The Clock is ticking. We are at a crossroad. Please help

[keithlucero]

My nephew had an undescended testicle and was removed when he was very young...just recently he had and orchidectomy...so now

We are now at a very important decision point, radiation (2500 cgy grade/rad) or chemo (carboplatin, 2 dozes in a 6 week period). Which one would have least long term effects? Radiation has shown tumors later/vs. carboplatin has only been out over a 4 year period. University of Indiana uses radiation, Europe uses carboplatin. Two options because his tumor was 5 cm and had invaded a lumph node within the testicle. So observation isn't recommended. We need to figure out long term which means of treatment is best for him.

I had read this while searching for an answer...your thoughts are so appreciated.

One shot of carboplatin
( http://health.dailynewscentral.com/c...ew/0001333/49/ ) appeared to be as effective as radiation therapy in treating early seminoma, a kind of testicular cancer, and also appeared safer, reducing the risk of second cancers. Further follow-up is needed to show whether the benefits last.

[dadmo]

Because the cancer has spread surveillance is certainly not an option. Don't focus on the long term effects of either treatment. What you need to do is choose the treatment that will cure him. Has the can spread beyond the lymph nodes?

[Fed]

Dadmo makes a great point here... if there is spread to the lymph nodes, then it will be either a higher dose of radiation (35-40 Gy) or chemo (3xBEP). With L/V invasion, surveillance is unlikely to be an option. That being said, either adjuvant radiation or adjuvant chemo are perfectly good options (the latter of which is gaining traction nowadays and is now regarded as an acceptable form of treatment).

[Scott]

Just to step back for a second, we don't know there's metastasis beyond the testicle. We just know from the tumor size and lymphatic invasion that there's a higher chance of metastasis. We're talking about adjuvant therapy.

To my knowledge, there isn't a lot of long-term data available yet on single-agent carboplatin.

[Scott]

We are now at a very important decision point, radiation (2500 cgy grade/rad) or chemo (carboplatin, 2 dozes in a 6 week period). Which one would have least long term effects?

To build on what Fed said, the most recent update to the NCCN guidelines changed the designation for single agent carboplatin for stage I seminoma from category 3 (major disagreement about whether it's appropriate) to 2B (non-uniform consensus, but no major disagreement). On the other hand, good data isn't available yet on long-term effectiveness and side effects, and whether having been treated with carboplatin changes the effectiveness of cisplatin if needed later in case of relapse.

[keithlucero]

More Information

Thanks so much for such a speedy response. Here are the particulars.
All CT Scans have indicated that it has not spread beyond his testicles.

Just to clarify, he has no remaining testicles. When he was twelve years old the undescended one
was removed. Noone told them that he should be checked routinely. (side note) Now he is 22.

I have read that Seminoma is best treated with radiation and Non-Seminomal is best treated by chemo.
The doctors are asking him to choose his treatment, which seems odd to me.
Here is a page that I have created for him to review.

http://keith.golucero.com/seminomas.html

Please tell me what you think.

Notice at the bottom of the page I have listed treatment facilities for him and his parents. They are entertaining the idea of going to Lance's facility. Any feedback is appreciated.

Finally...he has complaining for some time of chest pains, fatigue and dizzyness...in fact he has had this issue
for about a year...could this be because of a lack of Testosterone?

Thanks so much for caring...Words cannot express our appreciation.

Regards,

Keith

[Scott]

Hey, Keith: this would be a good time to reinforce that the cure rate for stage I seminoma is nearly 100%. This is a head-spinning time, but it's going to get better.

I'm not sure about the chest pains and dizziness. What does his doctor think? (He has had a clean CT scan, right?)

He will, of course, need testosterone replacement therapy, likely AndroGel or Testim. Has that started already?

[Scott]

I would add a link to the NCCN guidelines on your reference page. Some of the most relevant pages from that document for your nephew are TEST-3 and MS-2 to MS-3.

[dadmo]

Keith:
I would certainly get in contact with a facility that would give some firm guidance as to a perfered course of treatment. Indiana seems to be the most responsive of the centers of excellence.

[keithlucero]

More details (Thanks in advance)

Gentlemen,

I have stressed the cure rates table within the "Seminomas.html" page, but it is nice to hear it from guys that know. Thanks for the link to the NCCN guidelines...I have added it to the page.

I am talking with my uncle (his father) very soon for even more details.
So I will be posting more info very soon.

Regards,
Keith

[keithlucero]

UpToDate Online Research

Gentlemen,

Your thoughts regarding this course of action., (

Adjuvant chemotherapy — Cisplatin-based combination chemotherapy is the gold standard in treating advanced testicular germ cell cancer. However, these regimens are too toxic for use in the adjuvant setting.

One or two cycles of adjuvant single agent carboplatin have been extensively evaluated as an alternative to adjuvant RT in patients with clinical stage I seminoma

Several uncontrolled series have evaluated the efficacy of adjuvant carboplatin. Pooling of the published series using two cycles of carboplatin revealed 100 percent disease-specific survival, and only 15 relapses among 521 treated patients (2.9 percent)

Among 316 patients who received one cycle of carboplatin, there were 14 relapses (4.4 percent) and no deaths.

For patients with clinical stage I seminoma for whom active surveillance is not appropriate, and for those who want to minimize any risk of relapse, we suggest adjuvant chemotherapy with one or two cycles of single agent carboplatin.

[Fed]

I'm not sure if this helps, but when I was diagnosed at the Dana-Farber Cancer Institute (incidentally, where I work), I was told that adjuvant chemo would only be administered to stage I cases only if they were at least pT2 without nodal invasion. DFCI is at the forefront of developments in cancer treatment, so if I had been pT2 (I wasn't), I probably would have opted for that. An 0.7 cm node is still too small to warrant treatment, but certainly observation.

[Scott]

The size of the lymphnode that was invaded (on his left side) was 7 millimeters..which of course is less than the 10 millimeter guidelines

I'm assuming you don't really mean "invaded." If we knew this enlargement was caused by spread of the cancer, we wouldn't be talking about adjuvant therapy any more.

[Karen]

Keith,
Single agent carbo for stage I seminoma is relatively new and the numbers really aren't in yet on the efficacy and long term effects. I posted this to the Research Library and if you cannot access the full text e-mail the corresponding author for a reprint. email: Padraig Warde ([email protected])

Nice analysis of data culled from the literature that pulls together treatments, relapses, and suggested follow up schedules based upon relapse risk. Not enough data yet on 1 or 2 cycles of carboplatin, but the numbers so far look encouraging!!

http://www3.interscience.wiley.com/...10784/HTMLSTART

Cancer. 2007 Apr 16;

Evidence-based guidelines for following stage 1 seminoma.

Martin JM, Panzarella T, Zwahlen DR, Chung P, Warde P.

Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada.

BACKGROUND.: The authors developed evidence-based guidelines for a follow-up schedule after orchiectomy for stage 1 seminoma. Required investigations, frequency of assessment, overall duration of follow-up, and management strategies were identified. METHODS.: A systematic review of the literature was performed of prospective studies in stage 1 seminoma. Studies published after 1980 were considered eligible for inclusion. Data extracted included relapse-free rates, number of patients at risk, and relapse locations. Five strategies were identified: Surveillance, Extended-Field Radiotherapy, Para-aortic Radiotherapy, and either 1 or 2 cycles of Carboplatin Chemotherapy. For each strategy, Kaplan-Meier relapse-free estimates were used to calculate weighted-mean cumulative hazards of relapse over time. These were used to calculate semiannual weighted-mean relapse hazards. RESULTS.: Seventeen prospective studies with a total of 5561 patients were identified. Actuarial data on relapse was available in 5013 (90.1%) patients, and 92.9% of all relapses had location data reported. Annual hazard rates for relapse were determined. CONCLUSIONS.: Evidence-based recommendations for follow-up frequency based on risk of relapse were formulated. The authors suggested 3 times per year when the risk is >5%, 2 times per year when the risk is 1% to 5%, and annually until the risk is <0.3%. Investigations should reflect location(s) at risk of relapse and include computed tomography of the abdomen and pelvis for surveillance and adjuvant carboplatin, whereas for para-aortic radiotherapy, pelvic computed tomography alone is required. These recommendations offer the possibility of maximal patient convenience and optimal healthcare resource allocation without compromising disease control. Cancer 2007. (c) 2007 American Cancer Society.

[keithlucero]

Karen,

Thanks so much for that information.
Things have calmed down a bit. I have started a new post with the path report to provide more specific evidence.

Thanks again to everyone who has contributed and offered advice. It is much appreciated.I found a lot of information regarding Carboplatin