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NCCN Guidelines IndexTesticular Cancer TOC

Discussion

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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™)

Testicular Cancer

Version 1.2011





Discussion

Continue

NCCN Guidelines Panel Disclosures

NCCN Guidelines™ Version 1.2011 Panel MembersTesticular Cancer

*

† Medical oncology

‡ Hematology/hematology oncology

§ Radiotherapy/Radiation oncology

Diagnostic Radiology

£ Supportive Care including Palliative, PainManagement, Pastoral care and Oncology social work

Þ Internal medicineUrology

* Writing committee member

ф

Robert J. Motzer, MD/Chair Memorial Sloan-Kettering Cancer Center

Neeraj Agarwal, MD

Huntsman Cancer Institute at the

University of Utah

Clair Beard, MD

Michael A. Carducci, MD

The Sidney Kimmel Comprehensive

Cancer Center at Johns Hopkins

Sam S. Chang, MDVanderbilt-Ingram Cancer Center

Toni K. Choueiri, MD

† Þ

‡

§

†

† Þ

† Þ

§ Þ

Dana-Farber/Brigham and Women’s

Cancer Center

Sam Bhayani, MD

Siteman Cancer Center at Barnes-Jewish

Hospital and Washington University

School of Medicine

Graeme B. Bolger, MD

University of Alabama at Birmingham

Comprehensive Cancer Center

Dana-Farber/Brigham and Women’s

Cancer Center

Steven L. Hancock, MD

Stanford Comprehensive Cancer Center

Thomas W. Ratliff, MDSt. Jude Children’s Research Hospital/University

of Tennessee Cancer Institute

UCSF Helen Diller Family Comprehensive Cancer

Center

UNMC Eppley Cancer Center at

The Nebraska Medical Center

Richard B. Wilder, MDH. Lee Moffitt Cancer Center & Research Institute

†

†

†

†

§

Bruce G. Redman, DO

University of Michigan Comprehensive Cancer

Center

Cary N. Robertson, MD

Duke Comprehensive Cancer Center

Charles J. Ryan, MD

Joel Sheinfeld, MD

Memorial Sloan-Kettering Cancer Center

Philippe E. Spiess, MDH. Lee Moffitt Cancer Center & Research Institute

Jue Wang, MD

Gary R. Hudes, MDFox Chase Cancer Center

Eric Jonasch, MDThe University of Texas M. D. Anderson Cancer Center

David Josephson, MDCity of Hope Comprehensive Cancer Center

Ellis G. Levine, MDRoswell Park Cancer Institute

Daniel W. Lin, MDUniversity of Washington MedicalCenter/Seattle Cancer Care Alliance

Kim A. Margolin, MD

Fred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance

M. Dror Michaelson, MD, PhDMassachusetts General Hospital Cancer Center

Thomas Olencki, DOThe Ohio State University ComprehensiveCancer Center - James Cancer Hospital and

Solove Research Institute

Roberto Pili, MD

Roswell Park Cancer Institute

† ‡

†

†

† ‡

†

†

†

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Discussion

NCCN Testicular Cancer Panel Members

Summary of the Guidelines Updates

Workup, Primary Treatment and Pathologic Diagnosis (TEST-1

Seminoma: Postdiagnostic Workup and Clinical Stage (TEST-2

Stage IA, IB (TEST-3

Stage IS (TEST-3

Stage IIA, IIB (TEST-3Stage IIC, III (TEST-3

Nonseminoma: Postdiagnostic Work-up and Clinical Stage (TEST-5

Stage IA, IB, IS (TEST-6

Stage IIA, IIB (TEST-7

Postchemotherapy Management (TEST-8

Postsurgical Management (TEST-9Stage IIC, IIIA, IIIB, IIIC, and Brain Metastases (TEST-10

Follow-up for Nonseminoma (TEST-11

Recurrence and Second Line Therapy (TEST-12

Risk Classification for Advanced Disease (TEST-A

Primary Chemotherapy Regimens for Germ Cell Tumors (TEST-B

Second Line or Subsequent Chemotherapy Regimens for Metastatic Germ

Cell Tumors (TEST-C

Principles of Surgery (TEST-D

)

)

)

)

))

)

)

)

)

))

)

)

)

)

)

)

Clinical Trials:

Categories of Evidence andConsensus:NCCN

All recommendationsare Category 2A unless otherwisespecified.

Thebelieves that the best managementfor any cancer patient is in a clinicaltrial. Participation in clinical trials isespecially encouraged.

NCCN

To find clinical trials online at NCCNmember institutions, click here:nccn.org/clinical_trials/physician.html

See NCCN Categories of Evidenceand Consensus

The NCCN Guidelines™ are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to

treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual

clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no

representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any

way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the

illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2010.

NCCN Guidelines™ Version 1.2011 Table of ContentsTesticular Cancer

Staging (ST-1)



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Discussion

UPDATES

NCCN Guidelines™ Version 1.2011 UpdatesTesticular Cancer

Updates in Version 1.2011 of the NCCN Testicular Cancer Guidelines from Version 2.2010 include:

Nonseminoma

TEST-5

TEST-7

TEST-8

Post diagnostic workup, “Chest CT if abnormal abdominal CT or abnormal chest x-ray” was removed and “± chest imaging” was added to “abdominal/

pelvic CT”.

was added

Stage IS and Stage IIA,S1 and Stage IIB, S1 were added to the good risk category.

Footnote p, “It is preferred that patients with recurrent nonseminoma be treated at centers with expertise in the management of this disease” was added to

the page.:

Principles of Surgery is new to the guidelines.

Footnote j, “PET scan is not clinically indicated for nonseminoma” was added to the page.

Complete response, negative markers, “nerve-sparing RPLND” was changed to “bilateral RPLND ± nerve-sparing”.

TEST-6

TEST-10

TEST-11

TEST-12

TEST-A

TEST-D

Stage IB, primary chemotherapy, “BEP for 1 cycle” with a category 2B designation.Stage IS with persistent elevated markers has been redirected to TEST-10.Statement in the box was modified, “

Stage IIA and IIB with persistent marker elevation have been redirected to TEST-10.

For negative markers, residual mass.Negative markers, normal CT scan, no mass, “or residual mass < 1 cm” was added.“Bilateral” was added to “nerve-sparing RPLND.”

Surveillance after :

Year 1 from 2-3 mo to 3-4 mo Year 2 from 3-4 mo to 4-6 mo Year 3 from 4 mo to 6-12 mo Year 4 from 6 mo to 6-12 mo Year 6+ from 12 mo to 12-24 mo

Surveillance after complete response to chemotherapy and/or RPLND

Year 3 from 4 mo to 3-6 mo

“For advanced disease” was added to the title “risk classification”.“Post-orchiectomy” was added under the title.

The EP and BEP chemotherapy regimens may be considered as category 1

compared with other chemotherapy regimens”. Also for TEST-7 and TEST-10.

“ 1 cm” was added to

Stage IA, IB testicular cancer “Months between abdominal/pelvic CT” was change to “Months between abdominal CT”.The intervals for each year were modified as follows:

The intervals for each year were modified as follows:

Year 4 from 4 mo to 6 mo Year 5 from 6 mo to 6-12 mo

given at doses and schedules on TEST-B


P i t d b i ti i 2/17/2011 1 52 05 PM F l l N t d f di t ib ti C i ht © 2011 N ti l C h i C N t k I All Ri ht R d







Discussion

Note: All recommendations are category 2Aunless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

NCCN Guidelines™ Version 1.2011Testicular Cancer

WORKUP PRIMARY TREATMENTb PATHOLOGIC DIAGNOSIS

aQuantitative analysis of beta subunit.bThough rare, when a patient presents with rapidly increasing beta-hCG, symptoms related to disseminated disease and a

testicular mass, chemotherapy can be initiated immediately without waiting for a biopsy diagnosis.

Suspicious

testicular

mass

Pure seminoma germ cell

tumor (pure seminoma

histology and AFP

negative; may have

elevated beta-hCG)

Nonseminomatous germ

cell tumor (includesmixed seminoma tumors

and seminoma histology

with elevated AFP)

Discuss sperm bankingRadical inguinal orchiectomy

Consider inguinal biopsy of

contralateral testis if:Suspicious ultrasound for

intratesticular abnormalitiesCryptorchid testisMarked atrophy

H&P

Alpha-fetoprotein (AFP)

beta-hCG

Chemistry profile

Chest x-ray

a

LDH

Testicular ultrasound

SeePostdiagnosticWorkup andClinical Stage

(TEST-2)

See

PostdiagnosticWorkup andClinical Stage(TEST-5)

TEST-1


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Discussion



NCCN Guidelines™ Version 1.2011Testicular Cancer- Pure Seminoma

PATHOLOGIC DIAGNOSIS POSTDIAGNOSTIC WORKUP CLINICAL STAGE

Pure seminoma g

(

; may have elevated

beta-hCG)

cerm cell tumor

pure seminoma histology and

AFP negative d

Abdominal/pelvic CTChest CT if:

Positive abdominal CT or

abnormal chest x-ray

Repeat beta-hCG, LDH, AFP

Brain MRI, if clinically indicated

Bone scan, if clinically indicated

Discuss sperm banking

e

Stage

IA, IB

Stage

IIA, IIB

Stage

IIC, III

See Primary Treatmentand Follow-up (TEST-3)



c

d

e

Mediastinal primary site seminoma should be treated by risk status used for gonadal seminomas withetoposide/cisplatin for 4 cycles or bleomycin/etoposide/cisplatin for 3 cycles.

If AFP positive, treat as nonseminoma.

Elevated values should be followed after orchiectomy with repeated determination to allow precise staging.

TEST-2

Stage

ISSee Primary Treatmentand Follow-up (TEST-3)


Printed by cristian ramirez on 2/17/2011 1:52:05 PM For personal use only Not approved for distribution Copyright © 2011 National Comprehensive Cancer Network Inc All Rights Reserved







Discussion



NCCN Guidelines™ Version 1.2011Testicular Cancer - Pure Seminoma

CLINICAL

STAGE

Stage

IA, IB

Stage

IIA, IIB

RT: Infradiaphragmatic (30-35 Gy) to includepara-aortic and ipsilateral iliac nodes

Consider p

EP for 4 cycles or

rimary chemotherapy for selected

stage IIB patients:

BEP for 3 cycles

g

FOLLOW-UPPRIMARY TREATMENT

Surveillance for pT1 or pT2 tumors

Single agent carboplatin

(AUC=7 x 1 cycle or AUC=7 x 2 cycles)

(category 1) (preferred)

(category 1)

RT: Infradiaphragmatic (20-25 Gy) to include

para-aortic nodes (category 1) (preferred

for pT3 tumors or tumors > 4 cm)

h

H&P + AFP, beta-hCG, LDH: every 3-4

mo for year 1,

every 6 mo for year 2, then annually

Pelvic CT annually for 3 years (for

patients status post only para-aortic RT)

chest x-ray as clinically indicated

H&P + chest x-ray

for year 4, then annually

Abdominal CT at month 4 of year 1

, AFP, beta-hCG, LDH:

every 3-4 mo for years 1-3,every 6 mo

H&P, AFP, beta-hCG, LDH:every 3-4 mo for years 1-3,

every 6 mo for years 4-7, then annually

Abdominal/pelvic CT

at each visit up to 10

years;

every 3-4 mo for

years 1-3, every 6 mo for years 4-7,

then annually

chest x-ray as clinically

indicated

TEST-3

Recurrence, treat

according to extent of

disease at relapse

Recurrence, treat

according to extent of

disease at relapse

Recurrence, treataccording to extent of

disease at relapse

See Post Chemotherapy Management

and Follow-up (TEST-4)

f See Risk Classification (TEST-A

See Primary Chemotherapy Regimens for Germ Cell Tumors (TEST-B

)

)

.

.

g

Stage

IIC, III

Primary chemotherapy:

EP for 4 cycles (category 1)or BEP for 3 cycles (category 1)

g

Good riskf

Intermediate

risk f Primary chemotherapy:g

BEP for 4 cycles (category 1)

See Post Chemotherapy Management

and Follow-up (TEST-4)

EP = Etoposide/cisplatinBEP = Bleomycin/etoposide/cisplatin

Stage

IS

RT: Infradiaphragmatic (25 Gy) to include

para-aortic ± ipsilateral iliac nodes

or

h

In special circumstances, RT to ipsilateral iliac nodes may be administered (category 3).

or

or









Discussion

FOLLOW-UP

H&P + chest x-ray

every 2 mo for

for

then annually

Abdominal/pelvic CTPost RPLND:

3-6 mo, then as

clinically indicatedAfter all other

primary management

as clinically indicatedPET scan as clinically

indicated

, AFP,

beta-hCG, LDH:

year 1

every 3 mo year 2,

every 6 mo for year 3and 4,

Recurrence,See SecondLine Therapy(TEST-12)

TEST-4

Progressive

disease (growing

mass or rising

markers)

See Second Line Therapy for Nonseminoma (TEST-12)

Chest, abdominal,

pelvic CT scan

Serum tumor

markers

No residual mass

or residual mass

3cm and normal

markers

Residual

mass

(> 3 cm)

and

normalmarkers

Surveillance

Consider RPLND, if

technically feasibleor Second line

chemotherapyor RT (category 2B)

i

PET scan

(approximately

6 wks post

chemotherapy) Positive

Negative Surveillance

i

.See Second Line or Subsequent Chemotherapy Regimens for Metastatic Germ Cell Tumors (TEST-C)

STAGE IIB, IIC, III AFTER PRIMARY

TREATMENT WITH CHEMOTHERAPY

POST

CHEMOTHERAPYMANAGEMENT

RPLND = retroperitoneal lymph node dissection



NCCN Guidelines™ Version 1.2011Testicular Cancer - Pure Seminoma

y p y pp py g p , , g







Discussion



NCCN Guidelines™ Version 1.2011Testicular Cancer - Nonseminoma

CLINICAL STAGE

Stage IA

Surveillance

(in compliant patients)

or

Nerve-sparing RPLNDk,l

Stage IB

Nerve-sparing RPLND

or


BEP for 2 cycles or

BEP for 1 cycle (category 2B)

or

Surveillance (only if T2,

compliant patients [category 2B])

k,l

g

The EP and BEP chemotherapy regimens given

at doses and schedules on may be

considered as category 1 compared with other

chemotherapy regimens.

TEST-B


TEST-6

See Follow-up for Nonseminoma (TEST-11)


Stage IS

Persistent

marker

elevation

See PostchemotherapyManagement (TEST-8)

See Postsurgical

Management (TEST-9)

See PostsurgicalManagement (TEST-9)

g

k.

Retroperitoneal lymph node dissection (RPLND) is recommended within 4 weeks of CT scan and 7-10 days of markers (category 2B).

.l


See Principles of Surgery (TEST-D

)

)

PRIMARY TREATMENT

)See Primary Treatment (TEST-10








Discussion




CLINICAL STAGE PRIMARY TREATMENT

Stage IIA

Markers negative

Persistent marker

elevation

Nerve-sparing RPLND

or

Primary chemotherapy (category 2B):

EP for 4 cycles or BEP for 3 cycles

k,l

g


TEST-7


See PostchemotherapyManagement (TEST-8)


Stage IIB

Markers negative

Persistent marker

elevation

Lymph node metastases,

within lymphatic drainage

sites (landing zone positive)

Multifocal, symptomatic, or

lymph node metastases with

aberrant lymphatic drainage



g

Nerve-sparing RPLND

or



j,k

g

SeePostchemotherapyManagement(TEST-8)


g .kRetroperitoneal lymph node dissection (RPLND) is recommended within 4 weeks of CT scan and 7-10 days of markers (category 2B).

.l

See Primary Chemotherapy Regimens for Germ Cell Tumors (TEST-B)

See Principles of Surgery (TEST-D)





TEST-B









Discussion




Negative markers,

residual mass ( 1 cm)

Nerve-sparing bilateral RPLNDor Surveillance

(category 2B)

k,l

Negative markers,

normal CT scan, no

mass or residual

mass (< 1 cm)

Nerve-sparing bilateral RPLND

(category 2B)or Surveillance

(category 2B)

k,l

TEST-8

POSTCHEMOTHERAPY MANAGEMENT

Stage IB, IIA, IIBtreated with primary

chemotherapy


kRetroperitoneal lymph node dissection (RPLND) is recommended within 4 weeks of CT scan and 7-10 days of markers (category 2B).

.lSee Principles of Surgery (TEST-D)








Discussion




TEST-9

POSTSURGICAL MANAGEMENT

pN0

pN1

Surveillance (preferred)or Chemotherapy:

EP for 2 cycles

or BEP for 2 cycles

g

Surveillance

Noncompliant

Noncompliant

pN2

Compliant

Compliant

Chemotherapy (preferred):

EP for 2 cycles or BEP for 2 cyclesor

g

Surveillance

C ghemotherapy:

EP for 2 cycles

or BEP for 2 cycles

pN3

C (preferred)hemotherapy :

EP for 4 cyclesor BEP for 3 cycles

g

C ghemotherapy:


See Follow-up for Nonseminoma(TEST-11)

Stage IA, IB, IIA, IIB

treated with nerve-

sparing RPLND

gSee Primary Chemotherapy Regimens for Germ Cell Tumors (TEST-B).









Discussion




CLINICAL

STAGE

Intermediate

risk

Stage IIIB

f

Poor riskStage IIIC

f

Good riskStage IS

Stage IIA,

Stage IIB, S1

Stage IICStage IIIA

f

S1

Brain

metastasesm

Primary

chemotherapy: g


Primary

chemotherapy: g

BEP for 4 cycles

Clinical trial

(preferred)or

BEP for 4 cyclesor VIP for 4 cycles in

selected patients

Primary

chemotherapy: g

n

Complete

response,

negative

markers

Partial response,

residual masses

with normal AFP

and beta-hCG levels

o

Incompleteresponseo

Surgical

resection of

all residual

masses

Surveillance (category 2B)or Bilateral RPLND category 2B)k,l ± nerve-sparing (

Teratoma or

necrosis

Residual embryonal,

yolk sac,

choriocarcinoma, or

seminoma elements

Chemotherapy

for 2 cycles

(EP or TIP or

VIP /VeIP )

g

g

i

i

See Second LineTherapy (TEST-12)


TIP = Paclitaxel/ifosfamide/cisplatinVeIP = Vinblastine/ifosfamide/cisplatinVIP = Etoposide/ifosfamide/cisplatin

See Follow-up

for Nonseminoma(TEST-11)

Surveillance

TEST-10

Primary chemotherapy + RT

± surgery, if clinically indicated

g

f

g

i

m

o

.

.

.

Retroperitoneal lymph node dissection (RPLND) is recommended within 4weeks of CT scan and 7-10 days of markers (category 2B).

.

Patients should receive adequate treatment for brain metastases, in addition tocisplatin-based chemotherapy.

There is limited predictive value for PET scan for residual masses.k

lSee Risk Classification (TEST-A


See Second Line or Subsequent Chemotherapy Regimens for MetastaticGerm Cell Tumors (TEST-C

See Principles of Surgery (TEST-D)

)

)

)

nPatients who may not tolerate bleomycin.

PRIMARY TREATMENT





TEST-B







Discussion




ChemotherapyConventional

dose therapy

(VeIP or TIP)or High-dose

chemotherapy

i

Favorable prognosis:

Low markers

Low volume

Complete responseon first-line therapy

Testis primary

Unfavorable prognosis:

Incomplete response

High markers

High volume

Extratesticular

primary

Late relapse

Incomplete

response

or relapse

Complete

responseFollow-up

Relapse

i

pIt is preferred that patients with recurrent nonseminoma be treated at centers with expertise in the management of this disease.

See Second Line Chemotherapy Regimens for Germ Cell Tumors (TEST-C).or Subsequent

No prior chemotherapy

Prior

chemotherapy

Treat as per risk status on TEST-10

Chemotherapy

Best supportive care

i

High-dose chemotherapy

(preferred if not previously given)

or Clinical trial

Surgical salvage should be

considered if solitary site

Chemotherapy

High-dose chemotherapy (category 2B)

Surgical salvage should be considered if

solitary site

Best supportive care

i

Clinical trial (preferred) or Conventional dose therapy (VeIP or TIP) or

Palliative

chemotherapyor RT

i

TEST-12

RECURRENCEp SECOND LINE THERAPY

VeIP = Vinblastine/ifosfamide/cisplatinTIP = Paclitaxel/ifosfamide/cisplatin








Discussion




RISK CLASSIFICATION FOR ADVANCED DISEASE

Risk Status Nonseminoma Seminoma

Good Risk Testicular or retroperitoneal primary tumor

and

No nonpulmonary visceral metastases

and

- all of:

AFP < 1,000 ng/mL

hCG < 5,000 iu/L

LDH < 1.5 x upper limit of normal

Post-orchiectomy markers

Any primary site

and


and

Normal AFP

Any hCG

Any LDH

Intermediate Risk Testicular or retroperitoneal primary tumor

and


and

- any of:

AFP 1,000-10,000 ng/mLhCG 5,000-50,000 iu/L

LDH 1.5-10 x upper limit of normal


Any primary site

and

Nonpulmonary visceral metastases

and

Normal AFP

Any hCGAny LDH

Poor Risk Mediastinal primary tumor

or

Nonpulmonary visceral metastases

or

- any of:AFP > 10,000 ng/mL

hCG > 50,000 iu/L

LDH > 10 x upper limit of normal


No patients classified as poor

prognosis

Source: Figure 4 from the International Germ Cell Cancer Collaborative Group: International Germ Cell Consensus Classification: A Prognostic Factor-Based Staging System for Metastatic Germ Cell Cancers. J Clin Oncol 1997;15(2):594-603. Reprinted withpermission of the American Society of Clinical Oncology.

TEST-A

1Markers used for risk classification are post-orchiectomy.

(post orchiectomy)1








Discussion




PRIMARY CHEMOTHERAPY REGIMENS

FOR GERM CELL TUMORS

1

2

Xiao H, Mazumdar M, Bajorin DF, et al. Long-term follow-up of patients with good-risk germ cell tumors treated with etoposide and cisplatin. J Clin Oncol1997;15:2553-2558.

Saxman SB, Finch D, Gonin R & Einhorn LH. Long-term follow-up of a phase III study of three versus four cycles of bleomycin, etoposide, and cisplatin infavorable-prognosis germ-cell tumors: The Indiana University Experience. J Clin Oncol 1998;16:702-706.

Nichols CR, Catalano PJ, Crawford ED, et al. Randomized comparison of cisplatin and etoposide and either bleomycin or ifosfamide in treatment of advanced disseminated germ cell tumors: An Eastern Cooperative Oncology Group, Southwest Oncology Group, and Cancer and Leukemia Group BStudy. J Clin Oncol 1998;16:1287-1293.

3

TEST-B

*Some NCCN Institutions administer bleomycin on a 2, 9, 16 schedule.

EPEtoposide 100 mg/m IV on Days 1 - 5Cisplatin 20 mg/m IV on Days 1 - 5Repeat every 21 days

BEPEtoposide 100 mg/m IV on Days 1 - 5Cisplatin 20 mg/m IV on Days 1 - 5Bleomycin 30 units IV weekly on Days 1, 8, and 15*Repeat every 21 days

VIPEtoposide 75 mg/m IV on Days 1-5Mesna 120 mg/m slow IV push before ifosfamide on Day 1, thenMesna 1200 mg/m IV continuous infusion on Days 1-5Ifosfamide 1200 mg/m on Days 1-5Cisplatin 20 mg/m IV on Days 1-5Repeat every 21 days

2

2

2

2

2

2

22

2

1

2

3








Discussion




TEST-C1 of 2

SECOND LINE OR SUBSEQUENT CHEMOTHERAPY REGIMENS FOR

METASTATIC GERM CELL TUMORS

VeIPVinblastine 0.11 mg/kg IV Push on Days 1 - 2Mesna 400 mg/m IV every 8 hours on Days 1 - 5Ifosfamide 1200 mg/m IV on Days 1 - 5Cisplatin 20 mg/m IV on Days 1 - 5Repeat every 21 days

TIPPaclitaxel 250 mg/m IV on Day 1Ifosfamide 1500 mg/m IV on Days 2 - 5Mesna 500 mg/m IV before ifosfamide, and then 4 and 8 hours

after each ifosfamide dose on Days 2 - 5Cisplatin 25 mg/m IV on Days 2 - 5Repeat every 21 days

2

2

2

2

2

2

2

1

2

Palliative chemotherapy regimen

Conventional dose chemotherapy regimens High-dose chemotherapy regimens

GEMOXGemcitabine 1000 mg/m IV on Days 1 and 8 followed byOxaliplatin 130 mg/m IV on Day 1Repeat every 21 days

Gemcitabine 1250 mg/m IV on Days 1 and 8 followed byOxaliplatin 130 mg/m IV on Day 1Repeat every 21 days

2

2

2

2

3,4

5

Carboplatin 700 mg/m (Body Surface Area) IVEtoposide 750 mg/m IVAdminister 5, 4, and 3 days before peripheral blood stem cell infusion

for 2 cycles

Paclitaxel 200 mg/m IV over 24 hours on Day 1Ifosfamide 2000 mg/m over 4 hours with mesna protection on Days 2 - 4Repeat every 14 days for 2 cycles followed byCarboplatin AUC 7 - 8 IV over 60 minutes Days 1 - 3Etoposide 400 mg/m IV Days 1 - 3Administer with peripheral blood stem cell support at 14 - 21 day

intervals for 3 cycles

2

2

6

2

2

2

7

See Chemotherapy References (TEST-C 2 of 2)

or








Discussion




TEST-C2 of 2

SECOND LINE OR SUBSEQUENT CHEMOTHERAPY REGIMENS FOR

METASTATIC GERM CELL TUMORS

1

2

Loehrer PJ Sr, Lauer R, Roth BJ, et al. Salvage therapy in recurrent germ cell cancer: ifosfamide and cisplatin plus either vinblastine or etoposide. Ann InternMed 1988;109:540-546.

Kondagunta GV, Bacik J, Donadio A, et al. Combination of paclitaxel, ifosfamide, and cisplatin is an effective second-line therapy for patients with relapsedtesticular germ cell tumors. J Clin Oncol 2005;23:6549-6555.

3

4

5

6

7

Pectasides D, Pectasides M, Farmakis D, et al. Gemcitabine and oxaliplatin (GEMOX) in patients with cisplatin-refractory germ cell tumors: a phase II study. Ann Oncol 2004;15:493-497.

Kollmannsberger C, Beyer J, Liersch R, et al. Combination chemotherapy with gemcitabine plus oxaliplatin in patients with intensively pretreated or refractorygerm cell cancer: A study of the German Testicular Cancer Study Group. J Clin Oncol 2004; 22(1):108-114.

De Giorgi U, Rosti G, Aieta M, et al. Phase II study of oxaliplatin and gemcitabine salvage chemotherapy in patients with cisplatin-refractory nonseminomatousgerm cell tumor. Eur Urol 2006;50:893-894.

Einhorn LH, Williams SD, Chamness A, et al. High-dose chemotherapy and stem-cell rescue for metastatic germ-cell tumors. N Engl J Med 2007;357:340-348.

Kondagunta GV, Bacik J, Sheinfeld J, et al. Paclitaxel plus Ifosfamide followed by high-dose carboplatin plus etoposide in previously treated germ cell tumors.J Clin Oncol 2007;25:85-90.

CHEMOTHERAPY REFERENCES








Discussion




TEST-D

PRINCIPLES OF SURGERY

RPLND is the standard approach to the surgical management of nonseminoma germ cell tumor (NSGCT) in both primary andpost-chemotherapy setting.

A template dissection or a nerve-sparing approach to minimize the risk of ejaculatory disorders should be considered in patients

undergoing primary RPLND for stage I nonseminoma.

Referral to high volume centers should be considered for surgical resection of post-chemotherapy.

Completeness of resection is an independent and consistent predictive variable of clinical outcome. In post-chemotherapy RPLND,

surgical margins should not be compromised in an attempt to preserve ejaculation. Additional procedures and resection of adjacent

structures may be required.

Post-chemotherapy RPLND is indicated in metastatic NSGCT patients with a residual retroperitoneal mass following systemicchemotherapy and normalized post-chemotherapy serum tumor markers.

A full bilateral template RPLND should be performed in all patients undergoing RPLND in the post-chemotherapy setting, with the

boundaries of dissection being the renal hilar vessels (superiorly), ureters (laterally), and the common iliac arteries (inferiorly).

The “split and roll” technique in which lumbar vessels are identified and sequentially ligated allows resection of all lymphatic tissue

around and behind the great vessels (aorta, IVC) and minimizes the risk of an in-field recurrence.

masses

Post-chemotherapy setting







Discussion

Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this informationis the AJCC Cancer Staging Manual, Seventh Edition (2010) published bySpringer Science and Business Media LLC (SBM). (For complete informationand data supporting the staging tables, visit .) Any citation

or quotation of this material must be credited to the AJCC as its primarysource. The inclusion of this information herein does not authorize any reuseor further distribution without the expressed, written permission of Springer SBM, on behalf of the AJCC.

www.springer.com

NCCN Guidelines™ Version 1.2011 StagingTesticular Cancer

Serum Tumor Markers (S)

SX Marker studies not available or not performed

SO Marker study levels within normal limits

S1 LDH < 1.5 x N*

hCG (mIu/mL) < 5,000

AFP (ng/ml) < 1,000

S2 LDH 1.5-10 x N

hCG (mIu/mL) 5,000-50,000

AFP (ng/ml) 1,000-10,000

S3 LDH > 10 x N

hCG (mIu/mL) > 50,000

AFP (ng/ml) > 10,000*N indicates the upper l imit of normal for the LDH assay.

and

and

or

or

or

or

ANATOMIC STAGE/PROGNOSTIC GROUPS

Group T N M S (Serum Tumor Markers)

Stage 0 pTis N0 M0 S0

Stage I pT1-4 N0 M0 SX

Stage IA pT1 N0 M0 S0

Stage IB pT2 N0 M0 S0

PT3 N0 M0 S0

PT4 N0 M0 S0

Stage IS Any pT/TX N0 M0 S1-3

Stage II Any pT/Tx N1-3 M0 SX

Stage IIA Any pT/TX N1 M0 S0

Any pT/TX N1 M0 S1

Stage IIB Any pT/TX N2 M0 S0

Any pT/TX N2 M0 S1

Stage IIC Any pT/TX N3 M0 S0

Any pT/TX N3 M0 S1

Stage III Any pT/TX Any N M1 SX

Stage IIIA Any pT/TX Any N M1a S0 Any pT/TX Any N M1a S1

Stage IIIB Any pT/TX N1-3 M0 S2

Any pT/TX Any N M1a S2

Stage IIIC Any pT/TX N1-3 M0 S3

Any pT/TX Any N M1a S3

Any pT/Tx Any N M1b Any S

Table 1 (continued)

American Joint Committee on Cancer (AJCC)TNM Staging System for Testis Cancer (7th ed., 2010)

ST-2



testicular

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