Incomplete resection

All of the above

> 10% viable GCT in resection specimen

IGCCCG intermediate or poor risk status

Prior receipt of salvage chemotherapy

28-year-old male with a 5-cm interaortocaval mass after completion of BEPx3 for IGCCCG good-risk disease. At PC-RPLND, viable embryonal cell carcinoma makes up 30% of his specimen, with the remainder being teratoma and a small amount of fibrosis.

31-year-old male with history of clinical stage IIC good-risk NSGCT who has a 5-cm residual mass after EPx4. PC-RPLND reveals teratoma with enteric-type adenocarcinoma.

27-year-old male who experienced a clinical CR of a 5 cm left para-aortic mass to BEPx3 approximately 5 years ago. He demonstrates an AFP of 150 on follow-up, and CT scan reveals a 7-cm left para-aortic recurrence. Resection reveals 100% viable yolk sac tumor. AFP normalizes postoperatively.

32-year-old male who received BEPx4 with persistently elevated AFP that normalized with salvage VeIPx4, but has a 6-cm interaortocaval residual mass. PC-RPLND reveals viable yolk sac tumor in 50% of the resection specimen.

25-year-old male with a history of IGCCCG poor-risk NSGCT who after completing BEPx4 has a 15-cm para-aortic mass resected demonstrating teratoma and fibrosis.

(a) Declining or plateauing AFP after induction chemotherapy

(b) Slowly rising AFP after a complete serologic response to induction chemotherapy

a, b, c

(d) Persistently rising serum tumor markers (STMs) through induction chemotherapy

(c) All potentially curative chemotherapeutic options have been exhausted

The retroaortic and retrocaval regions are frequent sites of recurrence.

Ipsilateral pelvic recurrences are common.

Incomplete ipsilateral lumbar vessel ligation encountered at reoperative RPLND has been associated with ipsilateral infield recurrence.

The primary landing zone is the most common site of retroperitoneal recurrence.

Unresected ipsilateral gonadal vessels are frequently encountered at reoperative RPLND.

The retroperitoneum is the most common site of late relapse.

First-line treatment is generally systemic chemotherapy followed by consolidative PC-RPLND.

Patients who are chemotherapy-naïve demonstrate superior survival outcomes.

Yolk sac tumor is the most common viable histology encountered.

GCT with somatic-type malignancy is seen with increased frequency in this population.

20% to 60%

> 90%

70% to 80%

< 10%

a, b, c

(b) Closure of the bladder neck

(c) Contraction of the bulbospongiosis muscles

(a) Seminal emission through vasa deferentia

(d) Penile erection

Medium-chain triglyceride (MCT) diet.

Subcutaneous octreotide.

Placement of peritoneovenous shunt.

Total parenteral nutrition.

Limiting fat intake preoperatively.

31-year-old male with a large infrarenal left para-aortic mass that is found to be invading the L2 vertebral foramina during resection.

32-year-old male undergoing resection of left para-aortic mass with apparent aortic invasion who will most likely require resection of the infrahilar aorta and tube graft reconstruction.

29-year-old male with large-volume left para-aortic and interaortocaval masses that extend through the retrocrural region into the middle visceral mediastinum.

27-year-old male with a completed occluded IVC due to large interaortocaval, retrocaval, and right paracaval masses with a tumor thrombus up the inferior border of the right renal vein.