Page 2 - Guideline

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Wood et al.

Table 1. Mandatory investigations category according to the UICC classification, histological
type, the presence or absence of tubular intra-epithelial
Complete history and physical exam, including scrotal exam
neoplasia, as well as the presence or absence of vascular
Laboratory invasion of blood or lymphatic vessels. In tumours with
• Alpha-fetoprotein, ß-human chorionic gonadotrophin
• Lactate dehydrogenase multiple tumour types, each individual component and its
estimated relative proportion should be reported. Because
Imaging*
• Scrotal Ultrasound of the clinical importance of all histological specimens, it
• CT abdomen and pelvis is highly recommended that they are assessed by a pathol-
• CT thorax (chest x-ray if stage I seminoma) ogist experienced in testis cancer pathology. 12
CT = computed tomogramphy; * = Bone scan and brain imaging only in patients with
symptoms or poor prognosis metastatic disease.
2. Management of stage I and II testicular seminoma

Further investigations to determine their eventual place in
this setting are required. Stage I seminoma
Tumour marker values should be available prior to sur-
gery and should be repeated at intervals to measure the Although radiotherapy has been the standard treatment of
half-life kinetics (half-life AFP <7 days, ß-HCG <3 days). clinical stage I seminoma patients for the past 65 years,
Radical orchiectomy should be performed through an there is growing recognition that adjuvant radiotherapy is
inguinal incision and the testicle should be removed along associated with an increased risk of late side effects, includ-
with the spermatic cord to the level of the internal inguinal ing second non-testicular malignancies and cardiovascular
ring. In very rare cases where there is a possibility of a disease. Concerns regarding late toxicity of radiotherapy,
benign tumour, excisional biopsy with a frozen section should success of surveillance in stage I nonseminomatous GCTs
be performed prior to definitive orchiectomy to allow for and improvements in diagnostic imaging have led to an
the possibility of organ-sparing partial orchiectomy. assessment of close surveillance after orchiectomy for stage I
In patients with synchronous bilateral tumours, metachro- seminoma, with treatment reserved for those who relapse.
nous contralateral tumours or solitary testicles with normal
preoperative testosterone levels, organ-preserving surgery Surveillance
may be an alternative procedure to orchiectomy in very
select patients; this should be discussed with the patient. If Numerous prospective non-randomized studies of surveil-
this approach is considered, the patient should undergo lance have been performed (Table 3). 13-20 The data in these
surgery by a surgeon with experience in this procedure. If series are now mature and relapse rates have consistently
organ-preserving surgery is performed and intratubular germ been reported to be about 15% in unselected patients with
cell neoplasia unclassified is found in the remaining testic- stage I disease. The predominant site of relapse in all studies
ular tissue, adjuvant radiotherapy is recommended but may was in the paraaortic lymph nodes; 41 of 49 (82%) of relaps-
be delayed in patients who wish to father children. A full es in the Danish Testicular Cancer Study Group (DATECA)
discussion on semen cyropreservation and androgen replace- study and 57 of 64 (85%) in the Princess Margaret Hospital
ment should take place. (PMH) series. 18,19 The median time to relapse ranged from
In general, orchiectomy should be performed prior to 12 to 18 months, but late relapses (>4 years) have been
any further treatment. In patients with life-threatening metasta- reported in some series. Disease-specific survival is 99%
tic disease and an unequivocally elevated AFP and/or HCG, and thus comparable to other options.
orchiectomy should not delay the start of chemotherapy Tumour size and rete testis invasion have been shown
and can be postponed until later in the treatment course. in a pooled analysis of 638 cases from 4 centres to predict
The UICC (Union Internationale Contre le Cancer) TNM for relapse. 21 Using this prognostic model, a risk-adapted
classification system should be used for staging purposes approach to management has been reported by the Spanish
9
(Table 2a). Patients with metastatic disease are classified Germ Cell Cancer Cooperative Study Group with surveil-
according to the classification system of the International lance reserved for low-risk patients and adjuvant therapy
Germ Cell Cancer Collaborative Group (IGCCCG). 10,11 Using for patients with 1 or 2 adverse prognostic factors. 22 This
this system, patients are divided into “good,” “intermedi- study confirmed that low-risk patients (no adverse factors)
ate” and “poor” prognosis groups (Table 2b). had a small risk of relapse. However, a risk-adapted approach
The histopathological report should document the fol- to management cannot be recommended at the present
lowing points: localization and size of the tumour, multi- time because the prognostic model suffers from two major
plicity, tumour extension (rete testis, tunica albuginea, tuni- problems. Firstly, the model has not been validated in an
ca vaginalis, epididymis, spermatic cord, scrotum), pT independent data set; secondly, the model does not have

E20 CUAJ • April 2010 • Volume 4, Issue 2