Surgery is appropriate for tumors less than 11/4 in. (3 cm) on abdominal and pelvic CT scans, but the value of prophylactic chemotherapy has to be discussed with each patient. One trial compared no additional immediate therapy versus only two courses of PVB (BEP can be substituted) or VAB-6 (EP can be substituted) after surgery. Half of the patients with no additional therapy relapsed with tumor while less than 5 percent of those given two courses of prophylactic chemotherapy did so. Almost all relapsing cases completely responded when given the standard four courses of chemotherapy. What this means is that delayed chemotherapy given at relapse did not jeopardize curability, since overall survival was identical for both groups.
Relapse rates are very low for Stage II cases in whom there are only a few positive lymph nodes found at surgery, with none greater than 3/4 in. (2 cm). Consequently, chemotherapy can be withheld in such cases until relapse is found.
For non-seminomatous Stage II tumor masses between 1 1/4 and 2 in. (3 to 5 cm), urologists prefer surgery while some medical oncologists prefer chemotherapy, indicating that there are two possible and acceptable methods of treatment and we are not yet sure which is preferable. Both are correct choices. In any case, surgery is required for all patients who continue to show evidence of remaining masses after initial treatment with chemotherapy. However, for children with yolk-sac tumors, radiation after chemotherapy is preferred for residual masses.
