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Journal of Clinical Oncology, Vol 19, Issue 7 (April), 2001: 2020-2025
© 2001 American Society for Clinical Oncology

Low-Volume Nodal Metastases Detected at Retroperitoneal Lymphadenectomy for Testicular Cancer: Pattern and Prognostic Factors for Relapse

By Farhang Rabbani, Joel Sheinfeld, Hesam Farivar-Mohseni, Antonio Leon, Michael J. Rentzepis, Victor E. Reuter, Harry W. Herr, John A. McCaffrey, Robert J. Motzer, Dean F. Bajorin, George J. Bosl

From the Departments of Urology and Pathology and the Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY.

Address reprint requests to Joel Sheinfeld, MD, Department of Urology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, Room C-1076, New York, NY 10021; email: sheinfej{at}mskcc.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To determine the incidence, pattern, and predictive factors for relapse in patients with low-volume nodal metastases (stage pN1) at retroperitoneal lymphadenectomy (RPLND) and identify who may benefit from chemotherapy in the adjuvant or primary setting.

PATIENTS AND METHODS: Fifty-four patients with testicular nonseminomatous germ cell tumor had low-volume retroperitoneal metastases (pathologic stage pN1, 1997 tumor-node-metastasis classification) resected at RPLND, 50 of whom were managed expectantly without adjuvant chemotherapy. The dissection was bilateral in 12 and was a modified template in 38 patients. Retroperitoneal metastases were limited to microscopic nodal involvement in 14 patients. Follow-up ranged from 1 to 106 months (median, 31.4 months).

RESULTS: Eleven patients (22%) suffered a relapse at a median follow-up of 1.8 months (range, 0.6 to 28 months). The most frequent form of recurrence was marker elevation in nine (18%) patients. Persistent marker elevation after orchiectomy and before retroperitoneal lymphadenectomy was a significant independent predictor of relapse (relative risk, 8.0; 95% confidence interval, 2.3 to 27.8; P = .001). Four of five (80%) patients with elevated markers (alpha-fetoprotein alone in three, alpha-fetoprotein and beta human chorionic gonadotropin in one) suffered a relapse, compared with seven of 45 (15.6%) patients with normal markers.

CONCLUSION: Clinical stage I and IIA patients with normal markers who have low-volume nodal metastases have a low incidence of relapse and can be managed by observation only if compliance can be assured. In contrast, patients with elevated markers before retroperitoneal lymphadenectomy have a high rate of relapse and should be considered for primary chemotherapy.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
CURE RATES FOR clinical stage I and low-volume stage II testis tumor patients approach 100%; selecting the best initial modality of treatment and integration of surgery and chemotherapy is critical to optimizing cure and minimizing morbidity. Currently, three approaches are considered for treatment of stage I and low-volume stage II patients, including primary retroperitoneal lymphadenectomy (RPLND), surveillance (for stage IA) or primary chemotherapy (for stages IB and IS and for low-volume stage II). Patients on surveillance have a 24% to 31% risk of relapse,1-4 and most relapsing patients are treated with salvage therapy consisting of chemotherapy with surgery for residual masses.2 In the United States, primary RPLND has been favored5-8 because this approach has both a diagnostic and therapeutic role. The pattern of relapse is altered in patients with negative nodes because they are unlikely to relapse in the retroperitoneum.

Retroperitoneal nodal metastases detected at RPLND can be classified as low volume (pathologic stage pN1) or high volume (pathologic stage pN2-pN3), with pathologic stage as classified by the 1997 American Joint Committee on Cancer (AJCC) classification ( Table 1). 9 Patients with high-volume disease have a 33% to 56%10,11 relapse rate, which is virtually eliminated with two cycles of cisplatin-based adjuvant chemotherapy.11-13


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  		Table 1. Pathologic Nodal Staging Classification, 1997 AJCC Classification5
 
However, there is continued controversy regarding the optimal treatment of patients with low-volume nodal metastases. While some investigators have reported relapse rates as low as 6.3% in patients with low-volume (pN1) nodal disease managed expectantly,14 others have reported rates as high as 45%.11,15 Williams et al11 demonstrated a significant reduction in relapse rates with two cycles of adjuvant cisplatin-based chemotherapy in a multicenter, randomized trial, but 93 of 195 (48%) patients in this study had pN2-pN3 disease.11 Given the wide disparity in relapse rates reported after expectant management of pathologic stage pN1 disease, with three series reporting relapse rates more than 35%,10,11,15 we reviewed our experience in patients with low-volume nodal metastases to determine the incidence, pattern, and predictors of relapse to determine which patients would benefit from adjuvant chemotherapy after RPLND and which patients are best managed by initial chemotherapy.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Population
Between January 1988 and February 1998, 336 primary RPLNDs were performed on 335 patients with testicular germ cell tumor with clinical-stage distributions as follows: I in 217, IS in 7, IIA in 90, and IIB in 21 patients. Fifty-four patients (16%) with nonseminomatous germ cell tumors had low-volume (pN1) nodal metastases at RPLND. Four patients received adjuvant chemotherapy and are excluded from the analysis. Fifty patients did not receive adjuvant chemotherapy and form the subject of this report. Pathologic stage was assigned according to the 1997 AJCC classification (Table 1).9

Patients ranged in age from 14 to 62 years (median, 28.3 years), and median follow-up was 52.4 months (range, 1 to 117 months). Five patients (10%) have been lost to follow-up. The initial clinical stages, according to the 1997 AJCC staging classification,9 were I in 30 (60%), IS in two (4.0%), IIA in 17 (34%), and IIB in one (2.0%) patient. Forty-eight were diagnosed at radical orchiectomy, one at simple orchiectomy, and the other at partial orchiectomy. Twenty-one tumors were right-sided and 29 left-sided. The primary tumor contained elements of embryonal carcinoma in 42 (84%), yolk sac tumor in 22 (44%), seminoma in 15 (30%), mature teratoma in 15 (30%), immature teratoma in 13 (26%), and choriocarcinoma in five (10%) patients. Thirty-three (66%) patients had mixed germ cell tumor containing embryonal carcinoma, nine (18%) had pure embryonal carcinoma, and eight (16%) had no embryonal carcinoma. Vascular invasion was present in 29 (58%) patients.

Technique of RPLND
A bilateral infrahilar RPLND was performed in 12 (24%), and a modified template dissection was performed in 38 (76%) patients. The modified template for right-sided testis tumors included the infrahilar paracaval, right common iliac, precaval, and retrocaval nodes, as well as the interaortocaval, preaortic, and paraaortic nodes above the inferior mesenteric artery (IMA). The modified template for left-sided tumors included the paraaortic, left common iliac, preaortic and retroaortic nodes, as well as the interaortocaval nodes above the IMA. The ipsilateral gonadal vein was resected. Suprahilar dissection was performed only if there was suspicious lymphadenopathy.

Follow-Up
Patients were followed-up every month in the first year, every 2 months in the second, every 3 months in the third, every 4 months in the fourth, and every 6 months in the fifth year; they were followed-up annually thereafter. At each visit, a history and physical examination and chest x-ray were performed and serum tumor marker levels determined, including alphafetoprotein ({alpha}FP, Tosoh Nexia IEA assay, Tosoh Corporation, Tokyo, Japan; normal, < 15 ng/mL), beta-human chorionic gonadotropin (ßHCG; normal, < 2.0 mIU/mL), and lactate dehydrogenase (LDH; normal, < 200 U/l). Preoperative and postoperative imaging, operative, and pathology reports and patient charts were reviewed retrospectively.

Statistical Analysis
The end point for analysis was either radiologic or serologic relapse. In the analysis, patients with persistent or recurrent disease were classified as failures, whereas patients who were observed free of disease or were lost to follow-up during the study period were coded as censored. Disease-free survival times were measured from the date of RPLND to relapse or last follow-up. Survival curves were generated using the Kaplan-Meier method16 and were compared using the log-rank test.17 Cox proportional hazards analysis was used to obtain maximum likelihood estimates of relative risk and their 95% confidence intervals in multivariate analysis.18,19 Variables assessed as predictors of relapse included initial clinical stage, pre-RPLND marker status, primary tumor laterality, primary tumor histology, lymphovascular invasion in the primary tumor, limits of dissection, microscopic versus gross retroperitoneal metastases, presence of embryonal carcinoma in the retroperitoneal nodes, and number of positive sites in the retroperitoneum. Statistical analysis was performed using the SPSS statistical package (SPSS Inc, Chicago, IL).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Adjuvant Chemotherapy
Four patients received adjuvant chemotherapy with two cycles of etoposide and cisplatin13 because of poor compliance or a psychologically fragile patient profile. The retroperitoneal metastases were microscopic in one and gross in three patients. The primary tumor histology included embryonal carcinoma elements in all four, yolk sac tumor in one, immature teratoma in two, mature teratoma in one, seminoma in two, and choriocarcinoma in no patients. One patient had elevated markers before RPLND. All four patients had embryonal carcinoma in the retroperitoneal lymph nodes. All four patients have been free from relapse at 15.6 to 64.7 months (median, 30.5 months) after RPLND. These patients are excluded from further analysis.

Patterns of Relapse
The clinical and pathologic characteristics of the 50 patients who did not receive adjuvant chemotherapy are presented in Table 2. Eleven patients (22%) experienced a relapse at a median follow-up of 1.8 months (range, 0.6 to 28 months). Six patients had a relapse or persistent disease before 2 months, one at 2.1 months, three between 12 and 18 months, and one after 24 months. The most common pattern of relapse was marker elevation, which was noted in 9 of 11 patients. Radiographic evaluation revealed possible retroperitoneal adenopathy in four patients, definitive suprahilar adenopathy in one, retrocrural adenopathy in two, and pelvic adenopathy in two. Sites of visceral relapse include pulmonary nodules in four patients and skin (scalp) metastases in one. Some patients had relapses in more than one site. The results of univariate analysis of relapse/persistent disease, according to clinical and pathologic parameters are presented in Table 3. The Kaplan-Meier curve for disease-free survival, according to pre-RPLND marker status, is shown in Fig 1. Persistent marker elevation before RPLND, defined as marker elevation at the time of RPLND, was a significant independent predictor of relapse with a relative risk 8.0 (95% confidence interval, 2.3 to 27.8; P = .001).


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  		Table 2. Clinical and Pathologic Characteristics in the 50 Patients With pN1 Nodal Metastases at Retroperitoneal Lymphadenectomy Managed by Observation Only
 

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  		Table 3. Results of Univariate Analysis of Relapse According to Clinical and Pathologic Parameters
 


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  		Fig 1. Disease-free survival in patients with N1 nodal metastases according to pre-RPLND marker status (with log-rank P value).

 
Marker Status Before RPLND
There were five patients with persistent marker elevation before RPLND. Two patients with clinical stage IIA had an elevated {alpha}FP, with a normal half-life of decline after orchiectomy and normal serum concentration of ßHCG. One of these (with a preoperative {alpha}FP level of 18.3 ng/mL) had microscopic disease at RPLND and has had no relapse; the other (with a preoperative {alpha}FP level of 49 ng/mL) had gross nodal metastases and had persistent marker elevation after RPLND as the only manifestation of treatment failure. A third patient had an elevated {alpha}FP level of 77.5 ng/mL with a prolonged half-life after orchiectomy and a normal ßHCG. He presented with a right-sided stage IS tumor, had gross nodal metastases at RPLND, and has had a retrocaval recurrence with marker elevation at 16.7 months. He was treated with four cycles of etoposide and cisplatin,20 resection of residual disease and with salvage chemotherapy (vinblastine, ifosfamide, and cisplatin)21 for a second relapse. He died of disease at 31.6 months. The remaining two patients had either no decrease in or demonstrated rising values of {alpha}FP (both) or ßHCG (one) before RPLND. One of these patients, with a preoperative {alpha}FP level of 26.1 ng/mL and ßHCG level of 5.3 mIU/mL, had a left-sided stage IIA tumor with gross nodal metastases at RPLND and had a marker relapse after initially normalizing after RPLND with suspicious suprahilar adenopathy at 2 months. The other patient, with a preoperative {alpha}FP level of 18.6 ng/mL and a nonmeasurable ßHCG, had a left-sided stage IS tumor, with microscopic nodal metastases at RPLND, persistently elevated markers after RPLND, and a suspicious left external iliac node at 1 month.

The recurrence pattern in the four patients with relapse who had persistently elevated markers before RPLND was serologic in all four, possible retroperitoneal adenopathy in three, suprahilar adenopathy in one, and pelvic adenopathy in one patient. When patients with marker elevation before RPLND are excluded, the relapse rate was seven of 45 (16%). Among the seven patients with normal markers before RPLND who relapsed, the recurrence pattern distribution was as follows: serologic in five patients, suspicious retroperitoneal adenopathy in one, retrocrural adenopathy in two, pulmonary nodules in four, pelvic adenopathy in one, and scalp metastasis in one. Median time to recurrence in these seven patients was 2.1 months (range, 0.6 to 28 months). The median time to relapse was not significantly different for patients with relapse who had elevated markers versus those in whom pre-RPLND markers were normal (P = .55, median test).

Mortality
Two patients (4%) died of disease. The course for one patient with an elevated {alpha}FP with a prolonged half-life has been described above. This patient had stage IS disease with a primary tumor histology of embryonal carcinoma and mature teratoma. The other patient presented with clinical stage IIA disease and a primary tumor histology of yolk sac tumor and immature teratoma; gross disease was found at right-modified RPLND. He relapsed with serologic, right retrocrural, and pulmonary disease, as well as a scalp metastasis. He was treated with four cycles of etoposide and cisplatin20 with resolution of the scalp metastasis. Postchemotherapy thoracotomy revealed yolk sac tumor and teratoma on pathology. He initially refused additional chemotherapy but 6 weeks later agreed to one cycle of adjuvant vinblastine, ifosfamide, and cisplatin, refusing the second cycle. He had a pulmonary relapse 6 months later and died without further chemotherapy 2 months later, 16.4 months after RPLND.

Burden of Therapy
The four patients with relapse who had persistently elevated markers before RPLND received four cycles of etoposide and cisplatin20 (three patients) or three cycles of bleomycin, etoposide, and cisplatin22 (one patient). One patient received four cycles of etoposide and cisplatin20 and had a postchemotherapy resection of mature and immature teratoma. He required salvage chemotherapy with vinblastine, ifosfamide, and cisplatin21 for a second retroperitoneal relapse. The seven patients who relapsed despite normal pre-RPLND markers received four cycles of etoposide and cisplatin. Two of these seven patients underwent postchemotherapy thoracotomy that revealed fibrosis in one patient and yolk sac tumor and immature teratoma in the second. The latter patient received two cycles of postoperative adjuvant chemotherapy with vinblastine, ifosfamide, and cisplatin and remains free of disease. One patient underwent postchemotherapy right pelvic lymph node dissection; fibrosis was identified at pathologic review. That patient subsequently relapsed and received four cycles of taxol, ifosfamide, and cisplatin salvage chemotherapy.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The value of adjuvant chemotherapy for low-volume (pN1) nodal disease is controversial. Investigators have reported relapse rates ranging from 6.3% to 45% for patients with pN1 nodal metastases managed expectantly.11,14,15,23,24 In the present series, 11 of 50 (22%) of such patients managed expectantly after RPLND suffered relapse. Persistent marker elevation before RPLND was a significant independent predictor of relapse with a relative risk of 8.0. When the five patients with persistently elevated markers are excluded, the rate of relapse with expectant management is seven of 45 (16%). In our series of 50 patients managed expectantly, a total of 50 cycles of chemotherapy and four surgical procedures (one RPLND, one pelvic lymph node dissection, and two thoracotomies) were required, compared with 100 cycles of chemotherapy if each patient were to receive two cycles of adjuvant chemotherapy.

The relapse rate was within the range reported by other series.11,14,15,23,24 The wide range of relapse rates reported in the literature may be accounted for by the selection biases present in the different studies, including differing templates of dissection, patient selection, and different study criteria. A modified template dissection was performed in 76% of patients included in the present series, compared with 26% in Richie and Kantoff’s series.23 Although the likelihood of relapse was lower in patients undergoing a bilateral compared with a modified-template dissection (one of 12 = 8.3% v 10 of 38 = 26%), this difference did not attain statistical significance (P = .21, log-rank test). However, more extensive dissections were performed in patients with higher volumes of retroperitoneal disease. In one series,11 the likelihood of relapse in patients with pathologic stage II disease did not differ significantly between bilateral and modified template dissections when the latter was restricted to patients with no serologic, radiologic, or intraoperative evidence of disease. Nevertheless, in the presence of retroperitoneal disease, a bilateral RPLND with nerve sparing is the operation of choice. Surgical margins should not be compromised in an attempt to preserve ejaculation.

The various studies reported in the literature have used different selection criteria for patients included in the analysis. In the series by Socinski et al, patients with two separate involved lymph node areas received adjuvant chemotherapy.24 The relapse rate in the present series was seven of 41 (17%) with one positive site, compared with three of eight (38%) with two positive sites; however, the small numbers preclude meaningful statistical comparison. Finally, in Richie and Kantoff’s series,23 only patients with normal tumor markers before RPLND were included in the study, compared with our series in which five of 50 (10%) had persistently elevated markers before RPLND. In the present series, the relapse rate was four of five (80%) with elevated markers before RPLND, compared with seven of 45 (16%) with normal marker levels (P < .0001, log-rank test). Our series includes two patients with clinical stage IS, both of whom relapsed and for whom RPLND is no longer recommended.

In a 1994 report from Memorial Sloan-Kettering Cancer Center, all 11 patients with clinical stage IS disease treated with primary RPLND suffered relapse requiring chemotherapy, including four patients (two included herein) with low-volume disease.25 Saxman et al reported on 30 clinical stage IS patients with prolonged marker half-life treated with RPLND alone.26 Five of six (83%) patients with persistently elevated {alpha}FP with or without ßHCG elevation had a relapse. Eight of 27 (30%) patients with persistently elevated ßHCG with or without {alpha}FP elevation suffered a relapse, including five of eight (63%) patients with positive nodes. Taken together, these studies suggest that persistent marker elevation after orchiectomy often reflects systemic disease; patients with persistent marker elevation are best treated with primary chemotherapy.

In summary, our study does not support the routine use of adjuvant chemotherapy in patients with low-volume (pN1) nodal metastases and markers that are normal before RPLND. However, these data underscore the importance of careful patient selection and a meticulous bilateral RPLND in the presence of retroperitoneal disease. Additionally, patients with persistently elevated markers before RPLND have a high risk of relapse when treated with RPLND alone and should be considered for primary chemotherapy, followed by RPLND for residual disease.


   ACKNOWLEDGMENTS
 
Supported by a grant from the American Foundation of Urologic Disease, Baltimore, MD, and Ortho-McNeil Pharmaceuticals, Raritan, NJ, to F.R.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
1. Raghavan D, Peckham MJ, Heyderman E, et al: Prognostic factors in clinical stage I non-seminomatous germ-cell tumours of the testis. Br J Cancer 45: 167-173, 1982[Medline]

2. Sogani PC, Perrotti M, Herr HW, et al: Clinical stage I testis cancer: Long term outcome of patients on surveillance. J Urol 159: 855-858, 1998[Medline]

3. Freedman LS, Parkinson MC, Jones WG, et al: Histopathology in the prediction of relapse of patients with stage I testicular teratoma treated by orchiectomy alone. Lancet 2: 294-298, 1987[Medline]

4. Pizzocaro G, Zanoni F, Milani A, et al: Orchiectomy alone in clinical stage I nonseminomatous testis cancer: A critical appraisal. J Clin Oncol 4: 35-40, 1986[Abstract]

5. Bosl GJ, Bajorin DF, Sheinfeld J, et al: Cancer of the testis, in DeVita V, Hellman S, Rosenberg SA (eds): Cancer: Principles and Practice of Oncology ( ed 5 ). Philadelphia, PA, Lippincott-Raven, 1997, pp 1397-1425

6. Bosl GJ, Motzer RJ: Testicular germ-cell cancer. N Engl J Med 337: 242-253, 1997[Free Full Text]

7. Hesketh PJ, Krane RJ: Prognostic assessment in nonseminomatous testicular cancer: implications for therapy. J Urol 144: 1-9, 1990[Medline]

8. Sheinfeld J, Herr HW: Role of surgery in management of germ cell tumor. Semin Oncol 25: 203-209, 1998[Medline]

9. Fleming ID, Cooper JS, Henson DE, et al (eds): AJCC Cancer Staging Manual (ed 5). Philadelphia, PA, Lippincott-Raven, 1997

10. Pizzocaro G, Monfardini S: No adjuvant chemotherapy in selected patients with pathologic stage II nonseminomatous germ cell tumors of the testis. J Urol 131: 677-680, 1984[Medline]

11. Williams SD, Stablein DM, Einhorn LH, et al: Immediate adjuvant chemotherapy versus observation with treatment at relapse in pathological stage II testicular cancer. N Engl J Med 317: 1433-1438, 1987[Abstract]

12. Weissbach L, Harlapp JH: Adjuvant chemotherapy of metastatic stage II nonseminomatous testis tumor. J Urol 146: 1295-1298, 1991[Medline]

13. Motzer RJ, Sheinfeld J, Mazumdar M, et al: Etoposide and cisplatin adjuvant therapy for patients with pathologic stage II germ cell tumors. J Clin Oncol 13: 2700-2704, 1995[Abstract]

14. Hartlapp JH, Weissbach L, Bussarmaatz R: Adjuvant chemotherapy in nonseminomatous testicular tumour stage II. Int J Androl 10: 277-284, 1987[Medline]

15. Vogelzang NJ, Fraley EE, Lange PH, et al: Stage II nonseminomatous testicular cancer: A 10-year experience. J Clin Oncol 1: 171-178, 1983[Abstract]

16. Kaplan EL, Meier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53: 457-481, 1958

17. Peto R, Pike MC, Armitage P, et al: Design and analysis of randomized trials requiring prolonged observation of each patient: II. Analysis and examples. Br J Cancer 35: 1-39, 1977[Medline]

18. Cox DR: Partial likelihood. Biometrika 62: 269-279, 1975[Abstract/Free Full Text]

19. Cox DR: Regression models and life tables (with discussion). J R Stat Soc B 34: 187-220, 1972

20. Xiao H, Mazumdar M, Bajorin DF, et al: Long-term follow-up of patients with good-risk germ cell tumors treated with etoposide and cisplatin. J Clin Oncol 15: 2553-2558, 1997[Abstract/Free Full Text]

21. McCaffrey JA, Mazumdar M, Bajorin DF, et al: Ifosfamide- and cisplatin-containing chemotherapy as first-line salvage therapy in germ cell tumors: Response and survival. J Clin Oncol 15: 2559-2563, 1997[Abstract/Free Full Text]

22. Einhorn LH, Williams SD, Loehrer PJ, et al: Evaluation of optimal duration of chemotherapy in favorable-prognosis disseminated germ cell tumors: A Southeastern Cancer Study Group protocol. J Clin Oncol 7: 387-391, 1989[Abstract]

23. Richie JP, Kantoff PW: Is adjuvant chemotherapy necessary for patients with stage B1 testicular cancer? J Clin Oncol 9: 1393-1396, 1991[Abstract]

24. Socinski MA, Garnick MB, Stomper PC, et al: Stage II nonseminomatous germ cell tumors of the testis: An analysis of treatment options in patients with low volume retroperitoneal disease. J Urol 140: 1437-1441, 1988[Medline]

25. Davis BE, Herr HW, Fair WR, et al: The management of patients with nonseminomatous germ cell tumors of the testis with serologic disease only after orchiectomy. J Urol 152: 111-114, 1994[Medline]

26. Saxman SB, Nichols CR, Foster RS, et al: The management of patients with clinical stage I nonseminomatous testicular tumors and persistently elevated serologic markers. J Urol 155: 587-589, 1996[Medline]

Submitted January 5, 2000; accepted December 13, 2000.


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