Full Guidelines
Reproduced from the official EAU 2025 publication.
Recommendations
Recommendations for diagnosis and staging of testicular cancer
| Recommendation | Strength rating |
|---|---|
| Discuss sperm banking with all men prior to starting treatment for testicular cancer (TC). | Strong |
| Perform bilateral testicular ultrasound in all patients with suspicion of TC. | Strong |
| Perform physical examination including supraclavicular, cervical, axillary, and inguinal lymph nodes, breasts, and testicles. | Strong |
| Measure serum tumour markers both before and after orchidectomy taking into account half-life kinetics. | Strong |
| Perform orchidectomy and pathological examination of the testis to confirm the diagnosis and to define the local extension (pT category). In a life-threatening situation due to extensive metastasis, commence chemotherapy prior to orchidectomy. | Strong |
| Perform contrast enhanced computerised tomography (CECT) scan (chest, abdomen, and pelvis) in patients with diagnosis of TC. In case of iodine allergy or other limiting factors occur, perform abdominal and pelvic magnetic resonance imaging (MRI). | Strong |
| Perform MRI of the brain (or brain CECT if not available) in patients with multiple lung metastases, or high beta subunit of human Chorionic Gonadotropin (ß-hCG) values, or those in the poor-prognosis International Germ Cell Cancer Collaborative Group (IGCCCG) risk group. | Strong |
| Do not use positron-emission tomography computed tomography or bone scan for staging. | Strong |
| Encourage patients with TC to perform self-examination and to inform first degree male relatives of the need for self- examination. | Weak |
| Discuss testis-sparing surgery with frozen section examination in patients with a high likelihood of having a benign testicular tumour which are suitable for enucleation. | Strong |
| Discuss biopsy of the contralateral testis to patients with TC and high-risk for contralateral germ cell neoplasia “in situ”. | Strong |
Recommendations for the treatment of stage I seminoma
| Recommendation | Strength rating |
|---|---|
| Fully inform the patient about all available management options, including surveillance or adjuvant chemotherapy after orchidectomy, as well as treatment- specific recurrence rates and acute and long-term side effects. | Strong |
| Offer surveillance as the preferred management option if facilities are available and the patient is compliant. | Strong |
| Offer one dose of carboplatin at area under curve (AUC) 7 if adjuvant chemotherapy is considered. | Strong |
| Do not perform adjuvant treatment in patients at very low risk of recurrence (no risk factors). | Strong |
| Do not routinely perform adjuvant radiotherapy. | Strong |
| Adjuvant radiotherapy should be reserved only for highly selected patients not suitable for surveillance and with contraindication for chemotherapy. | Strong |
Recommendations for the treatment of stage I non-seminomatous germ cell tumour of the testis
| Recommendation | Strength rating |
|---|---|
| Inform patients about all management options after orchidectomy: surveillance, adjuvant chemotherapy, and retroperitoneal lymph node dissection, including treatment-specific recurrence rates as well as acute and long-term side effects. | Strong |
| Offer surveillance or risk-adapted treatment based on lymphovascular invasion. | Strong |
| Discuss one course of cisplatin, etoposide, bleomycin as an adjuvant treatment alternative in patients with stage I non- seminomatous germ cell tumour if patients are not willing to undergo or comply with surveillance. | Strong |
Recommendations for risk-adapted treatment for clinical stage I non- seminomatous germ cell tumour based on vascular invasion
| Recommendation | Strength rating |
|---|---|
| Stage IA (pT1, no vascular invasion): low risk | |
| Offer surveillance if the patient is willing and able to comply. | Strong |
| Offer adjuvant chemotherapy with one course of cisplatin, etoposide, bleomycin (BEP) in low-risk patients not willing (or unsuitable) to undergo surveillance. | Strong |
| Stage IB (pT2-pT4): high risk | |
| Offer adjuvant chemotherapy with one course of BEP, or surveillance and discuss the advantages and disadvantages. | Strong |
| Offer surveillance to patients not willing to undergo adjuvant chemotherapy. | Strong |
| Offer nerve-sparing retroperitoneal lymph node dissection (RPLND) to highly selected patients only; those with contraindication to adjuvant chemotherapy and unwilling to accept surveillance. | Strong |
Recommendations for the Prevention of thromboembolism events during chemotherapy
| Recommendation | Strength rating |
|---|---|
| Balance the individual patients’ potential benefits and risks of thrombo-prophylaxis during first-line chemotherapy in men with metastatic germ cell tumours. | Weak |
| Avoid use of central venous-access devices during first-line chemotherapy whenever possible. | Weak |
Recommendations for the treatment of metastatic germ cell tumours
| Recommendation | Strength rating |
|---|---|
| Treat low-volume non-seminomatous germ cell tumour (NSGCT) stage IIA/B with elevated markers like metastatic good- or intermediate-prognosis risk group IGCCCG with three or four cycles of cisplatin, etoposide, bleomycin (BEP). | Strong |
| Nerve-sparing retroperitoneal lymph node dissection when performed by an experienced surgeon in a specialised centre is the recommended initial treatment in clinical stage (CS) IIA NSGCT disease without elevated tumour markers. | Weak |
| Repeat staging after six weeks before making a final decision on further management should be considered in patients with small volume (CS IIA < 2 cm) marker-negative NSGCT. | Weak |
| Treat metastatic NSGCT (stage > IIC) with an intermediate prognosis with four cycles of standard BEP. | Strong |
| Treat metastatic NSGCT with a poor prognosis and favourable marker decline with four cycles of BEP. | Strong |
| Assess tumour marker decline after one cycle of standard chemotherapy in metastatic NSGCT with a poor-prognosis. With unfavourable decline, consider chemotherapy intensification. | Weak |
| Perform surgical resection of visible (> 1 cm in longest diameter) residual masses after chemotherapy for NSGCT when serum levels of tumour markers are normal or normalising. | Strong |
| Offer cisplatin chemotherapy according to IGCCCG prognosis groups, or alter-natively radiotherapy to seminoma patients with stage II A/B and, inform the patient of potential long-term side effects of both treatment options. | Weak |
| Treat seminoma stage IIC and higher, with primary chemotherapy according to IGCCCG classification (BEP x 3 in good- prognosis and BEP x 4 in intermedi-ate prognosis). | Strong |
Classification & Evidence Tables
| T - Primary Tumour1 |
|---|
| pTX Primary tumour cannot be assessed (see note1) |
| pT0 No evidence of primary tumour (e.g., histological scar in testis) |
| pTis Intratubular germ cell neoplasia (carcinoma in situ)+ |
| pT1 Tumour limited to testis (including rete testis) and epididymis without vascular/lymphatic invasion and without invasion of the epididymis*# |
| pT2 Tumour limited to testis with vascular/lymphatic invasion, or invading hilar soft tissue or the epididymis or tumour extending through tunica albuginea with involvement of visceral tunica vaginalis**# |
| pT3 Tumour invades spermatic cord with or without vascular/lymphatic invasion** |
|---|
| pT4 Tumour invades scrotum with or without vascular/ lymphatic invasion |
| N - Regional Lymph Nodes - Clinical |
| NX Regional lymph nodes cannot be assessed |
| N0 No regional lymph node metastasis |
| N1 Metastasis with a lymph node mass 2 cm or less in greatest dimension or multiple lymph nodes, none more than 2 cm in greatest dimension |
| N2 Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or more than 5 nodes positive, none more than 5 cm; or evidence of extranodal extension of tumour |
| N3 Metastasis with a lymph node mass more than 5 cm in greatest dimension |
| Pn - Regional Lymph Nodes - Pathological |
| pNX Regional lymph nodes cannot be assessed |
| pN0 No regional lymph node metastasis |
| pN1 Metastasis with a lymph node mass 2 cm or less in greatest dimension and 5 or fewer positive nodes, none more than 2 cm in greatest dimension |
| pN2 Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or more than 5 nodes positive, none more than 5 cm; or evidence of extranodal extension of tumour |
| pN3 Metastasis with a lymph node mass more than 5 cm in greatest dimension |
| M - Distant Metastasis |
| MX Distant metastasis cannot be assessed |
| M0 No distant metastasis |
| M1 Distant metastasis** |
| M1a N on-regional lymph node(s) or lung metastasis | |
|---|---|
| M1b D istant metastasis other than non-regional lymph nodes and lung | |
| S - Serum tumour markers (Pre-chemotherapy) | |
| SX Serum marker studies not available or not performed | |
| S0 Serum marker study levels within normal limits | |
| LDH (U/l) β- hCG (mIU/mL) AFP (ng/mL) | |
| S1 | < 1.5 x N and < 5,000 and < 1,000 |
| S2 | 1.5-10 x N or 5,000-50,000 or 1,000-10,000 |
| S3 | > 10 x N or 50,000 or > 10,000 |
| Good-prognosis group | |
|---|---|
| NSGCT 5-year PFS 90% 5-year survival 96% | All of the following criteria: • T estis/retro-peritoneal primary • N o non-pulmonary visceral metastases • AFP < 1,000 ng/mL • β -hCG < 5,000 IU/L (1,000 ng/mL) • LDH < 1.5 x ULN |
| SGCT 5-year PFS 89% 5-year survival 95% | All of the following criteria: • A ny primary site • N o non-pulmonary visceral metastases • Normal AFP • Any β-hCG • Any LDH |
| Intermediate-prognosis group | |
| NSGCT 5-year PFS 78% 5-year survival 89% | Any of the following criteria: • T estis/retro-peritoneal primary • N o non-pulmonary visceral metastases • AFP 1,000 - 10,000 ng/mL or • β-hCG 5,000 - 50,000 IU/L or • LDH 1.5 - 10 x ULN |
| SGCT 5-year PFS 79% 5-year survival 88% | All of the following criteria: • A ny primary site N on-pulmonary visceral metastases • Normal AFP • Any β-hCG • Any LDH |
|---|---|
| Poor-prognosis group | |
| NSGCT 5-year PFS 54% 5-year survival 67% | Any of the following criteria: • M ediastinal primary • N on-pulmonary visceral metastases • AFP > 10,000 ng/mL or • β -hCG > 50,000 IU/L (10,000 ng/mL) or • LDH > 10 x ULN |
| SGCT | No patients classified as poor- prognosis |
| Histological type | Seminoma | Non-seminoma |
|---|---|---|
| Pathological risk factors | • T umour size • I nvasion of the rete testis | • Lympho-vascular invasion in peri- tumoural tissue |
| pr | eferred |
|---|
| al | terna(cid:13)ve |
|---|
| pr | eferred |
|---|
| Modality | Year 1 | Year 2 | Year 3 | Years 4 & 5 | After 5 years |
|---|---|---|---|---|---|
| Tumour markers ± doctor visit | 2 times | 2 times | 2 times | Once | Further management according to survivorship care plan |
| Chest X-ray | - | - | - | - | |
| Abdominopelvic Computed tomography (CT)/ magnetic resonance imaging | 2 times | 2 times | Once at 36 months | Once at 60 months |
| Modality | Year 1 | Year 2 | Year 3 | Years 4 & 5 | After 5 years |
|---|---|---|---|---|---|
| Tumour markers ± doctor visit | 4 times* | 4 times | 2 times | 1-2 times | Further management according to survivorship care plan |
| Chest X-ray | 2 times | 2 times | Once, in case of LVI+ | At 60 months if LVI+ | |
| Abdominopelvic Computed tomography (CT)/ magnetic resonance imaging | 2 times | At 24 months** | Once at 36 months*** | Once at 60 months*** |
| Modality | Year 1 | Year 2 | Year 3 | Years 4 & 5 | After 5 years |
|---|---|---|---|---|---|
| Tumour markers ± doctor visit | 4 times | 4 times | 2 times | 2 times | Further management according to survivorship care plan** |
| Chest X-ray | 1-2 times | Once | Once | Once | |
| Abdominopelvic Computed tomography (CT)/ magnetic resonance imaging | 1-2 times | At 24 months | Once at 36 months | Once at 60 months | |
| Thorax CT | 1-2 times* | At 24 months* | Once at 36 months* | Once at 60 months* |