Advice on Therapy after Orcheictomy

[Manny]

I just became a new member and this is my first post. I am 43 and was diagnosed with testicular cancer in the 1st week of October. And had Orchiectomy surgery performed on Oct 10th. Prior to surgery, my AFP was 1200, LDH was 650, and hCG was 256. Prior to surgery, the CT Scan did not show any enlargment in lymph nodes.

The pathology report confirmed the tumor was cancerous and showed 90% embryonal carcinoma, 19 % yolk sac tumor, and less than 1% immature teratoma and choriocarcinoma. The pathology report also said –
- no extratesticular extension by timor is identified
- vascular invasion by tumor is present in the tunica albuginea
- intratubular germ cell neoplasia is noted
- negative spermatic cord and tunica margins of resection

My doctor said that the tumor seemed mostly self-contained, but showed microscopic elements of cancer in the blood veins / vessel of the tumor. And recommended I should consider either Chemo or RPLND because there was a possibility the cancer had spread to the lymph nodes. He recommended I get a second opinion from an oncologist and I have an appointment setup for next week. In the meanwhile, he performed the tumor marker blood test performed on Oct 17th (a week after surgery) and AFP was 260, LDH was 207, and hCG was 4. And the CT scan does not show enlarged lymph’s.

I am seeing a specialist next week. I wanted to reach out to the TC community and see if they had any guidance they could provide as well. My preference would be to go on Surveillance – do you feel I am a good candidate for that? Or is that high risk given I have embryonal carcinoma? And is that any guidance on RPLND vs. Chemo? What is the best therapy option I should take?

Thanks
Manny

[keepcouchfresh]

being that your AFP isn't normal yet after the I/O it sounds like you'll need chemo, but it sounds like there's a good chance you won't need the RPLND, how much chemo will depend on whether you're stage 2 or 3, I'm guesing you're stage 2

embroynal carcinoma tends to be aggressive so the makers will likely rise

[italian_tc]

...tha half life of afp is about 5 days...this mean every five days you should have half afp if you are tc free. In this sense your number looks very good! Bhcg is normal, chek every week afp since it will be zero...If afp will drop to zero (ask to your lab for the normal value, in mine is less than 12) you can choose beetween rplnd or surveillance, if not you should have chemo soon.

I had the same patology a year ago, i was in stage 1 and I choose to have rplnd, and i discovered a micromets in the lynph node, now everything seems fine...but...every choose is a good choice. The cure rate is about 98% for both way...
rplnd is the fastest way, surveillance is a long way to go...and a lot of people say that chemo could make more problem than a rplnd...with a rplnd you can avoid chemo in certain case...as I hope for me!

check this about advantages of rplnd and don't be scared of it (i know...I was very very scared too...)

http://www.moffitt.usf.edu/pubs/ccj/v9n4/pdf/277.pdf

sorry for my english...and good luck fo your choice, this will be the worst period with tc...
ciao
davide

[Scott]

I concur with Davide: you need to see your AFP return to normal -- and it's on track -- before deciding on surveillance or RPLND. If it doesn't, chemotherapy will be necessary.

[dadmo]

I just want to agree with the others. If your afp stays elevated it will be chemo, if it returns to normal you may be given the option of surveillance or RPLND.
Don't get too hung up on the amout of follow-ups if you choose surveillance, you will be monitored quite closely no matter which path you choose.

[Manny]

Follow-up at Memorial Sloan

I just became a new member and this is my first post. I am 43 and was diagnosed with testicular cancer in the 1st week of October. And had Orchiectomy surgery performed on Oct 10th. Prior to surgery, my AFP was 1200, LDH was 650, and hCG was 256. Prior to surgery, the CT Scan did not show any enlargment in lymph nodes.

The pathology report confirmed the tumor was cancerous and showed 90% embryonal carcinoma, 19 % yolk sac tumor, and less than 1% immature teratoma and choriocarcinoma. The pathology report also said –
- no extratesticular extension by timor is identified
- vascular invasion by tumor is present in the tunica albuginea
- intratubular germ cell neoplasia is noted
- negative spermatic cord and tunica margins of resection

My doctor said that the tumor seemed mostly self-contained, but showed microscopic elements of cancer in the blood veins / vessel of the tumor. And recommended I should consider either Chemo or RPLND because there was a possibility the cancer had spread to the lymph nodes. He recommended I get a second opinion from an oncologist and I have an appointment setup for next week. In the meanwhile, he performed the tumor marker blood test performed on Oct 17th (a week after surgery) and AFP was 260, LDH was 207, and hCG was 4. And the CT scan does not show enlarged lymph’s.

I am seeing a specialist next week. I wanted to reach out to the TC community and see if they had any guidance they could provide as well. My preference would be to go on Surveillance – do you feel I am a good candidate for that? Or is that high risk given I have embryonal carcinoma? And is that any guidance on RPLND vs. Chemo? What is the best therapy option I should take?

Thanks
Manny

I visited Memorial Sloan last week and met with Dr Bosl, and Dr Sheinfeld and they echoed what you all said. That I should go for RPLND - provided the AFP tumor marker drops to normal. They projected it should be normal in ~3 weeks. And recommended it would be better to do RPLND. And if needed, follow it up with 2 cycles of Chemo. They said since a fraction of my tumor contained teratoma, surgery would be necessary.

I did the tumor marker tests again on Oct 29th. AFP is 56 (big drop from 260 on 10/17), LDH is 137 (in normal range), and hCG is < 2 (in normal range). I am thrilled! And hope it keeps dropping at the same rate.

Surprisingly, I had 2 other components in my blood test come out high. My doctor ordered a CBC (Complete Blood Count) test. And the Eos and Eos (Absolute) were high at 10 and 0.7 respectively. Do you know if this is an indicator of cancer spread? I have mild asthma - could this be from asthma? I have not had a chance to discuss the result with the doctor - his assitant faxed me the report because I asked for it.

Thanks for your ideas / advice.

Manny

[Scott]

Manny, what were you told about the alternative of surveillance in your case?

[Manny]

Surveillance was not recommended

I asked about Surveillance. And the doctors at Memorial Sloan recommended against it. I pushed them about this point and they said there are some places (not sure if that meant countries or cancer center's) that would be ok with Surveillance, but Memorial's view was I should be aggresive and get it treated while it is in its infancy. They felt RPLND avoid's the potential need for chemo if it spreads after a few months.

They said the CT shows clean for now. But it could spread since micro-mets (sp?) of the cancer showed up in the blood vessels of the tumor they took out. They recommended RPLND because it would be both diagnostic because it would tell them if it has spread. As well as curative.

They told me I had a Non Seminoma. And EC, if it spreads, requires treatment - Chemo or RPLND. And the fractional teratoma if it spreads would require surgery. So I should just nip it in the bud.

Manny

[dadmo]

This is strictly my take on Sloan and RPLND's. They are super aggressive with that as part of a normal treatment for tc. Do they over do it? Perhaps. But they are will move in a direction that gives you the best chance of being cured. They are very conservative with moveing toward less invasive procedures, they stick with what is proven. Since Sheinfeld is a master with this procedure the chance of a surgery related problem are very small as compaired to problems that might arise from a recurrance.

[Manny]

Dadmo - the doctors at Memorial, by their own admission, said they treat TC aggresively because they believe that is best for the patient. So I agree. But after looking at the posts on this forum, and meeting the doctors, I feel comfortable with their recommedation.

I got scheduled for surgery on Nov 21st. They could change the date if my AFP does not keep dropping. So I am now in "white-knuckle" mode - hoping all will be ok.

[Scott]

So I am now in "white-knuckle" mode - hoping all will be ok.

Keep us posted, Manny. Plan A will probably be right for you, and there's an excellent plan B (or maybe "C" for chemotherapy) in case it's needed.

[Ampaman]

Ec

Hi Manny I was diagnosed with TC last june 28 (it was pure embryonal carcinoma no lymph invasion) Had orchietomy done that week and RPLND at sloan Jul 30th. I took the aggressive path.
You will be in good hands in sloan esp the nurses + the free unlimited supply of apple juice.
I'm on surveillance now X-ray and blood test every month and just had my first cat scan yesterday at sloan since my rplnd surgery.

[Margaret]

Hi Manny I was diagnosed with TC last june 28 (it was pure embryonal carcinoma no lymph invasion) Had orchietomy done that week and RPLND at sloan Jul 30th. I took the aggressive path.
You will be in good hands in sloan esp the nurses + the free unlimited supply of apple juice.
I'm on surveillance now X-ray and blood test every month and just had my first cat scan yesterday at sloan since my rplnd surgery.

My husband is still hooked on apple juice since his stay at Sk....those nurses must do something really special to it...or maybe just making you wait for 4 days before you can have a sip...makes it much better!

[Manny]

I have never been a big fan of apple juice. Personally, I am looking forward to wine, champagne, beer, scotch, and martini after surgery! Of course it all depends on the nurses serving the apple juice - I will see if my wife lets me meet and get to know the nurses.

[Manny]

I had blood work and a CT Scan at Memorial Sloan yesterday and just got the results. AFP is down to 18.7 - down from 1200 on Oct 3rd!! And bHCG and LDH have been normal since 10/17 - woohoo!!

The CT Scan came clean as well. It showed no evidence of progression of Metastatic disease. So I am off for RPLND surgery on 11/21. They have one more check next week - hopefully things will continue to track well.

A huge thanks to all the TC forum members. You have been such an invaluable source of learning, and support for me and my family!