Diagnostic dilemma in a man with seminoma

In January, 2003, a 30-year-old student was referred to our centre with a stage 1 seminoma with good prognostic indicators. He had a left orchidectomy and radiotherapy of para-aortic nodes. Because of an elevated α-fetoprotein (AFP) both before and after treatment, a microscopically undetected non-seminoma part of the tumour was suspected, and he was entered into our follow up surveillance programme for stage I non-seminoma testicular tumours. AFP is a well established tumour marker for diagnosis, staging, monitoring treatment, follow up, and prognosis in nonseminomatous germ-cell tumours1. AFP is normal (under 10 µg/L) in patients with seminoma and an elevated AFP is considered almost diagnostic of nonseminoma tumours. During a year of follow-up, his AFP fluctuated (figure), never rising above 51 µg/L nor decreasing to under 20 µg/L. He had no complaints and physical examination continued to be normal. Liver function tests, hepatitis serology, and imaging studies of the liver were normal. Routine CT scan showed enlarged mediastinal lymph nodes in October, 2003, which showed 2-fluoro-D-2-desoxyglucose uptake on PET scan.