De novo germinoma in the brain in association with Klinefelter's syndrome: case report and review of the literature

BACKGROUND

There are no previous reports about de novo germ cell tumors without any past history of germ cell tumor. We describe a case of de novo cerebral germinoma in association with Klinefelter's syndrome.

CASE DESCRIPTION

A boy had undergone growth hormone therapy for dwarfism because of hypopituitarism from 10 to 17 years old. The result of karyotyping at the age of 13 was 47,XXY. Magnetic resonance images (MRI) of the brain at the age of 17 years showed no lesions. Two years later, at the age of 19, the patient noticed onset of mild right hemiparesis. MR imaging revealed the existence of a brain tumor in the left temporal lobe and hypothalamus. The patient underwent an operation and the histologic diagnosis of the lesion was germinoma. After postoperative chemotherapy and radiation therapy, the lesion disappeared and the patient was discharged uneventfully.

CONCLUSIONS

To the best of the authors' knowledge, this is the first reported case of a germ cell tumor to be de novo without any past history of other germ cell tumor and the seventh case in which it occurred in association with Klinefelter's syndrome.

Survival and fertility of patients with malignant ovarian germ cell tumours

Disease-free survival (DFS), overall survival (OS) and fertility of patients treated for malignant ovarian germ cell tumours at the Institute of Oncology Ljubljana from 1990-2000 were assessed. Twenty-three patients with a median age of 25 (15-67) years were treated. Five had pure dysgerminoma, three endodermal sinus tumour, ten immature teratoma and five had mixed germ cell tumours. Eleven patients had FIGO Stage I and the others advanced stage disease. All patients underwent initial surgery; in 13 of 15 patients under 35 years unilateral salpingo-oophorectomy was performed. Twenty-one patients received adjuvant cisplatin-based chemotherapy. At the median follow-up of 68 (11-140) months DFS was 74% and OS 87%. Six patients (two did not receive adjuvant chemotherapy) relapsed at a median of 16 (3-63) months after surgery. At relapse four were treated with surgery and chemotherapy, one with chemotherapy only and one with palliative radiotherapy only: two are still in complete remission, one has residual disease and three died of disease. Ten of 13 patients with fertility-preserving surgery regained menstrual cycles and one gave birth to a normal child. DFS and OS in our group of patients (over 15 years of age) are comparable to other institution's experience. Fertility in young patients can be preserved without compromising outcome.

Prognostic Factors and Therapeutic Problems of Primary Intracranial Choriocarcinoma/Germ-Cell Tumors with High Levels of HCG

OBJECTIVE

Primary intracranial choriocarcinoma (PICCC)/germ-cell tumors (GCTs) with high levels of human chorionic gonadotropin (HCG) (PICCC/GCTs with HL-HCG) are rare and malignant. The goal of this study was to report our 3 cases of PICCC/GCTs with HL-HCG and to review the literature to elucidate the clinical problems and prognostic factors and to discuss the therapeutic modalities of this rare tumor.

METHODS

Survival was analyzed in 66 previously reported PICCC/GCTs with HL-HCG including our 3 cases, of which the clinical results have been described in the literature since 1975. In the 66 cases (mean age: 12.1 years; male/female: 45/21), 35 were verified histologically as pure choriocarcinoma, 23 were as mixed GCTs with choriocarcinoma element, and 8 were not verified as including choriocarcinoma element histologically but with very high HCG levels. Significance of the differences among survival curves concerning each parameter (age, sex, tumor location, serum HCG/beta-HCG level, precocious puberty, extent of surgery, radiotherapy, chemotherapy, mixture of other non-germinomatous GCT elements and extraneural metastasis) was tested using univariate and multivariate analyses.

RESULTS

The median survival time and the 1- and 2-year survival rates were 22 months, 61.2% and 49.8%, respectively. In univariate analysis, male, subtotal removal or more, radiotherapy and chemotherapy were revealed to be significantly good prognostic factors. However, suprasellar region and tumor hemorrhage were poor prognostic factors. Multivariate analysis showed that extent of surgery, radiotherapy and chemotherapy were independent prognostic factors.

CONCLUSIONS

Although, we should mind the limitations of this study design because of case selection bias, different treatment protocols and incomplete follow-up of patients, this study led the following results and suggestive conclusions. Tumor hemorrhage and progressive extraneural and cerebrospinal fluid metastasis were characteristic clinical problems of PICCC/GCTs with HL-HCG. In the cases with extremely elevated levels of HCG, biopsy for histological diagnosis may be no longer needed. Initial biopsy and radiotherapy may lead to tumor hemorrhage. To prevent tumor hemorrhage, gross tumor removal followed by radiotherapy and chemotherapy should be aimed for. A few courses of chemotherapy before surgery may prevent metastasis. Stereotactic radiotherapy and high dose chemotherapy may be promising options for treatment.

Clinical review of 55 cases of malignant ovarian germ cell tumors

PURPOSE OF INVESTIGATION

A retrospective analysis of 55 cases of malignant germ cell tumors in a 20-year period was done to evaluate the impact of conservative surgery and adjuvant treatment on survival and fertility.

METHODS

Fifty-five cases of malignant ovarian germ cell tumors (MOGCTs) were studied. Mean age was 22 years. Dysgerminoma was the most common histotype (45%).

RESULTS

Thirty-nine patients (71%) presented with FIGO surgical Stage I disease. Fertility-sparing surgery was performed in 39 (71%) women. Postoperative systemic chemotherapy was administered to 40 women (73%), 27 (68%) had received conservative treatment. One woman developed renal failure after the first cycle of chemotherapy and died a few days thereafter and there was one case of bleomycin-induced death due to pulmonary fibrosis. There were eight (14.5%) clinical recurrences. Overall survival rate for relapsing women was 75% (6/8). The recurrence rate for women treated conservatively was 15%, and it was 13% for those treated radically. With a median follow-up of 129 months the overall survival rate for the entire study-population was 90.9%. Eleven pregnancies occurred in 36 women treated with fertility-sparing surgery who were of child-bearing age.

CONCLUSION

The management of MOGCTs with fertility-sparing surgery is a safe, practicable treatment option. The majority of these patients can retain normal ovarian function and reproductive potential after chemotherapy treatment.

[Chronic myelogenous leukemia following therapy for pineal germinoma]

A 13-year-old male was diagnosed as having pineal germinoma in July 1998. Since then, he had been treated with tumor excision, radiation and chemotherapy. In June 2002, he was diagnosed as having the chronic phase of chronic myelogenous leukemia (CML), and following treatment with interferon-alpha, he achieved hematological complete remission. Although CML is rare in secondary leukemia, the present case seemed therapy-related CML because of its clinical course, as the CML occurred after the period with radiation and chemotherapy. This is the first case of secondary CML following therapy for intracranial tumors.

[Report of two cases with germinoma treated by individual adjuvant chemotherapy based on the mRNA expression of drug-resistance gene]

We reported two cases with germ cell tumor in which new preliminary treatment trials were performed by chemotherapy using anti-cancer drug selected on the basis of multidrug resistance gene mRNA expression, such as MDR1, MRP1, MRP2, MXR1, MGMT, GST pi and TopoII alpha, from RT-PCR assay. A 28-year-old male had gradually developed DI. MR imaging revealed enhanced tumors in the medulla oblongata, the pineal region and the suprasella region. Biopsy of tumor in the medulla oblongata demonstrated germinoma histologically. RT-PCR assay of this tissue revealed overexpression of MRP1, MGMT and GST pi mRNA, but neither MDR1, MRP2 nor MXR1 was observed. The patient was successfully given carboplatin, mitoxanthrone and ifosphamide after irradiation. A 15-year-old male was admitted to our hospital with high intracranial pressure syndrome. MR imaging revealed enhanced tumor in the pineal region. The tumor was diagnosed as a malignant germ cell tumor, histopathologically. RT-PCR assay of this tissue revealed overexpression of MRP1, MRP2, MXR1, MGMT and GST pi mRNA. Only MDR1 was not expressed. The patient was treated by irradiation including radiosurgery combined with chemotherapy, given cisplatin, etoposide and ifosphamide (ICE regimen), but he died because of progressive disease such as CSF dissemination. It seems that preliminary individual adjuvant chemotherapy based on mRNA expression of drug-resistance gene is available for the treatment of germ cell tumors.

Part II: testicular cancer--management of advanced disease

Up to 80% of metastatic germ-cell tumours are curable with conventional chemotherapy. The combination of cisplatin, bleomycin, and etoposide has become the gold standard in this disease. Patients can be divided into good, intermediate, and poor prognosis groups. For those patients with good prognostic features, cure rates reach 90% and attempts have been made to reduce toxic effects of treatment while maintaining efficacy. Patients that relapse require salvage treatment. This can involve the incorporation of drugs such as ifosfamide and taxol into conventional protocols or the use of high-dose chemotherapy with stem-cell transplants. Patients with poor prognosis disease are much more likely to fail conventional chemotherapy and are candidates for dose-intensive protocols or transplants as first-line treatment. Although the results obtained in treating metastatic germ-cell tumours are superior to those with other solid tumour types, there are still many areas that require further improvement.

Primary central nervous system germ cell tumors

The prognosis of primary germ cell tumors (germinal neoplasms) of the central nervous system varies, depending on the histology and size of tumor and the extent of disease at diagnosis. Although some patients receive therapy without a tissue diagnosis, it is strongly recommended that tumor tissue samples be obtained for accurate histologic diagnosis. Modern neurosurgical navigation techniques have made tissue sampling by stereotactic biopsy a safe and rapid method of determining tumor histology. Depending on tumor location, open surgical biopsy may be required in some patients. Typically, germinomas are exquisitely radiosensitive, although preirradiation chemotherapy reduces the total radiation exposure and may increase the cure rate. Induction cisplatin-based chemotherapy, followed by low-dose involved field radiotherapy, has excellent overall and relapse-free survival rates and is the optimal treatment for patients with germinomas. This combined chemoradiotherapy approach is associated with minimal endocrinopathy and minimal neurocognitive dysfunction. Patients with relapses after low-dose radiation therapy can respond well to salvage therapy (chemotherapy or chemoradiotherapy) without significant sequelae. Patients with nongerminomas respond best to chemotherapy combined with radiation, although the response and cure rates are lower compared to germinomas. Patients with residual masses and normal tumor markers after primary therapy should have a second-look resection because most patients have residual teratoma or necrotic tissue and can be spared additional chemotherapy or radiation. Pure mature teratomas are cured only by surgical extirpation. Immature central nervous system teratomas appear to benefit from radical surgical resection, but higher doses of locally directed radiotherapy are required with no benefit from the usual chemotherapy.

Central nervous system tumours in adolescents

Adolescents with brain tumours have been, and in most cases still are, haphazardly assigned, on referral, to either 'paediatric' or 'adult'-based treatment centres. In this age group, there is therefore a history of inconsistent treatment, delivery of inappropriate 'maturity-related' care and a reduced chance of gathering vital biological, clinical and treatment-related information germane to this group of patients and their tumours. These days, adolescents with brain tumours should be actively targeted for recruitment into clinical trials and admission into dedicated neuro-oncology centres or programmes that can deliver the necessary and age appropriate multidisciplinary management.

Malignant germ cell tumors in childhood: results of the first Italian cooperative study "TCG 91"

BACKGROUND AND AIMS

About 20% of patients with germ cell tumor (GCT) are still resistant to therapy. To investigate which features are present in resistant patients, a multicenter study on GCT in children was undertaken to correlate clinical and laboratory parameters with the outcome.

METHODS

Patients aged less than 16 years, with histologically proven extracranial GCT were included.

RESULTS

Ninety-five patients (median age 33 months, 45 males) were eligible. The site of the primary tumor was gonadal in 59, extragonadal in 36. The stage was I in 39; II in 5; IIIa (microscopic residue) in 7; IIIb (macroscopic residue) in 16; IIIc (unresectable) in 13; IV in 15. The treatment was surgery alone in 31; surgery plus radiotherapy in 1; chemotherapy +/- surgery in 63. Post-chemotherapy resection in 19 (10 complete, 9 partial). The chemotherapy regimen was carboplatin 400 mg/m2/day on days 1, 2; etoposide 150 mg/m2/day on days 1, 2; ifosfamide 1,500 mg/m2/day on days 21, 22; dactinomycin 1.5 mg/m2/day on day 21; vincristine 1.5 mg/m2/day on day 21. Three patients died because of toxicity and two non-responders (to primary chemotherapy), died of progression; among the remaining 90 patients 20 relapsed, 9 are in second remission, 2 are alive with disease, and 9 died of disease progression (one from progression and intracranial hemorrhage). Overall survival was 82.7% and event-free survival: 71.5%. Survival according to: (a) site: testis: 100%; ovary: 88%; sacrococcyx: 69.6%; other sites: 33.3% (P < 0.001); (b) stage: I and II: 100%; IIIa: 83.3%; IIIb: 84.6%; IIIc: 60.6%; IV: 53.2% (P < 0.001); (c) AFP levels: normal: 85.5%; 42-9,470 ng/ml: 84.6%; >/=10,000 ng/ml: 58.7% (P = 0.02). All the pts who had complete resection of the primary tumor at diagnosis or at delayed surgery, remained in remission.

CONCLUSIONS

Multivariate analysis showed that the primary site of tumor was the only independent prognostic factor for survival and EFS.

Successful twin pregnancy in panhypopituitarism caused by suprasellar germinoma

BACKGROUND

Pregnancy in a woman with hypopituitarism from a suprasellar germinoma is rare.

CASE

A 27-year-old woman presented with panhypopituitarism from a suprasellar germinoma. She had diabetes insipidus, hypothyroidism, adrenal cortex dysfunction, and hypogonadotropic ovarian failure. When treated with thyroxin, cortisol, antidiuretic hormone, human menopausal gonadotropin, and human chorionic gonadotropin, she conceived and gave birth to healthy twins.

CONCLUSION

Hormonal replacement therapy and ovulation induction resulted in a successful pregnancy in a woman with panhypopituitarism.

Management of recurrence and follow-up strategies for patients with nonseminoma testis cancer

This review serves as an outline of the clinical features and management options for the majority of recurrence situations in NSGCTs. The combination of reliable serum tumor markers, improved imaging techniques, effective cisplatin chemotherapy regimens, and application of meticulous surgical techniques has resulted in dramatic improvements in cure rates in NSGCT. These factors have caused the incidence of recurrent NSGCT to decline substantially in the past 20 years. This rarity of recurrence in combination with the low incidence of NSGCT prevents the practicing clinician from accumulating experience in this challenging patient population. Therefore, to ensure improvement in salvage rates, patients are best managed in centers with extensive experience in NSGCT.

An Approach for Cure: PEI-Chemotherapy and Regional Deep Hyperthermia in Children and Adolescents with Unresectable Malignant Tumors

BACKGROUND

Elevated temperatures of 40 - 44 degrees C increase the actions of various anticancer drugs including N-lost derivatives, cytotoxic antibiotics and platinum analoga. In clinical usage thermochemotherapy (TCH) should facilitate surgical resection and ameliorate local tumor control.

PATIENTS AND METHODS

From 07/1993 to 12/2002 a total of 39 patients have been enrolled onto a phase-II study (female = 24, male = 15, age 1 - 37.5 years, median 5.2). Among these, 24 patients had extracranial non-testicular germ cell tumors and 15 patients soft tissue or chondrosarcomas.

INDICATION

locoregional relapse (n = 29) or unresectable tumor after neoadjuvant chemotherapy (n = 10). Among these two groups, there were ten patients with poor response or progressive disease under primary or relapse chemotherapy. Ten out of the 29 relapse patients had more than one relapse. Tumor site: pelvis (30), abdomen (4), head and neck (2), proximal leg (2) and lumbar spine (1). Thermochemotherapy (TCH): 1800 - 2000 mg ifosfamide/m (2) and 100 mg etoposide/m (2) on days 1 - 4 and 40 mg cisplatin/m (2) on days 1 + 4 combined with regional deep hyperthermia (42 - 44 degrees C, 1 h) on days 1 + 4.

RESULTS

In 39 protocol patients a total of 166 TCH courses (332 heat sessions) were applied. 20 patients achieved complete response, and 10 patients achieved partial response. TCH was followed by surgical tumor resection in 28/39 patients and/or radiotherapy in 13/39 patients. At a median follow-up of 27 months, outcome in this high-risk patient population was 22 NED, 3 AWD, 12 DOD, 2 DOC. Five year event free (EFS) and overall survival (OS) for the whole study cohort was 0.39 +/- 0.11 (20/39 patients) and 0.52 +/- 0.11 (25/39 patients), respectively.

CONCLUSION

TCH shows substantial therapeutic efficacy and facilitates complete tumor resection in 14 out of 28 operated patients. Multimodal treatment including TCH, surgical resection and/or radiotherapy leads to sustained remission in the majority of patients with locoregional tumor recurrence. The therapeutic effect is most pronounced, if TCH is administered at first relapse. Due to the clinical and histologic heterogeneity the number of patients eligible for TCH is limited. Therefore, a more valid assessment of treatment efficacy can only be made by a matched-pair comparison in cooperation with the clinical registers.

Long-term results of first-line sequential high-dose etoposide, ifosfamide, and cisplatin chemotherapy plus autologous stem cell support for patients with advanced metastatic germ cell cancer: an extended phase I/II study of the German Testicular Cancer Study Group

PURPOSE

Patients with disseminated germ cell cancer and poor prognosis (International Germ Cell Cancer Collaborative Group [IGCCCG] classification) achieve only a 45% to 50% long-term survival by standard chemotherapy. First-line high-dose chemotherapy might be able to improve the result. This analysis reports toxicity and long-term results of a large phase I/II study of sequential high-dose etoposide, ifosfamide, and cisplatin (VIP) in patients with advanced germ cell tumors.

PATIENTS AND METHODS

Between July 1993 and November 1999, 221 patients with either Indiana "advanced disease" (n = 39) or IGCCCG "poor prognosis" criteria (n = 182) received one cycle of VIP followed by three to four sequential cycles of high-dose VIP chemotherapy plus stem cell support, every 3 weeks, at six consecutive dose levels.

RESULTS

Dose limiting toxicity occurred at level 8 (100 mg/m2 cisplatinum, 1750 mg/m2 etoposide, 12 g/m2 ifosfamide) with grade 4 mucositis (three of eight patients), grade 3 CNS toxicity (one of eight patients), grade 4 renal toxicity (one of eight patients), and prolonged granulocytopenia (one of eight patients). After 4-year median follow-up, progression-free survival and disease-specific survival rates in the poor prognosis subgroup were 69% and 79% at 2 years and 68% and 73% at 5 years, with 76% for gonadal/retroperitoneal versus 67% for mediastinal primaries. Severe toxicity included treatment related death (4%), treatment-related acute myeloid leukemia (1%), long-term impared renal function (3%), chronic renal failure (1%), and persistent grade 2-3 neuropathy (5%).

CONCLUSION

Repetitive cycles of high-dose VIP with peripheral stem cell support can be successfully applied in a multicenter setting. Dose level 6 with cisplatin 100 mg/m2, etoposide 1500 mg/m2, and ifosfamide 10 g/m2 is recommended for further investigation in randomized trials. An ongoing randomized trial within the European Organization for Research and Treatment of Cancer evaluates this protocol against four cycles of standard cisplatin, etoposide, and bleomycin.

Intratubular germ cell neoplasia of unclassified type occupying the whole testis accompanied by a small mature teratoma and metastatic choriocarcinoma and Sertoli cell-only tubules in the other testis

A 19-year-old man with mild mental retardation was diagnosed as having metastatic choriocarcinoma and a testicular tumor. Histopathological examination of the resected testis revealed the presence of a small lesion of mature teratoma but no trace of choriocarcinoma. The remaining seminiferous tubules were atrophic and lined by large atypical germ cells, which were diagnosed as intratubular germ cell neoplasia of the unclassified type (IGCNU). A small area with prominent tubules was also observed. Within this lesion, the tubules were dilated and contained several layers of cells with central necrosis. Immunohistological comparison of staining for several biological markers (Ki-67, c-kit and placental alkaline phosphatase) between cells in the atrophic tubules and those in the dilated tubules indicated a progression of the latter cells to cells with a more proliferative ability. In the opposite testis, examined at autopsy after death due to metastatic choriocarcinoma, all seminiferous tubules were lined by Sertoli cells only. It was therefore assumed that the germ cell tumor of the combined histological type had primarily arisen in the background of IGCNU, and that choriocarcinoma had spontaneously regressed. The early onset of these testicular neoplastic lesions strongly indicates their occurrence under the genetic background of gonadal dysplasia, the Sertoli cell-only syndrome. The possible relation of gonadal disease to mental retardation in this patient is also discussed.

[Germinal cell tumors in young and adolescent girls]

OBJECTIVE

Germ cell tumours are the most common ovarian tumours in childhood and adolescence. This diverse group of tumours derives from germ cells.

DESIGN

The aim of this work is presentation of germ cell tumours in the material from our clinic with characteristic clinical features, the scope of operation and effects of many years of observation.

MATERIALS AND METHODS

We treated 109 girls with germ cell tumours of the ovary: 13 had malignant tumours: there were 7 patients with dysgerminomas, 2 with endodermal sinus tumour of the ovary, 3 with immature teratomas, 1 with carcinoma embryonale. Gonadoblastomas was diagnosed 4 patients and mature teratomas in 92 patients.

RESULTS

11 patient had gonadal dysgenesia with abnormal karyotype. These girls had no follicle apparatus in gonads and had elevated levels of gonadotropins. Gonadoblastoma is almost always found in patients with gonadal dysgenesis. Gonadoblastoma often produces estradiol or testosterone. There can be problems with diagnosis of the syndrome, because developmental features imitate the onset of normal puberty. Most patients with dysgerminoma have stage I of disease and surgery is sufficient. It must be suggested that patients of stage I who wish to preserve childbearing function may be treated with unilateral salpingoophorectomy and adjuvant chemotherapy. Monitoring of the treatment is connected with measurement of biochemical markers. Some of these markers are useful for monitoring of response to therapy. When levels of markers are low second look laparoscopic operation should be performed. Cytological smears and biopsy specimens from the remaining ovary, peritoneum and subdiaphragmatic area should be obtained laparoscopically.

CONCLUSIONS

The sift ultrasonographic investigations can be helpful in the early diagnosis of germ cell tumours of the ovary in girls. Absence of follicle apparatus in the gonads requires determination of levels of gonadotropins and karyotype. Fertility sparing operative treatment is preferred when karyotype is normal.

Reversible hearing loss associated with a malignant pineal germ cell tumor. Case report

In patients with pineal tumors, clinical symptoms are due to direct compression of adjacent structures. The most common signs include increased intracranial pressure (80%) caused by obstruction of the sylvian aqueduct, and Parinaud syndrome (50%) caused by direct compression of the superior colliculi. Hearing loss is rare in patients with tumors in this location. The authors report on the case of a 12-year-old boy in whom a malignant pineal germ cell tumor was found together with the unusual occurrence of severe hearing loss due to direct bilateral compression of the inferior colliculi. This condition resolved completely after tumor regression.

Adult primary extragonadal germ cell tumors: Treatment results and long-term follow-up

BACKGROUND

Primary extragonadal germ cell tumors (PEGCT) are rare neoplasms. They have a poor prognosis, different behavior, and natural course compared to their gonadal counterparts. Both primary and salvage treatment of these tumors constitute a challenge. We retrospectively evaluated the clinicopathologic status, therapeutic implications, and outcome of our patients with PEGCT.

PROCEDURE

Between 1991 and 2000, 18 patients with PEGCT (median age 31 years; range 17-63), diagnosed with tru-cut biopsy and treated with cisplatin-based chemotherapy, were evaluated in respect to treatment response and outcome.

RESULTS

Cisplatin-based chemotherapy achieved a complete response rate of 27.8% and a partial response rate of 55.5%. Overall response rate was 83.3%. Only three patients were unresponsive to chemotherapy; an additional six patients with residual mass underwent surgical resection and were rendered disease-free by surgery. The 5-year actuarial event-free and overall survival were 63.4 and 71.3%, respectively.

CONCLUSIONS

The outcomes of our patients with extragonadal primaries including mediastinal localization appear to be slightly better than those previously reported. Multimodality therapy is essential for these patients and given the relatively poor prognosis, prospective trials with large sample sizes, and new treatment approaches to improve outcome are required.

Ovarian germ cell malignancy and human immunodeficiency virus (HIV) infection: a case report

The occurrence of germ cell tumors in patients with human immunodeficiency virus (HIV) infection has not been previously reported. However, with the HIV pandemic in certain parts of the world, this association has become a reality. The approach to management as well as the role of adjuvant radiotherapy and chemotherapy is problematic as many of these therapies are toxic. The appropriate management of such tumors will remain elusive for sometime. The presentation, management, and outcome of ovarian endodermal sinus tumor in a HIV-infected patient is reported.

Recommendations of follow-up after treatment of germ cell tumors

Patients diagnosed with germ cell tumors (GCT) are relatively young, and most are rendered disease-free by primary treatment. Also, second-line therapies in nearly all instances are potentially curative. Therefore, the schedule and modalities of follow-up testing are important issues in detecting recurrence of GCT and for detecting secondary malignancies and complications of therapy. Follow-up is usually based on the pattern and probability of recurrence following primary therapy according to stage and histology. The National Comprehensive Cancer Network has outlined guidelines (www.nccn.org/physician_gls/index.html). There is a paucity of randomized data regarding the follow-up regimens most effective in identifying relapsed disease. Optimal means of imaging and frequency of physician visits and serum marker level measurements need to be further addressed.