How would you treat a patient with late relapsed metastatic seminoma with only large (>10cm) pulmonary metastases and LDH nine times the upper limit of normal?

From the description, it is not really clear whether this is late relapse after initial surveillance or radiotherapy, versus relapse after chemotherapy.

If the former, which is what I think you are presenting, this is a pretty unusual pattern of presentation after surveillance or radiotherapy, and...

I agree with Dr. @Dr. First Last. I would re- emphasize the need for hCG and AFP and especially biopsy of the large lung mass. Anything is possible, but in my experience, if his abdominal CT is normal, close to zero possibility this type of presentation, early or late relapse, would be a pure semino...