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. Guidelines are not mandates and do not purport to be a legal standard of care.

1.2.Panel composition

The European Association of Urology (EAU) Guidelines Panel on Testicular Cancer consists of a multidisciplinary group of clinicians including, urologists, oncologists, radiotherapists and a pathologist. Members of this panel have been selected, based on their expertise, to represent the professionals treating patients suspected of having 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 (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 2016 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 2017 Testicular Cancer Guidelines, new references have been added throughout the 2017 Testicular Cancer Guidelines document. Key changes in this publication include:

Section 5.7 - Germ cell tumours histological markers. This is a new table.

  • Table 7.2 - An alternative schedule for salvage chemotherapy has been included.
  • Chapter 8 - Section 8.1 Rationale for follow up, has been completely replaced, including three new tables, based on the findings of an ESMO Testis Cancer Consensus Committee.

Recommendations were changed in the following sections:

5.9 Guidelines for the diagnosis and staging of testicular cancer

Recommendations

GR

Advise patients with a familiar history of testis cancer, as well as their family members, to perform regular testicular self-examination.

A

7.2.2.6 Risk-adapted treatment for clinical stage 1 based on vascular invasion

Stage 1B (pT2-pT4): high risk

GR

Offer surveillance to patients not willing to undergo adjuvant chemotherapy.

A*

Offer nerve-sparing RPLND to highly selected patients only; those with contraindication to adjuvant chemotherapy and unwilling to accept surveillance.

A*

*Upgraded following panel consensus.

7.4.6 Guidelines for the treatment of metastatic germ cell tumours

Recommendations

LE

GR

Initially offer radiotherapy for seminoma CS IIA.

When necessary, use chemotherapy as a salvage treatment with the same schedule as for the corresponding prognostic groups of NSGCT.

1a

A

Initially offer chemotherapy in seminoma stage CS IIB (BEP x 3 or etoposide, cisplatin (EP) x 4, in good prognosis) as an alternative to radiotherapy.

1a

A

Table 8.1: Recommended minimal follow-up for seminoma stage I on active surveillance or after
adjuvant treatment (carboplatin or radiotherapy)

Modality

Year 1

Year 2

Year 3

Years 4 & 5

After 5 years

Tumour markers

± doctor visit

2 times

2 times

2 times

once

Further management according to survivorship care plan

Chest X-ray

-

-

-

-

Abdominopelvic computed tomography/magnetic resonance imaging

2 times

2 times

Once at 36 months

Once at 60 months

Table 8.2: Recommended minimal follow-up for non-seminoma stage I on active surveillance

Modality

Year 1

Year 2

Year 3

Years 4 & 5

After 5 years

Tumour markers

± doctor visit

4 times**

4 times

2 times

1-2 times

Further management according to survivorship care plan

Chest X-ray

2 times

2 times

Once, in case of LVI+

At 60 months if LVI+

Abdominopelvic computed tomography/magnetic resonance imaging

2 times

At 24 months***

Once at 36 months*

Once at 60 months*

* Recommended by 50% of consensus group members.

**In case of high risk (LVI+) a minority of consensus group members recommended six times.

***In case of high risk (LVI+) a majority of consensus group members recommended an additional CT at
eighteen months.

Table 8.3: Recommended minimal follow up after adjuvant treatment or complete remission for
advanced disease (excluded: poor prognosis and no remission)

Modality

Year 1

Year 2

Year 3

Years 4 & 5

After 5 years

Tumour markers ± doctor visit

4 times

4 times

2 times

2 times

Further management according to survivorship care plan**

Chest X-ray

1-2 times

Once

Once

Once

Abdominopelvic computed tomography/magnetic resonance imaging

1-2 times

At 24 months

Once at 36 months

Once at 60 months

Thorax CT

*

*

*

*

*Same time points as abdomino-pelvic CT/MRI in case of pulmonary metastases at diagnosis.

**In case of teratoma in resected residual disease: patient should remain with uro-oncologist.

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