ABR OLA Seminoma Question: RT vs Chemo

[Radonc90]

I just came across a question on ABR OLA (Online Longitudinal Assessment) for MOC.
Pt is s/p right radical orchiectomy and has 1 .5 cm LN in right renal hilum.
I know the data very well and selected Chemo as to prevent late long-term sequelae for the pt.

Guess what? The answer was RT!
Sure, the people that wrote these OLA questions are radonc.
But what if medonc wrote the question?

I am all about science and data, I thought this was a poor question bc both answers are correct, per NCCN guidelines.
My bias is chemo for this particular problem.

What do you girls/guys think?

- First photo is the OLA question.
- Second photo is the NCCN guideline.

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[thecarbonionangle]

Both are reasonable choices per guidelines as you said. I have seen both scenarios where they have gone different ways. In one case, med onc did not want to give chemo, so patient got XRT and in the other case MO really wanted to avoid XRT for unclear reason so the patient got chemo.

 

[Radonc90]

Yeah,

But ABR OLA says I am wrong when choosing chemo!!!
Where is @dieABR when I need him/her? LOL...

 

[ramsesthenice]

I just came across a question on ABR OLA (Online Longitudinal Assessment) for MOC.
Pt is s/p right radical orchiectomy and has 1 .5 cm LN in right renal hilum.
I know the data very well and selected Chemo as to prevent late long-term sequelae for the pt.

Guess what? The answer was RT!
Sure, the people that wrote these OLA questions are radonc.
But what if medonc wrote the question?

I am all about science and data, I thought this was a poor question bc both answers are correct, per NCCN guidelines.
My bias is chemo for this particular problem.

What do you girls/guys think?

- First photo is the OLA question.
- Second photo is the NCCN guideline.

I have done all of these to date. There were only 2-3 like this where I thought there was not a clear choice. I had one recently about couch kicks towards or away from the gantry without specifying head or foot of the table. But these are the exception. Compared to almost all other certification tests we have done, these are usually pretty good. I’d say 80+% really don’t even need to be multiple choice. I’d take these over paying for SA CME any day of the week.

To your specific question, I just finished treating someone for this exact scenario about a month ago. I think it was a first for me as the MOs and urologists almost universally recommend chemo. Given that these are young guys, it really probably is the better move for most of them. This was patient driven.

 

[Chartreuse Wombat]

This is not a good question. There should be one unambiguous answer. My experience is similar to ramses. Most questions are straightforward and represent "walking around knowledge" for any competent radiation oncologist. I usually have little good to say about the ABR but in general I find OLA is a good development.

 

[Burt Radnolds]

This question is somewhat poorly written but the RT answer is the only correct one.

It says carboplatinum chemotherapy. That is an incorrect answer. Gross nodal disease would require multiagent chemo.

 

[Chartreuse Wombat]

Oops. Note to self. Read the question. On reflection the monckey is correct. There is only one correct answer. Carbo has no role in Stage II disease.

 

[Radonc90]

I was thinking "platinum-base chemotherapy" when I answered the test.

Agree that multi-agent chemo such as BEP is the way to go. Southeast Onc group did a randomized trial yrs ago BEP vs EP (bc Bleo was toxic).
BEP still stands the test of time.

Carbo has been used in place of CDDP for yrs. As you all know, Carbo is in the same family of heavy-metal compound as CDDP.

 

[medgator]

.

Carbo has been used in place of CDDP for yrs. As you all know, Carbo is in the same family of heavy-metal compound as CDDP.

Not felt to be as effective though

 

[Palex80]

This is a cN1-stage --> Stage IIA. This is not Stage I.
3 cycles of carboplatin AUC7 offer a PFS of merely 82% in this scenario, as per Krege et al

Single agent carboplatin for CS IIA/B testicular seminoma. A phase II study of the German Testicular Cancer Study Group (GTCSG) - PubMed

Four cycles of single agent carboplatin AUC 7 do not safely eradicate retroperitoneal metastases in patients with stage IIA/B seminoma.

pubmed.ncbi.nlm.nih.gov

Standard for stage IIA/B is either hockey-stick / dog-leg (call it as you like) RT with 30-36 Gy OR 3xBEP OR 4xEP.

Newer data from the UK do point out that multiple cycles of Carboplatin AUC10 can be an option with a PET-CT guided strategy.

A phase II study of carboplatin AUC-10 guided by positron emission tomography-defined metabolic response in metastatic seminoma - PubMed

2009-009882-33.

pubmed.ncbi.nlm.nih.gov

Thus, the question's formulation is quite "unfortunate" in my opinion, especially since on statement is just "carboplatin chemotherapy". Writing "1x carboplatin AUC7" would make things clearer.

Last, but not least: Slightly enlarged lymph nodes, like this 1.5cm lymph node, can often be false positive. There seems to be trouble in the way radiologists measure these nodes, they seem not to do it very consistently and some of these lymph nodes may shrink in repeat scans. In a patients with a 1.5cm big node (especially if it's not the short axis) and if the CT was acquired post-operatively and the markers are negative postoperatively (common in pure seminoma) one could opt for a repeat scan in 4-6 weeks and then decide how to treat. This may be a stage I after all...