Would the presence of only mature teratoma on orchiectomy specimen lead you to consider upfront RPLND followed by adjuvant chemotherapy as opposed to upfront chemotherapy in a patient with bulky para-aortic nodal disease (cN3) and AFP/beta-HCG elevation?

If there is an elevated AFP or hCG, then by definition, he has metastatic germ cell cancer and needs chemo initially, followed almost certainly by post-chemo RPLND done by a skilled and experienced urologist.

The patient almost certainly has a malignant nonseminomatous component with the elevated markers (assuming they are unequivocally elevated). With elevated markers, I would start with chemotherapy with the aim of completing it prior to a post-chemo RPLND. Very rarely, and often in the setting of mali...