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NCCN Flash Updates: NCCN Guidelines® and NCCN Compendium® for Testicular Cancer

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and the NCCN Drugs and Biologics Compendium (NCCN Compendium®) for Testicular Cancer. These NCCN Guidelines® are currently available as Version 1.2020.

  • Initial Evaluation (TEST-1)
    • Footnote b was updated: Mildly elevated, non-rising AFP levels may not indicate presence of germ cell tumor. Decisions to treat should not be based on AFP values <20 ng/mL. Further workup should be considered before initiating treatment for mildly elevated beta-hCG (generally <20 IU/L) since other factors, including hypogonadism and marijuana use, can cause false-positive results.
    • Footnotes were added:
      • Footnote d: Consider measuring baseline levels of gonadal function.
      • Footnote e: Inguinal exploration with exposure of testis with direct observation and directed biopsy.
  • Pure Seminoma: Postdiagnostic Workup and Clinical Stage (TEST-2)
    • Footnote m was added: The panel recommends staging tumors with discontinuous invasion of the spermatic cord as pT3 (high-risk stage I) and not as M1 (stage III) as is recommended in the 8th edition of the AJCC Cancer Staging Manual. If surveillance is elected, the pelvis should be included in the imaging due to a higher risk of pelvic relapses in these patients.
  • Nonseminoma: Postdiagnostic Workup and Clinical Stage (TEST-6)
    • In the evaluation of clinical stage, IS was moved from the top of pathway to the bottom pathway
    • Footnote hh was updated: Risk factors include lymphovascular invasion or invasion of spermatic cord or scrotum. Some centers consider predominance of embryonal carcinoma as an additional risk factor for relapse.
  • Stage I with and without Risk Factors, Stage IS (TEST-7)
    • Footnote jj was added: Retroperitoneal lymph node dissection (RPLND) is preferred as primary treatment for tumors with transformed teratoma. Patients with stage I pure teratoma and normal markers should receive either surveillance or RPLND.
  • Stage IS, IIA S1, IIB S1, IIC, IIIA, IIIB, IIIC, and Brain Metastases (TEST-11)
    • Response category was updated here and on TEST-12 to read “Partial response, residual masses with abnormal AFP and/or beta-hCG levels”
  • Postchemotherapy Management of Partial and Incomplete Response to Primary Treatment (TEST-12)
    • Partial response categories were added here and on TEST-14
      • Elevated and rising AFP and/or beta-hCG levels
      • Elevated but stable AFP and/or beta-hCG levels
      • Mildly elevated and normalizing AFP and/or beta-hCG levels
  • Recurrence and Second-Line Therapy (TEST-13)
    • There were significant changes made to Recurrence and Second-Line Therapy with prior chemotherapy
  • Third-Line Therapy (TEST-15)
    • “Clinical trial” was added as a preferred option in Third-Line Therapy
  • Third-Line Chemotherapy Regimens for Metastatic Germ Cell Tumors (TEST-G)
    • Dosing was added to the following Other Recommended Regimens for patients who previously did not receive high dose chemotherapy
      • Gemcitabine/paclitaxel/oxaliplatin
        • Gemcitabine 800 mg/m2 IV over 30 minutes on Days 1 and 8
        • Paclitaxel 80 mg/m2 IV over 60 minutes on Days 1 and 8
        • Oxaliplatin 130 mg/m2 IV over 2 hours on Day 1
          • Administered on a 21-day cycle for 8 cycles
      • Gemcitabine/oxaliplatin
        • Gemcitabine 1000–1250 mg/m2 IV over 30 minutes on Days 1 and 8 followed by
        • Oxaliplatin 130 mg/m2 IV over 2 hours on Day 1
          • Administered on a 21-day cycle until disease progression or unacceptable toxicity
      • Gemcitabine/paclitaxel
        • Gemcitabine 1000 mg/m2 IV over 30 minutes on Days 1, 8, and 15
        • Paclitaxel 100 mg/m2 IV over 60 minutes on Days 1, 8, and 15
          • Administered on a 28-day cycle for 6 cycles
      • Etoposide (oral)
        • Etoposide 50–100 mg PO daily on Days 1–21
          • Administered on a 28-day cycle until disease progression or unacceptable toxicity
    • Dosing was added to the following regimen that is Useful in Certain Circumstances for patients who previously did not receive high dose chemotherapy
      • Pembrolizumab (for MSI-H/dMMR tumors)
        • Pembrolizumab 200mg IV over 30 minutes on Day 1
          • Administered on a 21-day cycle until disease progression or unacceptable toxicity
  • Third-Line Chemotherapy Regimens for Metastatic Germ Cell Tumors (TEST-G 2 of 3)
    • Dosing was added to the following Preferred Regimens for patients who previously did receive high-dose chemotherapy
      • Gemcitabine/paclitaxel/oxaliplatin
        • Gemcitabine 800 mg/m2 IV over 30 minutes on Days 1 and 8
        • Paclitaxel 80 mg/m2 IV over 60 minutes on Days 1 and 8
        • Oxaliplatin 130 mg/m2 IV over 2 hours on Day 1
          • Administered on a 21-day cycle for 8 cycles
      • Gemcitabine/oxaliplatin
        • Gemcitabine 1000–1250 mg/m2 IV over 30 minutes on Days 1 and 8 followed by
        • Oxaliplatin 130 mg/m2 IV over 2 hours on Day 1
          • Administered on a 21-day cycle until disease progression or unacceptable toxicity
      • Gemcitabine/paclitaxel
        • Gemcitabine 1000 mg/m2 IV over 30 minutes on Days 1, 8, and 15
        • Paclitaxel 100 mg/m2 IV over 60 minutes on Days 1, 8, and 15
          • Administered on a 28-day cycle for 6 cycles
      • Etoposide (oral)
        • Etoposide 50–100 mg PO daily on Days 1–21
          • Administered on a 28-day cycle until disease progression or unacceptable toxicity
    • Dosing was added to the following regimens that are Useful in Certain Circumstances for patients who previously did receive high-dose chemotherapy:
      • Pembrolizumab (for MSI-H/dMMR tumors)
        • Pembrolizumab 200 mg IV over 30 minutes on Day 1
          • Administered on a 21-day cycle until disease progression or unacceptable toxicity
  • Staging (ST-1, ST-2, and ST-3)
    • Changes were made on the staging pages to align with the American Joint Committee on Cancer (AJCC) TNM Staging Classification for Testis Cancer 8th ed., 2017

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium®), the NCCN Biomarkers Compendium®, the NCCN Chemotherapy Order Templates (NCCN Templates®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.

To view the NCCN Guidelines for Patients®, please visit NCCN.org/patientguidelines.

Free NCCN Guidelines apps for iPhone, iPad, and Android smartphones & tablets are now available! Visit NCCN.org/apps

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