Saudi Oncology Society clinical management guidelines for testicular germ cell tumors

In this report, guidelines for the evaluation, medical and surgical management of transitional cell carcinoma of testicular germ cell tumors is presented. It is categorized according to the stage of the disease using the tumor node metastasis staging system, 7th edition. The recommendations are presented with supporting level of evidence.


INTRODUCTION
Testicular cancer is a rare disease. A total of 38 cases have been diagnosed in 2006, with an age standardized rate (ASR) of 0.5 cases per 100,000 representing 1% of all diagnosed cancer in Saudi Arabia (www.scr.org.sa).
Due to the rarity of the disease and the need for multidisciplinary approach in managing testis cancer the group recommended that ' All testicular cancer cases should be managed in tertiary care centers. ' A panel of experts in the management of testicular cancer was gathered under the umbrella of the Saudi Oncology Society. It included Urologists, Medical oncologists and Radiation oncologists. A subgroup was formed to work on testes cancer. The subgroup reviewed the literature, current international guidelines in testicular cancer management. The subgroup brought their recommendation to the panel where all references were discussed in several meetings and the guidelines were finalized.
We have used the following evidence level: • (EL1) High level: well-conducted phase III randomized trials or meta-analysis. • (EL2) intermediate level: good phase II trials or phase III with limitations. • (EL3) low level: Observational/retrospective studies or expert opinion.

STAGING
The American Joint Committee on Cancer (AJCC) TNM staging for testis cancer (7 th edition 2010) was used.

RISK STRATIFICATION
The international Germ Cell Cancer Collaborative Group Risk Classification [1] should be used: Serum AFP less than 1000 ng/mL, beta-hCG less than 5000 mIU/mL and LDH less than 1.5 times the upper limit of normal Four cycles of VeIP regimen (Vinblastine, Ifosfamide and cisplatin). [11] (EL2) or 3.1.5.2.
Management of patients failing second line chemotherapy: patients will be treated with combination paclitaxel and Gemcitabine for those who did not receive paclitaxel before. [13] 3.2.
Non-seminoma: all stages will undergo urgent inguinal orchiectomy. Trans-scrotal biopsy or orchiectomy for any intra-testicular lesion is absolutely contra-indicated. Further treatment will depend on the stage as follows: 3.2.1.
Treatment will depend on the presence of any the following risk factors: [ Serum AFP >10,000 ng/mL; serum beta-hCG >50,000 mIU/mL; LDH more than 10 times upper limit of normal

TREATMENT
Will depend on the histological subtype as follows: 3.1. Seminoma: All stages should undergo urgent inguinal orchiectomy. Trans-scrotal biopsy or orchiectomy for any intra-testicular lesion is absolutely contra-indicated. Further treatment will depend on the stage: 3.1.1.
Surveillance: this should be done only in compliant patients with primary tumors less than 4 cm and less than pT2. [ [20][21] if the nodal metastasis is in the primary landing zone. Further therapy will depend on the pathological stage as in item 3.  [12] 3.2.5. Management of patients failing second line chemotherapy: patients will be treated with paclitaxel and Gemcitabine if they did not receive paclitaxel before [13] 3.2.6.
Management of patients failing all lines of chemotherapy: In the case of markers progression after salvage treatment and exhaustion of all possible chemotherapeutic options, resection of residual tumors (desperation surgery) should be considered if complete resection of all tumors seems technically feasible. [26]