Objective	To be able to perform specialist assessment, guide systemic therapy in the context of multidisciplinary treatment and counselling of patients with malignant germ-cell tumours (GCT) of the adult male along the cancer continuum
Key Concepts	Recognise the rising incidence of malignant GCTs, their pre-natal origins and associated familial and clinical risk factors Recognise that there are different pathologic, anatomical, and biologic subtypes of GCT with different biologic behaviours, each associated with clinical implications for treatment planning and management Summarise the appropriate standard staging modalities of GCTs involving determination of classic serum tumour markers, three dimensional imaging (computed tomography scan of chest and abdomen), and testicular ultrasound Define the importance and limitations of tumour markers for staging, treatment evaluation and prognosis Describe prognostic criteria and the staging classifications for GCT and the important limitations thereof (TNM and the 1997 International Germ Cell Cancer Cooperative Group [IGCCCG] classification) Determine that the optimal treatment of GCTs is based on tumour stage/the IGCCCG classification and involves a multidisciplinary team, including medical oncologists, oncologic surgeons, urologic surgeons, radiation oncologists, pathologists, and radiologists. Indirect or direct consultation with high volume centres of excellence is highly encouraged. Referral of poor risk as well as relapsed patients to a high volume reference centre is strongly recommended Summarise the correct treatment modalities for the different stages of local, regional and metastatic GCT (stages I, II, III) Recognise that GCTs are uniquely chemotherapy (cisplatin)-sensitive with an excellent prognosis across all stages and that quality of survival is a major driver of management decisions Recognise that clinical stage I disease is, by far, the most common presentation and understand the advantages and disadvantages of active surveillance, primary retroperitoneal lymph node dissection and adjuvant chemotherapy for clinical stage I (CSI) non-seminoma and active surveillance, adjuvant chemotherapy or adjuvant radiation for CSI seminoma Describe and distinguish the different cisplatin-based combination chemotherapy regimens used in the treatment of GCTs (bleomycin, etoposide, and cisplatin; cisplatin, etoposide, and ifosfamide; paclitaxel, ifosfamide, and cisplatin; high dose chemotherapy; etc) and the strict number of cycles based on the IGCCCG risk profile Determine the negative impact of dose reductions and dose delays on treatment outcomes and the importance of maintaining dose intensity Explain the increased risk and risk factors for thromboembolic events in patients with metastatic GCT Recognise the essential importance of high volume centres for referral of complex cases (such as poor risk, relapsed disease or extragonadal GCT), for assistance in care and guidance and urgent expert consultation Recognise high-risk and unusual presentations in patients with GCT including metastatic choriocarcinoma and extragonadal GCTs and the need for urgent expert consultation and referral to a high-volume reference centre for these rare presentations Determine the predictable pattern of metastases in GCT and its impact on surveillance and follow-up strategies Explain management strategies for relapse after CSI disease and after first-line chemotherapy treatment of metastatic disease including high dose chemotherapy with autologous stem-cell support. Consider inclusion into clinical trials whenever possible Distinguish the different management strategies for post-chemotherapy residual lesions in non-seminoma and seminoma after first-line chemotherapy Identify the critical importance of guideline and expert guided treatment for optimal outcomes in GCT Evaluate carefully the rapidly emerging themes since 2017 with immediate practice changing implications for cancer care delivery improvement (liquid biomarkers miR371, centralisation or regional guidance in decision making, care in low-resource environments, quality of care delivery, and high quality survivorship) Identify the importance of survivorship care after successful treatment with platinum-based chemotherapy with continued attention for late effects such as fatigue, paraesthesia, Raynaud’s phenomenon, metabolic syndrome, and increased risk for second cancers and cardiovascular disease. Importance of cardiovascular risk management
Skills	Demonstrate the ability to: Perform an adequate and timely diagnostic plan for patients with suspected GCT Apply current staging classifications to individual patients with localised and metastatic disease based on the results of their staging procedures Discuss management options in CSI non-seminoma and seminoma including pros and cons of the different management strategies particularly with respect to overtreatment Design an overall management plan for patients including the various steps from diagnosis, diagnostic staging procedures to chemotherapy and post-chemotherapy surgery Select the correct chemotherapy regimen and cycle number according to the IGCCCG classification for patients with metastatic disease Present patients and their findings in the context of a multidisciplinary tumour board for optimal decision making or through high volume centres Use the information of cumulative dose of chemotherapy agents received or radiation delivered, develop a sufficient surveillance and follow-up schedule to avoid unnecessary follow-up investigations along with long-term survivorship plans