How long can you wait for a RPLND?

[mercyriver]

DH was talking to me last night about if he goes back in Oct and the CT shows the enlarged nodes and he has to have surgery that he would like to wait until the start of December to have the RPLND.

First off, I am very glad he is thinking about this and talking about it, because at the start of the month he was just ignoring it and acting like it couldn't happen.

Secondly, would they really let him wait for 9-10 weeks for surgery? Assuming the PET scan comes back as not active, that is.

I really have no idea why he would want to wait...maybe so he can have the ENTIRE month of December off from work....

Becki

[dadmo]

Becki:
If the nodes are still enlarged after chemo they will need to be removed within 8 weeks. Please don't wait, if the cancer is still alive you don't want it to spread.

[mercyriver]

The hope is if they are needing to be removed they are teratoma. They have been growing fairly slowly.

But are you saying even if the PET scan shows no active growing cancer and assuming they are growing from teratoma, they should still be taken out with in 8 weeks?


Becki

[Fed]

Becki,
Teratomas in men are actually very dangerous. Yes, they are slow growing, but that has the consequence that they are unresponsive to chemotherapy. Moreover, the real danger with a teratoma is that if it happens to be undifferentiated (immature), it has the possibility of evolving into an even more dangerous cancer such as a sarcoma or an adenocarcinoma. Both of these are far more difficult to treat than TC and are more aggressive and highly metastatic. If the CT scan in October shows enlargement, the masses should have to come out ASAP.

[mercyriver]

Point well taken, I will make sure I press the issue very hard if we end up there.

With that said though, can I pick your medical brain Fed? When we got his 2nd opinon on the pathology from Dr. Ulbright at IU, the language was quite confusing and didn't really pop out at me as to if it was mature teratoma or immature taratom. Can you humor me and read what was written and see if you can tell?

Thanks a million!

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.

Becki

[Fed]

Hey again,

While my experience with pathobiology is extremely limited (I only took a one week crash course last July, while actual M.D. pathologists do 4 years of this), I will give you a "pseudo-qualified" scientific opinion which in no means is a medical assessment.

Teratomas are some of the most difficult tumors to assign by histopathology because they mimic every single cell type in the body. In the crash course, we saw a tissue section of teratoma that had 27 (you read right, 27) different tissue types. Everything from brain, to lung, to intestine, to skin... you name it, it was there. That was a very well differentiated teratoma because you could actually tell what everything was. Undifferentiated teratomas are less mature and more naive, and that's why they can easily convert into something worse. What I understand from the highlighted portion of your post, the pathologists had a hard time figuring out what that other tissue was and it sounds they were stumped by this case, hence the assignment of teratoma: they said it kinda looked like embryonal, but there was something different about it that could indicate otherwise. This would suggest that if it was indeed teratoma, it could potentially be of the immature kind (or even partially differentiated) because you couldn't tell conclusively what it was -not as clear cut as the one I described above from class.

This was the second read on the pathology, and you did use a reputable lab for this. My first instinct back then would have been to get a third opinion to rule on this, since the first and the second were quite different (if at some point this becomes necessary, I would highly recommend Victor Reuter, the pathologist that Joel Sheinfeld always uses). At this point, though, trying to derive things from the written report would likely be an exercise in futility. My suggeston would be to wait for the PET/CT (is that what he's getting? a CT would likely be sufficient). If there is further enlargement or a change in shape, I would bet that any reputable TC expert would immediately want to do the RPLND.

I don't know whether this is any help. My interpretation is certainly no substitute for what a doc would say, and I could be wrong; but my take is to hold off dwelling on this and wait until the scan (but if the scan shows something's up, then prompt action is warranted). Let me know if there are other things I can help clear up.

[mercyriver]

Actually that helps quite a bit. I have been wondering about it on and off for over 6 months now. And really helped explain it. And it was better then what the Dr would say, because he never said anything other then "Oh, that changes things some, that is good to know". To him it is TC and he treats all cases of TC pretty much the same.

And yes, it is a PET/CT he is doing, to make sure nothing is active, he hasn't had positive tumor markers since before his I/O. That is the reason for the PET/CT, which is fine with me, gives me more peace of mind.

Thank again, it really did clear things up alot!

Becki

[Fed]

Glad to be of help .

Have a great Labor Day Weekend,

[mstlyn]

When Anthony finished chemo and the scan showed a residual mass, as far as I was concerned they couldn't get it out fast enough. Especially once his AFP started increasing again.

I remember when the doctors took him off the surgery schedule and asked us to come in and discuss starting more chemo. I was really angry that they took him off the surgery schedule because Einhorn had already said he needed the surgery, not chemo. As far as Im concerned, the longer you wait, the more opportunity you give the situation to worsen.

Thankfully, the surgeon told me he would change his schedule around and get Anthonys surgery done by the end of the week, so instead of having it done June 5th, he had it June 8th =)

I know the idea of major surgery is not something anyone likes to think about, but if it needs to be done it's better to get it done sooner rather than later.

My best,
Tammy