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CONSENSUS GUIDELINE

Canadian consensus guidelines for the management of testicular

germ cell cancer

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Lori Wood, MD; Christian Kollmannsberger, MD, FRCSC; Michael Jewett, MD, FRCSC; Peter Chung, MD; §
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Sebastian Hotte, MD, FRCSC; Martin O’Malley, MD; Joan Sweet, MD; Lynn Anson-Cartwright, CCRA; Eric
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Winquist, MD, FRCSC; Scott North, MD, FRCSC; Scott Tyldesley, MD; Jeremy Sturgeon, MD, FRCSC; Mary
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Gospodarowicz, MD, FRCSC; Roanne Segal, MD; Tina Cheng, MD; Peter Venner, MD, FRCSC; Malcolm
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Moore, MD, FRCSC; Peter Albers, MD; Robert Huddart, MD; Craig Nichols, MD; Padraig Warde, MB §
Can Urol Assoc J 2010;4(2):E19-E38
a total of 46 attendees from across Canada and interna-
tional invitees (Dr. Peter Albers, Dr. Robert Huddart and
esticular tumours are uncommon but constitute an Dr. Craig Nichols). The group reviewed and discussed the
important group of malignancies in young men. current literature and the Canadian experience with germ
TWorldwide, it is estimated that there were more than cell cancer. The group developed this Canadian Consensus
48 500 new cases and 8900 deaths from the disease in Guideline to cover many aspects of the diagnosis and man-
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2002. The vast majority are primary germ cell tumours agement of germ cell cancer.
(GCTs) and the incidence has doubled in the past 30 years
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(with most of the increase in seminomas). While most 1. Diagnosis and staging
patients present with early-stage and highly curable dis-
ease, the continued rise in the incidence of these tumours
presents a major challenge. Clinical presentation of germ cell tumour
Germ cell testicular tumours are the most common solid
malignancies in males between the ages of 20 and 35; it is Most patients present with a primary tumour in the testis.
estimated that in 2008 there will be 900 new cases and 30 Delay in diagnosing germ cell cancer, which has been shown
deaths from testicular cancer in Canada. 3 to affect outcome, may be caused either by patients who
Germ cell cancer is a rare disease that requires expert ignore symptoms for too long or by physicians who fail to
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treatment. Clear evidence has emerged that patients with make the correct diagnosis. In a minority of patients, the
germ cell cancer benefit from treatment in centres with primary tumour manifestation is located extragonadally (i.e.,
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special experience in the field. However, it is also of con- in the retroperitoneum or in the mediastinum). 5
siderable importance that clear, comprehensive and up-to-
date consensus guidelines are available which represent Consensus recommendations
the current “state of the art” in diagnosis and management
of germ cell cancer. The European Germ Cell Cancer There are mandatory diagnostic and staging examinations
Consensus Group published guidelines in 2004 (updated (Table 1). These include scrotal examination, determina-
in 2008) and these reflect the “European” approach to man- tion of the serum tumour markers alpha-fetoprotein (AFP),
agement of patients with GCTs. 5-7 In October 2007, the 1st ß-human chorionic gonadotrophin (HCG) and lactate dehy-
Canadian Germ Cell Cancer Consensus Conference was drogenase (LDH), scrotal ultrasound to image the testis,
held in Toronto with support from the Canadian Partnership computed tomography (CT) scan of the thorax, abdomen
against Cancer (CPAC), the Canadian Institute of Health and pelvis (chest x-ray should be used instead of CT tho-
Research, multiple provincial cancer agencies, the Dell’Elce rax in stage I seminoma). Bone scan and CT scan of the
Testicular Cancer Research Fund from the Princess Margaret brain are indicated in patients with symptoms suggestive
Foundation and industry sponsors. The initiative was of central nervous system or bone involvement and in patients
endorsed by the Canadian Urological Association, the with poor prognosis disease. Other imaging procedures,
Canadian Association of Medical Oncologists and the such as magnetic resonance imaging (MRI) and positron
Canadian Association of Radiation Oncologists. There were emission tomography (PET), should not be routinely used.

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