Testicular Cancer Clinical Practice Guidelines (2019)

European Association of Urology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

August 30, 2019

Guidelines on the diagnosis, staging, and treatment of testicular cancer were released in July 2019 by the European Association of Urology.[1]

Diagnosis and Staging Recommendations

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.

In patients at high risk for contralateral germ cell neoplasia in situ, biopsy of the contralateral testis should be offered and the consequences of findings should be discussed.

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 case of a life-threatening situation owing to extensive metastasis, chemotherapy should be started before 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.

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.

Treatment Recommendations for Stage I Seminoma

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 should be offered as a management option if there are facilities available and the patient is compliant.

If carboplatin chemotherapy is considered, one course at area under the curve (AUC) 7 should be offered.

Adjuvant treatment should not be performed in patients at very low risk (ie, no risk factors).

Radiotherapy should not be performed as adjuvant treatment.

Treatment Recommendations for Stage 1 Nonseminomatous Germ Cell Tumors

Patients with stage 1 nonseminomatous germ cell tumors (NSGCTs) 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.

Patients with stage 1 NSGCTs should be offered surveillance or risk-adapted treatment based on vascular invasion.

Patients who are unwilling to undergo surveillance should be offered one course of bleomycin/etoposide/cisplatin (BEP protocol) as an alternative adjuvant treatment because it has been proven to be better than RPLND in terms of recurrence rates.

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.

Recommendations for Risk-Adapted Treatment for Clinical Stage 1 Based on Vascular Invasion

Recommendations for stage IA (pT1, no vascular invasion), low-risk, are as follows:

  • Surveillance, if patient is willing and able to comply

  • Low-risk patients not willing (or able) to undergo surveillance: Adjuvant chemotherapy with one course of BEP chemotherapy

Recommendations for stage IB (pT2-pT4), high-risk, are as follows:

  • Primary chemotherapy with one course of BEP chemotherapy or surveillance

  • 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

Treatment Recommendations for Metastatic Germ Cell Tumors

Patients with low-volume NSGCTs at stage IIA/B that have elevated markers should be treated as if they have “good- or intermediate-prognosis” advanced NSGCT, to include three or four cycles of BEP chemotherapy.

For those with stage IIA/B NSGCTs without tumor marker elevation, marker-negative embryonal carcinoma should be excluded 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.

Patients with metastatic NSGCTs with an intermediate prognosis should be treated with four courses of standard BEP chemotherapy.

Patients with metastatic NSGCTs with a poor prognosis should be treated with one cycle of BEP chemotherapy, 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.

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.

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.

Patients with seminoma at clinical stage IIB (BEP x 3 or etoposide/cisplatin x 4, with a good prognosis) initially should be offered chemotherapy as an alternative to radiotherapy.

Patients with seminoma at stage IIC and higher should be treated with primary chemotherapy according to the same principles used for NSGCTs.

For more information go to Testicular Cancer.

For more Clinical Practice Guidelines, go to Guidelines.


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