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BACKGROUND: A testicular germ cell tumour (TGCT) predisposing gene has been mapped to the Xq27 region on the X chromosome. These linkage findings remain to be confirmed by other studies. METHODS: In 276 patients and 169 unaffected first-degree male relatives, 12 microsatellite markers covering the candidate region were genotyped and used to study possible association of TGCT with Xq27. RESULTS: In contrast to previously reported linkage of familial TGCT and cryptorchidism with Xq27, we observed an association between the subset of TGCT cases without a family history of TGCT or cryptorchism and marker DXS1193 (p=0.014). Carriers of minor alleles were at increased risk (odds ratio (OR) 4.7, confidence interval (CI) 1.1-19.6) CONCLUSION: We found an association on Xq27 in a subset of TGCT cases, which suggests the presence of an X-linked gene that slightly or moderately increases risk to develop sporadic TGCT but not cryptorchidism. [ABSTRACT FROM AUTHOR]

Purpose The aim of this research was to study the effectiveness on return to work (RTW) of an early tailored work-related support intervention in patients diagnosed with curative gastrointestinal cancer. Methods A multicenter randomized controlled trial was undertaken, in which patients were assigned randomly to the intervention or the control group (usual care). The intervention encompassed three psychosocial work-related support meetings, starting before treatment. Five self-reported questionnaires were sent over twelve months of follow-up. Primary outcome was days until RTW (fulltime or partial) and secondary outcomes included work status, quality of life, work ability, and work limitations. Descriptive analysis, Kaplan-Meier analysis, relative risk ratio and linear mixed models were applied. Results Participants (N = 88) had a mean age of 55 years; 67% were male and the most common cancer type was colon cancer (66%). Of the participants, 42 were randomized to the intervention group. The median time from sick leave until RTW was 233 days (range 187-279 days) for the control group, versus 190 days (range 139-240 days) for the intervention group (log-rank p = 0.37). The RTW rate at twelve months after baseline was 83.3% for the intervention group and 73.5% for the control group. Work limitations did statistically differ between the groups over time (p = 0.01), but quality of life and work ability did not. Conclusion Patients in the intervention group seem to take fewer days to RTW, albeit not to a statistically significant extent.Trial registration Trial NL4920 (NTR5022) (Dutch Trial Register https://www.trialregister.nl ).

Introduction: Surgical site infections (SSI) are a common postoperative complication. During the development of the new WHO guidelines on SSI prevention, also in the Netherlands was concluded that perioperative care could be optimised beyond the current standard practice. We selected a limited set of readily available, cheap and evidence-based interventions from these new guidelines that are not part of standard practice in the Netherlands and formulated an Enhanced PeriOperative Care and Health bundle (EPOCH). Here, we describe the protocol for an open-label, randomised controlled, parallel-group, superiority trial to test the effect of the EPOCH bundle added to (national) standard care in comparison to standard care alone on the incidence of SSI., Methods and Analysis: EPOCH consists of intraoperative high fractional inspired oxygen (0.80); goal-directed fluid therapy; active preoperative, intraoperative and postoperative warming; perioperative glucose control and treatment of severe hyperglycaemia (>10 mmol l-1 ) and standardised surgical site handling. Patients scheduled for elective abdominal surgery with an incision larger than 5 cm are eligible for inclusion. Participants are randomised daily, 1:1 according to variable block sizes, and stratified per participating centre to either EPOCH added to standard care or standard care only. The primary endpoint will be SSI incidence according to the Centers for Disease Control and Prevention (CDC) definition within 30 days as part of routine clinical follow-up. Four additional questionnaires will be sent out over the course of 90 days to capture disability and costs. Other secondary endpoints include anastomotic leakage, incidence of incisional hernia, serious adverse events, hospital readmissions, length of stay and cost effectiveness. Analysis of the primary endpoint will be on an intention-to-treat basis., Ethics and Dissemination: Ethics approval is granted by the Amsterdam UMC Medical Ethics Committee (reference 2015_121). Results will be disseminated through peer-reviewed journals and summaries shared with stakeholders. This protocol is published before analysis of the results., Trial Registration Number: Registered in the Dutch Trial Register: NL5572., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: After major abdominal surgery (MAS), 20% of patients endure major complications, which require invasive treatment and are associated with increased morbidity and mortality. A quality control algorithm after major abdominal surgery aimed at early identification of patients at risk of developing major complications can decrease associated morbidity and mortality. Literature studies show promising results for C-reactive protein (CRP) as an early marker for postoperative complications, however clinical significance has yet to be determined., Methods: A multicenter, stepped wedge, prospective clinical trial including all adult patients planned to undergo elective MAS. The first period consists of standard postoperative monitoring, which entails on demand additional examinations. This is followed by a period with implementation of postoperative control according to the PRECious protocol, which implicates standardized measurement of CRP levels. If CRP levels exceed 140 mg/L on postoperative day 3,4 or 5, an enhanced CT-scan is performed. Primary outcome in this study is a combined primary outcome, entailing all morbidity and mortality due to postoperative complications. Complications are graded according to the Clavien-Dindo classification. Secondary outcomes are hospital length of stay, patients reported outcome measures (PROMs) and cost-effectiveness. Data will be collected during admission, three months and one year postoperatively. Approval by the medical ethics committee of the VU University Medical Center was obtained (ID 2015.114)., Discussion: the PRECious trial is a stepped-wedge, multicenter, open label, prospective clinical trial to determine the effect of a standardized postoperative quality control algorithm on postoperative morbidity and mortality, and cost-effectiveness., Trial Registration: www.ClinicalTrials.gov, NCT02102217. Registered 5 February 2015.

Background: Sacrococcygeal teratomas are neoplasms that are ordinarily diagnosed intrauterinely. In case of complete or partial intrapelvic sacrococcygeal teratoma, it may happen that it is only ascertained at a later age., Case Description: During a regular monitoring visit for breast cancer a 58-year-old female reported that she had discovered a swelling at the level of her coccyx. MRI imagery appeared to indicate an ectopic ovary. After resection, it appeared that it was a mature teratoma from which mucinous adenocarcinoma had developed., Conclusion: Given the risk of malignant deterioration, it is important that sacrococcygeal teratoma be recognized and treated by means of complete resection, including resection of the coccygeal bone.

Obstetric injury comprising tearing of the rectovaginal septum, rectal mucosa, and anal sphincter complex with limited or no involvement of the perineal body may implicate the sudden appearance of an elbow, foot or head in the anal orifice during the second phase of labour. This complex type of obstetric injury is highly uncommon and reports have rarely been published. There are no guideliness as to how to respond to this obstetric emergency and there is no time for consultation. In order to reach clinical recommendations on repair and management of this unexpected obstetric injury for the midwife or obstetrician, we report three such cases. The three described cases with their corresponding sequence of events and interventions illustrate that successful repair of these types of injury can often be achieved. To minimize factors leading to long-term complications, repair requires the involvement of an experienced gynaecologist and sometimes even a colorectal surgeon.

A quarter of all intertrochanteric fractures are unstable with a fractured lesser trochanter. Mostly these fractures are treated with a gamma nail fixation. A rare complication of this treatment is a false aneurysm of the femoral artery. The authors present 2 cases of a false aneurysm of the femoral artery in association with intertrochanteric fractures. Because of its nonspecific symptoms, a false aneurysm is difficult to diagnose. A computed tomography angiography or duplex should be used to confirm the diagnosis and evaluate the options for treatment. Surgery is the preferred treatment in the case of a large aneurysm, whereas endovascular repair is preferred for smaller aneurysms.

Three patients, three women aged 40, 64 and 75, suffered from a trocar hernia, a specific complication of laparoscopic surgery. This type of hernia may result in small bowel obstruction and normally appears within two weeks after laparoscopy. The usual presentation is that of abdominal pain with nausea and vomiting. Trocar herniation implicates the necessity of reposition and might result in bowel resection with prolonged hospital stay. The advice for prevention is to use a trocar with a diameter as small as possible, as the chance of a hernia occurring increases withthe use of larger trocars. Fascial closure is advised for trocars to mm and larger. With a growing number of procedures being performed laparoscopically, the importance of recognizing and preventing this complication is evident. Three cases illustrate the importance of early recognition of small bowel obstruction resulting from trocar herniation.

Adult intussusception is a rare clinical presentation and often not considered clinically in the differential diagnosis of adult patients with vague abdominal complaints. A 44-year-old woman visited our emergency department with sudden onset of intermittent abdominal pain. Diagnostic imaging revealed an intussusception caused by a submucosal lipoma of the sigmoid. A laparotomy was performed and the diagnosis was proven by histological examination. Submucosal lipomas are usually asymptomatic but may cause bleeding, obstruction, intussusception, or abdominal pain and thus mimic a malignancy. Surgical excision is indicated for symptomatic cases.

A 15-year-old girl presenting with abdominal pain after a play-fight was diagnosed with a duodenal rupture, which was surgically repaired.

Testicular cancer (TC) as well as malignant lymphoma (ML), both have nowadays an excellent prognosis. However, both types of cancer may be diagnosed at young adulthood and patients may experience sexual concerns. In this article the need for information and support concerning sexuality will be explored, and the traumatic impact of cancer diagnosis with respect to this will be considered. A total of 264 patients with testicular cancer, median age 36 (S.D. 9.7) years, and 50 patients with malignant lymphoma, median age 42 (S.D. 11.7) years returned a questionnaire concerning sexual functioning; four items assessed the need for information or support concerning sexuality, at diagnosis and at follow-up. It appeared that more than half of the patients with testicular cancer reported a lack of information and support concerning sexuality during treatment; 67% of them still had a need for information at follow-up. These rates were significantly lower for patients with malignant lymphoma. Especially patients with testicular cancer who suffered sexual dysfunction reported extremely high needs for information and support. According to these findings it can be concluded that more attention should be paid to the doctor-patient communication with respect to sexual concerns in general, and especially where it concerns patients with testicular cancer.

Background: In patients with hereditary or constitutional chromosomal anomalies, testicular carcinoma can develop sporadically or on the basis of an underlying hereditary genetic defect. Greater knowledge of these genetic defects would provide more insight into the molecular pathways that lead to testicular carcinoma. To the authors' knowledge, little attention has been paid to date to the comorbid occurrence of testicular carcinoma in patients with hereditary disorders or constitutional chromosomal anomalies., Methods: The authors performed a review of the literature., Results: Twenty-five different hereditary disorders or constitutional chromosomal anomalies have been reported in patients who developed seminomatous or nonseminomatous testicular carcinoma., Conclusions: Although most of these malignancies were too rare to enable the detection of statistically significant correlations between the chromosomal/hereditary disorder and the testicular tumor, it was striking that many of the patients had also other urogenital abnormalities. Susceptibility to urogenital abnormalities seems to disrupt normal urogenital differentiation and suggests a correlation with testicular dysgenesis and, thus, also with testicular carcinoma. Other evidence of causal involvement has been found in the field of tumor cytogenetics. Some of the genes responsible for hereditary disorders have been mapped to regions that are of interest in the development of sporadic testicular carcinoma. Molecular studies on candidate genes will be required to provide definite answers. Completion of the human gene map and the availability of advanced gene arrays and bioinformatics are expected to greatly facilitate further exploration of the role of hereditary genetic defects in testicular carcinoma., (Copyright 2003 American Cancer Society)

A 24-year-old patient was admitted to the intensive care unit because he had swallowed about 20 cocaine packets 48 hours before admission; he also complained of abdominal cramps, perspiration and dizziness. The patient reported that he had not defecated since swallowing the packets. Abdominal X-ray revealed only coprotasis. On conservative therapy with bowel irrigation, two packets were eliminated, after which a second abdominal X-ray revealed several cocaine packets in the colon. Four days afterwards, the cocaine packets in the colon had not progressed despite adequate bowel irrigation. The patient now showed signs of mild cocaine intoxication (hallucinations and tachycardia). It was therefore decided to perform a laparotomy. Via a sigmoidotomy, 7 intact packets were removed; another 3 had already ruptured and were empty. The rupture of 3 cocaine packets in this patient was probably not fatal because of the sedation with midazolam and because the patient had diarrhoea as a result of the extensive irrigation, so that a large proportion of the cocaine was probably not absorbed. This case also shows that the presence of foreign bodies cannot be established adequately by an abdominal X-ray if there is coprostasis.

Background: The association with histocompatibility antigens (HLA), in particular Class II genes (DQB1, DRB1), has recently been suggested to be one of the genetic factors involved in testicular germ cell tumor (TGCT) development. The current study, which uses genotyping of microsatellite markers, was designed to replicate previous associations., Methods: In 151 patients, along with controls comprising parents or spouses, the HLA region (particularly Class II) on chromosome 6p21 was genotyped for a set of 15 closely linked microsatellite markers., Results: In both patients and controls, strong linkage disequilibrium was observed in the genotyped region, indicating that similar haplotypes are likely to be identical by descent. However, association analysis and the transmission disequilibrium test did not show significant results. Haplotype sharing statistics, a haplotype method that derives extra information from phase and single marker tests, did not show differences in haplotype sharing between patients and controls., Conclusion: The current genotyping study did not confirm the previously reported association between HLA Class II genes and TGCT. As the HLA alleles for which associations were reported are also prevalent in the Dutch populations, these associations are likely to be nonexistent or much weaker than previously reported., (Copyright 2002 American Cancer Society.)

Background: The current study reviews chronologic changes in the long term outcome of patients with metastatic nonseminomatous testicular germ cell tumors (NSTGCT) who were treated at a single institution during the past two decades. The 10-year survival of prognostic subgroups according to the classification of the International Germ Cell Consensus Classification Group (IGCCCG) and various other prognostic classifications is examined in time to evaluate whether cumulative experience has led to an improved outcome of patients with metastatic NSTGCT and to explore differences in outcome of prognostic subgroups., Methods: Two hundred ninety-nine patients with metastatic NSTGCT who were treated with cisplatin-based polychemotherapy during the period from 1977 to 1996 were staged retrospectively according to the Royal Marsden (RM) classification and the following prognostic classifications: IGCCCG, Indiana, Medical Research Council (MRC), and European Organization for Research and Treatment of Cancer (EORTC). The numbers of patients who were treated during the periods 1977-1986 and 1987-1996 were 146 and 153, respectively. Survival curves were constructed using the Kaplan-Meier method, and disease specific 10-year survival rates of prognostic subgroups treated during the two consecutive 10-year periods were compared using the log rank test., Results: The median follow-up of surviving patients during the periods 1977-1986 and 1987-1996 was 14.7 years (range, 0.2-20.6 years) and 7.0 years (range, 0.4-11.4 years), respectively. The actuarial disease specific 10-year survival rate of patients with metastatic NSTGCT increased from 76% during the period 1977-1986 to 88% during the period 1987-1996 (relative risk [RR], 0.51; 95% confidence interval [95% CI], 0.29-0.89; P < 0.05). The 10-year survival rates of patients with good, intermediate, and poor prognoses according to the IGCCCG classification were 95%, 74%, and 37%, respectively, during the period 1977-1986 and 94%, 87%, and 66%, respectively, during the period 1987-1996. Patients with a poor prognosis according to the IGCCCG classification showed the greatest increase in 10-year survival (RR, 0.43; 95% CI, 0.18-1.04; P = 0.06). Analysis using the RM, Indiana, and EORTC classifications also showed an improved 10-year survival rate of patients with a poor prognosis who were treated during 1987-1996 compared with those who were treated during 1977-1986., Conclusions: The 10-year survival rate of patients with metastatic NSTGCT who were treated with cisplatin-based chemotherapy significantly increased from 76% during the period 1977-1986 to 88% during the period 1987-1996. This improvement during the cisplatin era resulted mainly from an increase in the survival of patients with metastatic disease who had a poor prognosis. These results indicate that the management of patients with NSTGCT is still improving., (Copyright 2001 American Cancer Society.)

Today, the standard treatment for patients with clinical Stage I non-seminomatous testicular germ cell tumors (NSTGCT) following orchidectomy is either primary retroperitoneal lymph node dissection (RPLND) or close surveillance with cisplatin-based polychemotherapy in case of a relapse. Both treatment modalities provide excellent overall survival rates up to 100%. Consequently, selection of the most appropriate management option is not primarily guided by survival considerations. The choice between the available options, each having its merits and its drawbacks, should be made based on a number of factors including treatment-related morbidity, views and expertise of the physician, patient preferences, the expected degree of patient compliance, and prognostic factor analysis. To date, the role of adjuvant chemotherapy as an alternative management option for patients with clinical Stage I NSTGCT at high risk of occult metastases is limited. This systemic treatment modality would be a realistic alternative if the reliability of prognostic factors to identify high-risk Stage I patients could be improved. This review addresses relevant issues in the management of patients with clinical Stage I NSTGCT to provide information that will allow a rational selection of the most appropriate management option., (Copyright 1999 Wiley-Liss, Inc.)

Geographic variations in testicular cancer incidence may be caused by differences in environmental factors, genetic factors, or both. In the present study, geographic patterns of age-adjusted testicular cancer incidence rates (IRs) in 12 provinces in The Netherlands in the period 1989-1995 were analysed. In addition, the age-adjusted IR of testicular cancer by degree of urbanization was evaluated. Cancer incidence data were obtained from the Netherlands Cancer Registry. The overall annual age-adjusted IR of testicular cancer in The Netherlands in the period 1989-1995 was 4.4 per 100000 men. The province Groningen in the north of the country showed the highest annual IR with 5.8 per 100000 men, which was higher (P < 0.05) than the overall IR in The Netherlands (incidence rate ratio (IRR) 1.3, 95% confidence interval (CI) 1.1-1.6). The highest IR in Groningen was seen for both seminomas and non-seminomas. In addition, Groningen showed the highest age-specific IRs in all relevant younger age groups (15-29, 30-44 and 45-59 years), illustrating the consistency of data. The province Friesland, also situated in the northern part of the country, showed the second highest IR of testicular cancer with 5.3 cases per 100000 men per year (IRR 1.2, 95% CI 1.0-1.5, not significant). This mainly resulted from the high IR of seminoma in Friesland. Analysis of age-adjusted IRs of testicular cancer by degree of urbanization in The Netherlands showed no urban-rural differences at analysis of all histological types combined, or at separate analyses of seminomas and non-seminomas. Geographic clustering of testicular cancer seems to be present in the rural north of The Netherlands with some stable founder populations, which are likely to share a relatively high frequency of genes from common ancestors including genes possibly related to testicular cancer. Although this finding does not exclude the involvement of shared environmental factors in the aetiology of testicular cancer, it may also lend support to a genetic susceptibility to testicular cancer development. Testicular cancer cases in stable founder populations seem particularly suitable for searching for testicular cancer susceptibility genes because such genes are likely to be more frequent among affected men in such populations.

Familial occurrence of testicular cancer suggests a genetic predisposition to the disease. A genetic susceptibility may also be reflected by the occurrence of bilateral testicular neoplasms and the high rates of urogenital developmental anomalies in families prone to testicular cancer. In this study, the proportion of familial testicular cancer cases was analyzed retrospectively in a single-centre population of 693 testicular cancer patients treated between 1977 and 1997 and the relative risk (RR) for first-degree relatives of patients was estimated. In addition, the existence of bilateral testicular neoplasms and urogenital developmental anomalies in familial testicular cancer patients was evaluated. 24 of the 693 patients (3.5%) had a first-degree relative with testicular cancer. These 24 cases belonged to 17 families; in 7 of these 17 families both affected first-degree family members were part of the study population of 693 patients. Consequently, the 693 studied patients belonged to a total of 686 families. Thus, the actual proportion of familial testicular cancer was 2.5% (17 of 686 families). The familial cases consisted of 11 brother pairs, including 2 pairs of identical twins and 1 pair which also had two affected cousins, and 6 father-son pairs (in total 36 cases, 12 treated elsewhere). Estimates of the RR to first-degree relatives showed a 9- to 13-fold increased RR to brothers (P < 0.001) and a 2-fold increased RR to fathers (P = non-significant (n.s)) of testicular cancer patients. Among the 36 patients with familial testicular cancer, 2 (5.6%) had bilateral testicular cancer, 4 (11.1%) had undescended testis, 3 (8.3%) had inguinal hernia, and 1 (2.8%) showed renal hypoplasia. The present data on familial occurrence of testicular cancer may lend support to a role of genetic factors in the aetiology of testicular cancer.

Objective: To determine the changes between 1977 and 1996 in the distribution of stages of testicular cancer (TC)., Patients and Methods: The stage distribution was assessed, using various classifications, i.e. the Royal Marsden (RM), Indiana, European Organization for Research and Treatment of Cancer (EORTC), International Germ Cell Cancer Collaborative Group (IGCCCG) and the Medical Research Council (MRC), in 517 patients with nonseminomatous testicular germ cell tumours (NSTGCTs) diagnosed at a single institution between 1977 and 1996., Results: The number of patients in four consecutive 5-year periods (1977-81, 1982-86, 1987-91, 1992-96) was 119, 141, 141, and 116, respectively. Frequency analyses showed a significant increase of RM stage I, in proportion to stage II-IV, in 1982-86 (55%, odds ratio, OR, 2.54), 1987-91 (53%, OR 2.33) and 1992-96 (61%, OR 3.24) compared to the period 1977-81 (33%). A separate analysis of patients with disseminated disease showed a proportionate significant decrease of RM stage II in 1992-96 (29%, OR 0.43) compared with 1977-81 (49%). There was also a relative decrease of good-prognosis patients with disseminated disease in 1992-96 compared with 1977-81, using analyses of the Indiana (from 56% to 33%, OR 0.39) and EORTC classification (from 78% to 56%, OR 0.36). Analyses of the IGCCCG and MRC classification showed a significant decrease of good-prognosis patients in the 1982-86 compared with the first 5-year period (for IGCCCG, from 54% to 35%, OR 0.46, and for MRC, from 43% to 24%, OR 0.42)., Conclusion: The stage distribution of NSTGCT over the past two decades has changed. The proportion of stage I patients has increased since the early 1980s, apparently resulting from a shift of low-extent disseminated disease to stage I disease. This finding is relevant in reducing the treatment required in a higher proportion of patients and the subsequent reduction of long-term risk from treatment.

The presence of vascular and renal anatomical anomalies can create technical problems during abdominal aortic surgery and may give rise to serious intraoperative complications. We present a case of an abdominal aortic aneurysm resected in a patient with the extremely rare coexistence of a left-sided inferior vena cava and horseshoe kidney. The diagnosis of the anomalies was made prior to aortic surgery. CT-scan of the abdomen was the most accurate preoperative investigation. Aortic surgery was performed through a transperitoneal approach which allowed easy access to the aneurysm despite the presence of the left-sided inferior vena cava and horseshoe kidney. Recognition of vascular and renal anomalies on preoperative imaging studies is important in the surgical treatment of abdominal aortic aneurysms. If possible anomalies are recognized in time and treated correctly, the morbidity and mortality of aneurysm repair should not be influenced.

Development of second testicular tumours, i.e. bilateral testicular cancer, is influenced by systemic chemotherapy for the first tumour. The prevalence of bilateral testicular cancer was studied in patients with initial stage I disease, in which no systemic treatment was given after orchidectomy. All stage I testicular cancer patients entered a surveillance study with an intensive follow-up since 1982. We hypothesised that after 1982, bilateral testicular cancer was diagnosed at an earlier stage of disease. The prevalence of bilateral testicular cancer was 4.7% (8/170) in stage I patients treated between 1967 and 1981, and 2.9% (8/275) in stage I patients treated between 1982 and 1997 (P > 0.5 chi 2-test). In the period 1967-1981, 6 patients had stage I second tumours and 2 patients had stage III second tumours. The former 6 patients are alive with no evidence of disease and the 2 patients with metastatic tumours died of disease or treatment. In the period 1982-1977, all 8 patients had stage I second tumours and all are alive with no evidence of disease. The overall prevalence of bilateral testicular cancer in stage I patients was 3.6% and has slightly decreased over the past three decades. Intensive follow-up, improvement of radiodiagnostic computed tomography techniques, availability of serum tumour markers, and patient education have resulted in earlier diagnosis and lower stage of contralateral testicular tumours, contributing to improved prognosis.

Background: Mature teratoma is often found in resected retroperitoneal residual tumor masses (RRTM) after chemotherapy for disseminated nonseminomatous testicular germ cell tumors (NSTGCT). The aim of this report is to describe the clinical course of patients after resection of residual teratoma, with particular emphasis on relapse with either growing mature teratoma or secondary non-germ cell malignancy., Methods: During the period 1979-1995, 113 patients underwent a laparotomy for resection of RRTM after chemotherapy for NSTGCT. Only patients with mature teratoma in the RRTM were included in the current study, and data on the patients who experienced relapse were studied in detail., Results: Mature teratoma was found in 51 patients (45.1%) with RRTM resected after chemotherapy. Nine of these 51 patients (17.6%) relapsed; the relapses resulted from growing mature teratoma in 5 patients (9.8%), secondary non-germ cell malignancy in 3 patients (5.9%), and recurrent germ cell malignancy in 1 patient (2.0%). The primary treatment for all relapsing patients was surgical excision. All five patients with growing mature teratoma are alive without evidence of disease, as is the patient with recurrent germ cell malignancy. One of the three patients with non-germ cell malignancy died of disease, and the remaining two are alive with disease., Conclusions: Long term follow-up after resection of postchemotherapy residual teratoma is indicated because a proportion of patients develop growing mature teratoma or a secondary non-germ cell malignancy. The treatment for these recurrences should be complete surgical excision.