Elsevier

European Urology

Volume 60, Issue 2, August 2011, Pages 304-319
European Urology

Guidelines
EAU Guidelines on Testicular Cancer: 2011 Update

https://doi.org/10.1016/j.eururo.2011.05.038Get rights and content

Abstract

Context

On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy, and follow-up of testicular cancer were established.

Objective

This article is a short version of the EAU testicular cancer guidelines and summarises the main conclusions from the guidelines on the management of testicular cancer.

Evidence acquisition

Guidelines were compiled by a multidisciplinary guidelines working group. A systematic review was carried out using Medline and Embase, also taking Cochrane evidence and data from the European Germ Cell Cancer Consensus Group into consideration. A panel of experts weighted the references, and a level of evidence and grade of recommendation were assigned.

Results

There is a paucity of literature especially regarding longer term follow-up, and results from a number of ongoing trials are awaited. The choice of treatment centre is of the utmost importance, and treatment in reference centres within clinical trials, especially for poor-prognosis nonseminomatous germ cell tumours, provides better outcomes. For patients with clinical stage I seminoma, based on recently published data on long-term toxicity, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment. The TNM classification 2009 is recommended.

Conclusions

These guidelines contain information for the standardised management of patients with testicular cancer based on the latest scientific insights. Cure rates are generally excellent, but because testicular cancer mainly affects men in their third or fourth decade of life, treatment effects on fertility require careful counselling of patients, and treatment must be tailored taking individual circumstances and patient preferences into account.

Introduction

Testicular cancer is a relatively rare cancer that accounts for about 1–1.5% of male cancers and mainly affects younger men in the third or fourth decade of life [1], [2], [3]. It can be classified into three categories: germ cell tumours (90–95%), cord stromal tumours, and miscellaneous germ cell/sex cord stromal tumours (Table 1) [4].

The cure rates for low and intermediate risk testicular tumours are excellent, which is mainly due to careful staging at the time of diagnosis; adequate early treatment based on chemotherapeutic combinations, with or without radiotherapy and surgery, and very strict follow-up and salvage therapies.

In testicular cancer, the choice of treatment centre is of utmost importance. Although early stages can be successfully treated in a nonreference centre, the relapse rate is higher [5]. In poor-prognosis nonseminomatous germ cell tumours (NSGCTs), overall survival within a clinical trial depended on the number of patients treated at the participating centre (worse survival with fewer than five patients enrolled) [6]. Similarly, the likelihood of residual tumour resection following chemotherapy has been associated with perioperative mortality and overall survival [7], [8].

Section snippets

Evidence acquisition

A multidisciplinary team of urologists, medical oncologists, radiotherapists, and a pathologist were involved in producing this document, which is based on a structured review of the literature from January 2008 until December 2010 for both the germ cell tumour and non–germ cell sections. Also, data from meta-analysis studies, Cochrane evidence, and the recommendations of the European Germ Cell Cancer Consensus Group Meeting in Amsterdam in November 2006 have been included [9], [10], [11].

Diagnosis of testicular cancer

The epidemiologic, pathologic, and clinical risk factors for testicular cancer are well known [13], [14] (Table 2). Diagnosis of testicular cancer is based on (1) clinical examination of the testis, (2) general examination to exclude enlarged nodes or abdominal masses, and (3) ultrasound to confirm a testicular mass.

Staging of testicular tumours

To determine the presence of metastatic or occult disease, the half-life kinetics of serum tumour markers must be assessed, the nodal pathway screened, and the presence of visceral metastases ruled out [10], [11].

Guideline recommendations for diagnosis and staging

Table 6 lists the guidelines for the diagnosis and staging of testicular cancer.

Stage I testicular cancer seminoma

According to modern staging methods, about 15–20% of patients with stage I seminoma have subclinical metastatic disease, usually in the retroperitoneum, and relapse after orchidectomy alone [33].

Metastatic germ cell testicular carcinoma

The treatment of metastatic germ cell tumours depends on the histology of the primary tumour and prognostic groups as defined by the IGCCCG (Table 5).

Follow-up after curative treatment

The aims of follow-up are to detect the relapse of testicular cancer as early as possible and to monitor the contralateral testis. The following principles should be applied following treatment aimed at cure or prolonging life:

  • Ensure that the interval between examinations and duration of follow-up is consistent with the time of maximal risk of recurrence.

  • The choice of follow-up tests will depend on the increased risk of second malignancy, both at the primary site and in other tissues that may

References (98)

  • K.-P. Dieckmann et al.

    Diagnosis of contralateral testicular intraepithelial neoplasia (TIN) in patients with testicular germ cell cancer: systematic two-site biopsies are more sensitive than a single random biopsy

    Eur Urol

    (2007)
  • A. Heidenreich et al.

    Organ sparing surgery for malignant germ cell tumour of the testis

    J Urol

    (2001)
  • W.A. See et al.

    Chest staging in testis cancer patients: imaging modality selection based upon risk assessment as determined by abdominal computerized tomography scan results

    J Urol

    (1993)
  • M. de Wit et al.

    [18F]-FDG-PET in clinical stage I/II non-seminomatous germ cell tumours: results of the German multicentre trial

    Ann Oncol

    (2008)
  • O. Klepp et al.

    Early clinical stages (CS1, CS1Mk+ and CS2A) of non-seminomatous testis cancer. Value of pre and postorchidectomy serum tumour marker information in prediction of retroperitoneal lymph node metastases. Swedish-Norwegian Testicular Cancer Project (SWENOTECA)

    Ann Oncol

    (1990)
  • C.N. Sternberg

    The management of stage I testis cancer

    Urol Clin North Am

    (1998)
  • J. Aparicio et al.

    Multicenter study evaluating a dual policy of postorchidectomy surveillance and selective adjuvant single-agent carboplatin for patients with clinical stage I seminoma

    Ann Oncol

    (2003)
  • W.G. Jones et al.

    A randomized trial of two radiotherapy schedules in the adjuvant treatment of stage I seminoma (MRC TE 18)

    Eur J Cancer

    (2001)
  • S. Bieri et al.

    Seminoma of the testis: is scrotal shielding necessary when radiotherapy is limited to the para-aortic nodes?

    Radiother Oncol

    (1999)
  • R.T. Oliver et al.

    Long-term follow-up of Anglian Germ Cell Cancer Group surveillance versus patients with stage 1 nonseminoma treated with adjuvant chemotherapy

    Urology

    (2004)
  • C. Kollmannsberger et al.

    Non-risk-adapted surveillance for patients with stage I nonseminomatous testicular germ-cell tumors: diminishing treatment-related morbidity while maintaining efficacy

    Ann Oncol

    (2010)
  • C. Chevreau et al.

    Long-term efficacy of two cycles of BEP regimen in high-risk stage I nonseminomatous testicular germ cell tumors with embryonal carcinoma and/or vascular invasion

    Eur Urol

    (2004)
  • P. Maroto et al.

    Multicentre risk-adapted management for stage I non-seminomatous germ cell tumours

    Ann Oncol

    (2005)
  • T. Tandstad et al.

    Long-term follow-up after risk-adapted treatment in clinical stage 1 (CS1) nonseminomatous germ-cell testicular cancer (NSGCT) implementing adjuvant CVB chemotherapy. A SWENOTECA study

    Ann Oncol

    (2010)
  • A. Heidenreich et al.

    Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumours of the testis: experience of the German Testicular Cancer Study Group

    J Urol

    (2003)
  • J.P. Donohue et al.

    Retroperitoneal lymphadenectomy for clinical stage A testis cancer (1965 to 1989): modifications of technique and impact on ejaculation

    J Urol

    (1993)
  • D.B. Lashley et al.

    A rational approach to managing stage I nonseminomatous germ cell cancer

    Urol Clin North Am

    (1998)
  • J.P. Donohue et al.

    Clinical stage B non-seminomatous germ cell testis cancer: the Indiana University experience (1965–1989) using routine primary retroperitoneal lymph node dissection

    Eur J Cancer

    (1995)
  • G. Janetschek et al.

    Laparoscopic retroperitoneal lymph node dissection for clinical stage I non-seminomatous testicular carcinoma: long-term outcome

    J Urol

    (2000)
  • B.E. Davis et al.

    The management of patients with nonseminomatous germ cell tumors of the testis with serologic disease only after orchidectomy

    J Urol

    (1994)
  • P.W.M. Chung et al.

    Stage II testicular seminoma: patterns of recurrence and outcome of treatment

    Eur Urol

    (2004)
  • C.J. Logothetis et al.

    Primary chemotherapy followed by a selective retroperitoneal lymphadenectomy in the management of clinical stage II testicular carcinoma: a preliminary report

    J Urol

    (1985)
  • J.P. Donohue et al.

    The role of retroperitoneal lymphadenectomy in clinical stage B testis cancer: the Indiana University Experience (1965 to 1989)

    J Urol

    (1995)
  • C. Massard et al.

    Poor prognosis nonseminomatous germ-cell tumours (NSGCTs): should chemotherapy doses be reduced at first cycle to prevent acute respiratory distress syndrome in patients with multiple lung metastases?

    Ann Oncol

    (2010)
  • F. André et al.

    The growing teratoma syndrome: results of therapy and long-term follow-up of 33 patients

    Eur J Cancer

    (2000)
  • H.W. Herr et al.

    Residual mass after chemotherapy for seminoma: changing concepts of management

    J Urol

    (1987)
  • A. Heidenreich et al.

    Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: radical or modified template resection

    Eur Urol

    (2009)
  • K. Fizazi et al.

    Assessing prognosis and optimizing treatment in patients with postchemotherapy viable nonseminomatous germ-cell tumors (NSGCT): results of the sCR2 international study

    Ann Oncol

    (2008)
  • A. Lorch et al.

    High dose chemotherapy as salvage treatment for unresectable late relapse germ cell tumors

    J Urol

    (2010)
  • P. Albers et al.

    Salvage surgery of chemorefractory germ cell tumors with elevated tumor markers

    J Urol

    (2000)
  • Curado MP, Edwards B, Shin R, et al, editors. Cancer incidence in five continents, vol 9. IARC Scientific Publications...
  • G. Engholm et al.

    NORDCAN—a Nordic tool for cancer information, planning, quality control and research

    Acta Oncol

    (2010)
  • WHO histological classification of testis tumours. In: Eble JN, Sauter G, Epstein JI, Sesterhenn IA, editors. Pathology...
  • A. Jones et al.

    Is surveillance for stage I germ cell tumours of the testis appropriate outside a specialist centre?

    BJU Int

    (1999)
  • L. Collette et al.

    Impact of the treating institution on survival of patients with “poor-prognosis” metastatic nonseminoma. European Organization for Research and Treatment of Cancer Genitourinary Tract Cancer Collaborative Group and the Medical Research Council Testicular Cancer Working Party

    J Natl Cancer Inst

    (1999)
  • A. Fléchon et al.

    Long-term oncological outcome after post-chemotherapy retroperitoneal lymph node dissection in men with metastatic nonseminomatous germ cell tumour

    BJU Int

    (2010)
  • Oxford Centre for Evidence-Based Medicine Levels of Evidence (May 2001). Produced by Bob Phillips, Chris Ball, Dave...
  • K.P. Dieckmann et al.

    Is increased body mass index associated with the incidence of testicular germ cell cancer?

    J Cancer Res Clin Oncol

    (2009)
  • H. Møller et al.

    Testicular cancer, cryptorchidism, inguinal hernia, testicular atrophy and genital malformations: case-control studies in Denmark

    Cancer Causes Control

    (1996)
  • Cited by (0)

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