Guidelines for the Diagnosis and Therapy of Testicular Cancer and New Developments

Abstract

The guidelines of testicular cancer were elaborated and agreed upon interdisciplinarily. Standard therapy of stage I seminoma is infradiaphragmatic radiotherapy. Possible alternatives are adjuvant carboplatin therapy (still in test procedure) and, in case of lacking risk factors, the watch-and-wait strategy. If small metastases of lymph nodes exist, radiotherapy requires a higher dose and a larger beam field. Standard therapy in clinical stage IIC–III is cisplatin-based multidrug chemotherapy. In regard to nonseminomatous germ cell tumor there are no universal recommendations: retroperitoneal lymphadenectomy (RLA) with protection of ejaculation function, watch-and-wait strategy as well as adjuvant chemotherapy have the same cure rate but differ in relapse rate and morbidity. Knowing the crucial risk factors – depending on the expected relapse rate – it will be possible to recommend adjuvant chemotherapy or wait-and-see strategy in the future. In case of lymph nodes up to 5 cm, three different therapeutic strategies are possible. They reach the same cure rate, but are associated with different morbidity: primary nerve-sparing RLA plus adjuvant chemotherapy, primary nerve-sparing RLA without adjuvant chemotherapy, and primary chemotherapy. Advanced stages are related to three different groups in reference to their prognosis. At present, they are still treated with three or four cycles of PEB. In current protocols, patients with ‘poor prognosis’ receive high-dose therapy afterwards. These results have to be taken in consideration when updating the guidelines. The present guidelines also give notes for the therapy of TIN, residual tumor resection (RTR), management of CNS metastases, and therapy of recurrences.

Retrospective analysis of 74 cases of seminoma treated with radiotherapy

“…Patients with clinical stage I seminoma have traditionally been managed by orchiectomy followed by adjuvant RT 7 . Although infradiafragmatic RT is considered the standard treatment, follow‐up or carboplatin appear to be the new alternative treatments 8 . In infradiafragmatic RT, the field size consists of para‐aortic and ipsilateral iliac lymph nodes, so called ‘dog leg’.…”

“…Standard post‐orchiectomy radiotherapy (RT) has been accepted as a standard management option for stage I seminoma. Although infra‐diafragmatic RT is considered the standard treatment, follow‐up or carboplatin appear to be the new alternative treatments 7,8 …”

New Guidelines for Clinical Stage I Testicular Seminoma?

“…Serum tumor marker tests are mandatory for lactate dehydrogenase, α-fetoprotein, and human chorionic gonadotropin. The half-life is <3 days for human chorionic gonadotropin and <7 days for α-fetoprotein, and the tumor markers should be redetermined 6–8 days after orchiectomy in stage I disease [11]. If a germ cell tumor is histopathologically confirmed after surgical excision, the chest and abdomen must be examined by computed tomography to check for an intraabdominal or intrathoracic mass.…”

Diagnosis and Monitoring of Urological Tumors Using Positron Emission Tomography

“…A recurrence rate of approximately 20% within the first 5 years is to be expected among patients who undergo surveillance for a clinical stage I seminomatous germ cell tumor (SGCT) or nonseminomatous germ cell tumor (NSGCT) [31, 32]. It is therefore standard practice for patients with a stage I SGCT to receive additional radiation therapy [33].…”

“…It is therefore standard practice for patients with a stage I SGCT to receive additional radiation therapy [33]. For cases of NSGCT, the recovery rate for retroperitoneal lymphadenectomy (RLA), a watch–and–wait strategy or adjuvant chemotherapy is more or less the same, but with differing morbidity and rates of recurrence [32]. Given this situation, a diagnostic procedure which recognizes occult metastases and so can differentiate between stages I and II and perhaps even spare patients unnecessary therapy would therefore be highly desirable.…”