Extensive Intratublar Germ Cell Neoplasia

[Cruisestaff]

Hey all, I have a Stage I Seminoma. I was leaning to surveillance over radiation as one set of top doctors told me my risk was low as tumor was just 7mm. While my actual tumor measured 7 mm, there was extensive interstitial involvement by dispursed tumor cells, much beyond the tumor encompassing almost all of the tubules and in another set of doctors' opinions, it was as though the tumor encompassed the entire testicle (i.e., > 4cm). In support of this opinion, Drs. noted that it was highly unusual for a tumor of 7mm to have had rete testes invasion, vascular invasion and extensive cancer cell formation through the entire testicle. Other doctors do not share this view and still recommend surveillance and are focusing on 7mm tumor. I understand this may be a case of differing opinions on the subject, but I just wanted to confirm with people here that this makes sense and that maybe I should not do surveillance in light of this signficant interstitial tumor involvement.

[matthias]

Intratubular germ cell neoplasia = carcinoma in situ.

Of course, it is now well-established and -accepted that CIS (or IGCN) is a precursor to malignant lesions. Having a testicle full of CIS is not the same as a testicle overtaken by cancer. With CIS confirmed throughout, there is the potential for lesions to develop throughout. But apparently some 7 mm area "matured" before the rest, causing the eviction of all.

I'd still treat it as 7 mm tumor; at this time, in Europe you would probably be referred to a biopsy of the contralateral.

P.S.: Showing of my Latin prowess (yes, I had 5 yrs/5 h per week of Latin): carcinoma in situ very loosely translates into "cancer waiting to happen". But it's not cancer yet!

[Jens]

Tough call!
Playing it safe (treatment) vs. no side effects (risk of relapse).

Sounds like you had a complex tumor, that was looking for a way out.
Even though it may have found it (VI and Rete T. invasion) it's not necessarily the same as saying that it got out though.

Putting my own decision into it, I was in the group of non-semionomas where 70% is at risk of beeing overtreated. But adding 100% EC plus VI and LI to the equation made it easy. I'm pretty sure I would have gone for the chemo, if there had not been a biopsy. My doc dictated it though (great guy) so I had a reproperitoneal biopsy that showed cancer.

Your equation (imho) is more difficult:
Going with survelilence may do the trick.
If not, it will be caught early. Radiation is very likely to do the trick.
If not, chemo will! (statistics say close to 100%)

But it's a tough call and you should get more input. Anybody else got the same pathology?

Best wishes
Jens

[Cruisestaff]

thanks a lot for the replies

very helpful. I gues sthe CIS or ITGCN is not the concern. It must be the "extensive intersitial involvement by dispersed tumor cells" all through the testicle that is leading this dr to conclude that the tumor is biiger than 7mm.

[matthias]

Two ways to arrive at "dispersed tumor cells":

(i) as a result of spread from the 7 mm tumor;

(ii) as a result of CIS (confirmed ) transforming focally into full-blown TC but independant of the primary 7-mm tumor.

Under scenario (i) you have a tumor actively dispersing widely; I would agree with your doc that for all practical intents and purposes your tumor size is that of the widest spread observed (that is, larger than the 7 mm of the solid mass).

In case of (ii), you have a 7 mm tumor and independent events/transformations going on throughout the testicle. No aggressive spread by the primary tumor. No reason to believe that "virtual" tumor size transcends physical tumor size.

Is it (i) or (ii)? Nobody knows and I doubt that there is a standard test to address this issue.

Pick your level of risk-tolerance (or aversion): if you feel lucky, it's (ii); and if not, it has to be (i).

P.S.: The use of "dispersed" would, of course, imply (i): dispersion always also requires a "source". Not sure, if words were chosen that deliberately when communicating.

very helpful. I gues sthe CIS or ITGCN is not the concern. It must be the "extensive intersitial involvement by dispersed tumor cells" all through the testicle that is leading this dr to conclude that the tumor is biiger than 7mm.

[Cruisestaff]

Hard to say whether it's (i) or (ii). The pathologists arent clear. There view is that the 7mm tumor did send/disperse cells elsewhere, but other drs are saying that such a small tumor couldnt have sent such strong cells. Who knows. It's a game of craps. I just hope I dont crap out. I wonder what the risk is of having a tumor that is >4cm, vascular invasion and rete testes invasion - 40% or does that seem high for pure seminoma?

[Jens]

if you feel lucky, it's (ii); and if not, it has to be (i).

Why is it that I get this image of a young Clint Eastwood with an oversized Colt in his hand? I know TC is the most powerfull testicular disease ever made and I really gotta ask myself if I'm a punk....

As to the risk question, anything is possible, in time. It really depends on how long one is waiting. So again, statistics are for populations, not for individuals.

Best wishes
Jens

[matthias]

This insight by Jens cannot be overstressed. While we always talk about 70, 80, 95 % of this or that happening: statistics are for populations.

On an individual level, it's much simpler. You either have it or you don't: black or white; 0 or 1; Yin or Yang; live or die. There is nothing like an 85% testicular cancer...

[...] So again, statistics are for populations, not for individuals.

Best wishes
Jens