NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)TesticularCancerrsionJanuaryVersion2.2022,1/04/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:16:50AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dex*TimothyGilligan,MD,MS/Chair?CaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussignstitute*DanielW.Lin,MD/Vice-ChairωFredHutchinsonCancerResearchCenter/SeattleCancerCareAlliance*RahulAggarwal,MD??TUCSFHelenDillerFamilyComprehensiveCancerCenterAdityaBagrodia,MDωUTSouthwesternSimmonsComprehensiveCancerCenter*NicholasCost,MDωUniversityofColoradoCancerCenterDanielCosta,MD?§UTSouthwesternSimmonsComprehensiveCancerCenterNancyB.Davis,MD?Vanderbilt-IngramCancerCenterIthaarH.Derweesh,MDωUCSanDiegoMooresCancerCenterAlexandraDrakaki,MD,PhD?UCLAJonssonComprehensiveCancerCenterHamidEmamekhoo,MD?UniversityofWisconsineCancerCenterChristopherEvans,MDωUCDavisComprehensiveCancerCenteresPanelDisclosuresDarrenR.Feldman,MD?MemorialSloanKetteringCancerCenter*DanielM.Geynisman,MD?FoxChaseCancerCenterStevenL.Hancock,MD§TStanfordCancerInstitutePeterHumphrey,MD,PhD≠YaleCancerCenter/SmilowCancerHospitalEllisG.Levine,MD?RoswellParkCancerInstituteThomasLongo,MDωDukeCancerInstituteBenjaminMaughan,MD,PharmD?HuntsmanCancerInstituteattheUniversityofUtahBradleyMcGregor,MD?Dana-Farber/BrighamandWomen'senterPaulMonk,MD?TheOhioStateUniversityComprehensiveCancerCenter-JamesCancerHospitalandSoloveResearchInstitute*JoelPicus,MD?SitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineSoroushRais-Bahrami,MDωO'NealComprehensiveCancerCenteratUABPhilipSaylor,MD?MassachusettsGeneralHospitalCancerCenterNirmishSingla,MDωTheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsKanishkaSircar,MD≠TheUniversityofTexasDavidC.Smith,MD?UniversityofMichiganRogelCancerCenterBenjaminA.Teply,MD?Fred&PamelaBuffettCancerCenterKatherineTzou,MD§MayoClinicCancerCenterDavidVanderWeele,MD,PhD?RobertH.LurieComprehensiveCancerCenterofNorthwesternUniversityDavidVaughn,MD?AbramsonCancerCenterheUniversityofPennsylvaniaKosjYamoah,MD,PhD§MoffittCancerCenterJonathanYamzon,MDωCityofHopeNationalMedicalCenterdiMScPhD?Hematology/HematologyoncologyTInternalmedicine?Medicaloncology≠Pathology§Radiotherapy/RadiationoncologyωUrology*DiscussionwritingcommitteememberVersion2.2022,1/04/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:16:50AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexlievesthatthebestlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceandsusAllrecommendationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.SummaryoftheGuidelinesUpdatesWorkup,PrimaryTreatment,andPathologicDiagnosis(TEST-1)PureSeminoma:PostdiagnosticWorkupandClinicalStage(TEST-2)?StageIA,IB(TEST-3)?StageIS(TEST-3)?StageIIA,IIB(TEST-4)?StageIIC,III(TEST-4)?PostchemotherapyManagement(TEST-5)Nonseminoma:PostdiagnosticWorkupandClinicalStage(TEST-6)?StageIwithandwithoutRiskFactors,StageIS(TEST-7)?StageIIA,IIB(TEST-8)?PostchemotherapyManagement(TEST-9)?PostsurgicalManagement(TEST-10)?StageIS,IIAS1,IIBS1,IIC,IIIA,IIIB,IIIC,andBrainMetastases(TEST-11)?PostchemotherapyManagementofPartialResponsetoPrimaryTreatment(TEST-12)RecurrenceandSecond-LineTherapy(TEST-13)PriorSecond-LineTherapy;PostchemotherapyManagement(TEST-14)Third-LineTherapy(TEST-15)Follow-upforSeminoma(TEST-A)Follow-upforNonseminoma(TEST-B)PrinciplesofRadiotherapyforPureTesticularSeminoma(TEST-C)RiskClassificationforAdvancedDisease(TEST-D)PrimaryChemotherapyRegimensforGermCellTumors(TEST-E)Second-LineChemotherapyRegimensforMetastaticGermCellTumors(TEST-F)Third-LineChemotherapyRegimensforMetastaticGermCellTumors(TEST-G)PrinciplesofSurgeryforGermCellTumors(TEST-H)PrinciplesofImaging(TEST-I)TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNationalComprehensiveCancerNetworkAllrightsreservedTheNCCNGuidelinesandtheillustrationshereinmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2022.Version2.2022,1/04/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.odifiedToassessresponseaftertreatmentCTwithcontrastofchestabdomenpelvisandanyothersitesofdiseaseisrecommendedPEThasnoroleinodifiedToassessresponseaftertreatmentCTwithcontrastofchestabdomenpelvisandanyothersitesofdiseaseisrecommendedPEThasnoroleinassessingtreatmentresponsendresidualmassesfollowingchemotherapyinpatientswitheminomaAlsoforTESTanddexelinesforTesticularCancerfromVersionincludeTheDiscussionsectionhasbeenupdatedtoreflectthechangesinthealgorithm.elinesforTesticularCancerfromVersionincludeFootnoterraddedFootnoterraddedtopageandmodified:PatientswhoareathigherrbleomycinrelatedcomplicationsBleomycinbasedregimens?FootnoteamodifiedrbleomycinrelatedcomplicationsBleomycinbasedregimensshouldnotbegiventopatients>50yearsofage,shouldnotbegiventopatients>50yearsofage,thoseatincreasedriskforpulmonarycomplications,thosewithunderlyinglungdisseminatedriskforpulmonarycomplications,thosewithunderlyinglungoforTESTandbeoforTESTandModifiedNegativemarkers,nomassModifiedNegativemarkers,nomass<1cm(transaxiallongaxis)onperformedatcompletionofchemotherapy.TEST-2ModifiedNegativemarkers,nomassModifiedNegativemarkers,nomass≥1cm(transaxiallongaxis)on?Footnotejmodified:Elevatedvaluesshouldbe?Footnoteadded:Craniocaudalaxisshouldnotbe?Footnoteadded:Craniocaudalaxisshouldnotbeused.?Footnoteremoved:Referraltohigh-volumecentersshouldbeFollowdeclining?Footnoteremoved:Referraltohigh-volumecentersshouldbeconsideredforsurgicalconsideredforsurgicalresectionofmassespost-chemotherapy.TEST-10tsurgicalManagement?Footnotelmodified:Eg,beta-hCG>5000IU/L,non-pulmonaryvisceralmetastases,orextensivelungmetastasis,orneurologic?pNpN2:pNpN2:?PostChemotherapyManagementidecisplatinpModified:RepeatPET/CTorCTscaninidecisplatinFootnoteuuFootnoteuuadded:Thisisararecircumstance.BEPfor2cyclesisanoption.TEST-11panoption.TEST-11TEST-7pFootnoteooadded:Recommendreferraltoahigh-volumecentersurgeryifclinicallyurgeryifclinicallyindicated?Footnoteppmodified:RPLNDispreferredasprimarytreatmentforstageIItumorswithsomatictypemalignancystageIItumorswith(previouslyreferredtoastransformedteratoma),andshouldbeconsideredforstageIItumorswithteratomapredominanceinpatientswithnormalmarkers.?Footnoteadded:RPLNDshouldbeconsideredforstageIItumorswithteratomapredominanceinpatientswithnormalmarkers.UPDATESVersion2.2022,1/04/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:16:50AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexelinesforTesticularCancerfromVersioninclude?Footnotexxadded:Considerbrainimagingandtesticularultrasoundinpatientswithelevatedorrisingmarkersafterprimaryorsecondarychemotherapytoevaluateforoccultbrainmetastasesorcontralateralprimarydisease.TEST-15?Third-LineTherapy:pModified:MSI/MMRorTMBtestingifprogressionafterhigh-doseTEST-A1of2?Table1,Abdominal±Pelvic±CT:pModifiedYear1:At3,4–6,and12mo.?Footnoteemodified:Inselectcircumstances,aAnMRIcanbeconsideredtoreplaceanabdominal/pelvicCT.TheMRIprotocolshouldincludeallthenodesthatneedtobeassessed.Thesameimagingmodality(CTorMRI)shouldbeusedthroughoutsurveillance.TEST-A2of2?Table3,Abdominal±PelvicCT:pModifiedYear1:At3mo,thenat6-129or12moTEST-B1of3?Table5,Chestx-ray:pModifiedYear5:AnnuallyAsclinicallyindicated?Footnotedmodified:Inselectcircumstances,aAnMRIcanbeconsideredtoreplaceanabdominal/pelvicCT.TheMRIprotocolshouldincludeallthenodesthatneedtobeassessed.Thesameimagingmodality(CTorMRI)shouldbeusedthroughoutsurveillance.(AlsoforTEST-B2of3and3of3)TEST-B2of3?Footnotekrevised:Forpatientswithunresectableunresectedresidualmassesorresectedresidualmassescontainingviablecancer.?Footnoteladded:Considerannualtumormarkersforyears5–10.TEST-C1of5Secondbulletmodified:Asaresult,theriskofsecondcancersarisinginthekidneys,liver,orbowelmaybelowerwith3D-CRTthanIMRT,andIMRTisnotrecommendednecessary.TEST-D?Footnotebadded:Newerriskmodeltogiveprognosticinformationcanbeusedthroughnomogram:https://eortc.shinyapps.io/IGCCCG-Update/(GillessenS,etal.JClinOncol2021:39:1563-1574).?Footnotedadded:Patientswithgood-riskdisseminatedseminomawithanLDH>2.5xULNhaveaworseprognosisthanothergood-riskpatients.However,thereareinsufficientdataatthistimetorecommendtreatingthesepatientsdifferentlybasedonLDH.TEST-G1of3?Footnoteadded:Tumormutationalburden-high(TMB-H)[≥10mutations/megabase(mut/Mb)]tumors,asdeterminedbyavalidatedand/orFDA-approvedCGPassay.(AlsoforTEST-G2of3)Test-H1of2?Testis-SparingSurgery(TSS)?Firstsub-bullet,secondsub-bulletmodified:Non-palpabletesticularmasses<2cmareassociatedwithbenigntumorsinupto80%ofpatients,andtherefore,TSSmaybeconsideredinthesepatientsinwhomTSSistechnicallyfeasible.toavoidorchiectomyinpatientswithbenigntumors.TEST-H2of2?PostchemotherapySettingpFifthbulletmodified:LimiteddatasuggestincreasedfrequencyofaberrantrecurrenceswiththeuseofminimallyinvasivelaparoscopicorroboticapproachestoRPLND.Therefore,minimallyinvasiveRPLNDisnotrecommendedasstandardmanagementatthistime,butcanbeconsideredinhighlyselectedcasesathigh-volumecenters.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.UPDATESVersion2.2022,1/04/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.isgPrintedbyMinTangon3/14/20227:16:50AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.isgdexWORKUPusesticulars?H&PhCGbc?Alpha-hCGbc?LDH?Chemistryprofiled?TesticularultrasoundPRIMARYTREATMENTa?Radicalinguinalorchiectomye?Discussspermbanking,ifclinicallyindicated?Discusstesticularprosthesis?ForpatientswithbilateralguinalbiopsyfofguinalbiopsyfofcontralateralPATHOLOGICDIAGNOSISPureseminoma(pureseminomahistologyandAFPnormal;Nonseminomatousgermcelltumor(NSGCT)(includesmixedseminoma/nonseminomatumorsandseminomaostdiagnosticupandClinicalStageostdiagnosticupandClinicalStageaThoughrare,whenapatientpresentswithrapidlyincreasingbeta-hCGorAFPandsymptomsrelatedtodisseminateddiseasewithatesticularmass,chemotherapycanbeinitiatedimmediatelywithoutwaitingforabiopsydiagnosisorperformingorchiectomy.However,orchiectomyshouldbeperformedatcompletionofchemotherapy.bMildlyelevated,non-risingAFPlevelsmaynotindicatepresenceofgermcelltumor.DecisionstotreatshouldnotbebasedonAFPvalues<20ng/mL.Furtherworkupshouldbeconsideredbeforeinitiatingtreatmentformildlyelevatedbeta-hCG(generally<20IU/L)sinceotherfactors,includinghypogonadismandmarijuanause,cancausefalse-positiveresults.SeeDiscussion.cQuantitativeanalysisofbetasubunit.dConsidermeasuringbaselinelevelsofgonadalfunction.eMayconsidertestis-sparingsurgery(ie,partialorchiectomy)inselectpatients.SeePrinciplesofSurgery(TEST-H).fInguinalexplorationwithexposureoftestis,withdirectobservationandpartialorchiectomy.SeePrinciplesofSurgery(TEST-H).gIfultrasoundshowscryptorchidtestis,markedatrophy,orsuspiciousmass.Biopsiesarenotrecommendedformicrocalcifications.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version2.2022,1/04/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TEST-1?BrainMRI,kifclinicallyindicatedlRecommendspermbankingifclinicallylevatedbetahCGbPrintedbyMinTangon3/14/20227:16:50AM.Forpersonaluseonly.Notapproved?BrainMRI,kifclinicallyindicatedlRecommendspermbankingifclinicallylevatedbetahCGbdexPATHOLOGICDIAGNOSISPOSTDIAGNOSTICWORKUPCLINICALSTAGEPureseminomahdAFPnormaldAFPnormalimay?Abdominal/pelvicCT?Chestx-ray?ChestCTif:pPositiveabdominalCTorabnormalchestx-ray?Repeatbeta-hCG,LDH,andAFPtomyvaluesbjsinceTNMstagingistomyvaluesbjIBmIIA,nIIBImTTbMildlyelevated,non-risingAFPlevelsmaynotindicatepresenceofgermcelltumor.DecisionstotreatshouldnotbebasedonAFPvalues<20ng/mL.Furtherworkupshouldbeconsideredbeforeinitiatingtreatmentformildlyelevatedbeta-hCG(generally<20IU/L)sinceotherfactors,includinghypogonadismandmarijuanause,cancausefalse-positiveresults.SeeDiscussion.hMediastinalprimaryseminomashouldbetreatedbyriskstatususedforgonadalseminomaswithetoposide/cisplatinfor4cyclesorbleomycin/etoposide/cisplatinfor3cycles.iIfAFPiselevated,treatasnonseminoma.jElevatedvaluesshouldbefollowedafterorchiectomywithrepeateddeterminationtoallowprecisestaging.Followdecliningmarkersuntilnormalizationornadir.Stagingisbasedonmarkerlevelsatthetimethatthepatientstartspostorchiectomytherapy(forexample,forpatientsstartingchemotherapyfordisseminateddisease,prognosticcategoryandstagingshouldbeassignedbasedontheserumtumormarkerlevelsonday1ofcycle1ofchemotherapy).kWithandwithoutcontrast.lEg,beta-hCG>5000IU/L,non-pulmonaryvisceralmetastases,extensivelungmetastasis,orneurologicsymptomspresent.mThepanelrecommendsstagingtumorswithdiscontinuousinvasionofthespermaticcordaspT3(high-riskstageI)andnotasM1(stageIII)asisrecommendedinthe8theditionoftheAJCCCancerStagingManual.Ifsurveillanceiselected,thepelvisshouldbeincludedintheimagingduetoahigherriskofpelvicrelapsesinthesepatients.SeeDiscussion.nForselectcasesofclinicalstageIIAdiseasewithborderlineretroperitoneallymphnodes,waiting4–6weeksandrepeatingimaging(chest/abdomen/pelvicCTwithcontrast)toconfirmstagingbeforeinitiatingtreatmentcanbeconsidered.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version2.2022,1/04/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TEST-2PrintedbyMinTangon3/14/20227:16:50AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexCLINICALPRIMARYTREATMENToFOLLOW-UPSTAGEingtoextentaseingtoextentaseatingtoextentaseatingtoextentaseatingtoextentaseatESTAof(stronglypreferred)BBESTAof(AUC=7x1cycleorAUC=7x2cycles)ESTESTAofvatedserumtumormarkervatedserumtumormarkerupelvicCT(withcontrast)toscanforuqTherearelimitedlong-termfollow-updataonthetoxicityandefficacyofcarboplatin.Arecentpopulation-basedstudysuggestedpatientswithlargertumors,retetestisinvolvement,orbothderiveasmallerreductioninrelapseratetednonrisingAFPlevelsmaynotindicatepresenceofgermtednonrisingAFPlevelsmaynotindicatepresenceofgermcellDecisionstotreatshouldnotbebasedonAFPvaluesngmLFurtherworkupshouldbeconsideredbeforeinitiatingtreatmentformildlyelevatedbeta-hCG(generally<20IU/L)sinceotherfactors,includinghypogonadismandrSeePrinciplesofRadiotherapyforPureTesticularSeminoma(TEST-C).sForstageIseminoma,long-termfollow-upstudiesindicateanincreaseinlatetoxicitieswithradiationtreatment.SeeDiscussion.marijuanause,cancausefalse-positiveresults.SeeDiscussion.tForfurtherinformationmarijuanause,cancausefalse-positiveresults.SeeDiscussion.oDiscussspermbankingpriortochemotherapyorradiationtreatment.icCTscanandchestxrayorCTscanwithintheoDiscussspermbankingpriortochemotherapyorradiationtreatment.icCTscanandchestxrayorCTscanwithintheweekspriortotheinitiationofchemotherapytoconfirmstaging,evenifscanwasdonepreviouslySeePrinciplesofImagingTESTI).ChemotherapyRegimensforGermCellTumors(TEST-E).vPatientsshouldnotbetreatedbaseduponanelevatedLDHalone.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.TEST-3Version2.2022,1/04/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:16:50AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexCLINICALSTAGEwnGoodriskyIntermediateriskw,yPRIMARYTREATMENToFOLLOW-UPFollowupforSeminomaRecurrence,treataccordingtoextentofdiseaseatrelapsevdeparaaorticandipsilateraliliaclymphnodestoadoseof30GyrBEPaafor3BEPaafor3cyclesorEPfor4cyclestchemotherapyManagementTBEPaaforcyclesorEPBEPaaforcyclesorEPforcyclesselectnonbulkycmcasestoincludeparaaorticandipsilateraliliaclymphnodestoadoseof36GyrBEPaafor3BEPaafor3cycles(category1)orEPfor4cycles(category1)BEPaafor4BEPaafor4cycles(category1)orVIPfor4cycleshemotherapyntTensposidecisplatinlatinommendedRegimensVIPEtoposideifosfamide/cisplatinnForselectcasesofclinicalstageIIAdiseasewithborderlineretroperitoneallymphnodes,waiting4–6weeksandrepeatingimaging(chest/abdomen/pelvicCTwithoDiscussspermbankingpriortochemotherapyorradiationtreatment.contrast)oDiscussspermbankingpriortochemotherapyorradiationtreatment.(stageIIIC).StageIIIBdoesnotapplytopureseminomas.PatientswithelevatedAFPhavenonseminomas.Inpatientswithaserumbeta-hCG>1000IU/L,considerthepossibilityofanNSGCT,re-reviewsurgicalspecimenwithpathology,andconsiderdiscussionwithahigh-volumecenter.LDHandbeta-hCGaloneshouldnotbeusedtostageorriskstratifypatientswithpureseminoma.xAllstageIICandstageIIIseminomasareconsideredgood-riskdiseaseexceptforstageIIIdiseasewithnon-pulmonaryvisceralmetastases(eg,bone,liver,brain),whichisconsideredintermediaterisk.ySeeRiskClassificationforAdvancedDisease(TEST-D).zSeePrimaryChemotherapyRegimensforGermCellTumors(TEST-E).aaConsiderableomycin-freeregimeninpatientswithreducedorborderlineglomerularfiltrationrate(GFR)andinpatientsolderthan50yearsofage.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.TEST-4Version2.2022,1/04/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.scanbbPrintedbyMinTangon3/14/20227:16:50AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.scanbbdexPOSTCHEMOTHERAPYMANAGEMENTFOLLOW-UPSTAGEIIA,IIB,IIC,POSTCHEMOTHERAPYMANAGEMENTFOLLOW-UPTREATMENTWITHCHEMOTHERAPYSeeFollow-upforSeminomaSeeFollow-upforSeminoma,Table3Recur