Seminoma testis pT2N0M0S0 IB - what treatment?

[MySleepingKarma]

Hello everyone, unfortunately, I (32 years old) have the unpleasant experience of testicular cancer, below I will describe my case and questions. I am based in Gdansk, Poland.

• 06.10.2022 - visit the urologist because of a slightly enlarged testicle, in July I felt a little weaker - dizziness, anyway diagnosis - a tumor on more than half of the testicle
• 07.10.2022 - markers before removal and results (range in brackets) AFP 2.8 ng/ml (0-7), LDH 165 U/l (135-225), B-HCG 3.33 mIU/ml (0-2) - elevated B-HCG
• 08.10.2022 - since then the testicle starts to enlarge more, there is pain below the testicle, then spreading and pain radiating to the buttocks, by 28/10/2022 the size has increased 2x
• 09.10.2022 - thorough ultrasound of the testicles, lymph nodes around not enlarged
• 24.10.2022 - CT scan of the chest, abdomen, and pelvis - no enlarged lymph nodes. There are no signs of spreading the disease.
• 28.10.2022 - USG before the procedure, 90% testicle involved, orchidectomy of the testicle at the UCK in Gdansk, Poland
• 07.11.2022 - markers after removal and results (range in brackets) AFP 4.4ng/ml (0-7), LDH 160 U/l (135-225), B-HCG <0.20 mIU/ml (0- 2) - all markers are normal after orchidectomy
• 16.11.2022 - the result of histopathology:
  
  

  Macroscopically:
  Core size 7.2x5.3x4.5cm, subtracted with the spermatic cord, length 9.4cm, dia. up to 2.1 cm, covered with movable whitish and vaginal sheaths. A straw-colored liquid with a volume of approx. 20 ml is visible between the casings. In sections, the testicle is occupied in about 90% by a cream-colored, solid tumor with a diameter of 5.4x4.2x3.3cm. The tumor reaches the tunica albuginea but does not cross it. The tumor extends to the rete testis, but does not appear to invade it, nor does it invade the epididymis.
  
  Microscopically
  Seminoma testis
  A neoplasm formed from elements of a seminoma mixed with numerous lymphocytes.
  Phenotype: PLAP+, CD117+, CD30-, beta-hCG-.
  Vascular occlusions from tumor cells are present. The epididymis and sheaths are not involved. Focal necrosis, palisade type, up to 10% of the tumor mass.
  Intratubular germ cell neoplasia is visible in the vicinity of the tumor.
  The cutting line of the spermatic cord and sections from it do not contain tumor tissue.
  pT2NX

• 22.11.2022 - almost a month after the orchidectomy markers are: AFP 4.1 ng/ml (0-7), LDH 134 U/l (135-225), B-HCG <0.10 mIU/ml (0-2) - all markers are below the level before

Questions:

1. I had a CT scan 4 days before the orchidectomy - should I repeat a CT scan after the orchidectomy to interpret the proper cancer stage?
2. After all, I'm assuming it's pT2N0M0S0 stage for now but I have risk factors like tumor size >4cm and am not sure about LVI - is that "Vascular occlusions from tumor cells are present."?
3. I was proposed to have chemotherapy for a case with 1-2 risk factors but still don't know which one. Should it be a carboplatin 1x or 2x cycle? My oncologist says it can be 1x.
4. I started having pain in my lower back a month after the orchidectomy, feels like an inflammation of the kidneys that I had before, is this normal after the orchidectomy?

[Mike]

Questions:

1. I had a CT scan 4 days before the orchidectomy - should I repeat a CT scan after the orchidectomy to interpret the proper cancer stage?
2. After all, I'm assuming it's pT2N0M0S0 stage for now but I have risk factors like tumor size >4cm and am not sure about LVI - is that "Vascular occlusions from tumor cells are present."?
3. I was proposed to have chemotherapy for a case with 1-2 risk factors but still don't know which one. Should it be a carboplatin 1x or 2x cycle? My oncologist says it can be 1x.
4. I started having pain in my lower back a month after the orchidectomy, feels like an inflammation of the kidneys that I had before, is this normal after the orchidectomy?

Dzień dobry, I had to Google Gdansk. I lectured in Krakow once and loved the visit but the complete opposite side of Poland it looks like.

1. The CT just prior to the orchiectomy should be sufficient for staging and assume they will set up a follow up imaging schedule based off of your selected treatment.
2. With stage I seminoma, there are not any really good prognostic factors for relapse. Historically, tumor size >4cm (as a cutoff) and rete testis involvement have been mentioned as risk factors, but most experts agree there really are not any. Not sure about the vascular occlusion statement but lymphovascular invasion is the driving risk factor for stage I relapse for non-seminoma and doesn't really play a role in seminoma. More recent seminoma primary tumor size was shown to be a risk for relapse but more in a linear fashion (the larger it gets the higher the risk and not just a cut-off size) and even then 8 cm tumors had a rate of relapse of 26%. https://www.ncbi.nlm.nih.gov/pmc/art...40004-0155.pdf
3. For stage I semioma I would assume they are referring to carboplatin AUC7 dosing. The latest data from SWENOTECA was not that impressive to me, in using one dose, so would two doses be better? Not sure. https://www.sciencedirect.com/scienc...23753419356923 In the supplemental table to me it is showing that with tumor > 4 cm and no rete testis invasion the risk of relapse is 19% and if carboplatin x1 is used it was 10%
4. the pain would be worth mentioning to your doctor but could be any number of things and unrelated to the cancer.

Hopefully this all makes sense and ask away with any further questions.

Mike