J Urol 2000;164:381–384. Adv Urol 2018;2018:8781698. A trial of antibiotics is never warranted in a man with a mass suspicious for GCT but can be considered in men with pain without a mass on further workup. NCCN clinical practice guidelines in oncology: testicular cancer J Natl Compr Canc Netw. The role of retroperitoneal lymphadenectomy in clinical stage B testis cancer: the Indiana University experience (1965 to 1989). The study showed 6 grade-3 adverse events, but no immune-related adverse events were reported. If tumor marker levels are elevated and persistently rising, the panel recommends third-line therapy (see TEST-G, previous page and above, and “Third-Line Therapy,” subsequent section). Adv Urol 2018;2018:7272541. Surgical management of complex residual masses following systemic chemotherapy for metastatic testicular germ cell tumours. However, the high survival rate associated with surveillance depends on adherence to periodic follow-up examinations and subsequent chemotherapy for the 20%–30% of patients who experience relapse. However, mildly elevated levels of AFP or beta-hCG after orchiectomy must be interpreted with caution. Sweeney CJ, Hermans BP, Heilman DK, . Additionally, heterophile antibodies have been reported to result in substantially elevated false-positive beta-hCG results (>400 IU/L), so clinicians should consider repeating the test using a different assay if a false-positive result is suspected due to the absence of radiographic evidence of disease.17,18. Adverse surgical outcomes associated with robotic retroperitoneal lymph node dissection among patients with testicular cancer. J Urol 2011;186:2249–2252. Eur J Cancer 2000;36:472–475. Clin Cancer Res 2016;22:1265–1273. Maintaining success, reducing treatment burden, focusing on survivorship: highlights from the third European consensus conference on diagnosis and treatment of germ-cell cancer. Hearing loss before and after cisplatin-based chemotherapy in testicular cancer survivors: a longitudinal study. Jones RH, Vasey PA. Part II: testicular cancer--management of advanced disease. Cancer 2003;97:1624–1629. Stephenson AJ, Bosl GJ, Bajorin DF, . Similarly, further workup should be considered before initiating treatment of mildly elevated beta-hCG (generally <20 IU/L). Ann Oncol 2008;19:1619–1623. Histologically pure seminoma with elevated alpha-fetoprotein: a clinicopathologic study of ten cases. However, larger phase II and phase III trials of pembrolizumab in patients with metastatic or refractory testicular cancers are needed to fully assess the value of this therapy, especially in treating MSI-H/dMMR testicular GCTs. Int J Cancer . Shanmugalingam T, Soultati A, Chowdhury S, . If embryonal, yolk sac, choriocarcinoma, or seminoma elements are found in the residual mass, then 2 cycles of chemotherapy with EP; paclitaxel, ifosfamide, and cisplatin (TIP); VIP; or vinblastine, ifosfamide, and cisplatin (VelP) should be administered. The frequency of these tests varies with the primary treatment modality received by the patient (see Tables 5 and 6 on TEST-B, page 1541). Saito K, Suzuki K, Iwasaki A, . Testicular Cancer Treatment Regimens References 1. Nonrandomized comparison of primary chemotherapy and retroperitoneal lymph node dissection for clinical stage IIA and IIB nonseminomatous germ cell testicular cancer. Therefore, pembrolizumab was well tolerated but appears to have limited single-agent activity in refractory GCTs. Loriot Y, Pagliaro L, Fléchon A, . If an elevation of serum AFP is due to a metastatic nonseminomatous GCT, then the AFP typically will be steadily rising. The recommended third-line palliative chemotherapy options for patients with intensively pretreated, cisplatin-resistant, or refractory GCTs are combinations of gemcitabine with paclitaxel and/or oxaliplatin,121–127 or oral etoposide.128 The recommendation for gemcitabine and oxaliplatin (GEMOX) is based on data from phase II studies investigating the efficacy and toxicity of GEMOX in patients with relapsed or cisplatin-resistant GCTs.122,124,126 These studies showed that GEMOX is safe for patients with cisplatin-resistant testicular GCTs and may offer a chance of long-term survival.122,124,126 Gemcitabine and paclitaxel is another option that has shown promising results in a phase II study.123 Follow-up results showed long-term disease-free survival in patients who showed progression after high-dose chemotherapy and who had not received prior paclitaxel or gemcitabine.125 A phase II study of patients with treatment-resistant GCTs also found the combination of gemcitabine, oxaliplatin, and paclitaxel to be effective with acceptable toxicity.121 The overall response rate was 51% with 5% of patients experiencing a complete response. J Clin Oncol 2011;29:2178–2184. Pectasides D, Pectasides M, Farmakis D, . Repeated measurement of serum tumor markers is important because TNM staging is based on postorchiectomy values. RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Salem M, Gilligan T. Serum tumor markers and their utilization in the management of germ-cell tumors in adult males. Kollmannsberger C, Beyer J, Liersch R, . Several risk factors for testicular cancer have been identified, including personal or family history of testicular cancer and cryptorchidism. In patients with clinical stage I seminoma, the National Comprehensive Cancer Network (NCCN) recommends surveillance with history and physical examination (H&P) and abdominal and pelvic computed tomography (CT). Int Urol Nephrol 2006;38:621–624. J Clin Oncol 2007;25:4365–4369. Testicular prostheses for testis cancer survivors: patient perspectives and predictors of long-term satisfaction. Category 2A: The recommendation is based on lower-level evidence and there is uniform NCCN consensus. This selection from the NCCN Guidelines for Testicular Cancer focuses on recommendations for the management of adult patients with nonseminomatous GCTs. Huddart RA, Reid AM. Predominance of embryonal carcinoma has also been proposed as a prognostic indicator of relapse in stage I nonseminoma, with several studies showing that a high proportion of embryonal carcinoma in the primary tumor (>50%) is associated with an increased risk of relapse.37,44–51 However, very few patients have a high volume of embryonal carcinoma without also having LVI, and the value of embryonal carcinoma predominance in predicting relapse in the absence of LVI is unclear.37,44,47,51 Therefore, predominance of embryonal carcinoma is not used by the NCCN Guidelines to risk-stratify patients with stage I nonseminoma. Testicular Cancer Clinical Practice Guidelines in Oncology NCCN Categories of Evidence and Consensus Category 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) and there is uniform NCCN consensus. Turnbull C, Rahman N. Genome-wide association studies provide new insights into the genetic basis of testicular germ-cell tumour. Treatment options after primary nerve-sparing RPLND include either surveillance or chemotherapy, depending on the number of positive lymph nodes identified (see TEST-10, page 1535). De La Pena H, Sharma A, Glicksman C, . These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Culine S, Kramar A, Théodore C, . Phase II study of daily oral etoposide in refractory germ cell tumors. Kondagunta GV, Bacik J, Bajorin D, . Testicular cancer (TC) represents 5% … Gemcitabine and oxaliplatin (GEMOX) in patients with cisplatin-refractory germ cell tumors: a phase II study. Oncological outcomes in patients with stage I testicular seminoma and nonseminoma: pathological risk factors for relapse and feasibility of surveillance after orchiectomy. Rarely, a teratoma may contain elements of a somatic cancer, such as a sarcoma or adenocarcinoma, and it is then referred to as a “teratoma with somatic type malignancy.”. Mod Pathol 1996;9:762–766. A refined risk stratification scheme for clinical stage 1 NSGCT based on evaluation of both embryonal predominance and lymphovascular invasion. J Urol 2005;174:557–560. Any clinician seeking to apply or consult theNCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. Dieckmann KP, Anheuser P, Schmidt S, . Am J Surg Pathol 2018;42:306–311. Second malignancies among survivors of germ-cell testicular cancer: a pooled analysis between 13 cancer registries. Ann Oncol 2002;13:1616–1620. In select circumstances, an MRI can be considered to replace an abdominal/pelvic CT. All imaging in this setting is performed with contrast. Stage II disease may be treated with systemic therapy or RPLND. If there is a partial radiographic response to chemotherapy (as indicated by the presence of residual masses) and tumor marker levels are normal, then surgical resection of all residual masses is recommended (see TEST-12, page 1537).105–108 As previously stated, referral to high-volume centers should be considered for surgical resection of masses postchemotherapy. Elevated serum concentrations of beta-hCG may be present with both seminomatous and nonseminomatous tumors. Culine S, Kerbrat P, Kramar A, . Vasdev N, Moon A, Thorpe AC. Eur Urol 2004;46:209–215. Nichols CR, Catalano PJ, Crawford ED, . Etoposide and cisplatin chemotherapy for metastatic good-risk germ cell tumors. Adjuvant therapy for stage IB germ cell tumors: one versus two cycles of BEP. Results and outcome of retroperitoneal lymph node dissection for clinical stage I embryonal carcinoma--predominant testis cancer. Trevino KE, Esmaeili-Shandiz A, Saeed O, . J Clin Oncol 2005;23:6549–6555. Surveillance in stage I nonseminomatous germ cell tumours of the testis. The frequency of these tests varies with the primary treatment modality received by the patient (see Tables 6 and 7, pages 1541 and 1542, respectively). The NCCN Clinical Practice Guidelines for the treatment of testicular cancer have been updated to v.1.2010. Neurotoxicity among survivors of testicular cancer: a population-based study. Can Urol Assoc J 2015;9:381–384. Prognostic risk factors that identify patients with clinical stage I nonseminomatous germ cell tumors at low risk and high risk for metastasis. Stage II and stage III disease treated with systemic chemotherapy should be followed by surgical resection of any residual masses. 2017. Cardiovascular morbidity in long-term survivors of metastatic testicular cancer. Long-term follow-up of Anglian Germ Cell Cancer Group surveillance versus patients with stage 1 nonseminoma treated with adjuvant chemotherapy. 2009 Jun;7(6):672-93. doi: 10.6004/jnccn.2009.0047. If testicular cancer is being considered as a possibility, then a transscrotal ultrasound with Doppler should be performed (see TEST-1, page 1530). Do retroperitoneal extragonadal germ cell tumours exist? Loehrer PJ, Sr., Gonin R, Nichols CR, . Clin Oncol (R Coll Radiol) 2019;31:653–658. It would be extraordinarily rare for a patient to have an AFP >1,000 ng/mL or a beta-hCG >5,000 IU/L and yet have no evidence of metastatic disease on imaging studies. Rock CL, Thomson C, Gansler T, et al. Do nonseminomatous germ cell tumors of the testis with lymphovascular invasion of the spermatic cord merit staging as pT3? The ongoing international phase III TIGER trial aims to determine whether high-dose or conventional-dose chemotherapy is more effective in the second-line setting for patients with relapsed disease. J Clin Oncol 2000;18:358–362. In a recent retrospective study, a total of 76 relapses were detected among 561 patients with stage I nonseminoma managed using active surveillance after orchiectomy.66 All relapses were detected with either rising serum tumor markers or abnormal routine follow-up CT scans; not a single relapse was detected using chest X-ray alone. Eur J Cancer 2006;42:820–826. Urology 2004;63:556–561. Staging of testicular GCTs is based on determination of the extent of disease and assessment of postorchiectomy levels of serum tumor markers.12 The tumor (T), node (N), and metastasis (M) staging system used by the AJCC is the internationally accepted standard for cancer staging and is a major factor influencing prognosis and treatment decisions. J Clin Oncol 2003;21:113–122. The eighth edition of the AJCC Cancer Staging Manual also introduced changes to pathologic staging based on the type of spermatic cord involvement. Le DT, Durham JN, Smith KN, . Sperm banking should be discussed with patients of reproductive age, if clinically indicated, before undergoing any therapeutic intervention that may compromise fertility.28–31 If sperm banking is desired, it may be performed before orchiectomy in patients with risk factors for infertility (atrophic contralateral testicle, history of infertility), but certainly should be considered before subsequent therapy in patients who desire future fertility. Cumulative burden of morbidity among testicular cancer survivors after standard cisplatin-based chemotherapy: a multi-institutional study. Risk of contralateral testicular cancer: a population-based study of 29,515 U.S. men. J Urol 2003;170:1159–1162. Although both regimens are well tolerated and cure approximately 90% of patients with good-risk disease,96,99 4 cycles of EP should be considered in patients with reduced or borderline GFR and in patients over the age of 50. Toxicities associated with cisplatin-based chemotherapy and radiotherapy in long-term testicular cancer survivors. Although nonseminoma is the more clinically aggressive tumor subtype, 5-year survival rates exceed 70% with current treatment options, even in patients with advanced or metastatic disease. To assess response after second-line therapy, a CT scan with contrast of the chest, abdomen, pelvis, and any other sites of disease is recommended. Ann Oncol 2018;29:209–214. Int J Urol 2002;9:539–544. Randomized trial comparing bleomycin/etoposide/cisplatin with alternating cisplatin/cyclophosphamide/doxorubicin and vinblastine/bleomycin regimens of chemotherapy for patients with intermediate- and poor-risk metastatic nonseminomatous germ cell tumors: Genito-Urinary Group of the French Federation of Cancer Centers Trial T93MP. McHugh DJ, Feldman DR. Conventional-dose versus high-dose chemotherapy for relapsed germ cell tumors. Four cycles of BEP vs four cycles of VIP in patients with intermediate-prognosis metastatic testicular non-seminoma: a randomized study of the EORTC Genitourinary Tract Cancer Cooperative Group. J Clin Oncol 2010;28:1706–1713. This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Testicular Cancer focuses on the diagnosis and management of nonseminomatous GCTs (to view the complete and most recent version of these guidelines, visit NCCN.org). Meinardi MT, Gietema JA, van der Graaf WT, . In patients with clinical stage I seminoma, the National Comprehensive Cancer Network (NCCN) recommends surveillance with history and physical examination (H&P) and …
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