Editing Germ Cell Tumours (section)

=== General principles ===

* Any post-pubertal male, regardless of age, should be treated according to adult treatment guidelines.
* Management decisions should be made in a multidisciplinary setting involving experienced clinicians in urology, medical oncology, radiation oncology, pathology, and radiology.
** '''Review of primary tumor specimens by experienced pathologists is recommended.'''
*** Expert review of pathologic specimens should be considered in clinical scenarios where treatment decisions will be impacted.
**** Studies have shown that expert pathology review can change the pathological subtype in 1-4% of cases.[https://pubmed.ncbi.nlm.nih.gov/16045777/][https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704081/]
* '''<span style="color:#ff0000">Management decisions should be based on imaging obtained within the preceding 4 weeks and serum tumor markers (hCG and AFP) within the preceding 10 days.</span>'''
** Due to the rapid growth of many GCT, particularly NSGCT, there is a risk of disease progression between staging studies and intervention. Therefore, risk adapted management decisions (i.e. RPLND for Stage IIA disease) should be made based on recent imaging and serum tumor marker levels to avoid undertreatment.
* '''In patients with normal serum tumor markers (hCG and AFP) and equivocal imaging findings for metastasis, consider repeat imaging in 6-8 weeks to clarify the extent of disease prior to making a treatment recommendation'''.
* '''<span style="color:#ff0000">Prior to definitive management, patients should be counseled about the risks of (3):</span>'''
*# '''<span style="color:#ff0000">Hypogonadism</span>'''
*#* '''<span style="color:#ff00ff">Hormone levels in long-term survivors of testicular cancer</span>'''
*#** Population: 1235 patients with history of unilateral orchiectomy for testicular cancer and adjuvant RPLND only, radiotherapy only, or chemotherapy
*#** Compared to healthy controls
*#** '''Results'''
*#*** '''Approximately 11 years follow-up'''
*#*** '''No significant difference in serum testosterone between testicular cancer patients and healthy controls'''
*#*** Significantly higher age-adjusted LH in testicular cancer patients
*#** Nord, Carina, et al. "[https://pubmed.ncbi.nlm.nih.gov/12932930/ Gonadal hormones in long-term survivors 10 years after treatment for unilateral testicular cancer.]" ''European urology'' 44.3 (2003): 322-328.
*#* Over long-term follow-up, up to 10-15% of patients will have low serum testosterone levels or will require testosterone replacement therapy
*# '''<span style="color:#ff0000">Infertility</span>'''
*#* '''At diagnosis, up to 50% have impaired semen parameters and 10% are azoospermic'''
*#* '''<span style="color:#ff0000">Sperm cryopreservation</span>'''
*#** '''<span style="color:#ff0000">Timing</span>'''
*#*** '''<span style="color:#ff0000">Pre-orchiectomy</span>'''
*#**** '''Consider in patients without a normal contralateral testicle or with known subfertility'''
*#*** '''<span style="color:#ff0000">Post-orchiectomy</span>'''
*#**** '''Recommended before treatment (other than orchiectomy) is initiated in patients who are undecided or are planning future paternity.'''
*#***** '''Virtually all patients become azoospermic after chemotherapy, and 50-80% of patients with normal semen parameters at diagnosis return to these levels within 2 and 5 years, respectively.'''
*#***** '''Recovery of spermatogenesis after radiation therapy for seminoma may take 2-3 years or longer.'''
*#**** '''Consider in patients that do not require further treatment with a normal contralateral testicle or known fertility, who''' '''are undecided or are planning future paternity''', given the potential risk of pathologic process (testicular cancer, trauma) involving the normal contralateral testicle
*# '''<span style="color:#ff0000">Contralateral tumour</span>'''
*#* '''Patients with a history of GCT or GCNIS should be informed of risks of a second primary tumor, while rare, is significantly increased in the contralateral testis'''