Introduction: Seminoma comprises approximately 50% of testicular germ cell tumors. Retroperitoneal lymph nodes are the most common initial metastatic sites but renal metastases are infrequent and the majority of renal tumors represent primary neoplasm. Case Presentation: In this study, we present a 48-year-old male with metastases of seminoma to the cervical lymph nodes and kidney after a 25-year interval. Conclusion: This presentation emphasizes the necessity of advising all patients who are discharged from follow-up that there is a chance of late remote relapse and that if they acquire any illness after discharge, they must inform their doctor about their previous seminoma.

Germ cell tumors are the most common type of testicular cancer [1]. The most typical symptom of testicular cancer is a painless lesion in the testis. Less frequent symptoms include gynecomastia and testicular pain [2]. Males between the ages of 15 and 35 are most frequently affected by testicular malignancies, which make up 1% of all cancer cases in men [3]. Seminomas and nonseminomas are the two types of testicular germ cell cancers. More than half of diagnoses for germ cell cancers are seminoma [4].

Although only a small percentage of seminoma patients have distant metastases at diagnosis, lung, bone, liver, and retroperitoneal lymph nodes are among the organs where seminomas frequently metastasize [5, 6]. The majority of kidney malignancies are primary neoplasms. Secondary kidney tumors are relatively uncommon in clinical practice [7, 8].

In this study, we report the clinicopathological, radiological, and immunohistochemical findings of a case of seminoma metastasis to the kidney and cervical lymph node after 25 years of interval. The CARE checklist was followed in this article. In an online supplementary file, titles were mentioned (for all online suppl. material, see https://doi.org/10.1159/000532026).

Patient Information

A 48-year-old man who was previously diagnosed with a seminoma 25 years earlier visited an otorhinolaryngologist with a history of hoarseness, resistance to treatment headache, dysphagia to solids, odynophagia, hearing loss, and tinnitus of the right ear all started 1 month before admitting to hospital. The patient had a history of left orchiectomy, and adjuvant chemotherapy 25 years ago. Over the course of 2 months, the patient underwent four cycles of chemotherapy with bleomycin, etoposide, and cisplatin. The tumor had gone into complete remission after the therapies and during these years the patient did not experience any related complaints. Before the pathologic examination was completed, the patient and his family did not inform the healthcare professionals about his previous history.

Clinical Findings and Diagnostic Assessment

After undergoing multidetector computed tomography and magnetic resonance imaging, the patient showed some mass-like lesions at the base of the skull and in the right cervical region that also included lymph nodes. Prior to a pathologic examination, radiologic findings pointed to several potential diagnoses, such as lymphoma or kidney-originated tumors that had metastasis to the base of the skull and neck (shown in Fig. 1, 2).

Fig. 1.

Temporal bone high-resolution CT scan, bone window. a Axial view shows a lytic destructive lesion in the right petrous apex and right side of clivus invading the ipsilateral carotid canal (yellow arrow). b In coronal view, there is an extension of bony changes to the right side jugular frogmen (red circle) and right side of the C1 vertebra.

Fig. 1.

Temporal bone high-resolution CT scan, bone window. a Axial view shows a lytic destructive lesion in the right petrous apex and right side of clivus invading the ipsilateral carotid canal (yellow arrow). b In coronal view, there is an extension of bony changes to the right side jugular frogmen (red circle) and right side of the C1 vertebra.

Close modal
Fig. 2.

Brain MRI axial images: T1 weighted (a), FLAIR (b), diffusion-weighted sequences (c), and apparent diffusion coefficient (ADC) (d) map reveal extensive signal changes of the right petrous apex, encasing ipsilateral carotid artery (green arrow in b), with diffusion restriction.

Fig. 2.

Brain MRI axial images: T1 weighted (a), FLAIR (b), diffusion-weighted sequences (c), and apparent diffusion coefficient (ADC) (d) map reveal extensive signal changes of the right petrous apex, encasing ipsilateral carotid artery (green arrow in b), with diffusion restriction.

Close modal

A computed tomography scan revealed a 30 × 26 mm ellipsoid, hypodense mass in the lower pole of the left kidney. Yet, no images of this imaging technique are available. Initial tumor markers including AFP, B-HCG, and LDH were all negative.

Histologic and immunohistologic findings include the following:

Pathology laboratory guidelines recommend storing and archiving paraffin blocks and slides for a minimum of 20 and 10 years, respectively [9]. As a result, the laboratory’s initial data on seminoma from 25 years ago was unavailable.

Histology showed complete manifestations of seminoma in both metastatic sites, but the skull sample was unsuitable for imaging due to higher necrosis and crashing; therefore, the kidney sample was selected for presenting this morphology due to its better quality. However, morphologically, they both exhibit the same pattern and are identical to a classic seminoma.

The neoplastic proliferation of malignant tumoral cells is visible as a diffuse pattern in the left kidney mass core needle biopsy (shown in Fig. 3a, b). These cells range in size from medium to large, with a high N/C ratio, pale to eosinophilic cytoplasm, and hyperchromic nuclei that are rounded.

Fig. 3.

Renal core needle biopsy. Renal tissue is completely replaced by tumoral cells, composed of neoplastic germ cells with clear cytoplasm and large nuclei. Hematoxylin & eosin staining (a), *100 (b), *400 (c). Immunohistochemistry for PLAP antibody shows positive cytoplasmic staining in tumoral cells.

Fig. 3.

Renal core needle biopsy. Renal tissue is completely replaced by tumoral cells, composed of neoplastic germ cells with clear cytoplasm and large nuclei. Hematoxylin & eosin staining (a), *100 (b), *400 (c). Immunohistochemistry for PLAP antibody shows positive cytoplasmic staining in tumoral cells.

Close modal

A mass incisional biopsy of the right skull base reveals a broad pattern of medium to large cells with neoplastic growth. These cells exhibit pleomorphism, high mitotic rate, high N/C ratio, and crashing.

It needs to be mentioned that, in contrast to our case, the histological appearance in some metastatic situations is out of the ordinary [10]. The same immunohistochemistry was performed on two metastatic locations. PLAP, CD117, CD10, Ki67, and OCT IHC staining are all positive in renal tumor cells (Fig. 3c) and skull tumor cells. In contrast to vimentin, which was exclusively positive in renal cells, CK was only dot-like positive in skull cells.

Therapeutic Intervention

The patient underwent surgery of canal-wall-down and a complete radial mastoidectomy was done. Canal wall was drilled completely up to the facial ridge and middle ear mass was removed. The patient was offered chemotherapy, but his condition rapidly deteriorated, and he died before he could receive it.

Follow-Up and Outcomes

Unfortunately, the patient passed away 1 month after receiving a diagnosis of metastatic seminoma. The cause of his death was metastatic invasion to the brain since the skull tumor rapidly progressed to the intracranial, and the patient died as a result of the effects of these invasions.

Males between the ages of 15 and 35 most frequently develop testicular tumors, which have an improving rate of complete recovery [3]. Seminoma usually spreads metastatically along the lymphatic drainage routes to the retroperitoneal lymph nodes; however, involvement of the kidney, adrenal gland, psoas muscle, stomach, seminal vesicle, bladder, prostate, and pericardium is rarely present (<1%) [11].

In the research presented by the husband and colleagues on 650 patients with testicular cancers who underwent computed tomography, only 6 patients had kidney metastases, two of which were seminomas. This study indicates the infrequent occurrence of renal seminoma metastases [12].

Castelán-Maldonado et al. [8] describe a case of a 24-year-old man who underwent a left radical orchiectomy as a result of classic seminoma, left renal metastases from seminoma were also discovered in this instance. Despite this case, the renal metastasis in our patient occurred 25 years after the initial seminoma presentation.

Malignant tumors are the most frequent cause of neck masses in adults, and neck involvement may frequently be the first or only clinical symptom [13] and neck metastases from uterine, ovarian, prostate, and testicular malignancies have been described seldom. Supraclavicular metastases can develop in men as their prostate and testicular cancers progress [14].

Considering that, 4.5–15% of patients with testicular cancer may experience neck metastases during the course of the disease, the neoplastic diffusion to the cervical lymph node is not an unusual presentation of the disease [15]. A 59-year-old man who presented with a left indolent neck swelling that had developed gradually over 6 months is the focus of a case study by Corazzi and colleagues. [13]. The clinical history of the patient revealed a left testicular seminoma that had undergone surgery and adjuvant treatment 20 years ago.

For testis tumors, metastases during the first 2 years are considered as early, whereas those after 5 years are categorized as late. The majority of metastases occur within the first 2 years [16].

Table 1 shows 15 instances of seminoma metastases that occurred very late (10 years or later). The median age was 56.1 and cases ranged from 35 to 73 years old, with one case being undefined. Patients experienced metastases at a median interval of 20.25 years (range: 10–43) following initial treatment. Testis was affected unilaterally in 12 cases (left testis in 7 cases, right testis in 5 cases) and bilaterally in 3 cases.

Table 1.

Late seminoma metastases cases

AuthorAgeIntervalSite/stage seminomaSeminoma managementMetastasis siteMetastasis managementFollow-up
Fukushima et al. [17], 2019 56 13 Left testicle Orchiectomy Mediastinum None Died 
Stage I 
Türkoğlu et al. [18], 2015 45 10 Right testicle Orchiectomy Bladder Resection Successful treatment 
Stage IA Chemotherapy chemotherapy 
Corazzi et al. [13], 2020 59 20 Left testis Orchiectomy Neck Chemotherapy Successful treatment 
Chemotherapy 
Mukhtar et al. [19], 2011 64 43 Right testis Orchiectomy Pancreas Chemotherapy Died 
Lung 
Radiotherapy 
Liver 
Strohmeyer et al. [20], 1992 Not mentioned 30 Right testis (6 years later left testis) Orchiectomy Sigmoid Chemotherapy Died 
Radiotherapy Left testicular vein Resection 
Lung 
Salemis et al. [21], 2018 40 12 Left testicle Orchiectomy Sigmoid Sigmoidectomy Successful treatment 
Chemotherapy Chemotherapy 
Yamashita et al. [22], 2005 63 18 Left testicle Orchiectomy Left inguinal lymph nodes Lymphoidectomy No data 
Radiotherapy 
Washino et al. [23], 2017 58 10 Left testicle stage IA Orchiectomy Bladder Chemotherapy Successful treatment 
Cystectomy 
Baweja et al. [24], 2020 60 20 Right testicle Orchiectomy Prostate Chemotherapy Successful treatment 
Stage I Radiotherapy 
Swinney et al. [25], 2021 73 30 Right testicle Orchiectomy Pelvic lymph node Resection chemotherapy Successful treatment 
Stage I Radiotherapy Radiotherapy 
Crocetti et al. [26], 2021 67 23 Bilateral Orchiectomy Retroperitoneum Chemotherapy Successful treatment 
Stage I Radiotherapy 
Tavolini et al. [27], 2008 41 12 Left testicle Orchiectomy Chest wall Chemotherapy Died 
Radiotherapy 
Stage I Radiotherapy Pleura Resection 
Blanke et al. [28], 1997 68 21 Left testicle Orchiectomy Retroperitoneum (21 years later) Resection Successful treatment 
32 Lung hilum (32 years later) Radiotherapy 
Brown et al. [29], 2001 35 12 Right testicle Orchiectomy Mediastinum Chemotherapy Successful treatment 
Ng et al. [30], 2010 57 18 Bilateral Orchiectomy Liver Chemotherapy Successful treatment 
Stage I Resection 
AuthorAgeIntervalSite/stage seminomaSeminoma managementMetastasis siteMetastasis managementFollow-up
Fukushima et al. [17], 2019 56 13 Left testicle Orchiectomy Mediastinum None Died 
Stage I 
Türkoğlu et al. [18], 2015 45 10 Right testicle Orchiectomy Bladder Resection Successful treatment 
Stage IA Chemotherapy chemotherapy 
Corazzi et al. [13], 2020 59 20 Left testis Orchiectomy Neck Chemotherapy Successful treatment 
Chemotherapy 
Mukhtar et al. [19], 2011 64 43 Right testis Orchiectomy Pancreas Chemotherapy Died 
Lung 
Radiotherapy 
Liver 
Strohmeyer et al. [20], 1992 Not mentioned 30 Right testis (6 years later left testis) Orchiectomy Sigmoid Chemotherapy Died 
Radiotherapy Left testicular vein Resection 
Lung 
Salemis et al. [21], 2018 40 12 Left testicle Orchiectomy Sigmoid Sigmoidectomy Successful treatment 
Chemotherapy Chemotherapy 
Yamashita et al. [22], 2005 63 18 Left testicle Orchiectomy Left inguinal lymph nodes Lymphoidectomy No data 
Radiotherapy 
Washino et al. [23], 2017 58 10 Left testicle stage IA Orchiectomy Bladder Chemotherapy Successful treatment 
Cystectomy 
Baweja et al. [24], 2020 60 20 Right testicle Orchiectomy Prostate Chemotherapy Successful treatment 
Stage I Radiotherapy 
Swinney et al. [25], 2021 73 30 Right testicle Orchiectomy Pelvic lymph node Resection chemotherapy Successful treatment 
Stage I Radiotherapy Radiotherapy 
Crocetti et al. [26], 2021 67 23 Bilateral Orchiectomy Retroperitoneum Chemotherapy Successful treatment 
Stage I Radiotherapy 
Tavolini et al. [27], 2008 41 12 Left testicle Orchiectomy Chest wall Chemotherapy Died 
Radiotherapy 
Stage I Radiotherapy Pleura Resection 
Blanke et al. [28], 1997 68 21 Left testicle Orchiectomy Retroperitoneum (21 years later) Resection Successful treatment 
32 Lung hilum (32 years later) Radiotherapy 
Brown et al. [29], 2001 35 12 Right testicle Orchiectomy Mediastinum Chemotherapy Successful treatment 
Ng et al. [30], 2010 57 18 Bilateral Orchiectomy Liver Chemotherapy Successful treatment 
Stage I Resection 

All 15 cases had an orchiectomy, in addition to the orchiectomy, 3 cases received chemotherapy and 7 cases received radiotherapy. The most commonly afflicted sites of metastasis were lung in three cases, mediastinum, liver, bladder, sigmoid, and retroperitoneum in two cases, neck, pancreas, testicular vein, prostate, pelvic lymph node, chest wall, pleura, and inguinal lymph node in one case.

In 12 cases, chemotherapy was used as the primary treatment for metastatic seminoma, 9 cases underwent resection and 3 cases received radiotherapy. One case had unclear management. Four people died despite therapy, whereas 10 patients had favorable results.

In the present study, we discussed an exceedingly rare instance of late seminoma metastasis that simultaneously affected the kidney and neck that occurred 25 years after orchiectomy and chemotherapy. Unfortunately, the patient died 1 month after diagnosis.

The patient was initially admitted to the hospital with a history of hoarseness, headache, dysphagia, odynophagia, and hearing loss with no doubt associated with previous seminoma. Particularly in young patients with a history of testicular cancer, the likelihood of late metastases should be strongly considered. A very late relapse of testicular germ cell tumors occurred with a 1% annual chance of recurrence between 5 and 10 years [31]. Healthcare systems are unable to continue lifelong follow-up to detect such a low rate of relapses. It would be preferable to alert all patients who are discharged from follow-up that there is a potential risk of late remote relapse and if they develop any illness after discharge, they should inform their doctor about their previous seminoma.

Our review of the literature found no other cases with classic-type seminoma that had spread to the neck and kidney (both are uncommon sites for testicular metastases) 25 years later without having additionally spread to the retroperitoneal region (the most prevalent site of involvement).

In the natural history of testicular malignancies, late neck lymph node and renal metastasis are uncommon. In cases of positive clinical data, cancers of remote sites should always be considered, especially in the differential diagnosis of neck adenopathies with unknown etiology, even many years after the primary treatment.

Key Clinical Message

The current study focuses on late and remote seminoma metastasis. Patients should also be informed about the possibility of a late relapse, even many years after a successful course of treatment, and if they acquire any illness after discharge, they need to inform their doctor about their past seminoma.

We wish to thank in particular the patient for his collaboration.

Ethical approval for the study was obtained from Ethics Committee of Isfahan University of Medical Science on May 2023. Written informed consent was obtained from the patient for publication of this case report and any accompanying images on April 2022 2 weeks before his death. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

The authors declare that they have no competing interests.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Sohrabi contributed to data acquisition and prepared the manuscript. Hajiahmadi collected radiologic findings. Naimi prepared pathologic findings and supervised the study. Each author participated sufficiently in the work to take responsibility for appropriate portions of the content. All authors read and approved the final manuscript.

All data generated during this study are included in this article. Further inquiries can be directed to the corresponding author.

1.
Siegel
RL
,
Miller
KD
,
Fuchs
HE
,
Jemal
A
.
Cancer statistics, 2021
.
CA Cancer J Clin
.
2021
;
71
(
1
):
7
33
.
2.
Smith
ZL
,
Werntz
RP
,
Eggener
SE
.
Testicular cancer: epidemiology, diagnosis, and management
.
Med Clin North Am
.
2018
;
102
(
2
):
251
64
.
3.
Chen
W
,
Zheng
R
,
Baade
PD
,
Zhang
S
,
Zeng
H
,
Bray
F
.
Cancer statistics in China, 2015
.
CA Cancer J Clin
.
2016
;
66
(
2
):
115
32
.
4.
Williamson
SR
,
Delahunt
B
,
Magi-Galluzzi
C
,
Algaba
F
,
Egevad
L
,
Ulbright
TM
.
The world health organization 2016 classification of testicular germ cell tumours: a review and update from the international society of urological pathology testis consultation panel
.
Histopathology
.
2017
;
70
(
3
):
335
46
.
5.
Sharp
DS
,
Carver
BS
,
Eggener
SE
,
Kondagunta
GV
,
Motzer
RJ
,
Bosl
GJ
.
Clinical outcome and predictors of survival in late relapse of germ cell tumor
.
J Clin Oncol
.
2008
;
26
(
34
):
5524
9
.
6.
Schmoll
HJ
,
Jordan
K
,
Huddart
R
,
Laguna
MP
,
Horwich
A
,
Fizazi
K
.
Testicular seminoma: ESMO clinical recommendations for diagnosis, treatment and follow-up
.
Ann Oncol
.
2009
20
Suppl 4
83
8
.
7.
Tomita
M
,
Ayabe
T
,
Chosa
E
,
Nakamura
K
.
Isolated renal metastasis from non-small-cell lung cancer: report of 2 cases
.
Case Rep Surg
.
2015
;
2015
:
357481
.
8.
Castelán-Maldonado
EE
,
Peña-Ruelas
CI
,
Ignacio-Morales
CV
,
Romero-Martínez
SA
,
Sánchez-Arbea
PC
.
[Renal metastasis of classic seminoma]
.
Cir Cir
.
2013
;
81
(
2
):
153
7
.
9.
Gologan
D
,
Ștefan
AE
,
Militaru
M
,
Sanda
AC
,
Arjan
S
,
Mușat
S
.
Quality assurance and cost reduction in histopathology laboratories using tissue microarrays
.
Vet Sci
.
2023
;
10
(
4
):
280
.
10.
Marko
J
,
Wolfman
DJ
,
Aubin
AL
,
Sesterhenn
IA
.
Testicular seminoma and its mimics: from the radiologic pathology archives
.
Radiographics
.
2017
;
37
(
4
):
1085
98
.
11.
Balzer
BL
,
Ulbright
TM
.
Spontaneous regression of testicular germ cell tumors: an analysis of 42 cases
.
Am J Surg Pathol
.
2006
;
30
(
7
):
858
65
.
12.
Husband
JE
,
Bellamy
EA
.
Unusual thoracoabdominal sites of metastases in testicular tumors
.
AJR Am J Roentgenol
.
1985
;
145
(
6
):
1165
71
.
13.
Corazzi
V
,
Accorona
R
,
Negro
R
,
Calabrese
L
.
Late relapse in the neck: considerations from a case of seminoma and review of the literature
.
Acta Otorhinolaryngol Ital
.
2020
;
40
(
4
):
313
5
.
14.
López
F
,
Rodrigo
JP
,
Silver
CE
,
Haigentz
M
Jr
,
Bishop
JA
,
Strojan
P
.
Cervical lymph node metastases from remote primary tumor sites
.
Head Neck
.
2016
38
Suppl 1
E2374
85
.
15.
Akst
LM
,
Discolo
C
,
Dipasquale
B
,
Greene
D
,
Roberts
J
.
Metastatic seminoma with cervical lymphadenopathy as the initial manifestation
.
Ear Nose Throat J
.
2004
;
83
(
5
):
356
9
.
16.
Lipphardt
ME
,
Albers
P
.
Late relapse of testicular cancer
.
World J Urol
.
2004
;
22
(
1
):
47
54
.
17.
Fukushima
T
,
Noguchi
T
,
Kobayashi
T
,
Sekiguchi
N
,
Ozawa
T
,
Koizumi
T
.
Late and rapid relapse in mediastinum from testicular germ cell tumor stage I over 13 Years after surgery
.
Case Rep Oncol
.
2019
;
12
(
2
):
500
5
.
18.
Türkoğlu
AR
,
Coban
S
,
Guzelsoy
M
,
Demirbas
M
,
Mutlu
N
,
Yalcin
O
.
Rare late metastasis of testis seminoma to the bladder
.
Can Urol Assoc J
.
2015
9
11–12
E823
5
.
19.
Mukhtar
S
,
Beatty
J
,
Agrawal
S
,
Christmas
TJ
,
Jameson
C
,
Huddart
RA
.
Germ cell tumour: late recurrence after 43 years
.
Ann R Coll Surg Engl
.
2011
;
93
(
5
):
e24
6
.
20.
Strohmeyer
T
,
Buszello
H
.
Late metastases in seminoma: incidence, localization, and therapeutic implications
.
Urology
.
1992
;
39
(
6
):
515
8
.
21.
Salemis
NS
,
Boubousis
G
,
Liatsos
C
,
Nakos
G
,
Katikaridis
I
,
Tsoukalas
N
.
Colon obstruction as an isolated late gastrointestinal metastasis of testicular seminoma
.
J Gastrointest Cancer
.
2018
;
49
(
2
):
200
2
.
22.
Yamashita
S
,
Ogata
Y
,
Kawamura
S
,
Tochigi
T
,
Tateno
H
,
Kuwahara
M
.
[Inguinal lymph node metastasis of seminoma 18 years after initial treatment: a case report]
.
Jpn J Urol
.
2005
;
96
(
1
):
21
4
.
23.
Washino
S
,
Konishi
T
,
Saito
K
,
Ohshima
M
,
Nakamura
Y
,
Miyagawa
T
.
Two cases of somatic-type malignancy as a very late relapse of testicular cancer successfully managed by surgical resection
.
J Surg Case Rep
.
2017
2017
11
rjx233
.
24.
Baweja
A
,
Mar
N
,
Rezazadeh Kalebasty
A
.
Late recurrence of localized pure seminoma in prostate gland: a case report
.
World J Clin Oncol
.
2022
;
13
(
1
):
62
70
.
25.
Swinney
S
,
Medway
A
,
Brandi
L
,
Sharma
P
.
Late recurrence of Seminoma in the pelvis: a case report
.
Urol Case Rep
.
2021
;
39
:
101743
.
26.
Crocetti
S
,
Tassone
L
,
Torniai
M
,
Pierantoni
C
,
Burattini
L
,
Mandolesi
A
.
Seminoma retroperitoneal relapse 23 years after surgery
.
Oncol Ther
.
2021
;
9
(
1
):
239
45
.
27.
Tavolini
IM
,
Mazzariol
C
,
Dal Bianco
M
,
Bassi
P
.
Late recurrence of clinical stage I seminoma of the testis after 12 years despite adjuvant infradiaphragmatic irradiation
.
Urol Int
.
2004
;
73
(
1
):
84
6
.
28.
Blanke
CD
,
Delgalvis
SC
,
Nichols
GR
.
Late recurrence of seminoma
.
South Med J
.
1997
;
90
(
6
):
653
5
.
29.
Brown
RS
,
Hayne
D
,
Burcombe
RJ
,
Harbin
LJ
,
Coulter
CA
.
Massive mediastinal seminoma post-orchidectomy--late relapse with skip-metastases or new primary
.
Scand J Urol Nephrol
.
2001
;
35
(
5
):
422
4
.
30.
Ng
CF
,
Tsui
TM
,
To
KF
,
Hou
SM
,
Yip
SS
.
Late recurrent seminoma: 18 years after bilateral orchidectomy in patient with bilateral stage one testicular seminoma
.
Int Urol Nephrol
.
2010
;
42
(
1
):
69
72
.
31.
Shahidi
M
,
Norman
AR
,
Dearnaley
DP
,
Nicholls
J
,
Horwich
A
,
Huddart
RA
.
Late recurrence in 1263 men with testicular germ cell tumors. Multivariate analysis of risk factors and implications for management
.
Cancer
.
2002
;
95
(
3
):
520
30
.