Surveillance.

Surveillance with a repeat TDM after 3 months.

Surveillance alone or single-agent chemotherapy (carboplatin) is a possible option. A risk stratification cannot be performed accurately since the rete testis status was not reported and the 4-cm size of the tumour is borderline. Reassessment of the pathological specimen is indicated. If the rete testis is not involved, then the patient may safely be considered low risk, and surveillance alone will be sufficient. If the rete testis is positive, he will be intermediate grade and may require chemotherapy. However even then, surveillance may still be justified to avoid the side effects of carboplatin. But the patient should be compliant and agree to regular follow-up with repeated CT and serum markers. The delay of chemotherapy up to the time of recurrence (if this occurs) will not impact negatively on the prognosis.

In view of his altered GC, the patient needs surveillance with repeated markers and CT scanning after 3 months. If markers increase or the lesion grows, he will need RPLND. Moreover since he has dyspnoea, a laparoscopic approach should be proposed to minimize peri-operative complications and allow early ambulation.

This patient needs consolidation chemotherapy with 2 PEB cycles because of the incomplete resection and the presence of embryonal cell carcinoma in the primary tumour. However, caution must be taken with regard to the cumulative dose of bleomycin. This case illustrates the necessity of having only experienced surgeons performing post-chemotherapeutic RPLND for residual tumours.