Hi, I’m Mark Litwin, Chief of Urology at UCLA, and I’m here to talk for about 30 minutes about testicular cancer, and I want to talk about what you really need to know, and in the process of talking about what you need to know, I hope to share also some things that I think are things that you don’t need to know, some of the myths about testicular cancer, so I wanted to dispel the untruths and try to promote and promulgate the actual truths. So let’s just jump right in. In order to understand testicular cancer and testicular tumors, you got to know what’s located in the general vicinity. So what’s in the scrotum? What’s the basic anatomy of the scrotum? Well, as you can see here from the graphic, there are several things contained in the scrotum other than the testicles. You have the testicle, that’s the main event down there, but you also have a tube system called the epididymis. The epididymis is where the sperm travel up into the body in order to come out at the moment of truth. In addition, we have something called the spermatic cord, which includes arteries and veins and nerves that go to the testicle, blood vessels as I mentioned, and then there are linings around the testicle for protection. It’s important to understand the basic anatomy of what’s in your nether regions in order to know what can actually go wrong and what can feel like it’s going wrong but actually isn’t wrong. So before we get to testicular tumors, which is what people are concerned about in general, let’s talk about benign lesions, benign, non-cancerous abnormalities of the scrotum that sometimes people think are testicular tumors, but they’re not. Well, first of all, there’s a very common condition called varicocele. A varicocele–you see them, a live version there and then in the diagram here–a varicocele is simply a collection of blood vessels. It usually occurs on an individual’s left side and not on his right, but it can occur on either side, and it’s simply a dilated group of varicose veins, similar to what you might see in someone’s leg or elsewhere on their body, and for reasons that aren’t completely well understood, they tend to occur above the left testicle. In many guys, that can Impact fertility, it can create other issues, but it’s not cancerous, it’s not a concern. Other things that can go on inside the scrotum–and here I’m showing you both the graphic and also an ultrasound that I’ll tell you about in a moment–and the one that we probably see the most of that people come in concerned about being a tumor of the testicle, in fact, is not. It’s a cyst, something called a spermatocele, and you see the graphic here, pointing to this little cyst, and what It contains is sperm and bathing fluid that are normally around the sperm from that tube system that for one reason or another seem to pouch out and form into a little cyst. The ultrasound–and this will be interesting because I’m going to show you ultrasounds of a variety of different abnormalities that people sometimes experience–but the ultrasound you see here is oriented in the same way. This gray speckled oval shape right here is the testicle, believe it or not, and then this, of course, is the cyst, or the spermatocele. And when we do an ultrasound and we see something that’s without internal echoes or without sound waves or black, we feel reassured about that because it’s just a cyst, and that’s what a spermatocele looks like. If you’re not sure, it’s worthwhile to see a physician, a urologist or a general doctor, to do an examination. They may even order an ultrasound to just make sure, but in general, if it’s just a spermatocele, we don’t even follow up on those. They sometimes get better and go away over time, they sometimes get bigger over time, and sometimes they just stay the same, so it might just be part of you to have to learn to love. Another thing we often see is called a lipoma. A lipoma Is a benign fatty “tumor,” and I put “tumor” in quotes because it’s not a cancerous tumor, it’s just a growth. Many men develop fatty deposits in the area, the spermatic cord, where you see in yellow here. And then the ultrasound, similar to the other ultrasound, you’ll remember the testicle is this large gray oval, and this stuff up here is the lipoma. It’s very easy to make that diagnosis on ultrasound, and it’s usually pretty easy just on an examination, so this is called a spermatic cord lipoma. Many men come in complaining of this, concerned about it, worried about it, and we can reassure them that it’s nothing. Another very common non-cancerous swelling in the scrotum is called a hydrocele. Hydro means water, and cele means collection, a water collection adjacent to the testicle. So again, here you see the graphic, and purple is the hydrocele, which Is a collection of fluid that has formed in the linings around the testicle, and it’s just clear fluid that’s in there. Here’s the actual real-life picture, and you can aee how big these things can sometimes get, even bigger than that. And then the ultrasound, and you can see it quite dramatically here, where the testicle is, this–what appears to be small gray oval at the top, and the rest of the black fluid in there. Remember, black is a good thing to find in an ultrasound of a scrotum, that’s just the fluid. So this is a hydrocele, again, something that’s commonly seen but ends up not being really much of a concern. Medically, sometimes they get big enough that they need treatment, or the patient wants treatment, but this is not cancer. It is not cancer. Well, what about the main event? What about testicular tumors? And by tumor, I mean cancer. What about a test? The cancerous testicular tumor. So you see a couple of different versions of the diagram here, and whichever one speaks to you, or you can remember this is how it looks, or how we think of it graphically, a testicular tumor is a tumor of the testicle, not of the other structures around the testicle, and so it emanates from the testicle. It arises within the testicle, and most guys, when they feel a testicular tumor, will say that it feels like a painless swelling of the testicle, or like a rock that for some reason has started to grow from with inside the testicle. So generally, a man can squeeze it a little bit, and it’s remarkably not painful despite the squeeze, and it feels like a hard rock up on the surface of the testicle. Well, let’s look at the ultrasound of a testicular tumor. I’ve got a couple to show you. Now you’re an expert on testicular ultrasounds, and so you can tell quite clearly that in the testicle, which is this oval here, right in the center of it is a bad boy, and that needs to come out. We’re gonna get to that in a minute. So, that’s what a typical testicular tumor looks like on ultrasound. Here’s another example, and here is a pair of ultrasounds, where we have on the left side of the screen, the tumor, and the right side of the screen, the normal testicle. So this is a normal testicle here, and then over here, you see the normal rim of the testicle back here, but the rest of It is tumor. That bad boy is coming out, too. So this is what an ultrasound looks like of a normal testicle on the one side and of a testicular tumor on the other side. And you can palpate this, you could feel it on exam, and you can feel it in the shower, and anybody who’s got their fingers on your scrotum can feel it, so keep that in mind. If you feel a lump in your testicle, if you think you feel a lump on your testicle, go see your internist, go see your pediatrician from the old days, go see your family doctor, find a family doctor, or go see a urologist. This Is one of the few reasons that people often self refer directly to a urologist, is to find out about a testicular lump. You may need an ultrasound, or we may be able to make the diagnosis without the ultrasound, but If you actually have a testicular tumor, you must get yourself to the best possible urologist and academic medical center that you can find where they specialize in testicular cancer, because that makes a really big difference. So, what do we do if we find a testicular tumor that we think is cancerous? We do a removal, and what we do is called, in medical speak, orchiectomy. “Ectomy” means “removal,” and “orchi” or “orchid” is the testicle itself. It comes from the ancient roots of the medical language, and removing a testicle is an orchiectomy. Now, we don’t make an incision on the scrotum, down in the ball sack, as you might think we do, but we make an incision up there on the groin area where the arrow Is pointing to, and we do that in order to get out the testicle and the spermatic cord. Now, if you’re squeamish, you might want to avert your eyes for the next slide because I’m going to show you a picture from actual surgery, the removal of a testicle, an orchiectomy. Ready? Okay, here we go. That’s a surgical photograph, as you can see, obviously, and you see down here is the scrotum, the penis, and here’s where the incision was made. And you can see the clamp that’s been placed across the spermatic cord. There’s a little rubber loop-de-loop that we put around it as well, and this is the spermatic cord, the testicle, which contains a tumor, and some of the tube system that’s right next to it. And so we make the cut way up here, so we get out the whole testicle and the cord, and we need to do that in order to treat the patient properly. When we remove a testicle, you might be wondering, can you put in a falsie? And the answer is yes. We have saline filled prosthesis and silicone filled prosthesis that we’ve been using for many years in urology, and it looks, for all the world, like a regular testicle. We have 4 different sizes. They come in medium, large, extra large, and ginormous. There’s no such thing as a small size testicular prosthesis. You can imagine why. But these are the standard sizes, and we just plop it right in at the time that we’re doing the orchiectomy. It’s cosmetic, it’s just for a patient to feel better about his own symmetry in his own scrotum, but many people do decide to have that placed. Once we get the tumor out, we send it off to pathology, and we get back photographs and microscopic pictures, and this is the kind of thing that we see. So these are actual testicles with tumors in them, of course, after removal, after they’ve been soaked in formaldehyde, cut in half, are done what we call bivalved, meaning that the testicle’s cut in half, and you can obviously see doesn’t take a medical degree to see the testicular tumor here, and here and over here. So these are actual testicles that have been removed, and I would speculate that all 3 of these men, although they lost a testicle, were most likely cured of their testicular cancer. So the way you reach cure is by following really carefully designed algorithms that we have, but also by early detection. Really, the most common way that men tend to present, initially, to the doctor’s office is after having found a nodule or a lump in the testicle during what we call testicular self-examination. Women are taught from a very early age about breast self-examination. We don’t do quite as well teaching adolescent boys and young adult men about testicular self-examination. But it’s not that difficult. You can look it up on the internet, there’s lots of videos showing you how to do it, but it basically comes down to this. As you see in the graphics, usually we advise people to do it in the shower, where you can soap up the area and your skin is smoother, and you just take your fingers–either 1 hand, as you see on the left side in blue, or 2 hands in the right-sided diagram there–and just palpate, or feel, the testicle. You should feel your own anatomy so you know what your normal nooks and crannies feel like so that you can tell if something abnormal has happened. Testicular self-examination: the key to early detection and prevention of this disease. Why is this important, and who is it important to do testicular self-examination? Well, this is about as academic a slide as I’m going to show you during this webinar, but this is the epidemiology of testicular cancer, and what you see along The y-axis is the incidence, the rate per 100,000 men, and what you see along the horizontal axis as the age at diagnosis. And most cancers are up here in the 60s, 70s, 80s of diagnosis, but you see, testicular cancer is way down here. It peaks–for the 2 main types of testicular cancer that we’re going to talk about in a bit–it peaks way down here in the 20s and early 30s, so the most common age group is from 18 until about age 40. Beyond 40, we occasionally see testicular tumors, but it’s much less common. Younger than 18, occasionally, but not very common. But between 18 and 40, that’s the prime age range for testicular tumors. And so If you’re between 18 and 40 and you haven’t spent much time with your scrotum, get to know it better. Okay, once this Cancer is diagnosed, there’s some basic fundamentals that anybody who’s either got this disease or loves someone or knows someone with this disease should know. These are the fundamentals. First of all, if you had a history of what we call undescended testicle, which means a testicle that didn’t go all the way into the scrotum during fetal development, and this Is a very common situation that boys are brought to a pediatric urologist for, even if that testicle was surgically repaired and brought down into the scrotum, which is typically how we address this, it still has a higher risk of later developing testicular cancer. So if you have a history of that from when you were a little kid, ask your parents or ask someone who would know, you have a higher risk of developing testicular cancer, and so self-exam is that much more important. All right, number 1. Number 2– one of the things we measure once we make a diagnosis of testicular cancer is something called the tumor markers, or blood tests. Testicular cancers often secrete proteins and chemicals into the blood that we can measure, and those function as a marker for the testicular cancer. Not all of them secrete tumor markers, but many of them do. And you’ll hear these words thrown around a lot, AFP, which stands for alpha-fetoprotein, HCG, which stands for Human Chorionic Gonadotropin. The words don’t matter, but the letters HCG, you’ll get to know, and then LDH is the 3rd tumor marker that we measure, so these are blood tests that are measured from a routine blood work that can help us make the diagnosis and help us follow patients over time. Scans: when we make a diagnosis of testicular cancer, we’re very concerned about whether the tumor has or hasn’t spread to the lymph nodes of the abdomen, what we call the retroperitoneal lymph nodes, more on that later, or up to the chest in the lungs or possibly even elsewhere, so most all men end up with either a CAT scan or sometimes an MRI, occasionally a chest x-ray, nut we’ve got to be doing imaging of the abdomen, the pelvis, the chest, and occasionally of the brain. So that’s the scans. And then it’s important to know what the different types of testicular cancer are. They come in 2 main flavors, seminomas and non-seminomas–the non-seminomas have subtypes, which you see listed here, teratoma, embryonal carcinoma, chorio carcinoma, and yolk sac tumor, and overall we think of these as the non-seminomas, and we’ll come back to why that’s important, because the cell type, the tumor type, helps us determine exactly how we’re going to treat the patient. So we use that Information in combination with these tumor markers, as well as the scans, to see what we’re going to do next. So those are the fundamentals of testicular cancer. Staging. As with any cancer, once we make the diagnosis, we have to classify, is it stage 1, stage 2, or stage 3? Stage 1 means it’s contained in a testicle, we think. Stage 2 means that we think it has spread to the lymph nodes, and the lymph nodes Involved are usually up in the upper abdomen, an area called the retroperitoneum, adjacent to the aorta, the vena cava, the kidneys, and other structures of the abdomen, and then Stage 3 is the most advanced, and that’s when it has spread to the lungs, the brain, occasionally to the liver or other areas of the body. That’s the worst case scenario of course, but very typically still completely curable. Testicular cancer is almost unique among human malignancies in that even patients with widely disseminated, widely spread, metastatic cancer can very often be completely cured and live out normal, happy, healthy lives. You got to get to the right medical center and to the right doctors who know what they’re doing. So, I’m gonna run through just a handful of basic slides on the treatment. First, stage one seminoma. This is probably the most common type that we diagnose, and it has an excellent, excellent prognosis. Stage one, you remember, means contained within the testicle, or so we think, and seminoma, as opposed to the non-seminomas, which are different categories, so with a stage one seminoma, patients generally have an option of choosing 1 of these 3 treatments: either a single dose of something called carboplatin, or carboplatinum, which is a chemotherapy Agent which is very, very well tolerated, literally a single infusion and the iv in the arm goes in over a few hours, and that’s it. Or they sometimes choose to have 2-3 weeks of radiation to the lymph nodes, or very occasionally they will choose what’s called meticulous active surveillance, the idea of this is that once we remove the primary tumor with the orchiectomy, we manage the lymph nodes– so testicular cancer is always managed in 2 parts, part 1 is removing the primary tumor, we did that earlier, part 2 is treating the lymph nodes–so even if the CAT scans are clear and we think the lymph nodes are not involved, we shotgun it anyway, and we treat those lymph nodes just on the chance that they might still be involved, even if they didn’t show up on the scans as being involved. So the way we do that, as I said, is either with a single dose of chemo, carboplatinum, with 2-3 weeks of radiation, or occasionally people will hedge their bets and say I’m just gonna follow this very meticulously, hoping that there’s no involvement of the lymph nodes, and we track It out over time, and if it’s cured, it’s cured, if it’s not, we can zap in and do chemotherapy at a later date. So that’s seminoma stage one. Non-seminoma stage one is treated somewhat differently. So a non-seminoma tends not to be sensitive to radiation, and it tends to be sensitive to different types of chemo, so when we have a stage one non-seminoma, meaning that the testicle has been removed, the biopsy has come back, and it shows one of those categories of non-seminoma, and the CAT scan or MRI appears to suggest that there’s no spread to the lymph node, that’s what we call stage one. We manage the lymph nodes anyway. The treatment of choice at most major academic centers is a surgical operation called retroperitoneal lymph node dissection, RPLND, and that is an operation–I’ll show you a picture in a moment–where we go in surgically and remove those lymph nodes that we’re concerned might be involved even though the scan was clear. It traditionally has been done through an open approach, but it can be done at a major center through a laparoscopic approach as well. An alternative to surgery is something called upfront chemotherapy, or shotgun chemotherapy, with agents called bleomycin, etoposide, and platinum–I’m going to show you those words again in a moment–or sometimes just the E and the P. So either BEP or just EP, and its nuances are worked out by the medical oncologist. And then the 3rd option, which I put in brackets of question marks is something called active surveillance. Now, I’ll tell you in a moment why I think that active surveillance is riskier, but some people do choose active surveillance. So this is the retroperitoneal lymph node dissection, and you can see the diagram of the human body here. What you see is kidneys here, the blue structure is the inferior vena cava, this red structure is the aorta, and these 2 yellow structures are the tubes that the urine goes down through. And all throughout this area are the lymph nodes, the retroperitoneal lymph nodes, that is where these tumors spread, if they’re going to spread, and so we go in and we sample that. We don’t trust the CAT scan or the MRI. We sample that and we take out a series of those lymph nodes, and by doing that, we can find out for sure, was there cancer there? In which case, we need to know that because the patient might need closer follow-up or more treatment, or was there no cancer there? In which case, we breathe a sigh of relief. We will do periodic scans and blood work over the years, but we’re much more comfortable that the cure really has been obtained, and this can be done either the traditional way, which is through a incision in the abdomen, or more recently, at a major academic center, where there are very experienced neurologic oncologists doing this surgery, it can be done laparoscopically, or robotically, and you see here, 1, 2, 3, 4, 5 little dots there, and those are the little openings that are made–little poke holes that are made in the abdomen. You’re asleep, of course, when this is done, and we go in with long, skinny laparoscopic instruments that are hooked up to a robot that assists us, and we can get to those lymph nodes the same way. It’s newer, and it is not for the routine inexperienced surgeon. It must be done by a very experienced surgeon who knows very well how to do this operation, both open and both laparoscopically, in order to be able to provide the best quality care. So we talked about stage I. Now let’s go to stage II and III. So, these are cancers that are in the lymph nodes extensively, or perhaps spread to other places in the body, such as the lungs, or even the brain. Chemotherapy, chemotherapy, chemotherapy. It is highly effective and highly curable. Many cancers across the spectrum of human disease are sensitive to chemotherapy, but only somewhat so. Testicular cancer is among the most sensitive cancers in all of human medicine to chemotherapy, and the chemotherapy agents–you’ve heard these words earlier–are bleomycin, etoposide, and platinum. That standard treatment, BEP. They have various risks, and the physician, the oncologist who’s administering them is responsible for managing those risks, talking to the individual patient about the risks, and sometimes these agents are tailored a bit based on the particular situation. If the patient needs to have additional chemotherapy, if the BEP doesn’t work for some reasons, there are additional regimens, and then there are additional regimens after that, so there’s excellent chemotherapy for advanced testicular cancer. And again, even in the advanced case, it is usually curable. So let me come back to my bracketed question marks around surveillance, why I think that surveillance only is somewhat risky, and there’s a difference of opinion about this in the academic urology world, but my view of it is that it’s risky for the following reason. Here, you see a chart that’s pulled from a resource called the national comprehensive cancer and network, the NCCN, which you can get to online for free, and the NCCN guidelines for testicular cancer non-seminoma says that if the patient is going to do active surveillance, year 1, 2, 3, 4, 5, and then 6+ has to include a number of chest x-rays, bloodwork, and CT scans, and you can see here in year 1, there should be 1-2 months between chest x-rays and blood work and 3-4 months between each scan. What that means is that in year 1, we’re talking about 6 visits and chest x-rays, and over here we’re talking about 3-4 CAT scans in year 1. In year 2, there are gonna be 2-3 CAT scans, plus all the x-rays. In year 3, again, there are gonna be 1 or 2 CAT scans, etc., etc. So when you add all this up, It’s a lot of visits, a lot of chest x-rays, a lot of radiation from the CAT scans, and a lot of follow-up, and it requires a degree of attentiveness to detail that is really difficult to maintain, and the reason, mainly, that I think it’s risky is because when I think about the typical demographic of who gets testicular cancer, it is men in their 20s and 30s, and there are many things that men in their 20s and 30s do. They go bungee jumping, and they graduate from places and they lie around playing video games, and they work hard at starting a new job, and they get married and move away, and there are various things that 25-year-old men do. Going back for CAT scan after CAT scan after CAT scan tends not to be super high on the priority list, and so even the most well-intentioned in this demographic, young men tend not to be quite as meticulous with the follow-up as they should. And what that can lead to is the cancer advancing to a point where it’s much more difficult to cure, so that’s my pitch for why I think surveillance is more risky. This is what can happen if a patient is on surveillance and forgets to come back in or loses his insurance or chooses not to come back in. You can end up–and this is an actual scan from an actual patient who has a mass inside his abdomen, and this is a mass that was left even after the chemotherapy. And again, just like the diagram I showed, this is a real x-ray here, and what it shows is, in white, the aorta, there’s a bit of the liver over here, white up here is stomach and intestines, you can’t see the kidneys in this view, but what you do see from even across the country on this webinar is that very large tumor mass there and over there. That’s a tough problem to try to deal with with chemotherapy or surgically, to go in and take it out, so this is the reason that I think that active surveillance is particularly risky because we’re going to end up with situations like this. We give the chemotherapy, it often shrinks the mass down, but we’re often left with a situation like this, so retroperitoneal lymph node dissection is my pitch for what I think is the most appropriate management for someone with a stage one non-seminoma. If you’re diagnosed with testicular cancer or someone you love is diagnosed with testicular cancer, there are numerous support resources, many of them on the internet, many of them in community centers, hospital-based and doctor’s office-based. I’ve put a few of them up here. There are many, many others. The ones that I think are the best resources for background information include the American Cancer Society, which is cancer.org, the National Cancer Institute, which is cancer.gov, and then there’s a variety of other ones, such as the Testicular Cancer Society, such as the Testicular Cancer Foundation, and you see the websites here. There are Facebook interest pages and many, many, many others where you can get resources and get support, and it’s a condition in which there are with 7 or 8 thousand men diagnosed per year in the United States. Over the years, there are a lot of men who have accumulated, who are survivors of testicular cancer because it’s so curable, and so if you end up in this situation, ask around. It’s really just at your fingertips to find other guys who have been through this or people who love men who have had testicular cancer. The support systems for the moms, the partners, the spouses, etc., the kids, and so there’s a lot of resources that are there. Testicular cancer is almost always curable. That’s my final message, and if you think you have testicular tumor, if you think you have testicular cancer, get yourself to a top-drawer place, an academic medical center or someplace with a lot of experience in testicular cancer. My name is Mark Litwin, I’m the Chief of Urology at UCLA, and we are now open for questions. The first question: “If I have a testicle removed, will I still be able to have children?” The answer is yes, and the reason is that you have 2 testicles, of course, and the testicle that remains can still produce sperm, and all you need is 1 little guy to make a baby, and so the vast majority of men who have a testicle removed are still able to have children. Now, there’s a little extra comment that goes with that that you should be aware of. Many men who have testicular tumors, even when the tumor is removed, have sperm counts that aren’t quite as fertile as men who never had a testicular tumor, and so it’s not so much the removal of the testicle that can compromise fertility, but the fact that whatever it was that caused the testicular cancer genetically tends to lead to poor quality sperm counts, and that can create an issue, but just removing a testicle in and of itself doesn’t eliminate you from being able to have kids, and there are many, many Christmas cards I get every year of men who have had a testicle removed, and they send me cards of their kids growing up that they’ve had subsequently. Second question: “If I have a testicle removed, will my testosterone go down? And along with that, what happens to sexual activity?” So, the human body is a really incredible thing. When you lose a testicle, his best friend on the other side of your scrotum picks up the slack almost immediately. Within a couple of days, your blood levels of testosterone are exactly what they were before you lost a testicle, so testosterone levels, or the male hormone, tend to be almost identical even with 1 testicle as opposed to 2, and as long as you have that normal testosterone, then erections work normally, libido or sex drive works normally, and ability to perform sexually works normal. The man is not the testicles, the man is something greater than that. But the testicles make testosterone, and that is what allows you to have an environment in your body that is supportive of sexual function. Okay, next question: “If I have to have chemotherapy, will I lose my hair?” Basically, yes is the answer. If you have to have the chemotherapy that cures the cancer, in general you lose your hair. It’s very stylish, as you can see. Some of the most handsome men I know have no hair, and it’ll grow back. If you have the single dose carboplatinum for stage 1 seminoma, those individuals typically don’t lose their hair, but if you have BEP or EP, that does typically involve hair loss, and it grows back. Next question, ah yes, “Dr. Litwin, you seem to be against active surveillance. What’s the reason for that?” Well, you picked up on that. Active surveillance for non-seminoma can be accomplished if you’ve got a meticulous physician with a meticulous staff and a meticulous patient who is gonna follow it up and make a spreadsheet somewhere and make sure that he comes back for all those chest x-rays, all those bloodwork markers, and all those CAT scans or MRIs over the first 2 years in particular, but then really over the first 5 years, is important, and if you have a situation like that where everybody’s responsible, it can be done, and then you go in and give chemotherapy if there is a tumor that progresses during that time. My concern is that the demographics of the testicular cancer group are such that, based on my experience, it’s tough to do all that follow-up, and it’s a lot of x-rays over several years, and for that reason, I am not a big believer in active surveillance, but it can be used in very, very selective cases. No further questions that we see coming in at this time. If you have a question, you can always drop us a line on the internet, and otherwise, keep examining that scrotum. I’m Mark Litwin, Chief of Urology at UCLA, thanks for watching.