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  • #16
    NCCN Guidelines Version 1.2011

    The NCCN Clinical Practice Guidelines for the treatment of testicular cancer have been updated to v.1.2011. These are available free of charge after registration with the site. Unlike other versions, there are numerous updates mostly clarifying several terms. Aside from these clarifications, here are some of the most significant changes:

    • For a diagnosis, an ultrasound is now required (the older versions used to say "recommended").
    • A patient that presents with rapidly increasing levels of beta-HCG, symptoms of metastasis, and a testicular mass can skip the I/O and begin chemotherapy immediately (this is presumably to stymie the spread of choriocarcinoma).
    • While all three management strategies are equally accepted, surveillance is now considered the preferred treatment for stage I-A and I-B seminoma. XRT is the preferred treatment if the pathology report states the primary tumor is pT3 or greater than 4 cm or for stage I-S disease.
    • The upper limit for dosing radiation in seminoma has been reduced. For adjuvant XRT and stage I-S disease, the maximum dose was lowered from 30 Gy to 25 Gy and for stage II-A or II-B from 40 Gy to 35 Gy.
    • 1xBEP has been added as an alternative (without full consensus) to 2xBEP for adjuvant chemotherapy for stage I-B nonseminoma.
    • The surveillance intervals for stage I-A and I-B nonseminoma have been spread out. The same applies to surveillance post-RPLND or complete response to chemotherapy.
    • The Guidelines now recommend that patients with recurrent nonseminoma be treated at centers of expertise. On a similar vein, they also recommend that patients having a post-chemotherapy RPLND should have their surgeries performed at high volume centers.
    Last edited by Fed; 04-27-11, 01:03 PM.
    "Life moves pretty fast; if you don't stop and look around once in a while, you could miss it." -Ferris Bueller
    11.22.06 -Dx the day before Thanksgiving
    12.09.06 -Rt I/O; 100% seminoma, multifocal; Stage I-A; Surveillance; Six years out! I consider myself cured.

    Comment


    • #17
      Fed,
      Thanks for posting the update and summary of changes!
      Retired moderator. Husband, left I/O 16Dec2005, stage I seminoma with elevated b-HCG, no LVI, RTx15 (25Gy). All clear ever since.

      Comment


      • #18
        Seminoma Surveillance Change

        I also noticed that the follow-up for Stage I Seminoma has changed the x-ray frequency from alternative visits to "as clinically indicated".

        Kevin
        2 Feb 2009 - GP, Urologist, ultrasound
        3 Feb - Right I/O, Stage 1B (pT2) - Seminoma - 4.5cm , LVI+, Rete Testis "appears negative"
        Pathology 2nd opinion (MSKCC): Rete Testis involvement confirmed
        Treatment 2xCarboplatin: 10 Mar (800mg)/31 Mar (860mg)
        Surveillance protocols: NCCN v2.2009 through Jan 2012 (11 CTs) NCCN v1.2013 - through May 2014 -- All Clear

        Comment


        • #19
          The NCCN Guidelines have been updated to version 2.2011. The only change is a re-write of the discussion section to reflect the changes made in version 1.2011. The link to the Guidelines is a few posts above.
          "Life moves pretty fast; if you don't stop and look around once in a while, you could miss it." -Ferris Bueller
          11.22.06 -Dx the day before Thanksgiving
          12.09.06 -Rt I/O; 100% seminoma, multifocal; Stage I-A; Surveillance; Six years out! I consider myself cured.

          Comment


          • #20
            NCCN Guidelines Updated

            The latest version of the NCCN Guidelines 1.2012 has been posted.

            Major revision throughout - everyone should take a look. The biggest changes are a significant reduction in the recommended number and frequency of CT scans for for follow-up of Seminoma, especially following Carboplatin. Here are a couple of highlights

            Seminoma
            - Surveillance only: CT every 6 months for years 1-2, every 6-12 mo for year 3, then annually for years 4-5 (used to continue for 10 years). Chest x-rays as clinically indicated.
            - Follow-up following Carbo: CT annually for years 1-3 (used to continue for 10 years). Chest x-rays as clinically indicated.
            - Follow up following RT: Ab/Pelvic CT annually for 3 yrs (for only para-aortic RT) (used to be pelvic CT only). Chest x-rays as clinically indicated.

            RT - big new section on how to plan radiation fields and dosages.

            Non-seminoma - it looks mainly like clarification of some wording.

            Kevin
            2 Feb 2009 - GP, Urologist, ultrasound
            3 Feb - Right I/O, Stage 1B (pT2) - Seminoma - 4.5cm , LVI+, Rete Testis "appears negative"
            Pathology 2nd opinion (MSKCC): Rete Testis involvement confirmed
            Treatment 2xCarboplatin: 10 Mar (800mg)/31 Mar (860mg)
            Surveillance protocols: NCCN v2.2009 through Jan 2012 (11 CTs) NCCN v1.2013 - through May 2014 -- All Clear

            Comment


            • #21
              Thanks for posting the update. Downloaded.
              Young Adult Cancer Survivorship by Steve Pake
              April is Testicular Cancer Awareness Month!
              www.stevepake.com
              Feb 2011, Stage IIB, 4xEP, RPLND, PTSD
              My Survivorship Thread | All of my Blogs
              C
              ONTACT ME ANYTIME!

              Comment


              • #22
                Fantastic! Thanks!

                Edit: Just spoke to my oncologist -- we are moving to the new followup schedule immediately, which means that I now only have 2-3 CT scans left (knock on wood) instead of 17 under the previous guidelines. Yay!

                JPM
                Last edited by JPM; 01-26-12, 03:44 PM.
                JPM

                March 2011: Right I/O, Stage IA classic seminoma, 5.0 x 4.5 x 3.5 cm
                May 2011: Single-Agent Carboplatin
                Currently ALL CLEAR

                Comment


                • #23
                  I'm Not Volunteering To Be The 1

                  I am very curious to see what Dana Farber will recommend for surveillance imaging for seminoma when I get my checkup in a few weeks. We've been told that seminoma presents a significant number of relapses out to ten years. The NCCN 2011 guidelines called for A/P CT's annually for years 5-10. Chest X-rays are done as clinically indicated, by what isn't clear but I assume an A/P relapse. The 2012 guidelines changed that and end all imaging at 5 years.

                  Since seminoma rarely raises markers, how are we supposed to know if a relapse is occuring after 5 years? The study used to rationalize reduced imaging referenced in the other thread on adjuvant treatment http://www.tc-cancer.com/forum/showthread.php?t=16792 covers relapse after adjuvant radiation and carbo but I couldn't find anything specific to surveillance alone. The timeframe of the study is relatively short. There are many other studies out there using longer periods that show how the cumulative chances of relapse do continue increasing beyond 5 years, although the rate change over time does flatten out. The chances of a relapse do not drop to zero (nor does it for non-seminoma).

                  Let's say the relapse risk for stage I seminoma declines to only 1% per year after 5 years. That means I could be the 1 in 100 that relapses without any indication for years until the tumor was infringing on organs, i.e., suffering pain or physiological effects. I am not volunteering to be the 1.

                  I didn't volunteer to be the 1 in 250 males that developed TC in my lifetime, nor the 1 in 5000 that developed it after the age of 54.

                  I will admit that annual CT imaging at and beyond my age has advantages for picking up many other cancers that we face later in life. I think it's worth the small risk of CT radiation causing secondary cancers, particularly since good imaging centers are fine-tuning the amount of radiation down to the minimal levels needed to get the job done.

                  If I were younger, I might have a different perspective on eliminating CT's as soon as possible. Thoughts?
                  Paul
                  "Statistics are human beings with the tears wiped off" - Paul Brodeur
                  Diagnosis: 05Sept07 Right I/O: 13Sept07; Pure Seminoma; Surveillance only per NCCN: All Clear August2013 (CT scan, Markers)

                  Comment


                  • #24
                    My Oncologist knew these were coming back at the end of year 1 and was trying to get me over to them 2 years ago. We ended up finding some middle ground after many pleasant discussions on the subject. However, this past summer he did state that although frequency may change, he would be seeing me regularly till year 10... maybe he just enjoys the banter?

                    Paul, although I do share some of your thoughts and anxieties, I think that the guidelines can be negotiated with your caregiver to fit your personal situation. Personally I would be happy to get off the CT schedule, not because I fear radiation exposure but because of the PITA that it is. As far as recurrence after year 5, annual CXR with bloods should be ok.

                    I know I am supposed to have Mod superpowers, but memory is not part of it and I am not sure if I recall more than perhaps one person that had a recurrence here after 5years on this site, if that.
                    Best,

                    Zsolt


                    Friendship is born at that moment when one person says to another; "What! You too? I thought I was the only one." - C.S Lewis

                    “Experience: that most brutal of teachers. But you learn, my God do you learn.” - C.S. Lewis


                    Mass found 11/20/08
                    Left I/O 11/25/08
                    Pathology: Seminoma, Stage 1
                    Surveillance: All Clear since

                    Comment


                    • #25
                      I had my 6-month survey yesterday at Dana-Farber, which was a chest x-ray, markers and exam by a nurse practitioner. I alternate my oncologist and an NP. My onc is out on maternity leave. The NP was new and as usual got the look like "You're too old for this". Yes, I know. But she's nice plus she's a long-haul touring bicyclist who used to cover much of the territory I ride now. She road the Pan Mass Challenge a couple of times.

                      Anyway back to the topic, she checked the long-term orders file and told me that mine include annual A/P CT scans through year 7. She wasn't sure about the chest. I'll have to wait until my next visit in August

                      I don't have the x-ray and marker results yet, but I don't have any reason to suspect anything bad.
                      P-
                      "Statistics are human beings with the tears wiped off" - Paul Brodeur
                      Diagnosis: 05Sept07 Right I/O: 13Sept07; Pure Seminoma; Surveillance only per NCCN: All Clear August2013 (CT scan, Markers)

                      Comment


                      • #26
                        Originally posted by Aegean View Post
                        but memory is not part of it and I am not sure if I recall more than perhaps one person that had a recurrence here after 5years on this site, if that.
                        I'm here since less than a year but I already have seen a dude relapsing after 8 years, and another one asking for testosterone issues recently said he relapsed at 5 years and half. On a facebook group I have seen a guy with a reoccurance after 7 years. All of them were seminoma.
                        But the winner must be the dude who relapsed with chorio after 16 years, must be a 0,001% thing.
                        - early Apr/11: something is "wrong" in my righty
                        - 16/Apr/11: ultrasound find a mass in it
                        - 27/Apr/11: right I/O
                        - 29/Apr/11: stadiation CT scan shows "all clear"
                        - May/11: pathology: 1 cm Seminoma (90% necrotic), no RT/LV invasion
                        - Surveillance....
                        - March/13: relapse - para aortic node 1.7 cm, waiting for treatment...

                        Comment


                        • #27
                          With me having my I/O just a few weeks ago I'm brand new to this, but I too am already worried about the period between 5 and 10 years. My thoughts at this early stage in my experiences is that hopefully by then MRI and CT will be proved effective as each other and I'll then pay for a yearly MRI scan between years 5 and 10 myself (the regime here ends CT scans at 5years)
                          Last edited by steveb_uk; 02-24-12, 01:43 PM.
                          Jan 2012 suspicious lump detected, AFP 4, HCG 3, LDH 207 (UL 192)
                          Feb 2012 Seminoma, 5cm x 4cm, no LVI/RTI, pT1, Stage 1A, Surveillance, joined TRISST
                          Mar 2013 (1 year) relapse, Stage 2B, 2x Nodes 2.1 and 2.3cm (iliac and para-aortic)
                          Apr 2013 Carboplatin AUC10 x 3 cycles (Phase 2 trial), complete
                          Jun 2013, nodes down to 5mm, back on surveillance
                          ​Jun 2014, 1 yr post chemo CT Scan, all clear

                          Comment


                          • #28
                            I have been managing my own surveillance schedule and thus consult the guidelines for timing. This is the first time I have looked to the 2012 version and I realize that the "clarification" of wording on the nonseminoma follow-up guidelines (slide TEST-12) are rather weird.

                            The three choices for patient types are:
                            1) Surveillance only (italics theirs)
                            2) Complete response to chemo and RPLND (bold mine)
                            3) RPLND only

                            Well, what does someone who had chemo (adjuvant) only like myself do? I'm planning to use the "surveillance" schedule, but the presence of the italicized "only" makes it really seem like they're trying to make it clear that this is not for patients who have had any additional treatment. In the treatment chart it clearly shows chemo only as an option, yet for follow-up it acts as if chemo and RPLND are always paired.

                            Am I missing something and/or an idiot?

                            Comment


                            • #29
                              Did you have a non-seminoma & got 1 or 2X BEP? If so, I believe you can safely follow table 2. Even though it says chemo *and* RPLND I think they meant to say Chemo with or without RPLND. It is the only thing that makes sense to me, but I could be wrong.

                              Dave
                              Jan, 1975: Right I/O, followed by RPLND
                              Dec, 2009: Left I/O, followed by 3xBEP

                              Comment


                              • #30
                                Originally posted by Davepet View Post
                                Did you have a non-seminoma & got 1 or 2X BEP? If so, I believe you can safely follow table 2. Even though it says chemo *and* RPLND I think they meant to say Chemo with or without RPLND. It is the only thing that makes sense to me, but I could be wrong.

                                Dave
                                Yes, 1B nonseminoma, BEPx2. That is what I would like to assume as well but it is rather oddly worded. Especially strange given that this was a "clarification" - which excludes an entire patient population.

                                Comment

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