NSGCT Case - help!

[napoleondynamite]

79 y/o male who presented with a 5cm L testicular mass and AFP was elevated to 10 preop and remained elevated after surgery. Despite the AFP, path was read as a pure seminoma. But sounds like a stage IS NSGCT to me.

Medonc has reservations about giving this guy BEP, he's considering dose-reduced chemo vs observation. Has not yet had a PET/CT, but that is planned.

If the patient refuses chemo or is not deemed fit enough for chemo, any role for radiation?

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[Brim]

79 y/o male... could he have cirrhosis making the elevated AFP?

Here's an article re: pure seminoma with elevated AFP
http://www.ncbi.nlm.nih.gov/pubmed/9769381
"Histologically pure seminoma with elevated alpha-fetoprotein: a clinicopathologic study of ten cases."

All patients are alive and well, and none has developed evidence of YST at a mean follow-up of 6 years (range, 6 months to 10 years). ...
This study strongly suggests that minor elevations (</= 16 ng/ml) of AFP in patients with an otherwise pure seminoma may not indicate that there is a hidden focus of YST and that such patients should be treated with standard therapy for seminoma.
Caveat: small study
​

Also of some relevance: The ASCO Guidelines on Serum Tumor Markers for GCT
http://jop.ascopubs.org/content/6/4/199.full
Of note: "One reason for measuring STMs preorchiectomy is that seminomas do not produce AFP, and thus a significantly elevated AFP rules out a diagnosis of pure seminoma, regardless of histology. .... The Panel stressed caution when interpreting borderline elevations because false-positive results are possible (Appendix Table A2)"
http://jop.ascopubs.org/content/6/4/199/T2.expansion.html (Appendix Table A2)
Causes of elevated AFP:

• Benign liver disease: Hepatitis, hepatic toxicity from chemotherapy, and certain other benign liver disorders may elevate serum AFP.
• Constitutively elevated AFP: Some individuals have serum AFP levels that are chronically mildly elevated in the range of 15-30 ng/mL. Elevated AFP levels due to cancer will generally show a consistent pattern of increasing in value.

Thus, one option is to consider treating for a Stage I seminoma (RT), then recheck AFP and see if increasing. If increasing, then on to NSGCT treatment.

 

[napoleondynamite]

What a thoughtful and enormously helpful reply - thanks so much Brim!

I had it in my brain that pure seminoma will have no elevation whatsoever in AFP - but makes perfect sense to consider other causes with only a moderate rise in AFP.

 

[Palex80]

I'd rather observe than do anything right now. Prognosis and treatment are not different if you are treating elevated AFP with BEP or a measurable mass with BEP. It's the same, as long as you don't miss measurable progression at an early stage.

 

[Chartreuse Wombat]

79 y/o male who presented with a 5cm L testicular mass and AFP was elevated to 10 preop and remained elevated after surgery. Despite the AFP, path was read as a pure seminoma. But sounds like a stage IS NSGCT to me.

Medonc has reservations about giving this guy BEP, he's considering dose-reduced chemo vs observation. Has not yet had a PET/CT, but that is planned.

If the patient refuses chemo or is not deemed fit enough for chemo, any role for radiation?

I would manage as pure seminoma and observe with periodic imaging and tumor markers. I think that AFP is a red herring.