Surveillance or Chemo?

[skaempf]

First of all, sorry for my bad english, my native language is german...

I'm 29 years old and had orchiectomy a few weeks ago.

4 days after orchiectomy the AFP and Beta HCG was still elevated, but
the second blood test (11 days after orchiectomy) was good:

AFP: 9.7 mcg/l (lab reference < 10 mcg/l)
Beta HCG: <0.002 U/ml (lab reference < 0.002 U/ml)

The CT scans shows no signs of metastasis.

The pathology report mentions a mixed tumor:

- embryonal carcinoma (mainly)
- Yolk Sac Tumor
- intratubular germ cell neoplasms (carcinoma in situ/Seminoma)

Stage: pT1

I had a meeting with my oncologist.

He said the following:

- RPLND is nowadays uncommon (especially in europe)
- in my case a 2 cycle BEP chemotherapy would be the best option.

I did read a lot in the last few weeks about TC, different studies, cancer forums and so on.

In my case the oncologist would not recommend surveillance as an option, the risk of having small metastasis which are now not detectable is as high as 90 %, because of my mixed tumor.

I did read a lot about a risk of around 30 % on different webpages, this would be no problem for me to handle it. But a risk of 90 % is extremly high.

Any opinions or ideas? Is the risk really that high?

Good luck to all!

[matthias]

(1) Here in the US, two-cycle adjuvant BEP is not recommended. The reasoning is as follows (copied straight from tcrc.acor.org):

"Some countries in Europe (particularly the UK and Germany) plus a few sites in the US are now recommending 2 cycles of adjuvant chemo for patients with high risk stage I nonseminoma. Their thought is that if they can't see the spread of cancer on CT scan, but the pathology report indicates that it is likely to have spread, then they can save the patient from surgery or excessive chemo by giving them just two cycles of BEP chemo right away. Unfortunately, neither I nor most of the experts I have talked with agree with this thinking.


First of all, the success rate of the standard chemotherapy and surgical procedures is so high (~98%) that it would take a very large sample of people to ever prove that the 2 cycle regimen is equivalent to the existing protocol. It would take many years to get enough people to run the study, and even then, you would have to watch for many years to ensure that no one is suffering from recurrences years later.

Secondly, the argument for using two cycles of chemo is based on the fact that only microscopic clumps of cancer have spread so far. This is a very poor assumption. Unfortunately, the CT scan that we often rely on is only accurate 80% of the time. In other words, 20% of the time it may be falsely negative - 20% of the time it says there are no enlarged nodes when, in fact, there are enlarged nodes. I know of one person who was told that he was stage I, and was thinking about the two cycle approach. He decided to choose surgery instead. When they opened him up, they found LOTS of cancer. If he had been treated with just two cycles of chemo, it would not have been enough to cure him, but it probably would have been enough to make the cancer resistant to cisplatin based chemo.

Finally, a substantial number of men with high risk stage I nonseminoma were actually cured of their disease during the orchiectomy. The two cycle approach is not a lot of chemo, but it is two cycles more than many guys need."

(2) I think the 90% probability for metastasis is overstated. High risk for spread of non-seminoma Stage I (100% embryonal carcinoma with vascular and lymphatic invasion) is reported in the literature as 46%. That is, even in this high-risk category every second person is cured by the orchiectomy alone. Average risk quoted in the literature for spread of Stage I non-seminoma is 30%.

Beste Gruesse hier aus Atlanta. Stell sicher das Du nicht der erste Hodenkrebsfall bist den deine behandelnden Aerzte sehen. Du willst jemanden haben der eine erhebliche Falldichte (und damit Erfahrung) hat.