TABLE 1.

Common Pitfalls in Germ Cell Tumor Management

Disease Setting	Pitfall	Danger
Diagnostic workup	Use of PET scan for staging	Performs no better than CT, yet more expensive and excess radiation exposure; may lead to complacency about FDG-negative masses or overidentification of irrelevant conditions
Early-stage disease	Management based on pre-orchiectomy tumor markers	Can lead to overtreatment of stage I-A or I-B as I-S
	Lack of recognition of causes of false-positive elevations of AFP or HCG	Can lead to overtreatment of stage I-A or I-B as I-S
	Lack of recognition that borderline lymph nodes in the landing zone may be benign	Can lead to overtreatment of stage I as stage II
Advanced disease	Management based on pre-orchiectomy tumor marker levels	Can lead to incorrect IGCCCG classification with potential for over- or undertreatment
	Failure to recognize teratoma as the etiology of lack of shrinkage	Can lead to additional chemotherapy beyond three to four cycles and unnecessary toxicity
	Use of PET in postchemotherapy nonseminoma evaluation	Can lead to omission of surgery predisposing to relapse, particularly late relapse with teratoma or secondary somatic malignancy
	Failure to recognize the slow terminal decline rate of HCG in patients with a high starting HCG value	Can lead to unnecessary use of salvage chemotherapy with considerable toxicity
	Decreasing etoposide or cisplatin doses or substituting carboplatin for cisplatin	Leads to decrease in efficacy (cures and survival)
All phases	Failure to refer patients to expert center (e.g., salvage chemotherapy, need for RPLND, or other complicated situation)	Can lead to a variety of incorrect or insufficient treatments and suboptimal outcome

Abbreviations: GCT, germ cell tumor; FDG, 2-deoxy-2-fluoro--glucose; HCG, human chorionic gonadotropin; AFP, alpha-fetoprotein; IGCCCG, International Germ Cell Cancer Collaborative Group; RPLND, retroperitoneal lymph node dissection.