What are the guideline sources, guidelines and references for Testicular cancer ?
Guideline sources The following summarized guidelines for the evaluation and management of testicular cancer are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023; 2022), the European Reference Network on Rare Adult Solid Cancers (EURACAN/ESMO 2022), the European Association of Urology (EAU/ESPU 2021), the American Urological Association (AUA 2019), the U.S. Preventive Services Task Force (USPSTF 2011), and the American Society of Clinical Oncology (ASCO 2010). 1 2 3 4 5 6 7 8 Calculator Calculator Calculator Eastern Cooperative Oncology G International Germ Cell Cancer Karnofsky Guidelines 1. Screening and diagnosis https://web.pathway.md/diseases/recRCvQDUDCq2LMKF 1/8 6/24/23, 4:06 PM Testicular cancer Pathway Indications for screening: As per USPSTF 2011 guidelines, do not screen for testicular cancer in asymptomatic adolescent or adult males. D As per ASCO 2010 guidelines, do not obtain serum tumor marker assays to screen for germ cell tumors in asymptomatic adult males. D Self-examination: As per EAU 2023 guidelines, encourage patients with testicular cancer to perform self- examination and inform first-degree male relatives of the need for self-examination. B As per EAU 2023 guidelines, advise patients with testicular microcalcification to perform self- examination, even without additional risk factors, for early detection of testicular germ cell tumors. B Diagnosis: As per EAU 2023 guidelines, perform orchidectomy and pathological examination of the testis to confirm the diagnosis and to define the local extension (pT category). Initiate chemotherapy before orchidectomy in a life-threatening situation due to extensive metastasis. A As per ESMO 2022 guidelines: Diagnose germ cell tumors based on histology, except when urgent chemotherapy is required. B Initiate chemotherapy without delay caused by attempts to achieve a biopsy when the clinical picture is clear in symptomatic patients with high tumor burden and elevated tumor markers. B 2. Classification and risk stratification Staging: use the TNM staging system to guide management decisions. B Risk stratification: As per ESMO 2022 guidelines, use the IGCCCG classification for risk stratification of metastatic patients. B As per AUA 2019 guidelines, use the IGCCCG risk stratification to decide on the chemotherapy regimen and the number of cycles in patients with metastatic germ cell tumor (Stage IIC or III) requiring chemotherapy. Obtain the IGCCCG risk stratification based on serum tumor markers (hCG, AFP, and LDH) levels obtained before the initiation of chemotherapy, staging imaging studies, and tumor histology following radical orchiectomy. A 3. Diagnostic investigations Physical examination: perform a physical examination of supraclavicular, cervical, axillary, and inguinal lymph nodes, breast, and testicles. A Diagnostic imaging: https://web.pathway.md/diseases/recRCvQDUDCq2LMKF 2/8 6/24/23, 4:06 PM Testicular cancer Pathway As per EAU 2023 guidelines, obtain bilateral testicular ultrasound in all patients with suspected testicular cancer. A As per AUA 2019 guidelines, obtain scrotal ultrasound with Doppler in patients with a unilateral or bilateral scrotal mass suspicious for neoplasm. B Show 3 more Imaging for staging: As per EAU 2023 guidelines, obtain contrast-enhanced CT of the chest, abdomen, and pelvis in patients with a diagnosis of testicular cancer. Obtain abdominal and pelvic MRI in case of iodine allergy or other limiting factors. A Show 2 more As per ESMO 2022 guidelines, obtain contrast-enhanced CT of the thorax, abdomen, and pelvis in all patients with testicular cancer. B Show 2 more As per AUA 2019 guidelines, obtain CT of the abdomen and pelvis with IV contrast, or MRI if CT is contraindicated, in patients with newly diagnosed germ cell tumor. B Show 5 more Serum tumor markers: As per EAU 2023 guidelines, measure serum tumor markers both before and after orchidectomy taking into account half-life kinetics. A As per ESMO 2022 guidelines: Assess tumor markers (AFP, -hCG, and LDH) before and after orchiectomy and throughout follow-up for accurate staging and risk stratification to monitor treatment and to detect relapse. B Insufficient evidence to support the use of serum miRNA assessment in routine clinical practice. I As per AUA 2019 guidelines, obtain serum tumor markers (AFP, hCG, LDH) before any treatment, including orchiectomy, in patients with a solid mass in the testis suspicious for malignant neoplasm. B Evaluation of the contralateral testis: As per EAU 2023 guidelines, perform biopsy of the contralateral testis in patients with testicular cancer at high-risk for contralateral germ cell neoplasia in situ. A As per ESMO 2022 guidelines, obtain surveillance for malignancy in the contralateral testis with physical examination and/or ultrasound because 5% of patients with germ cell tumor harbor germ cell neoplasia in situ in the contralateral testis. B As per AUA 2019 guidelines, inform patients with a history of germ cell tumor or germ cell neoplasia in situ regarding the risks of a second primary tumor while rare is significantly increased in the contralateral testis. B 4. Medical management https://web.pathway.md/diseases/recRCvQDUDCq2LMKF 3/8 6/24/23, 4:06 PM Testicular cancer Pathway General principles: manage a solid mass in the testis identified by physical examination or imaging as a malignant neoplasm until proven otherwise. B Show 3 more Management of neoplasia in situ: inform patients with germ cell neoplasia in situ of the risks/benefits of surveillance, radiation, and orchiectomy. B Show 2 more Management of locoregional disease, seminoma: As per EAU 2023 guidelines, inform patients with stage I seminoma about all available management options, including surveillance or adjuvant therapy after orchidectomy, as well as treatment-specific recurrence rates and acute and long-term side effects. Offer surveillance as the preferred management option if resources are available and the patient is compliant. A Show 3 more As per EURACAN/ESMO 2022 guidelines, inform patients with stage I seminoma about the post-orchiectomy management options of surveillance or adjuvant carboplatin, as well as treatment-specific recurrence rates and acute and long-term side effects. B Take into account patient autonomy for selecting the post-orchiectomy management following thorough provision of the pros and cons of surveillance as opposed to one cycle of carboplatin. B Show 6 more As per AUA 2019 guidelines: Offer surveillance after orchiectomy in patients with stage I seminoma. Consider offering adjuvant radiotherapy and carboplatin-based chemotherapy as less preferred alternatives. B Offer radiotherapy or multi-agent cisplatin-based chemotherapy based on shared decision- making in patients with stage IIA-IIB seminoma with a lymph node 3 cm. Offer chemotherapy in patients with IIB seminoma with a lymph node > 3 cm. B Management of locoregional disease, nonseminoma: As per EAU 2023 guidelines, inform patients with stage I nonseminoma about all management options after orchidectomy, including surveillance, adjuvant chemotherapy, and retroperitoneal lymph node dissection, as well as treatment-specific recurrence rates and acute and long-term side effects. Offer surveillance or risk-adapted treatment based on lymphovascular invasion. A Show 5 more As per EURACAN/ESMO 2022 guidelines, inform patients with stage I nonseminoma about the post-orchiectomy management options of surveillance or adjuvant chemotherapy, as well as treatment-specific recurrence rates and acute and long-term side effects. B Take into account patient autonomy for selecting the post-orchiectomy management following thorough provision of the pros and cons of surveillance as opposed to one cycle of bleomycin, etoposide, and cisplatin. B Show 3 more As per AUA 2019 guidelines, offer risk-appropriate, multi-agent chemotherapy in patients with non-seminoma germ cell tumor with elevated and rising post-orchiectomy serum AFP or -hCG (stage TanyN1-2S1). B https://web.pathway.md/diseases/recRCvQDUDCq2LMKF 4/8 6/24/23, 4:06 PM Testicular cancer Pathway Show 10 more Management of advanced/metastatic disease, seminoma: As per EAU 2023 guidelines, offer 3-4 cycles of cisplatin, etoposide, and bleomycin in patients with low-volume, stage IIA/B nonseminoma with elevated markers, like metastatic good- or intermediate-prognosis risk group IGCCCG. A Show 5 more As per EURACAN/ESMO 2022 guidelines, offer cisplatin-based chemotherapy according to the IGCCCG classification as the standard of care in patients with stage IIB-IIC and III seminomas. B Show 3 more Management of advanced/metastatic disease, nonseminoma: As per EAU 2023 guidelines: Offer cisplatin-based chemotherapy according to IGCCCG prognosis groups, or alternatively radiotherapy in patients with stage II A/B seminoma informing the patient of potential long-term side effects of both treatment options. B Offer primary chemotherapy according to IGCCCG classification (3 cycles of cisplatin, etoposide, and bleomycin in good-prognosis and 4 cycles of cisplatin, etoposide, and bleomycin in intermediate prognosis) in patients with stage IIC and higher seminoma. A As per EURACAN/ESMO 2022 guidelines, offer 3 cycles of bleomycin, etoposide, and cisplatin or 4 cycles of etoposide and cisplatin, or 4 cycles of etoposide, ifosfamide, and cisplatin with G- CSF support if bleomycin is contraindicated, in IGCCCG good-prognosis patients. B Show 4 more Salvage treatment: offer second-line conventional-dose chemotherapy (such as cisplatin, ifosfamide, and paclitaxel) at a specialist center. B Show 2 more Thromboprophylaxis: As per EAU 2023 guidelines: Balance the individual patient's potential benefits and risks of thromboprophylaxis during first- line chemotherapy in patients with metastatic germ cell tumors. B Avoid using central venous-access devices during first-line chemotherapy whenever possible. D As per ESMO 2022 guidelines: Consider administering thromboprophylaxis in patients with metastatic germ cell tumors for the duration of chemotherapy, especially when presenting with 1 established risk factors: stage III disease retroperitoneal lymph nodes > 3.5 cm central venous access catheter intermediate or poor-risk features or immobilization. C Use peripheral venous access instead of an indwelling vascular access device. B https://web.pathway.md/diseases/recRCvQDUDCq2LMKF 5/8 6/24/23, 4:06 PM Testicular cancer Pathway Fertility preservation: As per EAU 2023 guidelines, discuss the option of sperm banking with all patients before initiating treatment for testicular cancer. A As per EAU 2023 guidelines: Offer sperm cryopreservation before planned orchidectomy or additional neoadjuvant or adjuvant oncological therapies, as patients with testicular cancer may have significant semen abnormalities (including azoospermia). B Offer onco-testicular sperm extraction during radical orchidectomy in patients with testicular cancer and azoospermia or severe abnormalities in semen parameters. B As per ESMO 2022 guidelines, obtain SA and offer sperm cryopreservation in all patients, preferably before orchiectomy. B As per AUA 2019 guidelines, counsel patients about the risks of hypogonadism and infertility before definitive management for testicular cancer B and offer sperm banking when appropriate. Consider offering sperm banking before orchiectomy in patients without a normal contralateral testis or with known subfertility. B 5. Surgical interventions Radical orchiectomy: As per ESMO 2022 guidelines, perform radical orchiectomy via an inguinal incision. B As per AUA 2019 guidelines, perform radical inguinal orchiectomy in patients with a testicular lesion suspicious for malignant neoplasm and normal contralateral testis. Avoid performing trans-scrotal orchiectomy. B Show 2 more Testis-sparing surgery: As per EAU 2023 guidelines, perform testis-sparing surgery with frozen section examination in patients with a high likelihood of a benign testicular tumor suitable for enucleation. A As per ESMO 2022 guidelines: Perform testis-sparing surgery in selected patients in experienced centers. B Perform completion orchiectomy or post-resection testicular radiotherapy (if solitary testis) in patients with a germ cell tumor diagnosed during testis-sparing surgery because of the high risk of germ cell neoplasia in situ in the remaining testis. B As per AUA 2019 guidelines, consider performing testis-sparing surgery through an inguinal incision as an alternative to radical inguinal orchiectomy in highly selected patients wishing to preserve gonadal function with masses < 2 cm and any of the following: equivocal ultrasound/physical examination findings and negative tumor markers (hCG and AFP) congenital, acquired, or functionally solitary testis bilateral synchronous tumors. C https://web.pathway.md/diseases/recRCvQDUDCq2LMKF 6/8 6/24/23, 4:06 PM Testicular cancer Pathway Show 2 more 6. Specific circumstances Prepubertal patients: As per EAU 2022 guidelines, recognize that testicular tumors in prepubertal patients have a lower incidence and a different histologic distribution compared to adolescent and adult patients. B Show 8 more As per ESPU 2021 guidelines, recognize that testicular tumors in prepubertal patients have a lower incidence and a different histologic distribution compared to adolescent and adult patients, B and up to 60-75% of testicular tumors are benign. B Show 7 more 7. Follow-up and surveillance Follow-up: As per ESMO 2022 guidelines, provide post-orchiectomy management only by highly experienced clinicians. B Show 3 more As per AUA 2019 guidelines, elicit history, perform a physical examination, and obtain cross- sectional imaging of the abdomen (with or without the pelvis) every 4-6 months for the first 2 years and then every 6-12 months in subsequent 3-5 years in patients with clinical stage I seminoma electing surveillance. Consider obtaining routine surveillance imaging of the chest and serum tumor markers assessment as clinically indicated. B Show 7 more Management of relapse: manage patients developing a late relapse only in expert centers. B Show 2 more References 1. Raimund Stein, Josine Quaedackers, Nikita R Bhat et al. EAU ESPU pediatric urology guidelines on testicular tumors in prepubertal boys. J Pediatr Urol. 2021 Aug;17 4 529 533. Open 2. J Oldenburg, D M Berney, C Bokemeyer et al. Testicular seminoma and non-seminoma: ESMO EURACAN Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2022 Apr;33 4 362 375. Open 3. Andrew Stephenson, Scott E Eggener, Eric B Bass et al. Diagnosis and Treatment of Early Stage Testicular Cancer: AUA Guideline. J Urol. 2019 Aug;202 2 272 281. Open 4. M.P. Laguna Chair), P. Albers, F. Algaba et al. EAU Guidelines on Testicular Cancer. EAU. 2023. Open https://web.pathway.md/diseases/recRCvQDUDCq2LMKF 7/8 6/24/23, 4:06 PM Testicular cancer Pathway 5. Lisette A 't Hoen, Guy Bogaert, Christian Radmayr et al. EAU guidelines on Paediatric Urology. EAU. 2022 Mar. Open 6. U.S. Preventive Services Task Force. Screening USPSTF for testicular cancer: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2011 Apr 5;154 7 483 6. Open 7. Timothy D Gilligan, Jerome Seidenfeld, Ethan M Basch et al. American Society of Clinical Oncology Clinical Practice Guideline on uses of serum tumor markers in adult males with germ cell tumors. J Clin Oncol. 2010 Jul 10;28 20 3388 404. Open 8. A. Salonia, C. Bettocchi, J. Carvalho et al. EAU Guidelines on Sexual and Reproductive Health. EAU. 2023. Open 9. No authors listed. International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group. J Clin Oncol. 1997 Feb;15 2 594 603. Open 10. Robert J Hamilton, Christina Canil, Noa Shani Shrem et al. Canadian Urological Association consensus guideline: Management of testicular germ cell cancer. Can Urol Assoc J. 2022 Jun;16 6 155 173. Open https://web.pathway.md/diseases/recRCvQDUDCq2LMKF 8/8