Testicular Cancer Guidelines

Updated: Sep 11, 2019
  • Author: Kush Sachdeva, MD; Chief Editor: E Jason Abel, MD  more...
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Guidelines

Guidelines Summary

The following organizations have released guidelines on the diagnosis, staging and treatment of testicular cancer:

  • National Comprehensive Cancer Network (NCCN) [15]
  • European Association of Urology (EAU) [32]
  • European Society for Medical Oncology (ESMO) [33, 34]
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Diagnosis and Staging

All guidelines concur with the following diagnosis and staging recommendations [15, 33, 32, 34] :

  • Sperm banking should be discussed with all men before embarking on treatment for testicular cancer.
  • Testicular ultrasonography should be performed on all patients in whom testicular cancer is suspected.
  • Biopsy of the contralateral testis should be performed in patients with ultasound findings of intratesticular mass suggestive for testicular cancer, cryptorchid testis, marked atropy or any suspicious mass
  • Orchiectomy should be performed and the testis should undergo pathological examination in order to confirm the diagnosis and to define the local extension (pT category).
  • In the rare cases of a patient presenting with rapidly increasing beta-hCG or AFP and symptoms of extensive metastasis, chemotherapy can be started before a biopsy diagnosis or orchiectomy.
  • For staging and prognostic purposes, serum determination of tumor markers (ie, alpha-fetoprotein, human chorionic gonadotrophin, lactate dehydrogenase) should be performed before orchiectomy, 5-7 days after orchiectomy, and until normalized. Staging is based on marker levels at the time that the patient starts potorchiectomy therapy.
  • The state of retroperitoneal, mediastinal, and supraclavicular nodes, as well as the viscera, should be assessed in testicular cancer.

Patients and family members with a familial history of testicular cancer should be advised to perform regular testicular self-examination. [32]

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Recommendations for treatment of seminoma

Stage I

All guidelines are in general agreement with the following treatment recommendations for stage I seminoma [15, 32, 33]

  • Patients should be fully informed about all available management options. This should include surveillance or adjuvant chemotherapy after orchiectomy, treatment-specific recurrence rates, and short- and long-term adverse effects.
  • Surveillance: NCCN and ESMO preferred treatment for for pT1-pT3 tumors [15, 33] , while EAU recommends if there are facilities available and the patient is compliant. [32]
  • Carboplatin chemotherapy: EAU and ESMO recommend one cycle at area under the curve (AUC) 7 [33, 32] ; NCCN recommends 1 or 2 cycles. [15]
  • Radiotherapy (RT): NCCN and ESMO recommend 20 Gy/10 fractions [15, 33] ; EAU recommends against RT as adjuvant treatment. [32]

EAU also recommends against adjuvant treatment for patients at very low risk (ie, no risk factors). [32]

Stage II

All guidelines agree that patients with clinical stage IIA seminoma should be offered radiotherapy or chemotherapy; they should also be informed about the possible long-term adverse effects of both management options. [15, 32, 33]

For clinical stage IIB, primary chemotherapy with BEP x 3 or etoposide/cisplatin (EP) x 4 is preferred by all guidelines. [15, 33, 32]  NCCN also recommends RT in slect non-bulky (≤3cm) cases at a dose of 36Gy. [15]

For good risk clinical stage IIC or III, NCCN gives a category 1 recommendation for chemotherapy with either BEP x 3 or EP x 4; for intermediate risk, the category 1 recommendation is BEP x 4.  Esposide/ifosfamide/cisplatin (VIP) x4 is an alternative regimen. [15]  ESMO guidelines are in agreeement with these recommendations. [33]

According to EAU guidelines, patients with seminoma at stage IIC and higher should be treated with primary chemotherapy according to the same principles used for NSGCTs (see below). [32]

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Recommendations for surveillance of seminoma

In patients with clinical stage I seminoma, the National Comprehensive Cancer Network (NCCN) recommends surveillance with history and physical examination (H&P) and abdominal and pelvic computed tomography (CT). The NCCN guidelines advise that follow-up for seminoma should be modified for the individual patient and may be extended beyond 5 years. [15]

Serum tumor marker assays are optional. Testicular ultrasound should be performed in patients with an equivocal exam. Chest x-rays should be performed as clinically indicated, with chest CT considered in symptomatic patients.

The NCCN surveillance schedule for clinical stage I seminoma patients treated with orchiectomy only is as follows:

  • Year 1 - H&P every 3-6 mo; abdominal/pelvic CT at 3, 6, and 12 mo
  • Years 2-3 - H&P and abdominal/pelvic CT every 6-12 mo
  • Years 4-5 - H&P annually; abdominal/pelvic CT every 12-24 mo

The NCCN surveillance schedule for clinical stage I seminoma patients treated with adjuvant chemotherapy or radiation therapy is as follows:

  • Years 1-2 - H&P every 6-12 mo; abdominal/pelvic CT annually
  • Year 3 - H&P and abdominal/pelvic CT annually
  • Years 4-5 - H&P annually

In patients with clinical stage IIA and non-bulky stage IIB seminomas, the NCCN recommendations for surveillance are as follows:

  • H&P
  • Abdominal and pelvic CT
  • Chest x-ray, with chest CT preferred in patients with thoracic symptoms
  • Serum tumor marker assays are optional
  • Testicular ultrasound should be performed in patients with an equivocal exam

In clinical stage IIA and non-bulky stage IIB seminoma, the NCCN surveillance schedule after radiotherapy or chemotherapy is as follows:

  • Year 1 - H&P every 3 mo; abdominal/pelvic CT at mo and then 6-12 mo; chest x-ray every 6 mo
  • Year 2 - H&P every 6 mo, abdominal/pelvic CT annually, chest x-ray every 6 mo
  • Year 3 - H&P every 6 mo, abdominal/pelvic CT annually
  • Years 4-5 - H&P every 6 mo, abdominal/pelvic CT as clinically indicated

In patients with bulky clinical stage IIB, IIC and stage III seminomas, the NCCN surveillance post-chemotherapy with no residual mass or residual mass < 3 cm and normal tumor marker recommend abdominal and pelvic CT scan with contrast at 3-6 months, then as clinically indicated. PET/CT scan as clinically indicated. The surveillance schedule is as follows:

  • Year 1 - H&P, tumor markers, and chest x-ray every 2 mo
  • Year 2 - H&P, tumor markers, and chest x-ray every 3 mo
  • Years 3-4 - H&P and tumor markers every 6 mo and chest x-ray annually
  • Year 5 - H&P, tumor markers, and chest x-ray annually
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Recommendations for treatment of nonseminoma

Stage I 

For stage I nonseminomatous germ cell tumors (NSGCTs), the guidelines are in agreement that patients should be informed about all adjuvant treatment options after orchiectomy (ie, surveillance, adjuvant chemotherapy, retroperitoneal lymph node dissection [RPLND]). Information should include treatment-specific recurrence rates and short- and long-term adverse effects. [15, 33, 32]

Stage I without risk factors

For the treatment of stage 1 NSGCTs with no risk factors (pT1), the guidelines recommend surveillance as the preferred treatment. [15, 33, 32]  If surveillance is not feasible, e.g. due to difficulties with repeated imaging, low compliance or patient's preferenceerred treatment, the guidelines vary in their treatment recommendations as follows:

  • NCCN recommends RPLND (preferred) or chemotherapy with one course of bleomycin/etoposide/cisplatin (BEP). [15]
  • EAU recommends adjuvant chemotherapy with one course of BEP. [32]
  • ESMO recommends adjuvant chemotherapy with one or two cycles of BEP. In patients not suitable for surveillance or adjuvant chemotherapy, RPLND in highly experienced centres is an option. The guidelines note that some experts consider nerve-sparing RPLND the preferred treatment of patients with teratoma and somatic transformation in the primary tumour. [33]

According to EAU guidelines, patients who have a marker-positive recurrent and/or progressing lesion during surveillance should receive salvage treatment that includes three or four courses of BEP chemotherapy according to the International Germ Cell Cancer Collaborative Group classification; this should be followed by postchemotherapy RPLND as necessary. [32]

Stage I with risk factors

Recommendations for treatment of stage I NSGCTs with risk factors (pT2-pT4), are as follows [15, 33, 32] :

  • NCCN: Surveillance or primary chemotherapy with BEP for one cycle, or nerve-sparing RPLND [15]
  • ESMO: Surveillance or adjuvant chemotherapy for one or two cycles of BEP. Nerve-sparing RPLND may be carried out if serveillance and chemotherapy are contraindicated. [33] ​ 
  • EAU: Primary chemotherapy with one course of BEP chemotherapy. In adjuvant chemotherapy, discuss advantages and disadvantages of one versus two cycles of BEP chemotherapy. Surveillance for patients not willing to undergo adjuvant chemotherapy. Nerve-sparing RPLND for highly selected patients only, to include patients with contraindications to adjuvant chemotherapy and those not willing to accept surveillance. [32]

​Stage II and III

Stage IIA/IIB (markers negative):  NCCN and ESMO recommend nerve-sparing RPLND or primary chemotherapy with BEP x 3 or EP x 4. [15, 33] EAU recommends excluding marker-negative embryonal carcinoma by histological examination after either RPLND or biopsy. If this is not possible, staging should be repeated after 6 weeks of surveillance before any final decisions are made on further treatment. [32]

Stage IIA/IIB (persistent marker elevation), IIC and IIIA:  NCCN gives category 1 recommendations for primary chemotherapy with BEP x 3 or EP x 4. [15]  ESMO and EAU guidelines concur. [33, 32]

Stage IIIB (intermediate risk):  NCCN gives category 1 recommendations for primary chemotherapy with BEP x 4 or VIP x 4. [15]  ESMO and EAU guidelines concur. [33, 32]

Stage IIIC (poor risk):  NCCN gives category 1 recommendations for primary chemotherapy with BEP x 4 or VIP x 4 (in selected patients). [15]  ESMO guidelines concur. [33]  EAU recommends one cycle of BEP or cisplatin/etoposide/ifosfamide (PEI) in case of poor lung function, followed by an assessment of tumor markers after 3 weeks. If tumor markers decline favorably, BEP (or PEI) should be continued for up to four cycles. If tumor markers decline unfavorably, chemotherapy intensification should be initiated. [32]

Surgical resection of residual masses should be performed after chemotherapy for NSGCTs when visible residual masses are noted and when serum levels of tumor markers are normal or normalizing. [15, 32]

 

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Recommendations for surveillance of nonseminoma

In patients with clinical stage I-III nonseminomas, the NCCN recommends surveillance with H&P, serum tumor markers, abdominal/pelvic CT, and chest x-ray, with chest CT preferred in patients with thoracic symptoms. Testicular ultrasound should be performed in patients with an equivocal exam. [15]

In clinical stage IA nonseminoma, the NCCN active surveillance schedule is as follows:

  • Year 1 - H&P and tumor markers every 2 mo; abdominal/pelvic CT every 4-6 mo; chest x-ray at 4 and 12 mo
  • Year 2 - H&P and tumor markers every 3 mo; abdominal/pelvic CT every 6-12 mo; chest x-ray annually
  • Year 3 - H&P and tumor markers every 4-6 mo; abdominal/pelvic CT annually; chest x-ray annually
  • Year 4 - H&P and tumor markers every 6 mo; chest x-ray annually
  • Year 5 - H&P, tumor markers, and chest x-ray annually

In clinical stage IB nonseminoma, the NCCN active surveillance schedule is as follows:

  • Year 1 - H&P and tumor markers every 2 mo; abdominal/pelvic CT every 4 mo; chest x-ray every 2 mo
  • Year 2 - H&P and tumor markers every 3 mo; abdominal/pelvic CT every 4-6 mo; chest x-ray every 3 mo
  • Year 3 - H&P and tumor markers every 4-6 mo; abdominal/pelvic CT every 6 mo chest x-ray every 4-6 mo
  • Year 4 - H&P and tumor markers every 6 mo; abdominal/pelvic CT annually; chest x-ray every 6 mo
  • Year 5 - H&P, tumor markers, and chest x-ray annually

In clinical stage IB nonseminoma treated with 1-2 cycles of adjuvant BEP chemotherapy, the NCCN surveillance schedule is as follows:

  • Year 1 - H&P and tumor markers every 3 mo; abdominal/pelvic CT annually; chest x-ray every 6-12 mo
  • Year 2 - H&P and tumor markers every 3 mo; abdominal/pelvic CT annually; chest x-ray annually
  • Years 3-4 - H&P and tumor markers every 6 mo
  • Year 5 - H&P and tumor markers annually

In clinical stage II-III nonseminoma that has shown a complete response to chemotherapy, with or without post-chemotherapy RPLND, the NCCN surveillance schedule is as follows:

  • Year 1 - H&P and tumor markers every 2 mo; abdominal/pelvic CT every 6 mo; chest x-ray every 6 mo
  • Year 2 - H&P and tumor markers every 3 mo; abdominal/pelvic CT annually; chest x-ray every 6 mo
  • Year 3 - H&P and tumor markers every 6 mo; chest x-ray annually (optional at month 36 and 48)
  • Year 4 - H&P and tumor markers every 6 mo; chest x-ray annually (optional at month 36 and 48)
  • Year 5 - H&P and tumor markers every 6 mo

In pathologic stage IIA-B nonseminoma, after primary RPLND and treatment with adjuvant chemotherapy, the NCCN surveillance schedule is as follows:

  • Year 1 - H&P and tumor markers every 6 mo; abdominal/pelvic CT after RPLND; chest x-ray every 6 mo
  • Year 2 - H&P and tumor markers every 6 mo; abdominal/pelvic CT as clinically indicated; chest x-ray annually
  • Years 3-5 - H&P and tumor markers annually; abdominal/pelvic CT as clinically indicated; chest x-ray annually

In pathologic stage IIA-B nonseminoma, after primary RPLND and NOT treated with adjuvant chemotherapy, the NCCN surveillance schedule is as follows:

  • Year 1 - H&P and tumor markers every 2 mo; abdominal/pelvic CT at 3-4 mo (assuming complete resection has taken place); chest x-ray every 2-4 mo
  • Year 2 - H&P and tumor markers every 3 mo; chest x-ray every 3-6 mo
  • Year 3 - H&P and tumor markers every 4 mo; abdominal/pelvic CT as clinically indicated; chest x-ray annually
  • Year 4 - H&P and tumor markers every 6 mo; abdominal/pelvic CT as clinically indicated; chest x-ray annually
  • Year 3 - H&P and tumor markers annually; abdominal/pelvic CT as clinically indicated; chest x-ray annually
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