AFP marker increased following orchiectomy?

[jimt]

I had a 2.3 x 1.5cm nonseminoma germ cell tumor (yolk sac) on my right testicle and a 1.3 x 1.3 cm seminoma tumor on my left testicle removed on Feb 27th. A CT scan has also indicated a 4.2 x 4.9 cm retroperitoneal mass in my abdomen. The AFP level prior to the orchiectomy was 3612 ng/mL. My Urologist had the opinion that I was Stage IIB.

Meet with the Encologist this week who told me I was in fact Stage III. He wasn't able to clearly explain to me why the switch. He has also ordered a 4XBEP protocol starting March 26th. I just got my latest blood work and the AFP is now up to 5535 ng/mL.

So much to learn so fast, but I understood that Stage III TC required an AFP marker above 10,000. Am I wrong or is the Uncologist just being conservative with the 4XBEP order - what to see how the cancer responds to the first 3 cyles?

[Scott]

Welcome, Jim. There's no question that you need chemotherapy as soon as possible. Stage III, though, means distant metastasis. Did your CT scans show spread to the lungs or elsewhere?

If you haven't already seen them, be sure to read the NCCN guidelines, which provide a pretty thorough explanation.

[dadmo]

Jim:
It's important to have the staging right and you should get a clear explanation as to why you are stage III. However, with your markers going up you will need treatment regardless of it being stage II or III. 4xBEP is done quite a bit but the standard is 3xBEP, maybe they saw someting in your lungs, which is the normal path for tc to travel.

[Scott]

Stage III, though, means distant metastasis.

Actually, the NCCN guidelines include a couple of stage III designations based on marker levels and regional lymph node involvement, without distant metastasis. Check pages ST-2 and TEST-10.

[Vinny]

Jim, sorry you had to pay a double entry fee to join our club!

Am I wrong or is the Uncologist just being conservative with the 4XBEP order - what to see how the cancer responds to the first 3 cyles?

No. Under the NCCN guidelines, your clinical status is intermediate risk by virtue of your high AFP levels, and 4xBEP is the standard protocol. My question is why you're having to wait so long (more than 1 month post-orchiectomy) to start chemo?

But don't worry. Even though the risk nomenclature is very ominous-sounding (my AFP was over 10,000 ng/mL, so I was "poor" risk), the treatment works just fine. You still may be a candidate for post-chemo RPLND to resect your retroperitoneal mass if it doesn't completely shrink away.

Good luck with your chemo treatment.

BTW, do you mind sharing your pathology report?

[jimt]

Pathology Info

Vinny / Scott/ dadmo,
Thank you for all of the responses - I would feel lost without this great resource.
The Orchiectomy was on Feb 27th, so technically the chemo is starting less than 30 days later. The tumor on the left testicle was first biopsied during surgery and then the bi-lateral orchiectomy was performed.

My Pathology Report is attached. Feedback is really appreciated.

Thanks,
Jim

[dadmo]

Jim:
It may be my machine but the image won't open for me. I wouldn't normally be concerned with a 30 day wait but your markers are rising which indicates that you still have active disease. You may want to see if you can't move that date in a bit.

[Scott]

The pathology report doesn't add a lot at this point, given confirmed spread and rising markers. 4xBEP is the right treatment, as soon as feasible.

[sin]

Also NCI the filler stage IIIB:

http://www.cancer.gov/cancertopics/pdq/treatment/testicular/HealthProfessional/page3

Standard treatment is four cycles of PEB.

[jimt]

Pathology Report_JPG

dadmo,
Here is the text of the report:

Right testicle, orchiectomy: mixed germ cell tumor (2.8 cm in greatest dimension grossly) with predominent yolk sac component. Vascular invasion is seen and is present at the spermatic cord margin. Surrounding testicular parenchyma shows intratubular germ cell neoplasia. No extracapsular tumor extension is identified.

Left testicle, orchiectomy: testicular parenchyma shows focal interstitial involvement by seminoma. Surrounding intratubular germ cell neoplasia. No extracapsular tumor extension identified.

Comments: Immunohistochemical stains show positive staining for cytokeratin AE1/AE3 and AFP in the yolk sac tumor. The yplk sac component is negative for PLAP. The seminoma shows positivity for PLAP and is negative for AFP. Both tumors are negative for CD30 and hCG.

The pathology stage is pT2 pNX pMX pSX.

Regards,
Jim