NSGCT Case - help!

Discussion in 'Radiation Oncology' started by napoleondynamite, Jul 28, 2015.

  1. napoleondynamite

    napoleondynamite Keepin' it real yo
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    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?
     
  2. Brim

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    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.
     
  3. napoleondynamite

    napoleondynamite Keepin' it real yo
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    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.
     
  4. Palex80

    Palex80 RAD ON
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    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.
     
  5. Chartreuse Wombat

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

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