Testicular Cancer

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

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P. Albers (Chair), W. Albrecht, F. Algaba, C. Bokemeyer, G. Cohn-Cedermark, K. Fizazi, A. Horwich, M.P. Laguna, N. Nicolai, J. Oldenburg

1.INTRODUCTION

1.1.Aim and objectives

The aim of these guidelines is to present the current evidence for the diagnosis and treatment of patients with cancer of the testis. Testicular cancer represents 5% of urological tumours affecting mostly younger males. This document addresses germ-cell tumours and sex cord/gonadal stromal tumours.

It must be emphasised that clinical guidelines present the best evidence available to the experts but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account.

1.2.Panel composition

The EAU Guidelines Panel on Testicular Cancer consists of a multidisciplinary group of clinicians including, urologists, a pathologist, oncologists and radiotherapists. Members of this panel have been selected, based on their expertise, to represent the professionals treating patients suspected of harbouring testis cancer. All experts involved in the production of this document have submitted potential conflict of interest statements which can be viewed on the EAU website: http://www.uroweb.org/guideline/testicular-cancer/.

1.3.Available publications

A quick reference document, the Pocket guidelines, is available, both in print and in a number of versions for mobile devices. These are abridged versions which may require consultation together with the full text version. Several scientific publications are available as are a number of translations of all versions of the EAU Testicular Cancer Guidelines. All documents can be viewed on the EAU website: http://www.uroweb.org/guideline/testicular-cancer/.

1.4.Publication history and summary of changes

1.4.1.Publication history

The European Association of Urology (EAU) published the first guidelines on Testicular Cancer in 2001. Since 2008, the Testicular Cancer Guidelines contain a separate chapter on testicular stromal tumours. This document presents a limited update of the 2015 publication. Review papers have been published in the society’s scientific journal European Urology, the latest version dating to 2015 [1].

1.4.2.Summary of changes

For the 2016 Testicular Cancer Guidelines, new and relevant evidence has been identified, collated and appraised through a structured assessment of the literature. For this 2016 print, updates include:

  • A new flowchart (Figure 2) on Treatment options in patients with seminoma clinical state IIA and IIB.
  • A new section on Quality of life and long-term toxicities after cure for testicular cancer (Section 8.6).

Conclusions and recommendations have been rephrased and added to throughout the current document. Changed or new conclusions and recommendations can be found in sections:

5.9 Guideline for the Diagnosis and staging of testicular cancer

Recommendation

GR

Offer biopsy of the contralateral testis and discuss its consequences with patients at high risk for contralateral TIN.

A

TIN=testicular intraepithelial neoplasia.

7.2.2 Guideline for the treatment of stage I seminoma

Recommendation

GR

If carboplatin-based adjuvant chemotherapy is considered, offer one course at AUC 7

A

AUC=area under curve.

7.5.6 Guideline for the treatment of metastatic germ cell tumours

Recommendation

LE

GR

In seminoma stage CS IIA/B, offer chemotherapy (3 x BEP or 4 x EP, in good prognosis) as an alternative to radiotherapy.

1

A

EP=etoposide, cisplatin; BEP=cisplatin, etoposide, and bleomycin.

7.3.6 Guidelines for the treatment of NSGCT stage I

CS1B (pT2-pT4): high risk

LE

GR

Recommend primary chemotherapy with one course of BEP.

2a

A*

Inform patients about the advantages and disadvantages of two courses of BEP.

2a

A*

BEP=cisplatin, etoposide, and bleomycin.

* Upgraded following panel consensus

Table 8.1: Recommended minimum follow-up schedule in a surveillance policy: stage I non-seminoma

Procedure

Year

1

2

3

4-5

Physical examination

4 times

4 times

4 times

Once/year

Tumour markers

4 times

4 times

4 times

Once/year

Plain radiography chest

Twice

Twice

Twice

Twice

Abdominopelvic CT

Twice at 3 and 12 months

Once at 24 months

Once at 36 months

CT=computed tomography.

Table 8.2: Recommended minimum follow-up schedule after retroperitoneal lymphadenectomy or adjuvant chemotherapy: stage I non-seminoma

Procedure

Year

1

2

3

4-5

6-10

Physical examination

4 times

4 times

4 times

Once/year

Once/year

Tumour markers

4 times

4 times

4 times

Once/year

Once/year

Plain radiography chest

Twice

Twice

Twice

Abdominopelvic CT

Once

Once

Once

Once/year

CT=computed tomography.

Table 8.3: Recommended minimum follow-up schedule for post-orchiectomy surveillance, radiotherapy or chemotherapy: stage I seminoma

Procedure

Year

1

2

3-5

Physical examination

3 times

3 times

Once/year

Tumour markers

3 times

3 times

Once/year

Plain radiography chest

Twice

Twice

Abdominopelvic CT

Twice

Twice

at 36 and 60 months

CT=computed tomography.

Table 8.4: Recommended minimum follow-up schedule in metastatic NSGCT and seminoma

Procedure

Year

1

2

3-5

Thereafter

Physical examination

4 times

4 times

Twice/year

Once/year

Tumour markers

4 times

4 times

Twice/year

Once/year

Plain radiography chest

4 times

4 times

Twice/year

Once/year

Abdominopelvic CT*

Twice

Twice

Once/year

As indicated

Chest CT†‡

Once/year

Once/year

Once/year

As indicated

Brain CT

Once/year

Once/year

Once/year

As indicated

CT=computed tomography.

* An abdominal CT must be performed at least annually if teratoma is found in the retroperitoneum.

If the post-chemotherapy evaluation in a seminoma patient shows any mass > 3 cm, the appropriate CT should be repeated 2 and 4 months later to ensure that the mass is continuing to regress. If available, FDG-PET/CT can be performed.

A chest CT is indicated if abnormality is detected on a plain radiography chest and after pulmonary resection.

In patients with headaches, focal neurological findings, or any central nervous system symptoms.

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