Both the American Urological Association (AUA) and the European Association of Urology (EAU) recently issued updates to their guidelines on diagnosing and treating testicular cancer, the most common malignancy among men aged 15-35 years. Here’s an overview of the key changes:
In The Journal of Urology, Andrew Stephenson, MD, MBA, Director of Urologic Oncology at Rush University Medical Center in Chicago, Illinois, and colleagues discussed updates in the management of early-stage 1-2B testicular cancers.
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Imaging
Imaging of the retroperitoneum and pelvis is essential for initial staging and treatment selection. For men with germ cell tumors, clinicians should obtain cross-sectional imaging of the abdomen and pelvis using computed tomography (CT) with IV contrast. Based on additional supportive evidence, use magnetic resonance imaging (MRI) if CT is contraindicated.
Seminoma Management
Retroperitoneal lymph node dissection (RPLND) has been added as a treatment option for patients with stage IIA or IIB seminoma with a lymph node diameter of 3 cm or less to avoid toxicity from radiation therapy or multi-agent cisplatin-based chemotherapy. For patients with IIB seminoma with a lymph node exceeding 3 cm, chemotherapy is recommended.
Non-Seminoma Management
Among men having a primary RPLND, pathology findings guide the choice between surveillance or adjuvant treatment. Men with pathologic stage 2 disease that is not pure teratoma histology can select either. For patients with pN1 and/or pN1-3 pure teratoma, the guideline prefers surveillance. For patients with pN2-3 at RPLND, multi-agent cisplatin-based chemotherapy is recommended.
Surveillance of Stage 1 Disease
New evidence further supports surveillance imaging for patients with stage I testicular cancer.
“Surveillance has become more important than ever for those with testicular cancer,” Dr Stephenson stated in an AUA news brief. “Since the last testicular cancer guideline was released [in 2019], the model for management has substantially changed, making an amendment like this critical to effectively treat and manage testicular cancer.”
For patients with clinical stage 1 seminoma, clinicians should obtain a history and perform physical examination and cross-sectional imaging of the abdomen with or without the pelvis every 6 months for the first 2 years, and then every 6-12 months in years 3-5. Chest imaging and serum tumor marker assessment can be ordered as clinically indicated.
Survivorship
The guideline recommends a comprehensive long-term survivorship program given the long survival of most patients. Clinicians should screen and assess the risk for clinical conditions such as anxiety, cardiovascular disease, cognitive impairment, chronic fatigue, depression, metabolic syndromes including hypogonadism, nephrotoxicity, neurotoxicity, infertility, ototoxicity, and secondary malignancies. Measure serum morning testosterone and luteinizing hormone levels to check for hypogonadism. Patients who received radiation therapy, chemotherapy, or both need to be monitored for cardiovascular disease and secondary cancers.
In European Urology, David Nicol, MB BS, of The Royal Marsden Hospital in London, UK, and colleagues published the 2023 guideline update addressing all stages of testicular cancer. The key changes include additional information on venous thromboembolism prophylaxis in men with metastatic germ cell tumors receiving chemotherapy, quality of life after treatment, an update of the histological classifications and inclusion of the World Health Organization 2022 pathological classification, inclusion of the revalidation of the 1997 International Germ Cell Cancer Collaborative Group prognostic risk factors, and a new section covering oncology treatment protocols.
Men with metastatic germ cell tumors undergoing chemotherapy are at high risk of venous thromboembolism and should receive thromboprophylaxis. The exception is men with choriocarcinoma and high-volume extraperitoneal disease, who are at high risk of bleeding. Avoid use of a central venous-access device.
The oncology treatment protocols discuss toxicity and emergency management specific to germ cell tumors.
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original references for a full list of authors’ disclosures.
References
Stephenson A, Bass EB, Bixler BR, et al. Diagnosis and treatment of early-stage testicular cancer: AUA guideline amendment 2023. J Urol. Published online September 14, 2023. doi:10.1097/JU.0000000000003694
AUA releases amendment to the diagnosis and treatment of early-stage testicular cancer guideline. News release. American Urological Association; September 14, 2023.
Patrikidou A, Cazzaniga W, Berney D, et al. European Association of Urology guidelines on testicular cancer: 2023 update. Eur Urol. 2023 Sep;84(3):289-301. doi:10.1016/j.eururo.2023.04.010