Primary Therapy Options A. External-beam radiotherapy 4,5 i. Include para-aortic and ipsilateral pelvic nodes to 20-25Gy ("dog leg" or "hockey stick"). ii. Boost grossly involved nodes by 10 Gy. B. Chemotherapy 6-8 i. Consider BEP  3 cycles when optimal radiotherapy not possible; EP  4 cycles may be considered in patients with contraindication to bleomycin. ii. Consider BEP  3 cycles, in extensive stage IIB disease (same as stage IIC); EP  4 cycles may be considered in patients with contraindication to bleomycin.A. P/E. B. Tumour markers. C. CXR (or CT thorax). D. CT abdomen/ pelvis (new baseline). Residual Disease (see section on residual disease below) Follow-up (click) T1-4, N3, M0, T1-4, Nx, M1 (Stages IIC, and III Seminomas): Indications include retro-peritoneal lymph node disease >5 cm in diameter, or distant metastases. Preparation for Therapy A. Baseline CBC, biochemistry, liver function tests, alkaline phosphatase. B. Discuss semen cryopreservation with the patient. Primary Therapy A. Cisplatin-based combination chemotherapy. 7, 8, 13 B. Good risk as per IGCCC: BEP  3; EP  4 may be considered if bleomycin is contraindicated. C. Intermediate risk as per IGCCC: BEP  4; VIP x 4 may be considered if contraindication to# Background
Testicular germ cell tumours (GCTs) account for about 1% of all new cancer cases in men (agestandardized incidence rate of 5.5 per 100,000 men in Canada); however, they are the most common type of cancer in adolescents and young adults aged 15 to 29 years. There are approximately 120 new cases of all types of testicular cancer in Alberta each year, most of which are GCTs. Testicular GCTs are a highly curable type of cancer with five-year survival rates of over 95%.  ii. Extensive lung metastases iii. Pure choriocarcinoma iv. B-HCG >5000 IU/L v. IGCCCG Poor risk disease G. Bone scan if relevant symptoms H. PET scans should only be used to evaluate residual masses post chemotherapy for seminoma; PET scan should not otherwise be routinely used Treatment A. Radical inguinal orchiectomy is the standard initial treatment. B. In rare instances, orchiectomy can be deferred in patients with life-threatening metastatic disease when a diagnosis of NSGCT (ex. unequivocally elevated AFP and/or B-HCG >5000) or seminoma (biopsy of metastatic site) is made, so as to not delay chemotherapy. Orchiectomy can be later performed after chemotherapy.

# Seminomas T1-4, N0, M0 (Stage I Seminomas):
Primary Therapy A. Management options include primary surveillance, adjuvant radiotherapy or adjuvant chemotherapy. 2 B. Surveillance is the preferred option and is indicated for the individual who will adhere with the surveillance protocol (below). C. Patients with a higher risk for recurrence (e.g. presence of a tumour >4 cm and/or rete testes involvement) should discuss risk factors with oncologists and could be offered radiotherapy; however, even patients in the high risk group have a 70-80% 3 chance of being relapse free without adjuvant treatment, as such surveillance remains the preferred option. D. Radiotherapy: 20-25 Gy in 10-20 fractions, to para-aortic  ipsilateral pelvic lymph nodes ("dog leg" or "hockey stick"). E. Chemotherapy (carboplatin AUC 7 x 1-2 cycles) can be considered in select cases and should be reviewed in multidisciplinary rounds. F. The possibility of semen cryopreservation should be discussed.

# Follow-up (click) T1-4, N1-2, M0 (Stages IIA and IIB Seminomas):
Indications include retroperitoneal lymph node disease <5 cm in diameter. bleomycin. D. Consider prophylactic anticoagulation to reduce risk of venous thromboembolic disease during chemotherapy. E. Primary prophylaxis with G-CSF is required for patients receiving ifosfamide.

# Management of Residual Disease
A.If residual mass  3 cm, consider PET scan 6-12 weeks after day 21 of the last cycle. C. If PET is positive, cases should be reviewed in multidisciplinary rounds for discussion of best therapeutic approach. Generally, these can be observed over time, especially if mildly positive. In cases where FDG-PET remains strongly positive over time and/or the mass is growing, complete surgical resection or biopsy is the management of choice; Radiation is an option in select cases, although this has been inadequately studied.
Follow-Up: Table 1. Seminomas Follow-up 14,15 Year since treatment completion P/E = physical exam, CXR = chest x-ray, markers = alpha-fetoprotein (FP), beta-human chorionic gonadotropin (-hCG), and lactate dehydrogenase (LDH) hormone levels: LH (Luteinizing hormone), FSH (Follicular stimulating hormone), total testosterone A. To reduce radiation risk/exposure, consideration of low dose CT scans is recommended where possible/feasible. B. If abnormality with hormone testing, endocrinology and/or urology referral should be considered.
C. Unless high risk features are present (i.e. tumour size >4 cm, lymphovascular invasion, or rete testis invasion), consider discharge to primary care provider after year 5 (i.e. for year 7 and 9 surveillance). 16

# Nonseminoma T1-4, N0, M0, S0 (Stage I Nonseminomas):
Indications include disease localized to testicle only and normalization of tumour markers post radical orchidectomy (t 12 = 24-48 hours for -hCG, 5-7 days for FP).
Primary Therapy 18,19 A. Options include surveillance (see below), bilateral nerve sparing RPLND, or adjuvant chemotherapy. C. For patients in any risk group, surveillance is the preferred option. RPLND and adjuvant BEP chemotherapy x 1 cycle are options in select cases.
i. High risk features for relapse include pure embryonal histology, lymphovascular invasion, and rete testis invasion. 16 ii. If choosing surveillancemeasuring tumour markers monthly in year one is recommended. 16 iii. If RPLND is performed and lymph node metastases are present, adjuvant chemotherapy may be consideredsee section below on Stage II NSGCT.   HDCT and PBSCT  A. Refer patients to local stem cell transplant program for management of stem cell collection and transplant.

# Follow-up (click)
Adjunctive Care For All Patients A. Patients with brain metastases should be referred to multidisciplinary rounds for review. i. Management options may include radiotherapy and/or neurosurgery. B. After completion of all chemotherapy, resection of any residual masses should be performed.

# Unique Clinical Situations
Late Relapses: A. A late relapse is defined as relapse occurring >2 years after completion of primary chemotherapy. B. This does not occur frequently, and as such, all cases should be reviewed in a multidisciplinary setting. C. These patients have disease that is more chemotherapy resistant and immediate surgical resection of recurrent disease should be undertaken if feasible, irrespective of the level of tumour markers. D. Whether or not to offer chemotherapy post-surgical resection in this setting is controversial but could be considered. E. TIP has been used with modest success in patients who relapse late that are not surgical candidates.

# Non-Testicular Germ Cell Tumours (GCT

# Development and Revision History
This guideline was developed by a multidisciplinary working group comprised of members from the Alberta Provincial GU Tumour Team, external participants identified by the Working Group Lead, and a methodologist from the Guideline Resource Unit. The draft guideline was externally reviewed and endorsed by members of the Alberta Provincial GU Tumour Team who were not involved in the guideline's development, including radiation oncologists, medical oncologists, urologists, nurses, pathologists, and pharmacists. A detailed description of the methodology followed during the guideline development process can be found in the Guideline Resource Unit Handbook.

# This guideline was originally developed in 2005.
A formal review of the guideline will be conducted in 2023. If critical new evidence is brought forward before that time, however, the guideline working group members will revise and update the document accordingly.
Abbreviations FP, Alpha fetoprotein; -hCG, Beta-human chorionic gonadotropin; CBC, Complete blood count; CT, Computed tomography; CXR, Chest X-ray; FSH, Follicular stimulating hormone; GCT, Germ cell tumour; LDH, Lactate dehydrogenase; LH, Luteinizing hormon; P/E, Physical exam;