will change regardless of if you start treatment now or in 2 months. If the primary nodes increase in size, showing a more clear picture of metastasis, I would not expect it to change your treatments or overall outcome but there is always risk. The safest thing to do to prevent further growth would be to start chemotherapy now but this is also at the risk of you not needing it at all either.

MRI maybe an option, depending on where you are and their experience with MRI, but if dose controls are being used on CT when I am not sure I would complicate matters more just due to the radiation risk but have no idea if dose controls are being used, etc.

Mike

[Harxxony]

I was on PET/CT and it showed no PET activity.

Do you have some reference to "With the Ct scan after the orchiectomy, there can be surgical changes that can be detected in the lymph nodes that can mimic early metastasis."
??

Now they recommend me 3xBEP chemotherapy even though PET was negative and I need to decide if I accept chemo now or not.

Please what do you think? I would rather avoid chemo if not necessarily...

Hi Erap.
Good PET/CT news.
I also have seminoma with 1,4 cm node, but radiologist was confident it was benign, and oncologist ordered surveillance. So far, I'm good.
I think you made a good choice.
Two months for next CT is also good.
About MRI, MRI results are not very well comparable with CT results, so no, no MRI in the meantime.
Zero risk of spreading to orher testicle.
Very small risk of spreading to other organs in this stage.

[erap]

Where about do you live/are you being treated?
...

I live in Bratislava, Slovakia

[Mike]

I live in Bratislava, Slovakia

OK, I am not sure who you are seeing but there is a Dr. Michal Chovanec is in Bratislava and he trained at Indiana University, one of if not the top place in the world for testicular cancer. The last I can tell his position was as 2nd Department of Oncology, Faculty of Medicine, Comenius University, Bratislava and National Cancer Institute, 833 10 Bratislava, Slovakia.

If it were me, I would keep this in mind if I needed local help for myself or for help guiding my doctor.

Mike

[Mike]

I forgot to mention that if you need any help getting in contact with him, then let me know and I can see what I can do.

Mike