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Practice Guidelines

Management of adult testicular germ cell tumours: summary of updated SIGN guideline

BMJ 2011; 342 doi: (Published 14 April 2011) Cite this as: BMJ 2011;342:d2005
  1. G C W Howard, consultant clinical oncologist1,
  2. M Nairn, programme manager2
  3. on behalf of the Guideline Development Group
  1. 1Edinburgh Cancer Centre, Western General Hospital, Edinburgh EH4 2XU, UK
  2. 2Scottish Intercollegiate Guidelines Network, Edinburgh EH7 5EA
  1. Correspondence to: M Nairn moray.nairn{at}

Testicular germ cell tumours are rare. In 2008, 203 new cases were diagnosed in Scotland,1 with a crude incidence of 8.1 cases per 100 000 of the male population.2 It is the 15th most common cancer among all men in Scotland1 and the most common cancer in younger adult men.3 It is one of the few curable solid cancers, even when it has metastasised, and has a crude overall five year survival rate in Scotland of 95.8%.1 Although the cure rate is high, the toxicity of treatment is substantial, resulting in treatment related deaths and long term adverse effects. Potential effects on employment and fertility are of particular importance in this age group.

This article summarises the most recent recommendations from the Scottish Intercollegiate Guidelines Network (SIGN) on the management of adult testicular germ cell tumours,4 updating 1998 SIGN guidelines on this condition.


SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (figure), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”), based on the clinical experience of the Guideline Development Group, is also indicated (as GPP).

Explanation of SIGN grades of recommendations

Initial assessment and referral in primary care

  • Presenting symptoms and history of patients with testicular cancer include5:

    • -A painless, solid, unilateral mass in the scrotum (most cases)

    • -Enlarged testicle

    • -Scrotal pain (20% of cases)

    • -Backache (11%)

    • -Gynaecomastia (7%)

    • -Dragging sensation in the scrotum

    • -Incidental recent trauma (it is not thought that the trauma causes the cancer, but rather that it brings an existing tumour to the attention of the patient and physician).

  • Examine patients presenting with a scrotal swelling carefully, and try to distinguish between lumps arising from the body of the …

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