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Testicular cancer

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Updated 2023 EAU guidelines for the diagnosis and management of testicular cancer.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of testicular cancer are prepared by our editorial team based on guidelines from the American Urological Association (AUA 2023), the European Association of Urology (EAU 2023), the European Association of Urology (EAU/ESPU 2023,2021), the European Reference Network on Rare Adult Solid Cancers (EURACAN/ESMO 2022), the U.S. Preventive Services Task Force (USPSTF ...
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Screening and diagnosis

Indications for screening: as per USPSTF 2011 guidelines, do not screen for testicular cancer in asymptomatic adolescent or adult males.
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  • Self-examination

  • Diagnosis

Classification and risk stratification

Staging: as per AUA 2023 guidelines, use the TNM staging system to guide management decisions.
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TNM classification for testicular cancer
Tumor classification
Tx: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Germ cell neoplasia in situ
T1: Tumor limited to testis (including rete testis invasion) without lymphovascular invasion
T1a: Tumor < 3 cm in size (only for pure seminoma)
T1b: Tumor ≥ 3 cm in size (only for pure seminoma)
T2: Tumor limited to the testis (including rete testis invasion) with lymphovascular invasion; or tumor invading hilar soft tissue or epididymis or penetrating visceral mesothelial layer covering the external surface of tunica albuginea with or without lymphovascular invasion
T3: Tumor directly invades spermatic cord with or without lymphovascular invasion
T4: Tumor invades scrotum with or without lymphovascular invasion
Lymph node classification
Nx: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis with lymph node mass ≤ 2 cm in greatest dimension and ≤ 5 nodes positive, none > 2 cm in greatest dimension
N2: Metastasis with lymph node mass > 2 cm but ≤ 5 cm in greatest dimension; or > 5 nodes positive, none > 5 cm; or evidence of extranodal extension of tumor
N3: Metastasis with lymph node mass > 5 cm in greatest dimension
Distant metastasis
M0: No distant metastasis
M1a: Non-retroperitoneal nodal or pulmonary metastases
M1b: Non-pulmonary visceral metastases
Serum tumor marker classification
Sx: Markers not available or not obtained
S0: Marker levels within normal limits
S1: LDH < 1.5 times ULN and hCG < 5,000 mU/mL and α-fetoprotein < 1,000 ng/mL
S2: LDH 1.5-10 times ULN or hCG 5,000-50,000 mU/mL or α-fetoprotein 1,000-10,000 ng/mL
S3: LDH > 10 times ULN or hCG > 50,000 mU/mL or α-fetoprotein > 10,000 ng/mL
Stage cannot be fully assessed

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  • Risk stratification

Diagnostic investigations

Physical examination: as per EAU 2023 guidelines, perform a physical examination of supraclavicular, cervical, axillary, and inguinal lymph nodes, breast, and testicles.
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  • Diagnostic imaging

  • Imaging for staging

  • Serum tumor markers

  • Evaluation of the contralateral testis

Medical management

General principles: as per AUA 2023 guidelines, manage a solid mass in the testis identified by physical examination or imaging as a malignant neoplasm until proven otherwise.
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  • Management of neoplasia in situ

  • Management of locoregional disease (seminoma)

  • Management of locoregional disease (nonseminoma)

  • Management of advanced/metastatic disease (seminoma)

  • Management of advanced/metastatic disease (nonseminoma)

  • Salvage treatment

  • Thromboprophylaxis

  • Fertility preservation

Surgical interventions

Radical orchiectomy: as per AUA 2023 guidelines, perform radical inguinal orchiectomy in patients with a testicular lesion suspicious for malignant neoplasm and normal contralateral testis. Avoid performing trans-scrotal orchiectomy.
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  • Testis-sparing surgery

Specific circumstances

Prepubertal patients: as per EAU/ESPU 2023 guidelines, recognize that testicular tumors in prepubertal patients have a lower incidence and a different histologic distribution compared to adolescent and adult patients.
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Follow-up and surveillance

Follow-up: as per AUA 2023 guidelines, elicit history, perform a physical examination, and obtain cross-sectional imaging of the abdomen (with or without the pelvis) every 4-6 months for the first 2 years and then every 6-12 months in subsequent 3-5 years in patients with clinical stage I seminoma electing surveillance. Consider obtaining routine surveillance imaging of the chest and serum tumor markers assessment as clinically indicated.
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  • Management of relapse