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Follow-Up

​Revised 08 May 2013

Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy.

Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g. symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request.

Notification is requested in the event of any of the following:

  • Local recurrence at the primary site (particularly in patients with clinically localized disease treated with surgery and/or radiotherapy)
  • Metastasis at regional or distant sites
  • Complications of therapy, especially if acute requiring hospitalization, or chronic and symptomatic
  • Death with primary cause and whether cancer or treatment contributed

The event, date, and evidence, where appropriate, should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BC Cancer Agency.

Germ Cell Tumours

The BC Cancer Agency chooses to particularly follow:

Patients with useful future treatment options (most testis tumours), especially if the relapse is difficult to detect and/or timing of treatment is important.

At each visit patients require, as a minimum, history and physical examination, plus the investigations outlined in the schedule below. All patients require annual blood pressure measurement. Post-chemotherapy patients will require annual creatinine, Mg, fasting lipid levels, fasting glucose levels as well as testosterone. Sperm counts may be measured at the patient's or physician's request and if necessary, related investigations may need pursuing.

The following guidelines are recommendations which may have to be adjusted in selected patients based upon the individual clinical situation.

Seminoma – CS I

Stage

Treatment performed

Clinical examination and diagnostics

Frequency of examination (i.e. every x months) * except when indicated by footnote

   

Year 1

Year 2

Year 3

Year 4

Year 5

Years 6-10

CS I

 



Surveillance

 

Or

Adjuvant chemotherapy

LDH, AFP, HCG, clinical examination

3,

6

6

6

12

12*

X-ray of the chest

3, 6*

6

12

12

12

-

CT scan of the abdomen/pelvis**

3,6*

6

12

-

12

-*


**The dose of radiation from each CT scan should be minimized. When a CT scan is used, for surveillance ideally the lowest dose CT should be used that allows the radiologist reasonable ability to delineate a 2 cm or greater retroperitoneal node. The role of MRI as an alternative to CT is being investigated and may become standard. For those with acceptable ultrasound assessment of the retroperitoneum (dependent on patients body habitus), alternating CT and ultrasound is an option to reduce radiation exposure.

* In year one, the first CT scan should be at 3 months, then every 6 months for the next 20 months, so that 4 CT scans are done over the first 2 years, followed by one CT in year 3, and one CT in year 5. There was a lack of consensus on whether to do a scan between year 7 and 8, but the majority opinion was that no scans were needed after year 5. Overall 6 CT scans will be done as part of surveillance over the entire 5 year period. There was no consensus on the need for tumour markers beyond 5 years.


Seminoma – CS I

Stage

Treatment performed

Clinical examination and diagnostics

Frequency of examination (i.e. every x months) * except when indicated by footnote

   

Year 1

Year 2

Year 3

Year 4

Years 5-6

Years 7-10



CS I

 



Post Radiotherapy

 

 

LDH, AFP, HCG, clinical examination

6

6

12

12

12

12

X-ray of the chest

6

12

12

12

24

-

CT scan of the pelvis
+/- abdomen

12

12

-

24*

24*

-

 

* One CT scan in year 1,2, 4, and 6, then stop. Total of 4 CT scans over 6 years.


Nonseminoma – CS I/ II

Stage

Treatment performed

Clinical examination and diagnostics

Frequency of examination (i.e. every x months) * except when indicated by footnote

   

Year 1

Year 2

Year 3

Year 4

Year 5

Years 5-10

 

CS I – Low risk and tumour marker positive

 



 

Surveillance

 



LDH, AFP, HCG, clinical examination

3

3

6

6

6

12

X-ray of the chest

3,6

6

6

6

6

12

CT scan of the abdomen/pelvis*

3rd and 12th months

24th month

-

-

56th month

-



CSI– High risk or tumour marker negative /unknown

 

 



Surveillance

 

 

LDH, AFP, HCG, clinical examination

2

2

6

6

6

12

X-ray of the chest

3

3

6

6

6

12

CT scan of the abdomen/pelvis*

3rd, 6th and 12th months

6

12

12

12

-

 

 

PS I (Pathologic stage I)

 

 



Primary RPLND

 

LDH, AFP, HCG, clinical examination

3

3

3

6

6

12

X-ray of the chest

6

6

6

12

12

-

CT scan of the abdomen/pelvis*

3rd and 12th months

24th month

-

-

56th month

-



CS I

 

 



adj. chemotherapy

 

 

LDH, AFP, HCG, clinical examination

3

3

6

6

6

12

X-ray of the chest

6

12

12

12

12

-

CT scan of the abdomen/pelvis*

6

24th month

-

-

56th month

-

*the CT of the pelvis can be omitted in patients who have not had scrotal or pelvic surgery that could alter the normal lymphatic drainage of the testicles.

Reference:

  1. Rustin, G. J., G. M. Mead, et al. (2007). "Randomized trial of two or five computed tomography scans in the surveillance of patients with stage I nonseminomatous germ cell tumors of the testis: Medical Research Council Trial TE08, ISRCTN56475197--the National Cancer Research Institute Testis Cancer Clinical Studies Group." Journal of clinical oncology 25(11): 1310-5.


Seminoma– advanced stages

Prognostic group

Clinical examination and diagnostics

Frequency of examination (i.e. every x months) * except when indicated by footnote

 
  

Year 1

Year 2

Year 3

Year 4

Year 5

Years 5-10

 

 

"good/

intermediate prognosis"

 



LDH, AFP, HCG, clinical examination

3

6

6

12

12

12+

 

X-ray of the chest or CT scan of the chest (if supradiaph. disease)+

3 then 6*

6

6

-

24*

  

CT scan of the abdomen/pelvis

3, then 6

6

12

-

24*

  


* depending on the presence of intrathoracic disease. For stage II seminoma, or after salvage radiotherapy for recurrence of stage I seminoma. CT scan should be done at 3 months then every 6 months for the first two years, then once in year 3, followed by a final scan at 5 years, then CT scans can be stopped. + After completion of 5 years of follow-up, patients can be discharged to their family physician for ongoing follow-up for relapse and late complications.


Nonseminoma – advanced stages

Prognostic group

Clinical examination and diagnostics

Frequency of examination (i.e. every x months) * except when indicated by footnote

 
  

Year 1

Year 2

Year 3

Year 4

Year 5

Years 5-10

 

 

 

"good prognosis"

 



LDH, AFP, HCG, clinical examination

3

3

6

6

6

12

 

X-ray of the chest or CT scan of the chest (if supradiaph. disease)+

3 then 6*

6

6

-

-

  

CT scan of the abdomen/pelvis

3, then 6

6

12

-

24*

  


"intermediate/poor prognosis

 

 

LDH, AFP, HCG, clinical examination

3

3

6

6

6

12

 

X-ray of the chest or CT scan of the chest (if supradiaph. disease)

3, then 6*

6*

6*

6

24*

  

CT scan of the abdomen/ pelvis

3, then 6

6

12

-

24*

  

* depending on the presence of intrathoracic disease. For stage II seminoma, or after salvage radiotherapy for recurrence of stage I seminoma. CT scan should be done at 4 months intervals x 2, then 6 months intervals x 2, then annually until 3 years, followed by a final scan at 5 years, then can be stopped.

Long Term Follow-Up

Follow-up after five years should be done once a year and can be done by the family doctor. The follow-up program should include the following: tumour marker AFP and HCG; examination of the remaining testicle; monitoring for potential cardiac risk factors (e.g. cholesterol, triglycerides, hypertension, microalbumenia, hypogonadism, etc). After radiotherapy, patients remain at higher risk for second malignancy, and appropriate screening for colon cancer should be initialed according to standard colorectal screening guidelines (see colorectal cancer section). After chemotherapy patients should be monitored for effects of pulmonary, renal and oto-toxicity. A higher index of suspicious for avascular necrosis of the hip should be maintained for those with ongoing hip pain, and hypogonadism for those with symptoms of fatigue and low sex drive.

References:

  1. Meinardi MT, Gietema JA, van der Graaf WT, et al: Cardiovascular morbidity in long-term survivors of metastatic testicular cancer. J Clin Oncol 18:1725-1732, 2000

  2. Strumberg D, Bruegge S, Korn MW, et al: Evaluation of long-term toxicity in patients after cisplatin-based chemotherapy for non-seminomatous testicular cancer. Ann Oncol 13:229-236, 2002

  3. Hauges HS, Bosl GJ, Boer H et al. Long-term and late effects of germ cell testicular cancer treatments and impications for follow-up. J Clin Onc 2012, 30:3752-3763.

Non-Germ Cell Tumours

A definitive follow up program cannot be specified. Most Sertoli cell tumours with metastatic potential will relapse within six months of diagnosis. The pattern of relapse is similar to nonseminomatous germ cell tumours. It is suggested these patients be followed for a minimum of two years. Urinary or serum androgens and estrogen assays can be helpful.

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