Approximately 50% of patients undergoing post-chemotherapy surgery with elevated serum tumor markers are alive at 5 years. Half of these patients are found to harbor residual viable non-teratomatous germ-cell tumor with a third alive at 5 years with no observed benefit from adjuvant chemotherapy. These studies demonstrate that a subset of patients with elevated serum tumor markers after chemotherapy are curable with surgery. The decision to proceed with surgery in lieu of second- or third-line chemotherapy includes identifying both patients felt unlikely to obtain a complete response with systemic therapy

(and thus require surgery), and patients with resectable tumors that are potentially curable with surgery. Identifying prognostic variables predictive of outcome at surgery including a rising preoperative ßHCG, elevated AFP (continuous variable), redo RPLND, and germ-cell cancer in the surgical specimen along with clinical and surgical experience should aid in determining the appropriate integration of surgery and chemotherapy in this population.

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