Chapters Transcript Video Testis Cancers: Screening, Treating & Surviving we talked about testes cancer uh tonight and many of you probably have some familiarity with it. Um And just the whole spectrum disease from detection and treating with a lot of emphasis on what I work with with uh conventional chemotherapy drugs. And I want to talk about some survivorship issues also as well. Uh I don't I do some work with pharmaceutical companies but not particularly in relation to this disease. So first we'll talk about screening for testes cancer incidents and uh the key issue of getting patients to medical attention and ultrasounds. Ultrasounds are really, it's hard to think of a test. It's less invasive than an ultrasound. Um And uh next there it is. Um I'm gonna talk about staging the testes cancer, how it spreads uh mostly in the retro peritoneum and then other distant locations like many cancers. It can spread to other places and some histological subtypes. Seminole most non Seminole most and the market proteins which are really of major use for this cancer uh somewhat different than a lot of other situations. Next click Talk about risk stratification of the within seven oma. and uh a separatist for non Semin OMA american Joint Cancer Committee has a T. N. M. S. System. Um and the International Germ cell Cancer consensus group which has the best acronym there which has a risk stratification. Talk about treating testes cancers uh with both surgical and medical treatment. Uh The first issue will be inguinal or key ectomy and then a question of adjuvant treatment and chemotherapy treatment and surgeries and then made some some summaries of different timelines that patient may expect. And a couple of new reports, 2020 oncology meetings. Although um not a lot of news this year but we'll round that up next and then just to round it up survivorship first space you've got to get through the chemotherapy and there's some long term issues with the history of testis cancer and otherwise. Androgens and fertility. Of course a key issue for the testes and surveillance and screening both for recurrence and for other other medical situations. So go to the next slide. Start off with screening we have of course the classic picture of the Nile delta. And um I won't say the joke again. But yeah patients really put off um Put off ah coming to an understanding that there's something wrong with the testicle. Um Sometimes they may understand it but they just don't have a good way to get to medical attention. A lot of young men they may not just may have never had any practical experience in the medical system. And we talked about ultrasounds next slide. Uh So uh it's about the world's shortest screening slide. This is the number one cancer in the 15-35 men age group. Which is not a group where there's a lot of cancers. About 7000 a year in the US. unfortunately four or 500 deaths. But many many survivors there um Older ages also can get it. Occasionally. You might hear someone say oh that that patient can't get uh testes cancer because they're outside that age group. They certainly can. Uh Even although it's not the number one cancer in that group um Pain and texture changes. That's typically what patients will say. Occasionally it'll be picked up just a symptomatically um symptoms for metastasis. Some patients will not really notice anything wrong with the testes and eventually some other part of the body may have pain. If it's in the retro peritoneum sometimes they'll feel it in the back of it's a massive lesion in the in the retro parent might actually feel in the front. Um The um the american cancer society doesn't have an official screening program for this disease which is odd but there's just not a there's just not a way to do it. There's a lot of funny things you can say like uh we really don't need to be telling young men to touch their testicles on a regular basis. But um they're just not a good way uh to to set that up. I'll show you one of the ads in a minute here. Um And uh the key thing I want to emphasize here is that patients can get a conscious awareness of the disease. Um And I think that that will eventually be helpful. Um So go to the next slide please. Um So here's uh some of the uh value ways that people can present uh a mass or enlargement or pain or some other incidental findings uh sometimes will be seen instantly on a chest X ray or chest C. T. Or an abdomen scan for done for some other reason. Um There's been a lot of differentials of a non cancer issues that can occur in the testes because he's some of them listed there. And of course someone might have both of those problems at the same time. Both uh trauma and a testis cancer. Next slide you think it's working time because it says no. Uh here's uh cancer advocacy website I heard guts dot com and uh remember that many. It's pretty pretty funny poster there we can zoom in on that. But um just really again making the point that the population where this occurs, they have no reference point about what what things should be or shouldn't be like. Um uh of course you know, human uh test is the right testicle should be slightly lower than the left. So sometimes a high writing right testicle, that's all that there may be there, but unless you have an art student or something like that, they may not really understand that something's changed, that's abnormal. Um So, uh next slide the work. Um Say so, yeah, So what causes testes cancer? There's definitely some kind of genetic events because uh there's a kind of racial predisposition, northern Europeans, especially. Um there's some populations who apparently have very little um African Americans, about 10% of the rate. Um talk about marijuana for a second. Maybe it causes it uh certainly doesn't cause mortality. Uh Next there. Um so here's uh here's a nice uh image from Xinjiang who had a very successful movie there, and although the incident goes up a little bit, um remember most of the, most of the cancers are non fatal, so it doesn't appear to impact how much on that. On the other hand, is marijuana useful in the when training camps are being treated, it may be useful for managing symptoms. So anyway, a little bit of uh of an angle on on marijuana there, but I don't think anything really to drive any public health decisions. Um so it's kind of jumping to it once here. Mm there is. Okay, good. Um so here's a uh an atomic diagram of testes and we see the dramatic cord coming in from the top and the reading test is in the testicle itself and the seminal vesicles there. And uh I kind of got a kick out of this one because it was from the encyclopedia Britannica online. So I thought, well that's how I should start off my presentation. Um And then there's an ultrasound of a normal testicle there, move the and then here's a couple of non malignant findings. So there's micro calcifications in that image on the left. It's a risk factor for testes cancers but it's not a cancer in itself. So somebody might have extra ultrasounds to evaluate that, but we wouldn't act on that on the right is a very rare situation called really test this ham martoma. It wasn't really proven until after removal. But again, not a dangerous situation at all. Even though it showed up on the ultrasound, here's a couple lesions which were found to be cancer. And uh a little more obvious. You can see them just sitting there and what should otherwise be a very uniform texture. Um Of the background of the tested there um circling back to the development anatomy of the testes. We can see in the in the fetal fetus in the embryo that the gonads start relatively high and the kidneys start relatively low and they kind of do a switch in their position and the kidneys end up high in the back of the abdomen. Um The kidneys get a new blood supplies. They move along, but the gun ads just take their blood supply with them. And here you can see that the blood supply seems to be very good. Um So uh and then the testicles continue uh and descend down to the scrotum. Um Who are of course they're found in the adult. They leave their blood supply back there. And the next I'm sorry, I apologize. The slides are jumping around a little bit. Um Next they're right there. So here we can see the the go Natalie veins there um And the ureter just right there in the back of the abdomen showing how the blood and for the limp supply on the left notes associated with the testes are up the level of the kidneys next, please. So this leads us to the key issue of somatic staging regional lymph node spread for the test. This means going to the landing zone. Air in the retro peritoneum occasionally may skip, especially if something that prior tested surgery like or key ectomy or or or Capex E. Or a mastectomy. Um As far as a distant spread. The longest. The number one distant location that's neutral for prognosis. Although it does form a basis for definitely not using just surgery whether chemotherapy, but there's also a high risk location. Deliver bones and brain uh are the key organs which are high risk. If something starts from a non gonad area and germ cells actually can can be in some of these non gonad areas. Then those are also considered high risk. And they'll have a different pattern of spread. They may not a media spinal germ cell cancer may never even go to the retro peritoneum. Next slide please. So here's some ways the staging is done. Cat scan or MRI probably equivalent for looking at the nodes of the back of the abdomen. Um For low risk patients with a negative retro party and they might just get a chest X ray or a cat scan. Is there some intermediate high risk situation then a cat scan of the chest ready to look carefully. We don't want to neglect distant pattern has spread and not give the patient chemotherapy brain pattern have spread. This seems to come up when you least expect it. Uh definitely a high risk situation. Uh And the high risk means we want to use medicines that uh well uh treat it and penetrate the brain. A lot of times user. I faster mind instead of blue mason as one of the partner drugs as far as pet scans. And uh they're mainly used in Seminole um a treatment uh if there's a residual mass which is ambiguous, pet scan may resolve that ambiguity about whether it's really persistent disease. But most seminar, most don't have large masses and most of the large masses will be a negative on pet after treatment. So it's only occasionally that that makes a big um impact. Here. We see a cat scan and that we see the right testis cancer landing zone in between the yard and the vena cava. That are marked with the and the V. And the red arrow shows that lift note. That's a normal life. No, but that's the position which is the landing zone for the right testes. The next scan here, uh we see just to the left of the aorta around that area there and I think there's an arrow on that and that's an abnormal left landing zone. Ah cancer in the para aortic lymph nodes. Uh The next image here, we can see that in the upper left. There was a couple sketchy notes there, but the patient had a normal beta HCG and AFP. About four months later. It was on observation and we see that note is getting bigger. It's not very big if that's all he ever had. Uh We might say, well let's just see what happens. It's it's not specific but actually as A. F. P. Was about 400 at that point. So that was the only disease that could be seen. But that shows uh a pattern that you might see on a surveillance the next night. Um So let's talk about some of the different findings. Um And there's really a lot of different things that might be seen uh in the pathology. There are also some non germ cell cancer. So everything is in the test is not a germ cell cancer. I really just talking about germ cell cancer is here. Um And some of those rare situations may require no treatment. We're having low malignant potential, for example, some lighting cell cancers. Other times a metastatic lighting cell cancer, which is which is rare. Uh those are very hard to treat. Uh the treatments we use here are not especially affect finally, the syrah market proteins that can also contribute to the typing. So, next slide Here we see that overall testes cancer seven or 8000 a year. Most of those germ cell cancers and two main categories Semin OMA and non Semin OMA. And uh a few of them will turn out to be uh these other rare situations, each which have a specialist treatment, although the majority of them could just be respect. Um looking at the non Semin Oma, we see uh five key types there and brian o yolk, sac, Korea, carcinoma and terra toma, which can be mature or immature and the seminar OMA, classic cars from a Hasidic or the two types that doesn't influence the treatment very much. But you may see that on a pathology report. Next slide here's a great pathology website with hundreds of images. Just picked a couple of them here for educational purposes. On the upper left, you see a Semi Noma. It's quite a distinctive appearance. Sometimes salmon almost take a long time to come back from pathology department. They can have a lot of different appearances and the differential may not be immediately obvious and then the right satisfied. There's four examples from the non Semin OMA category. Um And you can look at those who look at the at the website, the Saratoga in the lower right corner. That's the most interesting one. Terry thomas can look like any tissue. If it looks like tissue that's seen in an adult then it's called the mature to Arizona. If it looks like tissues which are normal tissues but are seen only uh in fetal development. And that's called an immature territo MMA. And then further a terra toma might have a somatic cancer growing within it. Um Which will need to be dealt with on a case by case basis. Down in the lower left there is an example of a lighting cell tumor that's a uh non germ cell cancer. Just to have an example. But hundreds, hundreds of pictures on that. Very useful website. Next slide please. Oh there should be a little a little tiny bricks on that wall cartoon there. Uh The germ cell cancer is, that's what I'm talking about here today. Germ cell cancer, the testes. And there's also a germ cell cancers in other parts of the body which were treated about the same way. Anything in the midline, the media steinem retro peritoneum brain. A few ovarian cancers are germ cell cancers as well. Although the more common situation is epithelial ovarian cancer. Um and then uh the test of cancers are not germ cell type. Not really talking about them today. They need to be addressed on a on with respect to their own pathology but they shouldn't be lumped in with the um the germ cell cancer is next slide. So let's talk about the market proteins. 3/4 of cancers will make some of these A. F. P. Beta HCG and LDH. And we'll talk about each of those in a minute. The point in time where these are evaluated on staging is after the or key ectomy. So you might have a primary tumor that's making some of these proteins that doesn't really influence the staging. Um But after after the testicles been removed, how low it goes or how high it goes at the influences the risk group as we'll see in a minute. Um The markers can be checked as the patients getting chemotherapy to give a very quick feedback that the cancer is responding. Um And just one exception of that during about the first cycle, there may be a surge of markers and we don't want to be distracted by that. That's just the cancer releasing at a higher rate than was expected. Um So if someone starts saying at 1000 and they go 2 to 3000 the first week, well the next week after that, it might be coming back down again nicely. But don't panic about that first week. So the first market beta HCG um of course this is famous from pregnancy tests. Men usually have undetectable levels, marijuana can cause some low level beta HCG. It would be unusual for that too cause of false diagnosis, but sometimes you're in surveillance. Um people really can be worried about every fluctuation of beta HCG and that may cause it, we see moderate elevations in some Semin Omagh's and non Semin Omagh's and Korea carcinoma. That's a subtype which can have extremely high levels. It clears from the body pretty quickly a half life of a day or two. So if on day one say it was 1000 then day three would expect it to be at 500 and day five down to 250 and Day seven by a week later, down to 1 25. So that should clear relatively quickly once you take away the source. Next slide, this is alpha feta protein. Everyone's got some alpha feta proteins circulating the liver makes a little bit, usually not enough to make anything be confused about the six or eight. That's typically the upper level of of normal on the testing. Uh There are some people physiologically who make some in the low teens. Uh We don't want to make them crazy to think they have testes cancer. Uh They will usually get a lot of a. F. P. Evaluations until we can establish that pattern As a general guideline. Uh if someone has an afb in a in a grey zone we wouldn't call them having a re occurrence until they crossed maybe 25. Um As more of a threshold as opposed to above normal limits. Um A couple other points about A FP seven Oma and tara toma don't make A F. P. So if someone thought to have a pure Seminole, more peer terra toma and a F. P is elevated, you have to suspect that it's actually a mixed germ cell cancer and Ronald Corey carcinoma can make some but yolk sac makes very high levels of a. F. P. Um The clearance, half life is six or seven days. So again if it started on day one at 1000 after a week it might be 500 another week to 50 another week, Which is 21 days, 125. So it takes a few weeks AFP is also used in a different cancer. Hepatitis alert cancer. Hepatic coma. I won't really talk about that, but it is the same as, say in the same protein. Next slide. Uh Finally LDH lactose the hydrogen is not specific to test his cancer. I would try to avoid using it in screening but um or for looking for a re occurrence but for differentiating intermediate and high risk patients. Uh This is useful. Um anybody with a large inflammatory situation might have an elevated LDH next line. Um So let's talk about risk stratification and staging first seven Oma and then on semin oMA next slide. So the histology from the or key ectomy matters a lot and we'll have that information usually is the first step um imaging evaluations uh definitely retro peritoneum and as I mentioned, sometimes the chest and uh so usually the chest and sometimes the brain. And then the TNM. S system which has the S for sierra marker, not just tumor node and mitosis metastasis. Next. Um So talk about seven oma. There's only two categories good and intermediate. And the only intermediate issue is if there's some non pulmonary visceral mets. So virtually all semin OMA can be wedged into the good risk group. And if it's intermediate, we actually don't escalate the treatment that much. But recognize that some of the more of them may have relapses. Uh in the reference group, about the 1995% of the good risk group, in about 80% of the intermediate group are cured. With the first line my treatment, the next one non seminar mothers, three tiers good, intermediate and high. Um Starting at the top, the high risk ones might have very high markers or visceral spread or media startled primary. Uh and then looking at the good risk only pulmonary metastasis and relatively low markers. Although beta HCG can be up to 5000 still not uh trigger high risk assessment. And then intermediate is anything that's not meeting either of those or a retro peritoneal primaries automatically. Intermediate unless there's some high risk features are. Next slide. That was the International Germ Cell, a consensus group. If you look at the american Joint Cancer Committee, they have one of these detailed TNM uh systems and you can definitely look up each patient here. I wouldn't need to go into a detail on that. I wouldn't even recommend to memorize it because we just want to check each person. Um So the plenty of references for that next slide, um turning to cancer treatment um and talk about the surgery and adjuvant strategies and chemotherapy strategies. Next slide, um to the first step is going to be the England or Key ectomy, although the fastest way in might be through the scrotum that doesn't really control this dramatic court. So the classic surgery is uh coming in from above. Um and it's a standard approach uh Usually an outpatient surgery surprisingly short, occasionally referred to after chemotherapy if the patient has a high risk and it seems like they need to get on with their medical therapy. Um The gun, it is a natural biologic sanctuary from chemotherapy, so we don't want to uh never treat it. Um But it doesn't always need to be treated first the next time. Um There's some special circumstances to consider a partial or key ectomy. Um Low suspicion masses, small tumors, especially if there might be Seminole MMA. Like an older patient. Here's a meta analysis. You can see a whole bunch of well selected patients, but only about 8% of them had local failure. Um and they were selected to be low risk. But again, 90% of those of those choices were good. And they were able to save part of the testes, save some testosterone production and often save fertility next line. Um So in this unusual situation, uh if the margins are good and the patient gets chemotherapy afterwards, uh and the patient understands that they might have a re operation. Uh that might uh be something that's worth doing to try and preserve some of that tissue. And that will be an individualized discussion. Next slide. Um So first we'll talk about agile and treatment. So supposed to patients had the reception and there's no visible treatment. And these are these are the best patients. So dominantly we're managing recurrence risk, not mortality. As long as we can expect that they will be in the system because we know the good risk patients are typically uh most of them will be curable whether they're treated immediately or later. Next slide here we see the some of the data for agile and treatment of semin oma. There's a noma graham which really just has two issues really. Test this invasion and size in this series here. The purple line for observation. Those were the lower risk patients and the high risk patients were treated with carbo platinum um agile and treatment you see they didn't even better than low risk patients and it's not an overall survival. All they all had disease specific survival. Um But this is a strategy um to improve progression free survival and use a lower intensity of chemotherapy. Um There's some special situations where someone might be on a a path to just be on observation but they really can't stand the risk. Maybe anxiety may be a risk of second test is cancer or something their social context or by her calcifications. Uh We'll look at that again with some of the newer data from the asthma. But the bottom line uh sometimes uh that that's a tipping point for adjuvant treatment. So this first seminar mom go to the next slide, please. Um Yeah next. And then here's here's a second series looking at the edge of treatment with Semin Oma. Either with the radiation or chemotherapy. This is a work of tim Oliver over a decade. And uh radiation seminar was very sensitive to radiation and we pull back in here um and radiation used for a long time. However, these are young men who have it. So a lot of interest in not using radiation. So this is a big trial and show that the carbo platon uh worked as well as radiation. It may be a little bit less second cancer uh next side. Um So here's what a carbon planning cycle looks like. One of those trials used a single dose. Most of the work that two doses, one where a single dose was used. They really used some really heroic doses because they would measure the area under the curve dose. Used to dose carbon platinum. Um and patients might be getting very high doses compared to other things and have some neutropenia. So pretty much the standard is uh two doses at that moderate a single agent schedule. Next slide. Um And then so there you can see a typical timeline. Either just go on observation and have chemotherapy which will do a deep dive on that in a minute or take a job and treatment. Next slide. Uh The non Semin Oma, the Sweden Norway Testes cancer group did a lot of work with this. The key factors there is whether the lymph of vascular invasion or not. Um And uh on the left panel there we see the patients with no limp of vascular invasion and the lower line, those were patients who got observation and the upper line. That is the one that got one cycle of chemotherapy on the right side, patients with lymph vascular evasion. The top line they had two cycles at 100%. Uh The next line 96 a half percent with one cycle and a few patients non randomized study. A few patients had. Um The just observation, they had the only 60% survival. So as far as developing a strategy, we can see that the more cycles you give and you can go ahead and click to put the arrows up on the screen there. Um If you give everybody uh cycle of treatment and uh 22 of them relapse. That's it spends 106 cycles if you give nobody agile and treatment and 14 of them relapse, that's 42. So the good risk patients on average you wouldn't treat them. But there might be special circumstances where they would take treatment and then uh go ahead and click to the other arrows will come up on the patients with the lymph of vascular invasion. um if everyone got zero then 126 cycles or everybody got 112 cycles with most of the patients getting cured, everybody got to. There were no salvage cycles given, but that was 200 cycles. So either 01 that seems to be the key recommendation for edge of and treatment next side. Next slide. So here's a typical timeline there and there's a chemotherapy block which we'll talk about again in a minute. Next slide, the patient's gonna have to make that decision. But fortunately it's just a chemotherapy exposure kind of decision as opposed to uh usually uh life threatening cancer risk type of decision. And uh it will be an individualized question. The next slide. Um How about patients who are not cured with the r key ectomy and we're not getting a job in treatment. Uh So classic chemotherapies remain the main way these are treated and uh I'll click through some of these. Um This will always be at a at a medical oncologist and you're certainly can reach out to me or other community medical oncologists um to discuss that next line. Um So the key drugs bloom isotope besides his platon, abbreviated B. E. P. Uh They have some uh some side effects. Lung fibrosis can happen with liam Neeson. Usually that can be treated with dexter methadone or other steroids and get that to settle down. An unusual rash. I think it's hard to see. They're kind of a, it looks like a flashlight er mitosis where everywhere the scratch you get a hyper pigmented area. The top aside and says flat contributed neutropenia. And uh this plant has its own problems with neuropathy and and ah hearing loss is risks and therefore empathy injuring the kidneys. That can certainly happen but that's solved by giving a lot of I. V. Fluids. Next slide please. Um And then here's a couple of the other medications just to get the names out there is using the acronym acronym has been blasting paclitaxel. Taxol seems to be a letter T. F. Awesome uh carbo platinum, sally platinum gym side of being. That's most of the drugs which are used next line. Um Here's some of the acronyms BP. If you only remember one thing BP will take you pretty far. E. P. Dropped the B. Uh T. I. P. Uh substitute those other tax on a fast Might in and V. I. P. The old name for a top aside vespas, it is used. VIP is just an appealing combination and then here's some other ones which are used in other circumstances. The next slide, here's a couple of diagrams of what some of those situations may look like. There's the B. P. In the ep next slide and there's either four Bps, like an intermediate might get or three Bps and four mps. Next slide. Um and then uh if someone has a problem with taking the CISplatin, chemotherapy and otherwise good risk disease. Semin almost for example, there are platinum sensitive and Carbo Platt might be substituted. There there's an older patient. We might drop some of the doses because of neutropenia risks and still expect good results on next side. Um Now for high risk patients, usually V. I. P. Key issue is used to foster mind which can penetrate the cNS and not injure the lungs. If someone is so sick that they can't get started, you give them a pre cycle with a couple doses. Don't count it against their overall ah cycles but that'll get them started, get the markers down, maybe get some pain relief, get things to shrink and then after they get out of ICU, they can get started and this begin with growth factor. Next slide. Um And here's some salvage options. T. I. P. The Taxol in four days. About passports is platinum and GOP Gem side of being oxalate, oxalic platon and paclitaxel also sometimes just jumps out jump side of being a salad platter without the paclitaxel adding the paclitaxel seems to improve the durability, but there's not a lot of randomized data on that. Those are just some retrospective european series. Next slide. Um and then high dose chemotherapy with stem cell rescue. This has been around for 20 years. It has not quite pushed the conventional chemotherapy out. But some patients uh if they have if they have chemotherapy responsive disease will get two cycles of fossil mind and Taxol collect the stem cells and then tandem transplants with the top aside and carbo plateau. The key thing with the tandem transplants is that the second one really come on the heels of the first one so that the cancer does not I recover during that first phase there and some patients can get cured with this in salvage setting. Next slide. Oh yeah. So we have a question. We have a question. What are the data for using VIP versus beep in first line? High risk. Yeah. So there have been several trials looking at the V. I. P versus B. E. P. And they're kind of unimpressive. The VIP a little bit better but not significantly better. Um If you then go to those trial and trials and kind of weed out the intermediate risk patients and concentrate just on the high risk patients, then we see that there's there's better survival but it's not a single trial. Several trials been put together. Sometimes the comparison was a T. Beppe. Taxol B. E. P. Another issue as we'll see in a minute for primary media style disease which is always high risk. The potential were injuring the lungs is a big issue. And using the I pacified displaces the blue mason and then finally for uh cNS penetration. Um The conventional chemotherapy is may be excluded by the blood brain barrier but there are some which penetrate and I fasten it is one of those so uh kind of a multifactorial decision. Not a single clean randomized study but tips it in favor of that impatient VIP treatment site. Next line please. And here's some timeline diagrams and we can just I look at them for minutes of BP or EP for a good risk non Semin OMA. And if there's some disease president they might get a surgery afterwards. The next slide. Um for a Semi Noma which still has metastatic disease. They make it the chemotherapy. And then surgery sometimes depending on whether there's a pet positive evaluation. Next slide um For intermediate risk. Uh We see that E. P. Has dropped off of the list and it's going to be B. E. P. Times three Bp times four. And especially for retro peritoneal primary or if there is substantial disease starting out they'll have a commitment to the R. P. L. And D. Surgery. Got your partner lymph node dissection are alternatively um if it's if there's a persisting disease then they'll have the next line um And then for high risk disease we can see here the V. I. P. Um And then more often than not they'll have the retro peritoneal infinite dissection or possibly a tip salvage if the post chemotherapy reception shows some viable cancer. Some of the time will consider uh adding a different cycles of T. I. P. Afterwards. Uh This is definitely not standardized and often it'll be a wait and see approach. Also. Next slide, let's talk about some of these post chemotherapy surgeries. Next slide the retro apparently a lymph node dissection is a template ID surgery. So as opposed to going in to look to find something um Just the whole area is carefully respected just leaving the blood vessels intact. And then it's up to the pathologist to identify nodes or metastasized in that landing zone volume and there's a left and right a diagram there next. Um And this should definitely be in the high experienced surgeon setting because it's not a very frequent operation. A post chemotherapy Semin OMA is generally more of a problem. Uh surprisingly, I mean it's not done as much. The disease is not as dangerous but there can be more fibrosis non Semin oma. Sometimes this can be done pre chemotherapies and agile and treatment um But otherwise uh residual masses. Uh You just have to know what's there and respected if there looks like there's something that may be a persisting disease. Next slide. Um So what are mixed germ cell cancers in the growing territo MMA syndrome? This can be very disconcerting. I'll show you there's a diagram on the next slide here and you might have a kind of average situation where there's a germ cell cancer and it's growing, give some chemotherapy and it resolves. On the other hand, you might have a terra toma on the next slide, which it just grows on its own pace. It's not sensitive to chemotherapy and at some point is going to need a surgery to get cured next slide. If both situations are happening, the cumulative amount of cancer might be ah going up initially and then seemed to be improving. But then there's some breakthrough disease and if you click one time there, you can see the disconnect between part of the disease being cleared and part of it. Not. The key thing to remember is that the patients should just finish out the chemotherapy be done with the non terrorist home apart, recover from that and then move on to a curative territory treatment. Sometimes it seems more urgent because of the disappointment, but other times it just, it can be done on a routine basis. Sometimes it may not occur for years after the chemotherapy. Um or there may be some ambiguous notes where this develop next line. So finally, uh to the intermediate high risk cases for retro peritoneal primary. It's the same surgery. But the commitment, the surgery will be there beforehand for media startled primary. Almost always a surgery should be planned for that next slide. The biggest experiences of this is ken kessler and at the University of Indiana and we see also there Dr Einhorn uh the godfather of B. E. P. And testes cancer, chemotherapy Anyway, over 20 years they accumulated 255 of these and we can see that when the specimen comes out, there is no live cancer. That's the blue line, that's the best group. If there's terra toma present, that's an intermediate group. But if there is residual non necrotic cancer, that's a much higher risk situation. This is also a situation where blue mice and exposure was identified as being adverse. Next slide, here's a typical timeline. They're just substituting in either are, sorry, there are retrofitted lymph node dissection there or the next image. Um Next slide or a media's donald reception next line. Um There is also a rare disease. Media's donald semin oma. That's actually pretty straightforward for treatment. Usually don't need any receptions the next slide. Um We have a couple of new reports. There's not a lot of, first of all, the oncology meetings were pretty abbreviated this year, but besides that actually not a lot of uh activity or testes cancer right now this year. So there's three reports we can look at um notably missing, you know, therapy and next generation sequencing. They just haven't had an impact yet on this disease, not for lack of trying, but uh no no particular trials on that next slide. Um So here's one looking at HIV positive patients versus a comparison group they did about as well. Uh nothing special there. So uh it's good, good work, but no practice change for that next slide. Um here's a drug which is called the theme is be strong. Uh So they've named their antibody be strong um ab and then the Heimerich version is be strong. Sin mob uh attached it to a toxin which is M. M. A. E. That's president, a couple of marketed drugs which are down there at the bottom there anyway that's a preclinical plan but uh very appealing idea to have an antibody that Goes to that imagine T. R. A. 160 brings a toxin. There will be hopeful that develops into something. Next slide from the ehsmoh european society meeting a couple of weeks ago. Um They did a deep dive. Looking at this issue of second testes, cancers and the chemotherapy exposure really impacted a lot and the age impacted a lot. So the younger patients, they're the ones where a second test is cancer seemed more often. And on the right panel there you see the more chemotherapy exposure there is, the less second test is cancer happens for a population. So there's a little bit more quantitative uh Look at that. Uh Second test is cancer risk which we know is out there next slide. Um So what about chemotherapy? And uh this uh I put some slides in here. There may be a little more detailed than someone who's not getting chemotherapy needs to know. Um But we can go ahead and look at some of these things and then some longer term issues there. So nausea management. Uh Most patients don't have problems with nausea because we have so many anti nausea drugs. Just a key thing to get some feedback from the patient as they go along that they don't need to suffer the next slide uh neuropathy. And tonight is from cis platon there's gonna be very hard to manage happily. Young people don't have that much neuropathy but if there are some pre existing problems or uh tonight is which is a former neuropathy, some of those may cause long term issues. Next slide infection risks, uh neutropenia, there's gonna be some significant neutropenia. Not a lot of infection seen, but we want the patients to be very conscientious to come in if there's something going on port lines and and pick lines. Those are also potential sites for infection, although not seen very often as far as covid. Um The patients have to come to infusions that are quite a bit that can be a source of anxiety. Um And also other people in their home environment. We're concerned about exposing the patient during low, with low uh white count times uh seasonal flu vaccine. Uh It should be theoretically less effective, but as soon as that's over, they should get vaccinated next slide. As far as work decisions don't have to be individualized. Uh Some people, a lot more people not working at home and they can probably keep doing that. Some jobs, they just can't work where they're doing chemotherapy. And some jobs, there's a lot of exposure to the public. So those are issues the next side um and wrapping up now with recovery and survivorship next time. Um So with uh one testicle out, there's going to be risk of things that testicles make being too low low testosterone symptoms, libido, muscle mass, hot flashes, depression. It's usually obvious if a patient is having this. I don't always check everyone's testosterone longitudinal, but a couple of valuations may give the patients some sense of control on that. If it is low testosterone supplementation is going to impair sperm angiogenesis. And um so uh they may not want to supplement with that. Uh Those with one testis. Not that often. Those with zero test is of course there's no fertility to sacrifice. And most of those patients will be on testosterone next slide as far as surveillance and testing most of the occurrences the first two or three years. You may have seen that on the on the curves of of some of those re occurrences. Um So that's where most of the surveillance. Is there not any randomized trials looking at different surveillance strategies? Although things like the N. C. C. N. Have a lot of tables and and guidelines basically a decelerating frequency of scans. Uh It can look that up on an individualized basis, recognizing that it's mostly about maintaining control. We don't want the patient to wander off if there is a rare occurrence definitely. We want to have them in early for a curative intent approach. Um and then after a prior testes cancer over the next 15-20 years at risk of a second test as cancer, we certainly would want to identify that an early point. Sometimes for a partial were key ectomy. The patients have a increased conscious awareness of this. Some patients will even get ultrasounds on a regular basis. Um, so that's uh, survivorship issue. We can't change their their history of treatment, cardiovascular risk factors and other cancers appear to be uh increased in the testes cancer survivors. Of course, this couldn't be identified until their work. Testes cancer survivors. These are actually very hard studies to do. Looking at 20 and 30 years out, we have to figure out who's a fair matching group and the things like roommates or uh, classmates or siblings. Those are all things that have been proposed. But if you look 2030 years down the road, uh, the comparison group may have self edited with things like jail and, and non cancer mortality, which distorted the, the assessment. But anyway, uh, obesity hypertension, second abdominal cancers. There is some excess risk of those, although no specific guidelines. And what did you to address as far as advocacy? Many patients like to tell their stories. Um, and it's very exciting to see them do well. Some of you may have seen, uh, the wrecks, culpepper scores, uh, touchdown there. He was treated here in Tampa that was on uh, Syracuse game and Lance Armstrong. You can be a fan or not a fan, but he definitely did a good job with the test, his cancer. And that's his book. It's not about the bike. So, some of your book readers may like that. Certainly pure interactions are are a great way to raise consciousness for, for really any age group of young men particularly. Yeah, we have a question. Speaking of sports, can trauma be a risk factor? Um Yeah, so it's been hard to identify what the risk factor is. There's some, you know, genetic things, but trauma uh, couldn't really be identified because when they survey men who had tested cancer, they had trauma. Everybody said yes. Um and then certainly men who didn't have testes cancer, and everybody also said yes. So, um we really can't find a specific group that that had a trauma and then had testes cancer afterwards. Um So it doesn't look like it's an obvious uh that um so just uh to wrap up here and you can certainly send some other questions in uh to me separately afterwards. I'll be here, we have click and we'll get the I think there's a 1 1 click ahead. There there we go. Uh Oh it's the most common cancer and young men delays are common. So I'd like to uh maintain a conscious awareness of this uh staging dominantly retro peritoneum but also the chest and the market proteins, treatments with uh a couple of key surgeries on the on the gonad, on the retro peritoneum. Uh Sometimes the media steinem and chemotherapy. Like I said, if you just remember B. E. P. Uh that's that's the key one there. Um high risk cases, really early referral, careful, multidisciplinary management. They may need thoracic surgery as well. Um And some internet resources. Probably my favorite is the University of indiana, T. C. R. C. Testes Cancer Resource Center, the N. C. C N. Cancer dot gov. These are some other resources as well. I think my phone numbers are on the last one more click there, one more outside uh the illustrations on the transition slides. Uh That's Rachel Fishman, uh and I know her that's my daughter. But otherwise, yeah, give me a call if you have any questions on testis cancer or refer patient. Um here at the Tampa General Medical Group. Good. So uh Gretchen we have another question and I encourage you to use the chat box while dr Fishman is answering this one. If you have any more questions, either chat or Q. And a type through and we can answer for you. Now in the meantime though, that's not the question that just came through. When should a patient get an ultrasound? Yeah. So the first few slides that show a couple different ultrasounds and you know, you can imagine an ultrasound, you could see a developing fetus, but there is no level of detail on a testicle. You couldn't see with an ultrasound. And really a lot of information for a very non invasive type of test. Um And additionally ultrasound would make the diagnosis on a lot of the benign conditions as well, like a traumatic steel or America's steel. Um So I would advocate that um instead of just palpitation or speculation, just move as needed, then ab urology referral, but very good information from that. Good. So anyway, thanks a lot to Gretchen. You can wrap up for this and look forward to hearing from you. Has any issues come up? Thanks, thank you everybody for joining us. I'll be emailing you with CMI Credit information within the next couple of days. If you have any questions for referrals or accreditation, you can let Dr Fishman or myself know we are here to help. Thank you so much for coming. Have a great evening. Published June 16, 2021 Created by
