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(>10,000 units) in these markers are rarely found in men except in NSGCT.

Furthermore, levels of AFP and phCG do correlate with the clinical stage of the disease. Elevated levels of phCG in seminoma and AFP in NSGCT increase from approximately 10% in stage I disease to 30-60% in disseminated disease. Histological tumor subtypes are associated with elevations in specific markers (see Table 2.5).

Prognostic value

The International Germ Cell Cancer Collaborative Group (IGCCCG) have now included serum levels of testicular markers as independent prognostic indicators, and three risk categories have been identified:

1. Good prognosis

2. Intermediate prognosis

■ LDH 1.5-10 times upper limit of normal

3. Poor prognosis • NSGCT

■ LDH >10 times upper limit of normal

Following therapy, the levels of elevated tumor markers should fall at a rate in keeping with the respective half-lives. Patients in whom the serum marker levels fail to decline rapidly, never reach normal, or increase, are more likely to have one or more of the following:

a) Residual disease b) Poor response to treatment c) Requirement of early salvage therapy

The time taken for normalization of markers should be—

Should the marker levels remain elevated following orchidec-tomy, further cross-sectional imaging must be undertaken as this often indicates systemic metastatic disease rather than nodal disease. It is also noteworthy that up to 20% of men with normalized tumor marker levels post-therapy may still have residual microscopic disease.

Rising tumor marker levels following systemic treatment—

• Is a poor prognostic indicator and is usually due to active disease

• A rising phCG represents increasing cancer burden and in such situations, radiological confirmation of recurrent disease may often lag behind increased marker activity by a few months

• A rising LDH is indicative of relapse. It is important to exclude any other causes of false-positive results prior to initiating therapy

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