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Guideline Summary
Guideline Title
Guidelines on testicular cancer.
Bibliographic Source(s)
Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, Horwich A, Laguna MP. Guidelines on testicular cancer. Arnhem, The Netherlands: European Association of Urology (EAU); 2011 Mar. 56 p. [369 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, Horwich A, Laguna MP. Guidelines on testicular cancer. Arnhem (The Netherlands): European Association of Urology (EAU); 2009 Mar. 50 p.

Scope

Disease/Condition(s)

Testicular cancer

Guideline Category
Diagnosis
Management
Risk Assessment
Treatment
Clinical Specialty
Medical Genetics
Oncology
Pathology
Radiation Oncology
Radiology
Surgery
Urology
Intended Users
Physicians
Guideline Objective(s)
  • To provide guideline recommendations for early diagnosis and treatment of testicular cancer
  • To present a major update to the 2009 guidelines on testicular cancer
Target Population

Men with, or suspected to have, testicular cancer

Interventions and Practices Considered

Screening/Diagnosis/Assessment

  1. Clinical examination
  2. Imaging of testis
  3. Serum tumour markers
    • Alpha-fetoprotein (AFP)
    • Human chorionic gonadotropin (hCG)
    • Lactate dehydrogenase (LDH)
  4. Inguinal exploration and orchidectomy
  5. Organ sparing surgery
  6. Pathologic assessment
  7. Post-orchidectomy tumour marker assessment
  8. Retroperitoneal, mediastinal, and supraclavicular lymph node and visceral assessment
  9. Screening through self-examination

Treatment/Management

  1. Surveillance
  2. Chemotherapy
  3. Radiotherapy
  4. Retroperitoneal lymph node dissection (RPLND) (not recommended for primary treatment of stage 1 seminoma)
  5. Risk-adapted treatment
  6. Restaging after chemotherapy
  7. Surgical resection, if indicated
  8. Treatment of brain metastases
  9. Follow-up
Major Outcomes Considered
  • Relapse rate
  • Cure rate
  • Perioperative mortality
  • Survival (disease-free, progression-free, and overall)
  • Adverse effects

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

General Methods for Germ Cell Tumours

These guidelines are 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 Collaborative Group Meeting in Amsterdam in November 2006 have been included. A validation scoping search with a focus on the available level 1 (systematic reviews and meta-analyses of randomised controlled trials [RCTs]) data was carried out in Medline and EMBASE on the Dialog-Datastar platform, covering a time frame of 2009 through September 2010. The searches used the controlled terminology of the respective databases. Both MesH and EMTREE were analysed for relevant terms.

Additional Methods for Testicular Stromal Tumours

A Medline search for Leydig cell tumours (synonym: interstitial cell tumour) and Sertoli cell tumours (synonym: androblastoma) also was performed. Approximately 850 papers were found. After excluding pure laboratory work without clinical data, female and paediatric tumours, and animal cases, 371 papers and abstracts were reviewed. Double publications and papers with unclear histology or missing data on clinical course were excluded. The majority of the remaining 285 publications are case reports, with only a few papers reporting series of more than 10 cases, most of them published in the pathology literature.

Number of Source Documents

General

Not stated

Testicular Stromal Tumours

285

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

1a Evidence obtained from meta-analysis of randomised trials

1b Evidence obtained from at least one randomised trial

2a Evidence obtained from one well-designed controlled study without randomisation

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies, and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

References used in the text have been assessed according to their level of scientific evidence (see the "Rating Scheme for the Strength of the Evidence" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

General Methods Used to Formulate the Recommendations

  • The first step in the European Association of Urology (EAU) guidelines procedure is to define the main topic.
  • The second step is to establish a working group. The working groups comprise about 4 to 8 members, from several countries. Most of the working group members are academic urologists with a special interest in the topic. Specialists from other medical fields are included as full members of the working groups as needed. In general, general practitioners or patient representatives are not part of the working groups. Each member is appointed for a four-year period, renewable once. A chairman leads each group.
  • The third step is to collect and evaluate the underlying evidence from the published literature.
  • The fourth step is to structure and present the information. All main recommendations are summarised in boxes and the strength of the recommendation is clearly marked in three grades (A-C), depending on the evidence source upon which the recommendation is based. Every possible effort is made to make the linkage between the level of evidence and grade of recommendation as transparent as possible.

Specific Methods Used for this Guideline

A multidisciplinary team of urologists, medical oncologists, radiotherapists and a pathologist were involved in producing the guidelines. References used in the text have been graded ("see the Rating Scheme for the Strength of Recommendations" field) according to the Oxford Centre for Evidence-based Medicine Levels of Evidence. The aim of grading recommendations is to provide transparency between the underlying evidence and the recommendation given.

It should be noted that when recommendations are graded, the link between the level of evidence and grade of recommendation is not directly linear. Availability of randomised controlled trials may not necessarily translate into a grade A recommendation where there are methodological limitations or disparity in published results.

Alternatively, absence of high level evidence does not necessarily preclude a grade A recommendation, if there is overwhelming clinical experience and consensus. In addition, there may be exceptional situations where corroborating studies cannot be performed, perhaps for ethical or other reasons and in this case unequivocal recommendations are considered helpful for the reader. The quality of the underlying scientific evidence – although a very important factor – has to be balanced against benefits and burdens, values, and preferences and cost when a grade is assigned.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
  2. Based on well-conducted clinical studies, but without randomised clinical trials
  3. Made despite the absence of directly applicable clinical studies of good quality
Cost Analysis
  • Magnetic resonance imaging (MRI) of the scrotum offers a sensitivity of 100% and a specificity of 95% to 100%, but its high cost does not justify its use for diagnosis. The main objections to the routine use of abdominopelvic MRI is its high cost and limited access to it.
  • The results of cost analyses comparing surveillance, retroperitoneal lymph node dissection (RPLND), and primary chemotherapy for non-seminomatous germ cell tumor (NSGCT) stage 1 show different results among the reported studies, possibly because of differences in intensity and costs related to follow-up procedures. With a low frequency of follow-up computed tomography (CT) scans (such as has been proven effective for the surveillance strategy in non-seminoma clinical stage 1), the costs of follow-up can be considerably reduced.
  • The follow-up after RPLND for NSGCT stage 1 is much simpler and less costly than that carried out during post-orchidectomy surveillance because of the reduced need for abdominal CT scans.
  • The treatment options post-orchidectomy in stage I seminoma are retroperitoneal radiotherapy, surveillance, and adjuvant chemotherapy. Due to extreme radio- and chemosensitivity, high cure rates of almost 100% are reached with each of the approaches, even in cases of relapse. The costs of the different therapies vary, as do the expected side-effects.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

There is no formal external review prior to publication.

The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used to analyse and assess a range of specific attributes contributing to the validity of a specific clinical guideline.

The AGREE instrument, to be used by two to four appraisers, was developed by the AGREE collaboration (www.agreetrust.org External Web Site Policy) using referenced sources for the evaluation of specific guidelines (see the "Availability of Companion Documents" field for further methodology information).

Recommendations

Major Recommendations

Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of March, 2011. However, because the EAU updates their guidelines frequently, users may wish to consult the EAU Web External Web Site Policy site for the most current version available.

Definitions for the grades of recommendation (A-C) are provided at the end of the "Major Recommendations" field.

Diagnosis and Staging of Testicular Cancer

Table. Recommended Tests for Staging at Diagnosis

Test Recommendation Grade
Serum tumour markers Alpha-fetoprotein
hCG
LDH
A
Abdominopelvic CT scan All patients A
Chest CT scan All patients A
Testis ultrasound (bilateral) All patients A
Bone scan In case of symptoms  
Brain scan (CT/MRI) In case of symptoms and patients with metastatic disease with multiple lung metastases and high beta-hCG values  
Further Investigations
Fertility investigations:
Total testosterone
LH
FSH
Semen analysis
B
Sperm banking should be offered A

hCG = human chorionic gonadotrophin; LDH = lactate dehydrogenase; CT = computed tomography; MRI = magnetic resonance imaging; LH = luteinising hormone; FSH = follicle-stimulating hormone

Guidelines for the Diagnosis and Staging of Testicular Cancer

  1. Testicular ultrasound is mandatory assessment (Grade of Recommendation: A).
  2. Orchidectomy and pathological examination of the testis are necessary to confirm the diagnosis and to define the local extension (pathologic tumour [pT] category). In a life-threatening situation due to extensive metastasis, chemotherapy must be started before orchidectomy (Grade of Recommendation: A).
  3. Serum determination of tumour markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [hCG], and lactate dehydrogenase [LDH] must be performed before and after orchidectomy for staging and prognostic reasons (Grade of Recommendation: A).
  4. The state of the retroperitoneal, mediastinal and supraclavicular nodes and viscera must be assessed in testicular cancer (Grade of Recommendation: A).

Treatment: Stage I Germ Cell Tumours

Guidelines for the Treatment of Seminoma Stage I

  1. Surveillance is the recommended management option (if facilities available and patient compliant) (Grade of Recommendation: A)*.
  2. Carboplatin-based chemotherapy (one course at area under curve [AUC] 7) can be recommended (Grade of Recommendation: B).
  3. Adjuvant treatment is not recommended for patients at very low risk (Grade of Recommendation: A).
  4. Radiotherapy is not recommended as adjuvant treatment (Grade of Recommendation: A).

*Upgraded following panel consensus.

Guidelines for the Treatment of Non-Seminomatous Germ Cell Tumor (NSGCT) Stage I

Risk-Adapted Treatments for Clinical Stage (CS) 1 Based on Vascular Invasion

CS1 risk-adapted treatments based on vascular invasion or surveillance without using risk factors are recommended treatment options.

CS1A (pT1, No Vascular Invasion): Low Risk

  1. If the patient is willing and able to comply with a surveillance policy, long-term (at least 5 years) close follow-up should be recommended (Grade of Recommendation: A)*.
  2. In low-risk patients not willing (or suitable) to undergo surveillance, adjuvant chemotherapy or nerve-sparing retroperitoneal lymph node dissection (RPLND) are treatment options if RPLND reveals PN+ (nodal involvement) disease, chemotherapy with two courses of cisplatin, etoposide, and bleomycin (PEB) should be considered (Grade of Recommendation: A).

CS1B (pT2-pT4): High Risk

  1. Primary chemotherapy with two courses of PEB should be recommended (one course of PEB within a clinical trial or registry) (Grade of Recommendation: A)*.
  2. Surveillance or nerve-sparing RPLND in high-risk patients remain options for those not willing to undergo adjuvant chemotherapy.

    If pathological stage II is revealed at RPLND, further chemotherapy should be considered (Grade of Recommendation: A).

*Upgraded following panel consensus.

Treatment: Metastatic Germ Cell Tumours

  1. Low volume NSGCT stage IIA/B with elevated markers should be treated like 'good or intermediate prognosis' advanced NSGCT, with three or four cycles of PEB (Grade of Recommendation: A).
  2. In stage IIA/B without marker elevation, histology can be gained by RPLND or biopsy. A repeat staging can be performed after six weeks of surveillance before final decision on further treatment (Grade of Recommendation: B).
  3. In metastatic NSGCT (>stage IIC) with a good prognosis, three courses of PEB is the primary treatment of choice (Grade of Recommendation: A).
  4. In metastatic NSGCT with an intermediate or poor prognosis, the primary treatment of choice is four courses of standard PEB and inclusion in clinical trials is strongly recommended (Grade of Recommendation: A).
  5. Surgical resection of residual masses after chemotherapy in NSGCT is indicated in the case of visible residual masses and when serum levels of tumour markers are normal or normalising (Grade of Recommendation: A).
  6. Seminoma CSII A/B can initially be treated with radiotherapy. When necessary, chemotherapy can be used as a salvage treatment with the same schedule as for the corresponding prognostic groups of NSGCT (Grade of Recommendation: A).
  7. In seminoma stage CS IIB, chemotherapy (4 x etoposide and cisplatin [EP] or 3 x PEB, in good prognosis) is an alternative to radiotherapy. It appears that 4 x EP or 3 x PEB achieve a similar level of disease control (Grade of Recommendation: B).
  8. Seminoma stage IIC and higher should be treated with primary chemotherapy according to the same principles used for NSGCT (Grade of Recommendation: A).

Follow-up after Curative Therapy

General Considerations

The selection of the test to be performed in follow-up should adhere to the following principles.

  • The interval between examination and duration of testing should be consistent with the time of maximal risk of recurrence and the natural history of the tumour.
  • The tests should be directed at the most likely sites of recurrence and should have a high predictive value, both positive and negative.
  • Therapy should be available that will result in cure of the recurrence, significant prolongation of life or palliation of symptoms. The initiation of earlier therapy should improve the outcome compared with therapy given when the patient becomes symptomatic from the tumour recurrence.
  • The increased risk of second malignancy, both in the primary site and in other tissues that may have been exposed to the same carcinogens, or in which there is epidemiological evidence of increased risk, should also guide the ordering tests. Malignant and non-malignant complications of therapy must also be considered. Such testing should also be performed with a frequency and duration consistent with the nature of the risk, and include only tests with high positive- and negative-predictive values.

The following considerations apply in a general manner for the selection of an appropriate schedule and testing in the follow-up of all stages of testis tumour.

  • Most recurrences after curative therapy will occur in the first 2 years; surveillance should therefore be most frequent and intensive during this time.
  • Late relapses can occur beyond 5 years, and therefore yearly follow-up for life may be advocated.
  • After RPLND, relapse in the retroperitoneum is rare, the most likely site of recurrence being the chest.
  • The value of chest X-ray has been recently questioned in the follow-up of patients with disseminated disease after complete remission.
  • CT of the chest has a higher predictive value than chest X-ray.
  • The results of therapy are dependent on the bulk of disease; thus an intensive strategy to detect asymptomatic disease may be justifiable.
  • After chemotherapy or radiotherapy, there is a long-term risk of the development of secondary malignancies.
  • Exposure to diagnostic X-rays causes second malignancies. Thus, the frequency of CT scans should generally be reduced and any exposure to X-rays should be well justified in a patient cohort with a very long life-expectancy after successful treatment.
  • In specialised centres, CT can be substituted by magnetic resonance tomography (MRT). However, MRT is a protocol-dependent method and, thus, should be performed in the same institution with a standardised protocol.
  • With special expertise, ultrasound may be used as a method to screen the retroperitoneum during follow-up. However, the method is very much dependent on the investigator and cannot be recommended as general method during follow-up.
  • Longer follow-up in patients after radiotherapy and chemotherapy is justified to detect late toxicities (e.g. cardiovascular, endocrine).

The follow-up tables presented below present the minimum follow-up criteria and should therefore be considered as a Grade of Recommendation: A.

Follow-Up: Stage I Non-Seminoma

Table. Recommended Follow-Up Schedule in a Surveillance Policy: Stage I Non-Seminoma

Procedure Year
  1 2 3-5 6-10
Physical examination 4 times 4 times Once/year Once/year
Tumour markers 4 times 4 times Once/year Once/year
Chest X-ray Twice Twice    
Abdominopelvic CT scan Twice (at 3 and 12 months)      

CT = computed tomography

Table. Recommended Follow-Up Schedule after Retroperitoneal Lymphadenectomy or Adjuvant Chemotherapy: Stage I Non-Seminoma

Procedure Year
  1 2 3-5 6-10
Physical examination 4 times 4 times Once/year Once/year
Tumour markers 4 times 4 times Once/year Once/year
Chest X-ray Twice Twice    
Abdominopelvic CT scan Once Once    

CT = computed tomography

Follow-up: Stage I Seminoma

Table. Recommended Follow-Up Schedule for Post-Orchidectomy Surveillance, Radiotherapy or Chemotherapy: Stage I Seminoma

Procedure Year
  1 2 3-4 5-10
Physical examination 3 times 3 times Once/year Once/year
Tumour markers 3 times 3 times Once/year Once/year
Chest X-ray Twice Twice    
Abdominopelvic CT scan Twice Twice    

CT = computed tomography

Follow-Up: Stage II and Advanced (Metastatic) Disease

Table. Recommended Minimum Follow-Up Schedule in Advanced 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
Chest X-ray 4 times 4 times Twice/year Once/year
Abdominopelvic CT scan*† Twice Twice As indicated As indicated
Chest CT scan†‡ As indicated As indicated As indicated As indicated
Brain CT scan§ As indicated As indicated As indicated As indicated

CT = computed tomography

*Abdominal CT scanning 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 scan should be repeated 2 and 4 months later to ensure that the mass is continuing to regress. If available, fluorodeoxyglucose-positron emission tomography (FDG-PET) scanning can be performed.
‡A chest CT scan is indicated if abnormality is detected on chest X-ray and after pulmonary resection.
§In patients with headaches, focal neurological findings, or any central nervous system symptoms.

Testicular Stromal Tumours

Leydig Cell Tumours

Diagnosis

Diagnostic work-up must include markers, hormones (at least testosterone, luteinising hormone [LH] and follicle-stimulating hormone [FSH]; if not conclusive, additionally oestrogen, oestradiol, progesterone, and cortisol), ultrasound of both testes, and CT scan of chest and abdomen. On ultrasound, it may be possible to observe well-defined, small, hypoechoic lesions with hypervascularisation, but the appearance is variable and is indistinguishable from germ cell tumours.

Treatment

Asymptomatic testicular tumours of small volume are often misinterpreted as germ cell tumours, and inguinal orchidectomy is performed. It is highly recommended to perform an organ-sparing procedure in every small intraparenchymal lesion in order to obtain the histological diagnosis. Especially in patients with symptoms of gynaecomastia or hormonal disorders, a non germ-cell tumour should be considered and immediate orchidectomy avoided. In cases of germ cell tumour in either frozen section or paraffin histology, orchidectomy is recommended as long as a contralateral normal testicle is present.

In stromal tumours with histological signs of malignancy, especially in patients of older age, orchidectomy and retroperitoneal lymphadenectomy is recommended to prevent metastases. Without histological signs of malignancy, an individualised surveillance strategy after orchidectomy is recommended (CT follow-up may be most appropriate since specific tumour markers are not available).

Tumours that have metastasised to lymph nodes, lung, liver, or bone respond poorly to chemotherapy or radiation and survival is poor.

Follow-up

Recommendations for appropriate follow-up cannot be given because of the lack of follow-up data in most reported cases and the lethal outcome of metastatic tumours, irrespective of the therapy chosen.

Sertoli Cell Tumour

Diagnosis

Diagnostic work-up must include tumour markers, hormones (at least testosterone, LH and FSH; if not conclusive, additionally oestrogen, oestradiol, progesterone, and cortisol), ultrasound of both testes and CT scan of chest and abdomen.

Treatment

Testicular tumours of small volume, otherwise asymptomatic, are often misinterpreted as germ cell tumours and inguinal orchidectomy is performed. It is highly recommended to proceed with an organ-sparing approach in small intraparenchymal testicular lesions until final histology is available. Especially in patients with symptoms of gynaecomastia or hormonal disorders or typical imaging on ultrasound (calcifications, small circumscribed tumours), organ-sparing surgery should be considered. Secondary orchidectomy can be performed if final pathology reveals a non-stromal (e.g., germ cell) tumour. Organ-sparing surgical approaches are justified as long as the remaining testicular parenchyma is sufficient for endocrine (and in stromal tumours also exocrine) function.

In tumours with histological signs of malignancy, especially in patients of older age, orchidectomy and retroperitoneal lymphadenectomy are recommended to prevent metastases. Without signs of malignancy, an individualised surveillance strategy after orchidectomy is recommended (CT scans may be most appropriate since specific tumour markers are not available). Tumours metastasising to lymph nodes, lung, or bone respond poorly to chemotherapy or radiation, and survival is poor.

Follow-up

Recommendations for appropriate follow-up cannot be given because of the lack of follow-up data in most reported cases and the lethal outcome of metastatic tumours, irrespective of the therapy chosen.

Definitions:

Grades of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
  2. Based on well-conducted clinical studies, but without randomised clinical trials
  3. Made despite the absence of directly applicable clinical studies of good quality
Clinical Algorithm(s)

The original guideline document contains clinical algorithms for:

  • Treatment after orchidectomy according to individual risk factors in patients with non-seminoma germ cell tumour (NSGCT) clinical stage 1 (CS1)
  • Treatment options in patients with non-seminoma clinical stage IIA

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and management of testicular cancer

Potential Harms

General Harms

  • Infertility will result after radiotherapy and the risk of long-term Leydig cell insufficiency after radiotherapy of a solitary testis is increased.
  • The side-effects of radiotherapy for stage I seminoma include temporary impaired spermatogenesis, gastrointestinal symptoms (peptic ulceration), and induction of second malignancies. Up to 50% of patients can develop moderate toxicity grade I-II.
  • After chemotherapy or radiotherapy, there is a long-term risk of the development of secondary malignancies.
  • Exposure to diagnostic X-rays causes second malignancies.

Treatment of Stage I Germ Cell Tumours

Stage I Seminoma

  • In one study, in patients with testicular seminoma stage I, T1-T3 and with undisturbed lymphatic drainage, acute toxicity was reduced and the sperm count within the first 18 months was significantly higher after para-aortic (PA) irradiation than after irradiation of the traditional dog-leg field. On the other hand, the relapse rate in the iliac lymph nodes was about 2% (all of them on the right side) after PA and 0% after dog-leg irradiation. Another possible site of failure is in the left renal hilum.
  • The rate of severe radiation-induced long-term toxicity is less than 2% with 20 Gy versus 30 Gy PA radiation in stage I seminoma. Moderate chronic gastrointestinal side-effects are seen in about 5% of patients, and moderate acute gastrointestinal toxicity in about 60%. The main concern surrounding adjuvant radiotherapy is the increased risk of radiation-induced second non-germ cell malignancies.
  • One or two courses of carboplatin-based chemotherapy is an effective alternative treatment in stage I seminoma. In general, this treatment is well tolerated, with only mild, acute, and intermediate-term toxicity.

Non-Seminomatous Germ Cell Tumour (NSGCT) Stage I

The risk of retroperitoneal relapse after a properly performed nerve-sparing retroperitoneal lymph node dissection (RPLND) is very low (less than 2%), as is the risk of ejaculatory disturbance or other significant side-effects.

Treatment of Metastatic Germ Cell Tumours

  • In stage IIB seminoma, chemotherapy (4 x etoposide and cisplatin [EP] or 3 x cisplatin, etoposide, and bleomycin [PEB] in good prognosis) is an alternative to radiotherapy. Although more toxic in the short term, 4 x EP or 3 x PEB achieve a similar level of disease control.
  • Data support a 3-day regimen of administering combination chemotherapy in patients with advanced metastatic germ cell tumors to be equally effective as a 5-day regimen, but associated with increased toxicity when 4 cycles are used.
  • For patients with a 'poor prognosis' for advanced metastatic germ cell tumours, standard treatment consists of four cycles of PEB. Four cycles of cisplatin, etoposide, and ifosfamide (PEI) have the same effect, but are more myelotoxic.

Contraindications

Contraindications
  • Computed tomography (CT) scan is contraindicated because of allergy to contrast media, or when the physician or the patient is concerned about radiation dose.
  • Stage IIA/B non-seminoma patients with a growing lesion and a concomitant increase in the tumour markers alpha-fetoprotein (AFP) or beta-human chorionic gonadotropin (beta-hCG) should not undergo surgery.

Qualifying Statements

Qualifying Statements
  • The aim of clinical guidelines is to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. A guideline is not intended to take the place of physician judgment in diagnosing and treatment of particular patients.
  • Guidelines may not be complete or accurate. The EAU and their Guidelines Office, and members of their boards, officers and employees disclaim all liability for the accuracy or completeness of a guideline, and disclaim all warranties, express or implied to their incorrect use.
  • Guidelines users always are urged to seek out newer information that might impact the diagnostic and treatment recommendations contained within a guideline.
  • Due to their unique nature – as international guidelines, the EAU Guidelines are not embedded within one distinct healthcare setting – variations in clinical settings, resources, or common patient characteristics, are not accounted for.

Implementation of the Guideline

Description of Implementation Strategy

The European Association of Urology (EAU) Guidelines long version (containing all EAU guidelines) is reprinted annually in one book. Each text is dated. This means that if the latest edition of the book is read, one will know that this is the most updated version available. The same text is also made available on a CD (with hyperlinks to PubMed for most references) and posted on the EAU website Uroweb (http://www.uroweb.org/guidelines/online-guidelines/ External Web Site Policy).

Condensed pocket versions, containing mainly flow-charts and summaries, are also printed annually. All these publications are distributed free of charge to all (more than 17,000) members of the Association. Abridged versions of the guidelines are published in European Urology as original papers. Furthermore, many important websites list links to the relevant EAU guidelines sections on the association websites and all, or individual, guidelines have been translated to some 25 languages.

Implementation Tools
Clinical Algorithm
Foreign Language Translations
Pocket Guide/Reference Cards
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, Horwich A, Laguna MP. Guidelines on testicular cancer. Arnhem, The Netherlands: European Association of Urology (EAU); 2011 Mar. 56 p. [369 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2001 (revised 2011 Mar)
Guideline Developer(s)
European Association of Urology - Medical Specialty Society
Source(s) of Funding

European Association of Urology

Guideline Committee

Testicular Cancer Guidelines Writing Panel

Composition of Group That Authored the Guideline

Panel Members: P. Albers (Chairman); W. Albrecht; F. Algaba; C. Bokemeyer; G. Cohn-Cedermark; K. Fizazi; A. Horwich; M.P. Laguna

Financial Disclosures/Conflicts of Interest

All members of the Testicular Cancer Guidelines working group have provided disclosure statements on all relationships that they have and that might be perceived to be a potential source of conflict of interest. This information is kept on file in the European Association of Urology (EAU) Central Office database. This guidelines document was developed with the financial support of the EAU. No external sources of funding and support have been involved. The EAU is a non-profit organisation and funding is limited to administrative assistance and travel and meeting expenses. No honoraria or other reimbursements have been provided.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, Horwich A, Laguna MP. Guidelines on testicular cancer. Arnhem (The Netherlands): European Association of Urology (EAU); 2009 Mar. 50 p.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the European Association of Urology (EAU) Web site External Web Site Policy. Also available in a variety of translations from the EAU Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Availability of Companion Documents

The following are available:

  • Guidelines on testicular cancer. Pocket guidelines. Arnhem, The Netherlands: European Association of Urology (EAU); 2011 Mar. 21 p. Electronic copies: Available in Portable Document Format (PDF) from the EAU Web site External Web Site Policy. Also available in a variety of translations from the EAU Web site External Web Site Policy.
  • EAU guidelines office template. Arnhem, The Netherlands: European Association of Urology (EAU); 2007. 4 p.
  • The European Association of Urology (EAU) guidelines methodology: a critical evaluation. Arnhem, The Netherlands: European Association of Urology (EAU); 2009. 6 p. Electronic copies: Available from the European Urology Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on July 2, 2008. The information was verified by the guideline developer on August 29, 2008. This NGC summary was updated by ECRI Institute on December 15, 2009. The information was verified by the guideline developer on January 20, 2010. This NGC summary was updated by ECRI Institute on December 14, 2011. The updated information was verified by the guideline developer on December 29, 2011.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Downloads are restricted to one download and print per user; no commercial usage or dissemination by third parties is allowed.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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