Testicular Cancer

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

2019

For the Germ Cell Tumour section, new and relevant evidence has been identified, collated and appraised through a structured assessment of the literature. The search was limited to studies representing high levels of evidence (i.e. systematic reviews with meta-analysis, randomised controlled trials (RCTs), and prospective non-randomised comparative studies) published in the English language. The search was restricted to articles published between November 8th 2017 and June 13th 2018. Databases covered by the search included Pubmed, Ovid, EMBASE and the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. After deduplication, a total of 1,230 unique records were identified, retrieved and screened for relevance. Thirty new papers have been included in the 2019 print.

For testicular stromal tumours additional literature has been added. Two scoping searches covering the time frame between Jan 1st, 2014 and Aug 26th, 2018 were performed. After deduplication, a total of 159 unique records were identified, retrieved and screened for relevance. Conference abstracts, editorials, letter to the editor and case reports were excluded from the searches.

Aside from the new references identified and added to the text and detailed above,  key changes in this publication include:

  • Additional remarks on pathology examination and description have been added to the text for the 2019 print. This relates, in particular, to the definition and morphological description of Rete Testis Invasion and vascular invasion;
  • Citations relating to a number of low quality papers (SEER database on stromal tumors incidence and retrospective biased FDG-PETscan) have been removed  from the text. However, a decision has been made to include some small phase II studies in the relevant text section on second relapse since there are few publications addressing this rare and desperate clinical scenario;
  • A number of minor semantic modifications have been corrected in the text and the tables for 2019.

2018

For the 2018 Testicular Cancer Guidelines, new references have been added throughout the document. Key changes in this publication include:

  • Section 6.1 – Risk factors for metastatic relapse in clinical stage I was updated by means of a systematic review.

 

7.2.1.5 Guidelines for the treatment of stage I seminoma

Recommendation Strength rating
Fully inform the patient about all available management options, including surveillance or adjuvant chemotherapy after orchiectomy, as well as treatment-specific recurrence rates and acute and long-term side effects. Strong

 

 

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

Recommendation Strength rating
Stage 1B (pT2-pT4): high risk
Offer primary chemotherapy with one course of BEP, or surveillance. Strong

BEP = bleomycin, etoposide and cisplatin.

 

7.4.6 Guidelines for the treatment of metastatic germ cell tumours

Recommendations Strength rating
In metastatic NSGCT with a poor prognosis, treat with one cycle of BEP, or PEI in case of poor lung function, followed by tumour marker assessment after three weeks. In case of a favourable marker decline, continue BEP (or PEI) up to a total of four cycles. In case of an unfavourable decline, initiate chemotherapy intensification. Strong

 

In CS IIA seminoma, offer radiotherapy or chemotherapy and inform the patient of possible undesirable long-term side effects of both management options. Strong

 

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

 

BEP = bleomycin, etoposide and cisplatin; PEI = cisplatin, etoposide and ifosfamide.

2017

New relevant references have been identified through a structured assessment of the literature and

incorporated in the various chapters of the 2017 Testicular Cancer Guidelines.

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

Recommendation 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 36

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.

2016

No significant new information has been included for the 2016 print. This is the current version of the EAU Testicular Cancer Guidelines.

2015

The literature in the entire document has been assessed and updated, whenever relevant.

Key changes for this 2015 print:

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

Conclusions and recommendations have been rephrased and added to throughout the current document. The sections where changes were made (additional information was added or a change in the grade of recommendation occurred) can be found below:

 

5.9           Guidelines for the Diagnosis and staging of testicular cancer 

GR
Biopsy of the contralateral testis should be offered (and its consequences discussed) to patients at high risk for contralateral TIN. A

TIN = testicular intraepithelial neoplasia.

 

7.3.6        Guidelines for the treatment of NSGCT stage I

CS1B (pT2-pT4): high risk LE GR
Primary chemotherapy with one course of BEP is recommended. 2a A*
Patients should be informed about the advantages and disadvantages of two courses of BEP.

BEP = cisplatin, etoposide, and bleomycin.

 

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 in year 2 (at 24 months)
once in year 3 (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.

2011

  • The entire text was revisited and changes have been made throughout but in particular in the treatment of CS1
  • Chapter 7 (Treatment of metastatic germ cell tumours)
  • Chapter 8 (Follow-up)