eUpdate – Testicular Seminoma and Non-Seminoma Treatment Recommendations

Published: 29 June 2017. Authors: Oldenburg J and Horwich A, on behalf of the ESMO Guidelines Committee

Clinical Practice Guidelines

This update refers to the Testicular seminoma and non-seminoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Oldenburg J, Fosså SD, Nuver J et al, Ann Oncol 2016; 24 (Suppl 6): vi125–vi132.

Section

Post-orchiectomy staging and risk assessment

Text update

A new third paragraph is added: In summary, stage I tumours appear to be confined to the testis (although those in stage I with rising post-orchidectomy markers are accepted to have subclinical metastatic disease). Stage II tumours have abdominal node metastases IIA < 2 cm diameter, IIB 2–5 cm and IIC > 5 cm) and stage III tumours have more widespread metastases. Serum tumour marker (S) levels for prognostication of metastatic non-seminomas are classified into three groups, as follows:

All the markers must be in the stated range to be considered S1;
Only one marker needs to be in the stated range to be considered S2 or S3.

Section

Tables 1–5.

Text update

This eUpdate provides a new Table 1 and a new Table 2 to replace the original Table 1. ‘Post-orchiectomy staging of metastatic seminoma and non-seminoma according to AJCC/UICC and IGCCCG classification.’ Original Tables 2–4 are now Tables 3–5.

Serum tumour markers for non-seminoma testicular cancer

---	LDH (U/L)	HCG (IU/L)	AFP (ng/mL)
SX	Marker studies not available or not carried out	Marker studies not available or not carried out	Marker studies not available or not carried out
S0	Normal	Normal	Normal
S1	< 1.5x ULN	< 5000	< 1000
S2	1.5–10x ULN	5000–50 000	1000–10 000
S3	> 10x ULN	> 50 000	> 10 000

AFP, alpha-fetoprotein; hCG, human chorionic gonadotropin; LDH, lactate dehydrogenase; ULN, upper limit of normal.

The IGCCCG Prognostic Classification for metastatic germ cell cancers

Good-prognosis group

Non-seminoma (56% of cases)	All of the following criteria:
5-year PFS 89% 5-year survival 92%	Testicular/retroperitoneal primary No non-pulmonary visceral metastases AFP < 1000 ng/mL hCG < 5000 IU/L (1000 ng/mL) LDH < 1.5x ULN
Seminoma (90% of cases)	All of the following criteria:
5-year PFS 82% 5-year survival 86%	Any primary site No non-pulmonary visceral metastases Normal AFP Any hCG Any LDH

Intermediate prognosis group

Non-seminoma (28% of cases)	---
5-year PFS 75%	Testicular/retroperitoneal primary No non-pulmonary visceral metastases
5-year survival 80%	And any of the following criteria: hCG 5000–50 000 IU/L or LDH 1.5–10x ULN
Seminoma (10% of cases)	All of the following criteria:
5-year PFS 67% 5-year survival 72%	Any primary site Non-pulmonary visceral metastases Normal AFP Any hCG Any LDH

Poor prognosis group

Non-seminoma (16% of cases)	Any of the following criteria:
5-year PFS 41% 5-year survival 48%	Mediastinal primary Non-pulmonary visceral metastases AFP > 10 000 ng/mL or hCG > 50 000 IU/L (10 000 ng/mL) or LDH > 10x ULN
Seminoma	No patients classified as poor prognosis

Pre-chemotherapy serum tumour markers should be assessed after orchiectomy and immediately prior to the administration of chemotherapy (same day).

AFP, alpha-fetoprotein; hCG, human chorionic gonadotropin; IGCCCG, International Germ Cell Cancer Collaborative Group; LDH, lactate dehydrogenase; PFS, progression-free survival; ULN, upper limit of normal.