Surgery Followup

On Friday I met with the surgeon to go over the surgery and pathology results and learn about followup treatment options. The pathology showed that I have a stage one pure seminoma that had vascularized. This was mixed news. Because it is a pure-seminoma, the cure rates are really high; this type of tumor responds very well to radiation. On the other hand, the sizing and vascularization meant that this is considered a late stage one tumor which puts me at increased risk of recurrence if we choose to do nothing.

The National Comprehensive Cancer Network (NCCN) has treatment recommendations (pdf) and general information for testicular cancer. My pathology report lists the AJCC tumor staging as pt2. Since my CT, X-Rays and blood markers were all negative, I believe translates to Stage IB. This staging is one of the primary determinants of followup treatment.

There are generally three treatment options for Semiomas at this stage.

• Watchful Waiting
• Radiation
• Chemotherapy
  

Watchful Waiting

Watchful waiting is monitoring through blood markers, chest x-rays and CT scans for up to 10 years. The NCCN recommendations are:

Years	Blood Work	CT Scans	X-Rays
1-3	4 times	Abdomen/Pelvic 4 times	Chest: twice
4-7	Twice	Abdomen/Pelvic: twice	Chest: Once
After	Once/Year	Abdomen/Pelvic: Once/Year	Chest: every other year

Watchful waiting works well for early stage seminomas: the side affects of chemotherapy and radiation are avoided, but the recurrence rate is between 15 and 30%. The NCCN guidelines state a 15-20% recurrence rate with the median time to relapse being 12 months, but with relapses reported after 5 years. Keeping up with the monitoring schedule can be tough and if there is a recurrence, the treatment tends to be more invasive as you are now dealing with a metastasized tumor.

Radiation

The second main treatment, and until recently, the standard treatment is 25-30 Gy (2500-3000 rads) of infradiaphragmatic radiation administered to the para-aortic and ipsilateral iliac lymph nodes, the likely first metastization sites. Radiation is very effective in treating Seminoma, but there are potential side affects including: potential infertility and an increased chance of developing cancer later in life.

Chemotherapy

Chemotherapy for seminoma is a relatively new treatment. A study of 1477 people with stage 1 seminoma randomly treated some people with radiation therapy and others with a single course of carboplatin. (second reference) After 5 years, with 1148 patients reporting follow-up results, the relapse-free rates were 94.7% with carboplatin and 96% with radiation. The study authors concluded that a single dose of carboplatin is less toxic and as effective in preventing disease recurrence as radiation therapy in stage 1 seminomas after surgery. There are quite a few side-affects with carboplain, including:

• Decreased white blood counts. Red blood cell counts and platelet counts can also be reduced.
• Nausea, vomiting, and loss of appetite.
• Diarrhea or constipation.
• Numbness and tingling in the hands or feet (peripheral neuropathy).
• Hearing changes or hearing loss.
• Mild rash.
• Hair loss (reversible)
• Mouth sores.
• Changes in kidney and liver function tests

I'm not sure which is the right treatment at this point. I tend to agree with the doctor that watchful waiting is probably not the best course, but I don't know how to choose between radiation and chemotherapy right now. With both those treatments, I still have a pretty rigorous followup x-ray/CT scan/blood work schedule to monitor for relapse. If I had to pick right now, I'm probably leaning towards chemotherapy. I have a couple of recommended oncologists that I'll be scheduling appointments with on Monday that will help in this decision and my treatment.