How do you approach therapy for a patient with stage IIIA NSGCT who received 4 cycles of EP followed by RPLND which revealed residual mixed teratoma and embryonal carcinoma?

This is a query that can never be answered by evidence based medicine. Instead, all we have is (very old) historical data and perhaps common sense and logic. In 1974, we initiated our phase II study of PVB, with 4 courses of induction chemo followed by 2 years of maintenance vinblastine. That was our standard until a subsequent phase III study conducted from 1981-1984 failed to demonstrate any value for maintenance vinblastine. During those earlier times, we had 12 patients who underwent a post-chemo RPLND and had persistent germ cell cancer, and like all other patients during that time period, they received maintenance vinblastine. 9 of 12 subsequently relapsed and died.

Today, when we have this scenario, regardless of initial chemo, we tak...