Testicular Cancer Page 1 of 17

This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.

TABLE OF CONTENTS

Suspicious Testicular Cancer ………………………………………………………. Page 2

Nonseminomatous Germ Cell Tumor (NSGCT): workup and clinical stage …… Page 3
Seminoma: workup and clinical stage ……………………………………………... Page 4
Clinical Stage I Nonseminoma: post-orchiectomy management…………………. Page 5
Clinical Stage I Pure Seminoma: post-orchiectomy management……………….. Page 6
Stage IIA, IIB, IIC Nonseminoma: post-orchiectomy management……………... Page 7
Stage IIIA, IIIB Nonseminoma: post-orchiectomy management………………… Page 8
Stage IIIC (poor prognosis) Nonseminoma: initial management ……………….. Page 9
Seminoma: treatment and follow-up ……………………………………………..... Page 10
Management for Advanced Seminoma ……………………………………………. Page 11
Nonseminoma: post-chemotherapy management ………………………………... Page 12
Nonseminoma Surveillance ………………………………………………………... Page 13
Nonseminoma Post-chemotherapy Recurrence ………………………………….. Page 14
APPENDIX A: International Classifications for Germ Cell Cancer …………… Page 15
Suggested Readings ……………………………………………………………….... Page 16
Development Credits ……………………………………………………………….. Page 17

Department of Clinical Effectiveness V6

Approved by the Executive Committee of the Medical Staff 10/31/2017
 Testicular Cancer Page 2 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

CLINICAL INITIAL TUMOR

PRESENTATION EVALUATION HISTOLOGY
See workup and
Nonseminomatous
clinical stage for
germ cell tumor or
nonseminoma on
mixed histology
Page 3

● Radical inguinal orchiectomy

● History and physical Yes ● Evaluate contralateral testicle See workup and
1
● Lifestyle risk assessment Pure seminoma clinical stage for
● Discuss sperm banking
● Alpha-fetoprotein (AFP) (and normal AFP) pure seminoma on
● Beta-hCG (quantitative) Page 4
● Sodium, potassium, chloride, CO2,
Solid
Suspicious BUN, creatinine, magnesium, total
intratesticular Management
testicular bilirubin, AST, ALT, alkaline Non-germ cell
mass on according to
mass phosphatase, albumin, calcium, testicular tumors
ultrasound? tumor type
uric acid, phosphorus, and total
LDH
● Scrotal ultrasound
● Chest x-ray
No Consider other etiologies

1
See Physical Activity, Nutrition, and Tobacco Cessation algorithms; ongoing reassessment of lifestyle risks should be a part of routine clinical practice

Department of Clinical Effectiveness V6

Approved by the Executive Committee of the Medical Staff 10/31/2017
 Testicular Cancer Nonseminomatous Germ Cell Tumor (NSGCT): workup and clinical stage Page 3 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

HISTOLOGY FURTHER WORK-UP

“Average risk Stage I”:
Stage IA (no lymphovascular
Clinical invasion)
Stage I See Page 5
“High risk Stage I”: tumor has
Tumor Yes lymphovascular invasion or
● Repeat AFP, beta-hCG, and markers normalize embryonal predominant or
Yes Stage IB
LDH with appropriate
● CT abdomen and pelvis with half-life?
No
contrast
Treat as “Good Prognosis”1
Mixed or ● CT chest if embryonal Clinical
Imaging metastatic nonseminoma germ
Nonseminomatous carcinoma-predominant or Stage IS
negative for cell tumor (See Page 5)
Germ Cell Tumor abnormal chest x-ray, or
metastasis?
Histology abnormal CT of abdomen/pelvis
● Bone scan if clinically indicated Consider emergency chemotherapy 2
● Brain imaging if clinically Yes
indicated
● Discuss sperm banking
Symptomatic
No from metastases (brain,
lung, retroperitoneal For IIA, IIB,
mass)?
Stages: IIA, “Good and IIC, See
No IIB, IIC, IIIA Prognosis”1 Page 7

Stage IIIB “Intermediate For IIIA

Prognosis”1 and IIIB,
See Page 8
“Poor
1
See Appendix A for International Classifications of Germ Cell Cancer See Page 9
2
Stage IIIC Prognosis”1
It is acceptable to administer emergency chemotherapy to selected patients with advanced metastatic nonseminomatous
germ cell tumor on the basis of clinical presentation before orchiectomy, and without a tissue diagnosis.
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 Testicular Cancer Pure Seminoma: workup and clinical stage Page 4 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

HISTOLOGY FURTHER WORK-UP

Consider occult
metastasis or
Yes See Page 6
Post- consider PET
operative scan
Yes beta-hCG or
LDH
elevated? Clinical Stage I
No
See Page 6
Imaging
Yes negative for
metastasis?
● Repeat AFP, beta-hCG, and LDH
“Intermediate See Page 11
● CT abdomen and pelvis with Yes
Prognosis”1
contrast Extra-
● CT chest if abnormal chest x-ray pulmonary
AFP
Pure seminoma or involved lymph nodes on No metastases?
within normal
histology CT of abdomen/pelvis ● Bone
limits? Metastases in
● Bone scan if clinically indicated ● Liver
● Brain imaging if clinically Yes ● Brain
lymph nodes or
No See Page 10
indicated lungs only “Good
● Discuss sperm banking
Prognosis”1
Suspect
unrelated source of
No
non-specific
AFP? Follow algorithm for
No
Nonseminomatous Germ Cell Tumor

1
See Appendix A for International Classifications of Germ Cell Cancer

Department of Clinical Effectiveness V6

Approved by the Executive Committee of the Medical Staff 10/31/2017
 Testicular Cancer Clinical Stage I Nonseminoma: post-orchiectomy management Page 5 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

TUMOR
MARKERS MANAGEMENT OPTIONS

● Any pT/Tx See Page 12

Stage IS: Consider 2
● N0 ● 3 cycles BEP or for post-
● Beta-hCG or AFP elevated sperm
● M0 ● 4 cycles etoposide and cisplatin chemotherapy
● Metastatic workup negative banking
● S1-3 management

Consider management options:

Yes ● Surveillance (in compliant patients, pT1-2) or
High Risk – probability 2
● Adjuvant chemotherapy (1-2 cycles BEP )
of recurrence is Embryonal
approximately 50% carcinoma
● Consider sperm predominant?
Yes banking See appropriate
Consider management options:
surveillance
● Any pT/Tx ● Surveillance (in compliant patients, pT1-2)
No schedule based
● N0 High risk ● Prophylactic RPLND
2 on treatment
● M0 features1? ● Adjuvant chemotherapy (1-2 cycles BEP )
● S0

No Average Risk – probability

of recurrence is Consider management options:
approximately 30% ● Surveillance (in compliant patients)
● Consider sperm ● Prophylactic RPLND
1
High Risk Features (in the primary tumor): banking
a. Lymphovascular invasion
b. Invasion of tunica vaginalis
c. Invasion of spermatic cord or scrotum (pT3-4)
d. Embryonal carcinoma predominant
2
Medical oncologist should discuss options with patient based on clinical data
BEP = bleomycin, etoposide, and cisplatin
RPLND = retroperitoneal lymph node dissection Department of Clinical Effectiveness V6
Approved by the Executive Committee of the Medical Staff 10/31/2017
 Testicular Cancer Clinical Stage I Pure Seminoma: post-orchiectomy management Page 6 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

TUMOR MANAGEMENT OPTIONS

MARKERS Consider management options:
Surveillance or single-dose
carboplatin AUC = 7 or
Yes AUC = 7 x 2 cycles for all
others
See appropriate
Any of surveillance
● Any pT/Tx Stage IS: Consider the following? schedule based
● N0 ● Horseshoe or pelvic kidney
● Beta-hCG or AFP elevated sperm on treatment
● M0 ● Inflammatory bowel disease
● Metastatic workup negative banking
● S1-3 ● Prior radiotherapy

Most patients with clinical stage IA pure

seminoma can be offered three options:
● Surveillance in compliant patients who are
No
committed to long term follow-up or
Yes ● Radiotherapy to para-aortic with or
● Any pT/Tx Primary without ipsilateral iliac lymph nodes or
● N0 tumor greater than ● Adjuvant carboplatin single dose, AUC =7
● M0 4 cm or pT3-4 ? or AUC = 7 x 2 cycles
● S0 No

Consider
sperm
banking

Department of Clinical Effectiveness V6

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 Testicular Cancer Stage IIA, IIB, IIC Nonseminoma: post-orchiectomy management Page 7 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

TNM PRETREATMENT TREATMENT

STAGE WORKUP

Etoposide
Stage
● Baseline pulmonary and cisplatin
● Any pT/Tx IIB See Page 12
function testing Surgical option: (EP) for
● N1-3 for post-
● Consider baseline retroperitoneal lymph 2 cycles
● M0 chemotherapy
audiometry testing node dissection management
● S0-1 Stage
● Consider sperm banking Stage IIA, IIB and
● Surveillance
Yes IIA
● N0 (markers not elevated) and
Good ● Teratoma component in primary tumor
Prognosis and
● Not embryonal carcinoma No
predominant tumor?
● Bleomycin, etoposide, and
cisplatin (BEP) for 3 cycles or
Yes ● Etoposide and cisplatin for 4 cycles
Total LDH
●
less than 1.5 times
upper limit of normal and
● Beta-hCG less than ● Total LDH 1.5-10 times upper limit of normal or
5,000 mIU/mL and Intermediate
● Beta-hCG 5,000-50,000 mIU/mL or
● AFP less than
Prognosis
● AFP 1,000-10,000 ng/mL
1,000 ng/mL? See Page 8
No for treatment
of Stage III
● Total LDH greater than 10 times upper limit of normal or
Poor
● Beta-hCG greater than 50,000 mIU/mL or
Prognosis
● AFP greater than 10,000 ng/mL

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 Testicular Cancer Stage IIIA, IIIB Nonseminoma: post-orchiectomy management Page 8 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

TREATMENT
TNM STAGE PRETREATMENT
WORKUP
● Bleomycin, etoposide, and cisplatin for
IIC, IIIA 3 cycles or
Good Prognosis
● Etoposide and cisplatin

IIC, IIIA and IIIB: ● Baseline pulmonary ● Total LDH for 4 cycles
● Any pT/Tx function testing less than 1.5 times Yes
upper limit of normal and See Page 12
● Any N, M1a, S0-2, ● Consider baseline
● Beta-hCG less than 5,000 mIU/mL for post-
or N1-3, M0, S2 audiometry testing and chemotherapy
(May be good or ● Consider sperm
● AFP less than No management
intermediate prognosis banking 1,000 ng/mL?
by tumor markers) ● Total LDH 1.5-10 times upper ● Bleomycin,
IIIB limit of normal or etoposide, and
Intermediate ● Beta-hCG 5,000-50,000 mIU/mL cisplatin for
Prognosis or 4 cycles or
● AFP 1,000-10,000 ngk/mL ● Clinical trial
NOTE: See Page 9 for treatment of Stage IIIC

Department of Clinical Effectiveness V6

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 Testicular Cancer Stage IIIC (poor prognosis) Nonseminoma: Initial Management Page 9 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

TNM STAGE TREATMENT

After first cycle, continue for a minimum of
4 cycles:
IIIC, Poor Prognosis: First line
1
● Any pT/Tx, Any N, M1b , Any S Patient with ● Vincristine and cisplatin ● Clinical trial (preferred) or
● Total LDH greater than 10 times respiratory ● Etoposide and cisplatin (limit
● Bleomycin, etoposide, and cisplatin or
upper limit of normal or distress to 3 days in unstable patient) ● Etoposide, ifosfamide, and cisplatin or
● Beta-hCG greater than 50,000 mIU/mL
Yes Second line
or ● Paclitaxel, ifosfamide, and cisplatin (TIP) or
● AFP greater than 10,000 ng/mL
● High dose chemotherapy regimens or
Patient with Primary chemotherapy with or ● Stem Cell Transplant or
symptomatic without surgery if clinically ● Clinical trial (preferred)
To avoid delay in brain metastases indicated
the start of (Monitor pulmonary function tests for patients
chemotherapy, the receiving bleomycin)
Respiratory
diagnosis can be
distress or
made on clinical
symptomatic brain
grounds.
metastases?
Orchiectomy can
See Page 12
be deferred.
for post-
Yes
chemotherapy
● Baseline pulmonary Tumor management
function testing ● Clinical trial preferred or markers
No ● Consider baseline ● Bleomycin, etoposide,
normalized or
audiometry testing cisplatin for 4 cycles plateau2?
● Consider sperm banking
Additional
No
1
M1b - Distant metastases other than to non-regional lymph nodes and lungs
chemotherapy
2
Plateau: The observed rate of decline in tumor markers should be compared to the expected serum half-lives of 5-7 days (AFP) and 2-3 days (beta-hCG). It is
common to see a slower rate of decline after the second cycle of chemotherapy. A continued rate of decline that is much less than the expected half life and
does not normalize should be interpreted as a plateau. The decision to stop chemotherapy should be based on clinical judgement, taking into consideration
the clinical status of the patient, which of the markers are elevated, extent of elevation, and after ruling out potential sources of spurious elevation.

Department of Clinical Effectiveness V6

Approved by the Executive Committee of the Medical Staff 10/31/2017
 Testicular Cancer Seminoma: Treatment and Follow-up Page 10 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

CLINICAL STAGE/TREATMENT FOLLOW-UP RECURRENCE

● History and physical, tumor markers (AFP, beta-hCG, LDH) every 3

months for years 1 and 2, then every 4 months for year 3, then every 6
Adjuvant carboplatin months for years 4-7, then annually for up to 10 years
● CT abdomen/pelvis annually for years 1-3
● Chest x-ray at alternate visits

● History and physical, tumor markers (AFP, beta-hCG, LDH), every 3

months for years 1 and 2, then every 4 months for year 3, then every 6
IA or IB
months for years 4-7, then annually for up to 10 years
No adjuvant therapy
● CT abdomen/pelvis every 6 months for years 1-3, then annually for up to
10 years
● Chest x-ray at alternate visits Treat according to
Tumor histology and stage
● History and physical, tumor markers (AFP, beta-hCG, LDH), and recurrence (post-orchiectomy
chest x-ray every 4 months for year 1, then every 6 months for year 2, then management)
Radiation therapy
annually for up to 10 years
● CT abdomen/pelvis annually for years 1-3

IS
● History and physical, tumor markers (AFP, beta-hCG, LDH), and
chest x-ray every 3-4 months for years 1-3, then every 6 months for year 4,
IIA or IIB Radiation therapy then annually for up to 10 years
● CT abdomen/pelvis every 6 months for year 1, then annually for years
2 and 3

IIC or III See management for advanced seminoma on Page 11

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 Testicular Cancer Management for Advanced Seminoma Page 11 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

CLINICAL STAGE/TREATMENT RESPONSE TO FOLLOW-UP

TREATMENT

● History and physical, tumor markers (AFP, beta-hCG, LDH),

abdominal/pelvic CT every 3 months for years 1 and 2, then
Complete every 4 months for year 3, then every 6 months for years 4-7,
response then annually for up to 10 years
● Chest x-ray at alternate visits
● PET scan as clinically indicated

Good risk EP for 4 cycles

PET negative
IIC or III Partial
PET Consider:
response
Intermediate VIP for 4 cycles ● Radiotherapy
PET positive or
risk ● Biopsy
not feasible
● Surveillance if
less than 3 cm
See Page 14 for nonseminoma
Progression management of post-chemotherapy
tumor recurrence1

EP = etoposide and cisplatin

VIP = etoposide, ifosfamide, and cisplatin
1
Seminoma that is refractory to chemotherapy is rare and should be managed as nonseminoma
Department of Clinical Effectiveness V6
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 Testicular Cancer Nonseminoma: Post-chemotherapy management
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
Page 12 of 17
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

ClLINICAL STAGE RESPONSE TO FOLLOW-UP

CHEMOTHERAPY

Markers negative,
Complete response

IB (or high risk) See Surveillance on Page 13

IS Residual mass,
IIA, IIB, IIC Retroperitoneal lymph
Markers negative, or
node dissection
plateau1

Rising markers or
Salvage treatment See post-chemotherapy recurrence on Page 14
Clinical progression

Markers negative,
Orchiectomy if not already done
Complete response
See Surveillance on Page 13
● Retroperitoneal lymph node dissection
Partial response and resection of any other residual mass
IIIA, IIIB, IIIC
● Orchiectomy if not already performed

Rising markers, or
Salvage treatment See post-chemotherapy recurrence on Page 14
Clinical progression
1
Plateau: The observed rate of decline in tumor markers should be compared to the expected serum half-lives of 5-7 days (AFP) and 2-3 days (beta-hCG). It is common to see a slower rate of decline after
the second cycle of chemotherapy. A continued rate of decline that is much less than the expected half life and does not normalize should be interpreted as a plateau. The decision to stop chemotherapy
should be based on clinical judgement, taking into consideration the clinical status of the patient, which of the markers are elevated, extent of elevation, and after ruling out potential sources of spurious
elevation.
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 Testicular Cancer Nonseminoma Surveillance Page 13 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.

Table 1: IA, IB NONSEMINOMA SURVEILLANCE Table 2: NONSEMINOMA FOLLOW-UP after Complete Response to
Chemotherapy and/or Retroperitoneal Lymph Node Dissection (RPLND)

Year Visits, Markers, and Chest X-ray Abdominal/Pelvic CT Year Visits, Markers, and Chest X-ray Abdominal/Pelvic CT1

1 Every 1-2 months Every 4 months 1 Every 2-3 months Every 6 months

2 Every 2-3 months Every 6 months 2 Every 2-3 months Every 6-12 months

3 Every 3 months Every 6 months 3 Every 4 months Annually

4 Every 4 months Every 8 months 4 Every 6 months Annually

5 Every 6 months Annually 5 Every 6-12 months Annually

6 and above Annually Annually 6 and above Annually Every 12-24 months

1
CT scans for patients treated with chemotherapy. Baseline CT scan for patients status post RPLND

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 Testicular Cancer Nonseminoma: Post-chemotherapy tumor recurrence Page 14 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.
Note: Consider Clinical Trials as treatment options for eligible patients.

RESPONSE TO SUBSEQUENT TREATMENT

TREATMENT
Complete response
Nonseminoma -
and normalization of
Prior
tumor markers
Chemotherapy
See Surveillance on Page 13

Incomplete response Consider adjuvant

and anatomically Resect all
chemotherapy if viable
resectable residual masses
Salvage chemotherapy: malignant tumor
Incomplete ● TIP (preferred)
response or ● VeIP
first relapse ● POMB-ACE
Yes
● Consider HDC
● Consider surgery if solitary site
● Clinical trial (preferred) ● Palliative
● Second or subsequent salvage chemotherapy
Incomplete response
chemotherapy: Response? No or radiotherapy
that is unresectable or
○ Consider HDC ● Best supportive
second relapse ○ TIP care
○ Gemcitabine and oxaliplatin
Potential
No
○ POMB-ACE for salvage?

Yes Third or
subsequent relapse
TIP = paclitaxel, ifosfamide, cisplatin
VeIP = vinblastine, ifosfamide, cisplatin, mesna
POMB-ACE = cisplatin, vincristine, methotrexate and bleomycin alternaing with actinomycin-D, cyclophosphamide, and etoposide
HDC = high-dose chemotherapy and autologous stem cell transplant

Department of Clinical Effectiveness V6

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Testicular Cancer Page 15 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.

APPENDIX A: International Classifications for Germ Cell Cancers 1

NONSEMINOMA SEMINOMA
FEATURES Testes/retroperitoneal primary and Any primary site and
No non-pulmonary visceral metastases and No non-pulmonary visceral metastases and
All Good Markers:
GOOD PROGNOSIS ● AFP less than 1,000 ng/mL and Normal
● Beta-hCG less than 5,000 iu/L (1,000 ng/mL) and Any value
● LDH less than 1.5 times upper limit of normal Any value

FEATURES Testes/retroperitoneal primary and Any primary site and

No non-pulmonary visceral metastases and Non-pulmonary visceral metastases and
Markers any of:
● AFP greater than or equal to 1,000 and Normal
INTERMEDIATE less than or equal to 10,000 ng/mL or
PROGNOSIS
● Beta-hCG greater than or equal to 5,000 iu/L and Any value
less than 50,000 iu/L or
● LDH greater than or equal to 1.5 times normal and Any value
less than 10 times normal

FEATURES Mediastinal primary or No patients classified as poor prognosis

Non-pulmonary metastases

Markers any of:

POOR PROGNOSIS ● AFP greater than 10,000 ng/mL or
● Beta-hCG greater than or equal to 50,000 iu/L
(10,000 ng/mL) or
● LDH greater than 10 times normal
1
From the International Germ Cell Consensus Classification from the International Germ Cell Cancer Collaborative Group

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 Testicular Cancer Page 16 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.

SUGGESTED READINGS
AJCC Cancer Staging Handbook. (2010). (7 ed.). Chicago, IL: American Joint Committee on Cancer.
Albers, P., Siener, R., Krege, S., Schmelz, H. U., Dieckmann, K. P., Heidenreich, A., ... & hrmann, K. U. (2008). Randomized phase III trial comparing retroperitoneal lymph node
dissection with one course of bleomycin and etoposide plus cisplatin chemotherapy in the adjuvant treatment of clinical stage I nonseminomatous testicular germ cell tumors:
AUO trial AH 01/94 by the German Testicular Cancer Study Group. Journal of Clinical Oncology, 26(18), 2966-2972.
Beyer, J., Kramar, A., Mandanas, R., Linkesch, W., Greinix, A., Droz, J. P., ... & Nichols, C. R. (1996). High-dose chemotherapy as salvage treatment in germ cell tumors: a
multivariate analysis of prognostic variables. Journal of Clinical Oncology, 14(10), 2638-2645.
Bokemeyer, C., Kollmannsberger, C., Meisner, C., Harstrick, A., Beyer, J., Metzner, B., ... & Nichols, C. (1999). First-line high-dose chemotherapy compared with standard-dose PEB/
VIP chemotherapy in patients with advanced germ cell tumors: a multivariate and matched-pair analysis. Journal of clinical oncology, 17(11), 3450-3456.
Einhorn, L. H., Williams, S. D., Chamness, A., Brames, M. J., Perkins, S. M., & Abonour, R. (2007). High-dose chemotherapy and stem-cell rescue for metastatic germ-cell tumors.
New England Journal of Medicine, 357(4), 340-348.
Fizazi, K., Delva, R., Caty, A., Chevreau, C., Kerbrat, P., Rolland, F., ... & Malhaire, J. P. (2014). A risk-adapted study of cisplatin and etoposide, with or without ifosfamide, in
patients with metastatic seminoma: results of the GETUG S99 multicenter prospective study. European urology, 65(2), 381-386.
Fizazi, K., Prow, D. M., Do, K. A., Wang, X., Finn, L., Kim, J., ... & Pagliaro, L. C. (2002). Alternating dose-dense chemotherapy in patients with high volume disseminated non-
seminomatous germ cell tumours. British journal of cancer, 86(10), 1555-1560.
Wilkinson, P. M., & Read, G. (1997). International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ
Cell Cancer Collaborative Group. Journal of Clinical Oncology.
Kondagunta, G. V., Bacik, J., Donadio, A., Bajorin, D., Marion, S., Sheinfeld, J., ... & Motzer, R. J. (2005). Combination of paclitaxel, ifosfamide, and cisplatin is an effective second-
line therapy for patients with relapsed testicular germ cell tumors. Journal of Clinical Oncology, 23(27), 6549-6555.
Margolin, K., Doroshow, J. H., Ahn, C., Hamasaki, V., Leong, L., Morgan, R., ... & Tetef, M. (1996). Treatment of germ cell cancer with two cycles of high-dose ifosfamide,
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or without high-dose chemotherapy and autologous hematopoietic stem-cell rescue as first-line treatment for patients with poor-prognosis metastatic germ cell tumors. Journal
of Clinical Oncology, 25(3), 247-256.
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testicular germ cell cancer. Journal of clinical oncology, 18(12), 2413-2418.
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germ cell tumors: treatment results and prognostic factors for survival and toxicity. Journal of clinical oncology, 14(4), 1098-1105.
National Comprehensive Network. Testicular Cancer (Version 2.2017- December 8, 2016) https://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf Accessed September 5,
2017
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testicular cancer: the SWENOTECA management program. Journal of Clinical Oncology, 27(13), 2122-2128. Department of Clinical Effectiveness V6
Approved by the Executive Committee of the Medical Staff 10/31/2017
 Testicular Cancer Page 17 of 17
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers.

DEVELOPMENT CREDITS

This practice algorithm is based on majority expert opinion of the Genitourinary Center Faculty at the University of Texas MD Anderson Cancer Center.
It was developed using a multidisciplinary approach that included input from the following:

Ana Aparicio, MD
John Araujo, MD
Seungtaek Choi, MD
Paul Corn, MD
Olga Fleckenstein♦
Eric Jonasch, MD
Jeri Kim, MD
Karen Hoffman, MD
Deborah Kuban, MDŦ
Andrew Lee, MD
Christopher Logothetis, MD
Yago Nieto, MD
Louis Pisters, MDŦ
Padmanee Sharma, MD
Arlene O. Siefker-Radtke, MD
Nizar M. Tannir, MD
Shi-Ming Tu, MDŦ
Gloria Trowbridge, MSN, RN♦
John Ward, MD
Amado Zurita-Saavedra, MD
Ŧ
Core Development Team Lead
♦
Clinical Effectiveness Development Team
Department of Clinical Effectiveness V6
Approved by the Executive Committee of the Medical Staff 10/31/2017