Data Supplement Table DS1: Pre-Treatment STM Assays to Evaluate Patients with CUP and Predict Chemotherapy Response

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1 American Society of Clinical Oncology Clinical Practice Guideline on Uses of Serum Tumor Markers in Adult Males with Germ Cell Tumors Gilligan, et al. SUPPLEMENTAL TABLES DS1-DS13 Data Supplement Table DS1: Pre-Treatment STM Assays to Evaluate Patients with CUP and Predict Chemotherapy Response STUDY TYPE OF STUDY PURPOSE N TUMOR MARKERS (% elevated) OUTCOMES &/OR UNIVARIATE PROGNOSTIC FACTORS TO PREDICT OUTCOME MULTIVARIATE PROGNOSTIC FACTORS Hainsworth et al to report clinical characteristics, Tx results, and prognostic factors in pts w poorly-differentiated carcinoma (PDC) or adenocarcinoma (PDA) from unknown primary sites given cisplatin-based chemotx 220 (N=34 w dominant sites in mediastinum or peritoneum, suggesting GCT) AFP: 5% (N=201) hcg: 16% (N=206) LDH: 48% (N=199) (increased AFP &/or hcg in 6 of 34 w clinical features suggesting GCT) dominant met site in peritoneum or peripheral nodes: CR, 52% vs 19% p<0.001; DFS, 37% vs 9%, p< metastatic sites: CR, 37% vs 17%, p<0.001; DFS, 27% vs 5%, p<0.001 normal LDH: CR, 35% vs 18%, p=0.01; DFS, 24% vs 11%, p=0.018 (32 of 96 w LDH had liver mets) normal CEA: CR, 33% vs 4%, p<0.001; DFS, 22% vs 2%, p=0.002 <10 pack-years, smoking Hx,: CR, 37% vs 21%, p=0.007; DFS, 23% vs 12%, p=0.025 AFP or hcg, not significant predictors By Cox proportional hazards (authors did not specify whether for CR, DFS, or both): dominant met site in peritoneum or peripheral nodes: p< metastatic sites: p<0.001) negative smoking history (P =.003) younger age (P =.028) neither tumor marker (AFP &/or hcg) nor LDH levels were statistically significant independent prognostic factors by Cox regression analysis for N=34 w clin features suggesting GCT: OR = 85%; CR = 50%; DFS = 29% Pavlidis et al to measure STM levels in pts with CUP & test histologies, no. & locations of mets, & outcomes 85 AFP: 17% hcg: 44% LDH: AFP and hcg levels were not statistically significant predictors of histology (adeno- vs undiff. carcinoma), no. of mets (1 vs 2 vs 3), location (liver vs LN), response to chemotx (regimens not reported), or survival (4 other markers also not significant for response, OS) Pouessel et al to describe Dx and Tx strategies used for pts presenting w hepatic mets from unknown primaries 118 AFP: 17% hcg: 3% LDH: 58% shorter overall survival: WHO PS>1, p<0.001 liver mets detected first, p=0.029 non-neuroendocrine histol, p= CA 19-9, p=0.024 LDH, p< AFP, not significant hcg, not significant (8 other markers & 4 baseline characteristics also not significant) LDH, OR = 2.4 (95% CI: ) PS>1, OR = 2.4 (95% CI: ) 2010 by American Society of Clinical Oncology 1 of 41

2 Data Supplement Table DS1 (continued): Pre-Treatment STM Assays to Evaluate Patients with CUP and Predict Chemotherapy Response STUDY TYPE OF STUDY PURPOSE N TUMOR MARKERS (% elevated) OUTCOMES &/OR UNIVARIATE PROGNOSTIC FACTORS TO PREDICT OUTCOME MULTIVARIATE PROGNOSTIC FACTORS Lenzi et al to assess outcomes and prognostic factors in unselected consecutive patients with poorlydifferentiated carcinoma or adenocarcinoma from unknown primary sites 997 (includes 337 with PDC or PDA) (data on both STMs for 51 w PDC or PDA) only AFP : 13 (25%) hcg : 17 (33%) median OS (95% CI), months: neither STM : 17 (11-?) only AFP : 6 (5-?) hcg ± AFP : 5 (2-?) Yonemori et al to evaluate usefulness of marker measurements, identify prognostic factors in patients with CUP receiving platinum-based combination chemotherapy, & verify adjustment of reported prognostic models 93 AFP: 5.4% hcg: 54.8% LDH: 46.2% response rate: AFP elevated: 80% normal: 38% p=0.08 hcg elevated: 37% normal: 43% p=0.67 LDH elevated: 40.0 normal: 40.0 p=0.99 (of 22 other factors, none were significant predictors for response) shorter median overall survival: performance status >1 p<0.01 >2 involved organs p=0.01 LDH: 10 vs 18 mos p=0.01 NSE: 9 vs 14 mos p=0.01 AFP: 7 vs 12 mos p=0.18 hcg: 10 vs 13 mos p=0.62 (of 19 other factors, none were significant predictors) response rate: no significant predictors in univar. analysis median OS: PS >1 p=0.01 >2 organs p=0.033 LDH p=0.006 Poor vs good risk, by prognostic model of Culine et al.: 10 vs 21 mos, p=0.003 Poor vs interm vs good risk, by prognostic model of van der Gaast et al.: 7 vs 12 vs 20 mos; p=0.001good vs poor p=0.047 good vs interm p=0.054 interm vs poor 2010 by American Society of Clinical Oncology 2 of 41

3 Data Supplement Table DS2: Pre-Orchiectomy STM Assays, to Stage Patients with NSGCT and Predict Nodal or Retroperitoneal Status STUDY TYPE OF STUDY PURPOSE N TUMOR MARKERS (% Elevated) UNIVARIATE CORRELATION OF PRE-ORCHIECTOMY STM (CS1) AND PATHOLOGICAL STAGE (PS) OF THE RETROPERITEUM MVA (LOGISTIC REG) OF RELATIONSHIP BETWEEN POTENTIAL PREDICTIVE FACTORS AND RISK OF PS2 DISEASE AT RPLND OR RELAPSE IN PS1 CASES OVERALL Klepp et al. 1990a 173 prosp To investigate whether clincopathologic findings at diagnosis predicted the outcome of surgical staging (RPLND) 279 (100% testicular NSGCT; 26.9% w RP mets at RPLND) AFP Normal 40.2% p=0.001 Elevated 18.5% AFP/hCG Both Normal 42.5% p= Either Elevated 17.4% AFP/hCG Both Normal 42.5% p=0.019 Both Elevated 21.8% Insufficient sample size * * Univariate Analysis, Potential Predictors for MET+ Pre-orch AFP normal p=0.018 Vascular Inv Present p< Path tumor stage (pt2-4) p< Embryonal ca present p=0.024 Yolk sac elts absent p=0.05 Teratoma (any type) absent p<0.001 Immature teratoma absent p= Mature teratoma absent p=0.006 Klepp et al. 1990b 174 prosp To evaluate the relationship between radiological and serological exams as basis for staging & clinical decisions (authors state this as one aim of several for SWENOTECA program) Total: evaluated by RPLND for path. stage (PS) AFP (N=243): 56% hcg (N=246): 39% LDH: * Pre-Orch. AFP (to predict PS2 in CS1 patients) Normal 37 of 92 (40%) Elevated 20 of 108 (19%) p=0.001 Pre-Orch. AFP/hCG (to predict PS2 in CS1 patients) AFP & hcg Normal 37 of 87 (43%) AFP or hcg Elevated 21 of 121 (17%) p= vs both normal AFP & hcg Elevated 12 or 55 (22%) p=0.019 vs both normal CS1 Patients Only Vascular Invasion p< (incr risk) Elevated preorch AFP p= (decr risk) All Patients Vascular Invasion p< (incr risk) Teratoma Elements p=0.013 (decr risk) (no STMs are predictive of PS2 disease) * * (nothing is significant if analyzed all patients rather than CS1 subset) *Not Reported 2010 by American Society of Clinical Oncology 3 of 41

4 Data Supplement Table DS3: Post-Orchiectomy STM Assays before RPLND for Patients with Low Stage or Good Risk NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE and TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OS PROGRESSION- FREE Aass et al To analyse their experience with primary RPLND in low-stage NSGCT of the testis 154 csi patients (RPLND showed 97 in psi, 57 in psii) Testis 100% NSGCT 100% AFP and/or hcg elevated before RPLND normal levels (M-): 121 elevated(m+): 33 Univariate Analysis in Pts with csi; Factors Predicting psii (p<0.05): prolonged AFP &/or hcg t postorchiectomy (75% had psii disease) lymphovascular invasion elevated markers pre-rplnd (67% of those with elevated hcg and 60% of those with elevated AFP had psii disease) Kulkarni & Kamat, To describe their experience with the management of NSGCT of the testis using AFP and hcg before (group 1: ) and after (group 2: ) STM measurements were routinely included in clinical staging 166 Grp1 81 Grp2 85 Testis 100% NSGCT AFP or hcg Elevated Group 1 Stage I (n=22) Elevated 23% Normal 77% Stage IIab (N=29) Elevated 86% Normal 14% Stages IIc/III/IV (n=30) Elevated 80% Normal 20% Group 2 Stage I (n=31) Elevated 81% Normal 19% Stage IIab (n=15) Elevated 100% Normal 0.0% Concordance Between Tumor Markers and RPLND Group 1 Stage I Concordant 81% Discordant 19% Stage IIab Concordant 92% Discordant 8% Group 2 Stage 1 Concordant 77% Discordant 23% Stage IIab Concordant 100% 3-yr NED Elevated: 86.3% Normal: 100% Group 1 Stage I Elevated Ms 80% Normal Ms - 100% Stage IIab Elevated Ms 92% Normal Ms 100% Group 2 Stage 1 Elevated Ms 66% Normal Ms 100% Stage IIab Elevated - 86% 2010 by American Society of Clinical Oncology 4 of 41

5 Data Supplement Table DS3 (continued): Post-Orchiectomy STM Assays before RPLND for Patients with Low Stage or Good Risk NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE and TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OS PROGRESSION- FREE Rabbani et al To determine predictive factors for relapse in pts with low-volume nodal mets at RPLND in NSGCT initially managed by observation 50 Testis 100% Primary Histol Pure embry ca 9(18%) Embry ca & other histology 33(66%) No embry ca 8(16%) Markers pre-rplnd Elevated 10% Normal 90% Univariate Analysis of Relapse by pre- RPLND marker status Elevated 80% Normal 16% p= RR=8.0( ) p= mo DFS by pre- RPLND marker status) Normal 85% Elevated 20% (data estimated from Fig. 1 survival curves) Stephenson et al Retro To evaluate the impact of patient selection citeria on peritoneal pathology and relapse rates after RPLND for patients with clinical stages I to IIB NSGCT 453 (n=345 pre-1999; n= or later) Testis 100% Orch. Histol predominantly embry. ca: 28% teratoma 60% yolk sac: 48% lymphovasc inv: 59% Markers pre-rplnd: Elevated: 26 (8%) (all treated pre-999, when selection criteria changed to exclude those with STMs from RPLND; includes 10 stage I, 9 stage IIA, 7 stage IIB) Cox MVA on Pre-RPLND Predictors of Progression*: HR 95% CI p val adj chemo < STM post-orch.: < clinical stage I: clinical stage IIA: clinical stage IIB (* adjusted for use of adj chemo) n=47 (10.4%) relapsed after RPLND 99% at 4 years for pre (95% CI: 98 to 100%); 100% for post-1999 FFP at 4 years: 83%, pre %, post-1999 P= by American Society of Clinical Oncology 5 of 41

6 Data Supplement Table DS4: Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Price et al To determine relationship of marker production doubling time (MPDT) to tumor growth rate in patients who will receive BEP as first-line treatment for metastatic testicular NSGCT 51 Testis 100% Daily production (range), based on 3 consecutive measurements from orchiectomy to start of chemotherapy: AFP (N=45): ,985 IU/l/day hcg (N=34): ,404 IU/l/day MPDT 4 days more likely to fail BEP than MPDT >4 days AFP p=0.009 HCH p=0.005 Small volume of disease equals longer MPDTs than large volume of disease AFP p=0.02 hcg p=0.04 MPDT independent of initial tumor marker level AFP p>0.05 hcg - p=0.20 Toner et al To determine the role of adjunctive surgery in patients with NSGCT by assessment of clinical, pathologic and radiologic features that are potentially predictive of post-chemo residuals 148 NSGCT 100% Univariate Analysis of Factors Predictive of RPLND pathology p<0.05 Pre-chemo LDH Pre-chemo AFP Pre-chemo no. of met sites Post-chemo residual mass size Post-chemo product of the perpendicular diameters of the residual mass Post-chemo shrinkage of residual mass Post-chemo size & shrinkage combined Univariate Analysis of Factors Predictive of Lung Resections No significant factors Univariate Analysis of Factors Predictive of Mediastinal Resections Post-chemo size p=0.014 RPLND no pre- or post-chemo factors found that could reliably identify pts without residual viable cancer or teratoma in the RP LUNG or MED no factors found to selectively choose pts for whom it was safe to avoid surgery 2010 by American Society of Clinical Oncology 6 of 41

7 Data Supplement Table DS4 (continued): Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Toner et al To analyze survival & prognostic features of pts with poor risk NSGCT by MSKCC classification; treated with high-dose platinum-based regimen, and RTR if STMs normal post chemo; Cox model used prechemo STM levels 149 Testis 66.4% Med 21.5% RP 12.1% Elevated AFP Testis 64% Med 75% RP 61% p=0.46 Elevated hcg Testis 94% Med 31% RP 72% p< Elevated LDH Testis 98% Med 84% RP 100% p=0.004 Univariate Cox Reg for Poor Prognostic Factors for Event-Free Survival Elevated hcg Elevated LDH Presence of either brain or liver mets Med primary CR (chemo only) Testis 31% Med 19% RP 50% CR (overall) Testis 38% Med 38% RP 61% Median Survival n=149 Testis 14.8 mos Med mos RP 34.9 mos Median Event-Free Survival mos (N=149) Testis 13.6 Med 10.1 RP 24.7 p=0.023 Median Relapse- Free Survival - mos (n=61) Testis NYR Med 20.2 RP NYR p=0.053 Aass et al To determine prognostic factors in unselected patients with advanced NSGCT who rec d induction cisplatin-based chemotherapy followed by RTR if STM normalized 200 NSGCT 100% Prechemo Levels AFP ( g/l) Missing - 7 hcg (U/L) < , Missing - 9 LDH 2.5N 123 >2.5N 39 Missing 38 Univariate Analysis for Survival Extent of disease (MRC grping) p=0.06 Pretrtm AFP/hCG (MRC levels) - p<0.01 Pretrtm LDH p<0.02 Age p= Time btw orch & chemo p=0.03 No risk factors vs 1 p=0.01 Place of trtm (LV &VLV) p=0.01 MVA for Survival (N=193) Extent of disease (MRC grping) p= Age>35 p=0.03 Time btw orch & chemo - p=0.01 Pretrtm AFP/hCG (MRC levels) p=0.03 Place of trtm p= yr OS 82% 2010 by American Society of Clinical Oncology 7 of 41

8 Data Supplement Table DS4 (continued): Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Mead et al To determine prognostic factors in metastatic NSGCT, treated with cisplatinbased chemotherapy from gonadal or extragonadal sites 795 Testis 93% Med 1% RP 4% Unk 1% AFP level (ku/l) Unk 1 hcg level (IU/L) - % , Unk 1 LDH - % Low 29 High 6 Unk 66 MVA for Mortality HR(95% CI) Liv/Bn/Br Mets 3.13( ) -p< STM Elevated 2.57( )-p< Incr Age 1.03( )-p< Size med mass 4.38( )p< No. lung mets 2.17( ) p= CR(chemo only) 52% CR(Cx + Sx) 16% PR(ca) 12% PR(Res mass) 16% No Resp 2% Died before assess - 2% Lost to FLUP <1% 3-yr OS 85% (95% CI 82-88%) 3-yr Survival by no. of poor-risk features 0 93% 1 78% 2 60% 3 26% 5-yr Survival by no. of poor-risk features 0 92% 1-71% 2 48% 3 26% 3-yr - 82% (95%CI: 79-85%) Jensen & Venner, To determine utility of STMs & histology to predict prognosis & outcome of PVB chemo ± RTR 77 AFP>20ng/ml 9.3% hcg>5ngml 59.7% LDH>200U/L 27.3% Individual STMs did NOT predict outcome Accuracy of Classification Systems Indiana Classification 84.4 % Bosl predict formula Pi (prob of CR) 87% MD Anderson classification 61% Fossa et al (STM results during chemo in Table 5) To identify parameters that are predictive for fibrosis/necrosi s prior to RPLND 78 Testis 100% NSGCT 100% Prechemo AFP - g/l Median 27(5-81,000) Prechemo hcg U/L Median 13(5-16,000) Preop Tumor Markers (AFP & hcg) Normal 76 Elevated 2 Univariate Analysis for Predictors of Residual Histology (n=76) Prechemo hcg (norm vs elevated) p=0.014 Prechemo markers(norm vs elevated) p=0.005 Residual Histology Necrosis 65% Mature terat 28% Cancer 6% 2010 by American Society of Clinical Oncology 8 of 41

9 Data Supplement Table DS4 (continued): Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Gerl et al To determine prognostic utility of baseline STM in patients with poor risk disease 86 Testis 75.6% Extrg 24.4% Univariate Factors for Lower Survival Very lg pulm involvement p=0.031 Presence of liver mets p=0.018 Presence of brain mets p=0.003 No. of elevated markers p=0.301 hcg>10,000 U/L p=0.399 AFP>1000 U/ml p=0.401 LDH>1000U/L p=0.270 hcg HL>3.5 days p=0.524 AFP HL>7 days p=0.479 All pts - 49% PVB 44% ECBC 66% DFS PVB - 33% ECBC 54% Stoter et al (update of Stoter et al. 1990) To determine prognostic factors in metastatic NSGCT in pts entered into 2 randomized cisplatin-based combo chemo studies from EORTC-GU group 632 Testis 100% Univariate Analysis (CR and Survival) Malign trophobl terat p=0.06 p=ns RP mets p=0.06 p=ns Size of RP mets p<0.001 p<0.001 Med mets p=0.009 p<0.001 Size of med mets p=ns p<0.001 Supraclav mets p=0.04 p<0.001 Lung mets p<0.002 p<0.001 No. lung mets p<0.001 p<0.001 Size of lung mets p<0.001 p<0.001 Liver mets p=0.10 p<0.001 AFP p<0.001 p<0.001 hcg p<0.001 p<0.001 LDH p<0.001 p<0.001 Tumor volume p<0.001 p<0.001 Risk groups for CR based on number of risk factors 0 95% 1 79% 2 54% % Risk groups for Survival based on number of risk factors (% dead) 0 4% 1 14% 2 30% % MVA for Complete Response hcg ( 10,000 IU/L) p<0.001 Size of abd mass( 5 cm) p<0.001 AFP ( 1000 IU/L) p=0.003 No. lung mets ( 10) p=0.008 MVA for Survival No lung mets ( 10) p<0.001 Size of abd mass ( 5 cm) p<0.001 Supraclav mets (yes) p=0.002 hcg ( 10,000 IU/L) - p= by American Society of Clinical Oncology 9 of 41

10 Data Supplement Table DS4 (continued): Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE and TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Steyerberg et al To analyse prognosis of metastatic NSGCT after cisplatinbased regimen followed by RTR (if STMs normal) 86 Testis 100% NSGCT 100% Elevated AFP 73% hcg 70% LDH (analysis of predictive factors used highest pre-chemotherapy STM levels) Univar Prognostic Factors for Relapse Prechemo Factors No. of lung mets p=0.003 hcg level p=0.001 Postchemo Factors Residual lung mets w/o abdom mets p=0.001 Size of lung mets p=0.003 Resection Factors Completeness of Resection p= Histology at Resection (N=86) Necrosis 44% Mature terat 37% Viable ca 19% 2-yr 91.4% 5-yr 87.2% Relapse-Free Survival 5-yr 87.4% (95%CI:78-93%) Steyerberg et al metaanalysis (18 reports, ; plus 95 in own series) To determine predictors of residual histology after chemo for metastatic NSGCT 996 NSGCT 100% (analysis of predictive factors used prechemo STM levels) Predictors of Necrosis OR(95%CI) (signif, but most p values ) No teratoma in primary 5.1( ) Normal AFP pre-chemo 2.8( ) Normal HGC pre-chemo 1.9( ) Both normal pre-chemo 5.7(2.5-13) Smaller post-chemo masses 10 vs 10 mm 3.6( ) 15 vs 15 mm 8.4(3.2-22) 50 vs 50 mm 4.3( ) Lg shrinkage ( 90%) 3.1( ) Lung vs abdom resect 1.7( ) p=0.04 Histology of Residual at RTR Necrosis 48% Teratoma 36% Cancer 16% Predictors of Cancer OR(95%CI) (signif, but most p values ) No teratoma in primary tumor Abd Resect 0.48( ) p=0.008 Lung + Abdom 0.71( )p=0.002 Lung Resection 3.7 ( )p=0.051 Smaller pre-chemo RP mass 20 vs>20 mm 0.32( ) 50 vs >50 mm 0.25( ) Smaller post-chemo RP mass 10 vs 10 mm 0.4( ) 15 vs 15 mm 0.33( ) 20 vs 20 mm 0.12( ) 50 vs 50 mm 0.35( ) 2010 by American Society of Clinical Oncology 10 of 41

11 Data Supplement Table DS4 (continued): Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE and TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Kawakita et al To assess prognostic factors in patients with metastatic NSGCT 60 Testis 83% Extrag 7% AFP Elevated Testis 88% Extrag 50% hcg Elevated Testis 76% Extrag 70% LDH Elevated Testis 72% Extrag 50% Univariate Analysis for Survival (adverse factors) Hist (choriocarinoma) - p= hcg (>10,000 ng/ml) p=0.028 (only 1 pt) LDH (2xULN) p=0.016 Med mets p= Liver mets p<0.001 Liver or br or med mets p< sites of disease p=0.033 RP (>5 cm) - p=0.037 Complete Response Good Risk 46.9% Poor Risk 7.1% p= CR with Surgery Good Risk 96.9% Poor Risk 60.7% p= yr OS Good Risk 88.7% Poor Risk 49.7% p< yr OS Good Risk 88.7% Poor Risk 33.6% p< yr Event-Free Survival Good R 71.0% Poor R 35.7% p= yr Relapse-Free Survival Good R 73.4% Poor R 52.9% p=0.087 Steyerberg et al To develop models to predict histology of residuals after cisplatin-based induction chemo for metastatic NSGCT (separate models: a) to estimate probability of necrosis; and b) to estimate ratio of cancer to teratoma, or probability of cancer, in those without necrosis) 556 Testis 100% NSGCT 100% Terat pos 53% Elevated AFP 66% hcg 62% LDH 69% (analysis of predictive factors used prechemo STM levels) Univariate Predictors of Necrosis vs Other OR(95%CI) Primary terat neg 3.35( ) p<0.001 Prechem AFP norm 2.74( ) <0.001 Prechem hcg norm 2.17( ) p<0.001 Prechem LDH norm 1.69( ) p=0.011 Prechemo mass size - p=0.008 Postchemo mass size p<0.001 Shrinkage - p<0.001 Univariate Predictors of Cancer vs Teratoma OR(95%CI) Prechem LDH norm 2.62( ) p=0.20 MVA Predictors of Necrosis vs Other (N=544) OR(95%CI) - all p<0.03 Primary terat (neg vs pos) 2.46( ) Prechemo AFP (norm vs elev)-2.49( ) Prechemo hcg(norm vs elev)-2.22( ) ln(ldh) 2.76( ) sqrt(postchem resid size) 0.744( ) Per 10% shrinkage 1.17( ) Overall Model p< Reliability of Models (authors conclusion on correspondence between observed and predicted probabilities based on visual inspection of Fig 1): good Necrosis Model: Hosmer- Lemeshow goodness-of-fit test (observed vs predicted): p=0.59 Cancervs Teratoma Model: goodness-of-fit test (observed vs predicted): p=0.34 Discrimination of Models (area under ROC curve) Necrosis model (0.839) better than cancervs teratoma model (0.661) External Validity Better for necrosis model than cancer vs teratoma model MVA Predictors of Cancer vs Teratoma (N=299) Model using prechemo LDH, postchemo mass size and shrinkage p= by American Society of Clinical Oncology 11 of 41

12 Data Supplement Table DS4 (continued): Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Hartmann et al (entries duplicated in Table 6, STM assays after chemotx) To determine predictive factors affecting survival after cisplatin-based chemo for metastatic NSGCT and RTR 134 total (109 after firstline chemo) Site Gonadal 94% RP 5% Unk 1% Elevated pre-chemo AFP 44.9% hcg 48.6% Both 33.9% Predictive Factors for Histology at RTR after first-line chemo (N=89) Incomplete Resection p< Pre-RTR AFP & hcg pos p=0.001 Pre-RTR AFP pos p=0.005 Pre-RTR LDH p=0.03 Pre-RTR hcg p=0.04 pre-chemo STM: not significant Prognostic Factors for OS at RTR after first-line chemo Initial med LNs p=0.02 Pre-chemo LDH pos p=0.01 Pre-Sx AFP pos p=0.005 Early recur(<3 mo) p= RTR after first line chemo (N=109) Response Type PRm-: 75% PRm+: 10% PDm+: 11% PRm?: 4% (PR = partial remission; PD = progressive disease) Histology of Residual Necrosis 46% Diff d teratoma 22% Undiff d terat 32% Histology of residual in PRm- (N=82) Necrosis 52% Diff d teratoma 27% Undiff d terat 21% Estimated 5-yr OS = 80% Estimated Relapse- Free Survival =60% IGCCCG, (data on seminoma patients in Table 12) To outline a prognostic factor-based staging system for metastatic GCTs 5202 Site Testis 94% Med 3% RP 3% Other 1% AFP ng/ml < % ,000 12% >10, 000 4% Unk 2% hcg IU/L (N=3529) < % ,000 7% >50, 000 7% LDH <1.5N 42% N 20% >10N 1% Unk 37% Univariate Analysis for Progression and Survival Almost all factors significant p<0.01 MVA for Progression and Survival (each had same factors) Primary site AFP hcg LDH Extent of disease (no. mets sites or NPVM) 5-yr - % (95% CI) 80(79-81) OS Based on Model Good 92% Interm 80% Poor 48% 5-yr - % (95%CI) 75(74-76) Based on Model Good 89% Interm 75% Poor 41% 2010 by American Society of Clinical Oncology 12 of 41

13 Data Supplement Table DS4 (continued): Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Steyerberg et al To validate prediction of histology of RTR masses in pts treated with chemo for metastatic NSGCT 172 Testis 100% Histology NSGCT 100% Terat neg 53% Terat post 47% Prechemo Levels AFP Normal 30% Elevated 70% hcg Normal 28% Elevated 72% LDH Normal 20% Elevated 80% Histology of Residual Necrosis 45% Mature terat 42% Cancer 13% Necrosis Model Reliability 0.97 Discrimination 0.82 Cancer Model Reliability 0.49 Discrimination 0.59 Steyerberg et al To determine 641 the role of CT (includes measurement of 544 from residuals in Steyerberg, et decision-making for RTR after al. 1995) induction chemo for metastatic NSGCT Residual Histology Necrosis 47% Teratoma 42% Cancer 11% (analysis of predictive factors used pre-chemo STM levels) Univar Factors to Predict Necrosis Size after chemo p= Reduction in size p= Teratoma negative p<0.01 Normal AFP before chemo p<0.01 Normal hcg before chemo - p<0.01 Elevated LDH before chemo p<0.01 MVA Logistic Regression (Model 3) OR(95%CI) Size post chemo 1.22( ) p=0.01 Reduction in size 30( ) p < Simple score* ( ) p<0.001 *Composite of 4 items Kollmannsberger et al To identify subsets of patients with more or less favourable outcome among the IGCCCCG poor risk group in pts with metastatic NSGCT using CART modeling 332 Gondl 69% Med 22% RP 9% AFP Good 57% Interm 20% Poor 22% Missing 1% hcg Good 54% Interm 10% Poor 35% Missing 1% LDH Good 24% Interm 59% Poor 12% Missing 5% CART Modelling Factors Primary site Visceral mets Lung mets Abdominal mets hcg levels CART Modelling OS Factors Visceral Mets Primary Site Abdominal mets Estimated 2-yr OS by Group - %(95%CI) Good-poor 84(76-92) Interm-poor 64(52-72) Poor-poor - 49(29-70) Estimated 2- yr by Group - %(95%CI) Good-poor 5(65-85) Interm-poor 60(52-65) Poor-poor 36(12-60) 2010 by American Society of Clinical Oncology 13 of 41

14 Data Supplement Table DS4 (continued): Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Vergouwe et al Validation of a prediction model for histology of residual masses in nonseminomous testicular cancer 276 Primary Histology Terat pos 38% Terat neg 62% PrechemoTx levels AFP Normal 25% Elevated 73% hcg Normal 28% Elevated 73% Univariate Analysis to Predictor Residual Histology (benign vs tumor) OR(95%CI) Primary teratoma pos 6.0( ) Pre-chemo AFP elevated 4.0( ) Pre-chemo hcg elev d 1.6( ) Postchem size(5-10 cm ) 1.8( ) Postchem size (>10 cm) 0.3( ) Reduction during chemo 1.8( ) Progr n during chemo 0.2( ) MVA for Residual Histology OR(95%CI) Primary ( teratoma neg vs pos) 5.0( ) Prechemo AFP (norm vs elev d) 3.7( ) Prechemo hcg (norm vs elev d) 1.2( ) Postchemo mass ( 5 vs 5-10 cm) 0.8( ) Postchemo mass ( 5 vs >10 cm) 0.8( ) Size during chemo (none vs ) 1.8( ) Size during chemo (none vs ) 0.2( ) Postchemo Mass Size (cm) (44%) (30%) >10 73(26%) Mass size change during chemo Reduction 130(47%) No change 105(38%) Progression 41(15%) Residual Histology Benign 76(28%) Tumor 200(73%) Hartmann et al (same pts as in Bokemeyer et al. 2001, , , 112 and Hartmann et al ) to evaluate prognostic variables for long term OS after cisplatin-based chemo-therapy for extragonadal GCT (extragonadal seminoma data of Bokemeyer et al in Table 3) 524 mediastinal 55% RP 43% uncertain 2% (masses in both mediastinum & RP) mets at: 2 sites 85% >3 sites 14% Levels at Dx: AFP (ng/ml): median: 10 range: 1 5x10 5 AFP: 63% hcg (miu/ml): median: 56 range:1 9.9x10 6 >2 ng/ml: 54% LDH (IU/L): median: 598 range: LDH: 56% Univariate analyses for predictors of OS mediastinal vs RP primary: p = lung mets, yes vs no p = CNS mets, yes vs no p < liver mets, yes vs no p = IGCCCG intermed vs poor p < cisplatin sensitivity p < AFP at Dx, vs normal: p = 0.08 hcg at Dx, vs normal: p = 0.04 LDH at Dx, vs normal: p = 0.13 CART model for OS at 2 years (95% CI): RP primary: 76% (70% - 82%) mediastinal 1 o : 57% (51% 63%) p< NPVM yes: 34% (17% 52%) NPVM no: 60% (54% 67%) p<0.001 lung mets yes: 42% (29% 56%) lung mets no: 65% (58% 73%) p= age >29 yrs: 52% (40% 64%) age 29 yrs: 74% (65% 82%) p= hcg at Dx: 62% (46% 78%) normal hcg: 83% (73% 94%) p=0.01 Mediastinal: CR: 19% PR w normal markers: 45% Retroperitoneal: CR: 28% PR w normal markers: 40% MVA for OS, HR (95% CI): mediast. 1 o : 2.29 ( ) p < liver mets: 1.72 ( ) p = lung mets: 1.43 ( ) p = CNS mets: 2.53 ( ) p = hcg at Dx: 1.48 ( ) p=0.022 Actuarial, at 5 years: mediastinal: 45% RP: 62% mets: lung CNS liver yes 44% 24% 38% no 57% 53% 55% IGCCCG poor: 48% IGCCCG interm.: 75% cisplatin sensitive: 68% cispt rel. refract.: 33% cispt abs. refract.: 6% AFP at Dx : 54% AFP at Dx normal: 48% hcg at Dx : 51% hcg at Dx normal: 59% LDH at DX : 52% LDH at Dx normal: 65% MVA for, HR (95% CI) : CNS mets: 1.9 ( ) p = lung mets: 1.6 ( ) p = medias. 1 o : 1.5 ( ) p = hcg@dx:1.4 ( ) p < by American Society of Clinical Oncology 14 of 41

15 Data Supplement Table DS4 (continued): Post-Orchiectomy STM Assays Before First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCT, to Predict Prognosis, Response, or Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Kesler et al (data on post-chemo STM in Table 6) To determine predictors of long-term survival in those with med metastases from testicular NSGCT who undergo surgery after cisplatin-based chemo 268 Testis: 100% NSGCT:100% AFP (ng/ml) N= : 18.5% : 12.8% 101-1E3: 25.9% 1E3-1E4: 34.4% >10,000: 8.4% hcg(ng/ml) N= : 19.3% 1.6-1E4: 40.3% 1E4-5E4: 27.5% >5E4: 12.9% Univariate Analysis of Survival HR(95%CI) Age at Dx 1.04( ) p=0.014 hcg at Sx 1.86( ) p=0.036 Malig lung disease removed 2.11( ) p=0.012 Path type of med disease 1.55( ) p=0.006 elevated hcg pre-chemo: 0.76 ( ) p=0.102 elevated AFP pre-chemo: 1.09 ( ) p=0.507 Histology of residual med disease Necrosis 14.9% Teratoma 58.8% NSGCT 15.6% Non GCT 10.7% 5-yr: 86±2% 10-yr: 74±4% DFS 5-yr: 80±3% 10-yr: 63±4% LDH Van Dijk et al To evaluate validity of the Kollmannsberger tree, develop new tree for poor prognosis pts w metastatic NSGCT, & compare it to the Kollmannsberger tree 456 Testis 67% Med 22% RP 11% AFP Good 54% Interm 18% Poor 28% hcg Good 57% Interm 12% Poor 31% LDH Good 23% Interm 70% Poor 7% Tree 2-yr OS Factors Number of mets Primary site Size of abdominal mets Lung mets Discriminative Ability c-statistic (95%CI) Koll r Tree 0.63( ) IGCC Tree 0.59( ) - neither model good Vergouwe et al (contains data from Steyerberg, ) To determine predictors of RP histology after cisplatinbased chemo in advanced testicular GCT Devm=544 Valid=550 Total=1094 (analysis of predictive factors used pre-chemo STM levels) MVA for benign residual Logistic Regression OR(95%CI) Teratoma absent 3.1( ) AFP normal 3.0( ) hcg normal 2.0( ) LDH transformed 2.3 ( ) Postchemo mass size 0.76( ) Change in mass size per 10% ( ) 2010 by American Society of Clinical Oncology 15 of 41

16 Data Supplement Table DS5: Post-Orchiectomy STM Assays During First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCTto Monitor Response or Predict Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Toner et al To analyze the prognostic value of AFP & hcg half life after start of cisplatin- or carboplatinbased chemotherapy in patients with metastatic NSGCT 198 Testis 87% Med 7% RP 6% AFP % Elevated All - 76 Good Risk - 77 Poor Risk - 75 hcg % Elevated All 68 Good Risk - 60 Poor Risk - 79 LDH % Elevated All - 72 Good Risk - 54 Poor Risk - 98 Correlation of response with prolonged marker HL: either AFP or hcg HL prolonged All pts p< Good Risk p< Poor Risk p= Cox Regression Poor Prognostic Factors for Survival - RR Prolonged HL 3.63 Poor Risk Grp 4.10 (model p<0.0001) Complete Response (%) All Patients Satisf Markers 89 Prolonged HL 29 p< Good Risk Patients Satisf Markers 95 Prolonged HL 44 p< Poor Risk Patients Satisf Markers 70 Prolonged HL 24 p=< yr OS AFP & hcg From survival curves (Fig 1) N=198 Satisf Markers 80 Prolonged HL 23 p< AFP From survival curves (Fig 2) N=145 Satisf Markers 77 Prolonged HL 30 p< hcg From survival curves (Fig 2B ) N=131) Satisf Markers 81% Prolonged HL 19% p< Fossa et al (prechemotx STM results in Table 4) To identify parameters that are predictive for fibrosis/necrosi s prior to RPLND 78 n=40 evaluable Testis 100% NSGCT 100% hcg post cycle 2 <90%: 18/ 40 (45%) 90%: 22/40 (55%) AFP post cycle 2 <90%: 11/40 (27%) 90%: 29/40 (73%) Univariate Analysis for Predictors of Residual Histology (n=40) hcg <90%: p=0.061 AFP <90%: p=0.90 Residual Histology (% necrosis only) hcg <90%: 6/18 (33%) hcg 90%:15/22 (68%) AFP <90%: 6/11 (55%) AFP 90%: 17/29 (59%) 2010 by American Society of Clinical Oncology 16 of 41

17 Data Supplement Table DS5 (continued): Post-Orchiectomy STM Assays During First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCTto Monitor Response or Predict Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Stevens et al To determine the prognostic role of marker half life (MHL) early during front-line platin-based chemo in pts with metastatic GCTs (95% had metastatic disease) 183 Testis 100% Histology unk Marker Half Life AFP N=142 Median MHL 6.0 days ( ) Normal 65% Prolonged 35% hcg N=111 Median MHL 2.6 days ( ) Normal 65% Prolonged 35% MHL during first 3 wks after chemo does not predict relapse PPV for both relapse and survival are poor CR more likely with normal MHL p=0.046 OS HR(95%CI) AFP 2.2( ) p=0.066 hcg 2.2( ) p=0.071 Either 2.4( ) p=0.016 HR(95%CI) AFP 1.7( ) p=0.188 hcg 1.8( ) p=0.271 Either 1.5( ) p=0.262 LDH de Wit et al To determine prognostic value of STM half-life (HL) during induction chemo (cycle 1 of cisplatin based regimen) and initial STM concentrations in patients with metastatic NSGCT 669 Testis 100% AFP n=537 Normal 31% <1000 IU/L 59% >1000 IU/L 10% hcg n=526 Normal 34% <1000 IU/L - 54% >1000 IU/L 12% LDH - Univariate Predictors of Failure AFP HL (0-6 vs 6-10 vs >10 days) p=0.851 Init Conc (<1000 vs 1000 IU/L) p<0.001 hcg HL (0-3 vs 3-6 vs >6 days) p=0.558 Init Conc (<1000 vs 1000 IU/L) p<0.001 MVA initial marker values were predictive of treatment failure, HL were not (no data given) AFP (init) Treatment Failure Normal 10% <1000 IU/L 13% >1000 IU.L 36% hcg (init) Treatment Failure Normal 10% <1000 IU/L 14% >1000 IU/L 29% Gerl et al To determine the influence of marker HL during first 2 cycles of chemo on long-term outcome in metastatic NSGCT 147 AFP prolonged HL vs not 10-yr OS: 39% vs 70% p=0.02 hcg prolonged HL vs not 10-yr OS: 36% vs 66% p= by American Society of Clinical Oncology 17 of 41

18 Data Supplement Table DS5 (continued): Post-Orchiectomy STM Assays During First-Line Chemotherapy for Poor Risk, Advanced, or Metastatic NSGCTto Monitor Response or Predict Outcome STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Fizazi et al To determine if time to normalization (TTN) of AFP & hcg after chemo predicts progression and survival in the IGCCCG classified NSGCT 653 Testis 91.7% RP 2.9% Med 5.4% AFP Median TTN 7.6 wks hcg Median TTN 5.7 wks MVA for 4-yr HR(95%CI) Unfavorable TTN 1.50( ) - p=0.036 InitAFP>1000 ng/ml- 0.67( ) - p=0.073 Init hcg>5000 U/L 1.28( ) - p=0.248 MVA for 4-yr OS HR(95%CI) Unfavorable TTN 2.17( ) - p=0.005 Init AFP>1000ng/ml 0.59( ) - p=0.073 Init hcg>5000u/l 0.68( ) - p=0.197 MVA 4-yr OS Fav TTN 94% Unfav TTN 74% p=0.005 MVA 4-yr AFP & hcg Day 21 91% AFP &/or hcg w/ short pred TTN 79% Unfav TTN 61% p=0.036 Motzer et al RCT of BEP x2 HDCT versus BEP X4 To determine if decline ( ) in STM during 1 st two cycles of chemotherapy predicts outcome and/or benefit from HDCT 108 vs 111 BEP HDCT: Testis 72% Med 24% RP 4% Unk - 0 BEP x4: Testis 64% Med 29% RP 6% Unk 1% AFP >15 ng/ml: All 66% HDCT 69% BEPx4 63% hcg >10 U/L: All 70% HDCT 73% BEPx4 68% LDH >200 U/L: All 89% HDCT 87% BEPx4 90% IGCCCC risk status: Poor 79% Intermediate 21% Analysis of marker decline X Tx effect interaction (proportional hazards): Unsatisfactory STM 42% (n=38, HDCT; n=31, BEP alone) Satisfactory STM 58% (n=33, HDCT; n=63, BEP alone) BEP+ BEP HDCT alone CR 56% 55% PR/STM- 10% 5% STM still 33% 39% BEP+ BEP HDCT alone Unsatisfact. STM : at 2 yr: 78% 55% 95% 65%- 37%- CI: 92% 74% Cox adjusted p=0.11 Satisfactory STM : at 2 yr: 78% 85% 95% 64%- 76%- CI: 93% 94% Cox adjusted p=0.29 Durable CR: BEP+ BEP HDCT alone Unsatisfact. STM : at 1 yr: 61% 34% 95% 45%- 17%- CI: 76% 52% Cox adjusted p=0.04 Satisfactory STM : at 1 yr: 58% 66% 95% 41%- 54%- CI: 74% 78% Cox adjusted p= by American Society of Clinical Oncology 18 of 41

19 Data Supplement Table DS6: Post-Chemotherapy STM Assays for Poor Risk, Advanced or Metastatic NSGCT, to Predict Outcome of Subsequent RPLND or other Surgery, or Response to more Chemotherapy STUDY TYPE PURPOSE N PRIMARY SITE and TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL PROGRESSION- FREE Hartmann et al (duplicate entries in Table 4, prechemo STM assays) To determine predictive factors affecting survival after cisplatin-based chemo for metastatic NSGCT and RTR 134 total (109 after first-line chemo) Site Gonadal 94% RP 5% Unk 1% Elevated pre-chemo AFP 44.9% hcg 48.6% Both 33.9% (analysis used both preand post-chemo STM levels as separate predictive factors) Predictive Factors for Histology at RTR after first-line chemo (N=89) Incomplete Resection p< Pre-RTR AFP & hcg pos p=0.001 Pre-RTR AFP pos p=0.005 Pre-RTR LDH p=0.03 Pre-RTR hcg p=0.04 STM levels pre-chemo: not significant Prognostic Factors for OS at RTR after first-line chemo Initial med LNs p=0.02 Pre-chemo LDH pos p=0.01 Pre-Sx AFP pos p=0.005 Early recur(<3 mo) p= RTR after first line chemo (N=109) Response Type PRm-: 75% PRm+: 10% PDm+: 11% PRm?: 4% (PR = partial remission; PD = progressive disease) Histology of Residual Necrosis 46% Diff d teratoma 22% Undiff d terat 32% Histology of residual in PRm- (N=82) Necrosis 52% Diff d teratoma 27% Undiff d tumor 21% Estimated 5-yr OS = 80% Estimated Relapse- Free Survival =60% Ravi et al Salvage surgery of residual masses in pts with chemoresistant metastatic NSGCT Mpos 30 Mneg 77 Post-Chemo Marker Positive (n=30) AFP 67% hcg 23% Both 10% Histology of Residual Marker Positive (N=30) Viable 73% Necrosis 27% Post-Chemo Marker Negative (N=77) Viable 65% Necrosis 35% median FU of 57 mos Marker positive NED after Sx 57% Marker negative NED after Sx 92% 2010 by American Society of Clinical Oncology 19 of 41

20 Data Supplement Table DS6 (continued): Post-Chemotherapy STM Assays for Poor Risk, Advanced or Metastatic NSGCT, to Predict Outcome of Subsequent RPLND or other Surgery, or Response to more Chemotherapy STUDY TYPE PURPOSE N PRIMARY SITE and TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL PROGRESSION- FREE Kesler et al (data on prechemo STM levels in Table 4) To determine predictors of longterm survival in those with med metastases from testicular NSGCT who undergo surgery after cisplatin-based chemo 268 Testis 100% NSGCT 100% Diagnosis (ng/ ml) N= % % % , % >10, % AFP Pre-op N= % % % % >10, % Diagnosis (ng/ml) N= % % , % >50, % Univariate Analysis of Survival HR(95%CI) Age at Dx 1.04( ) p=0.014 hcg at Sx 1.86( ) p=0.036 Malig lung disease removed 2.11( ) p=0.012 Path type of med disease 1.55( ) p=0.006 MVA of Poorer Survival Cox Regression Model Older age at Dx p=0.005 Elevated hcg at Sx p=0.028 More serious path class of residual med disease p=0.006 Histology of residual med disease Necrosis 14.9% Teratoma 58.8% NSGCT 15.6% Non GCT 10.7% 5-yr: 86±2% 10-yr: 74±4% DFS 5-yr: 80±3% 10-yr: 63±4% hcg Pre-op N= % % , % >50, % LDH 2010 by American Society of Clinical Oncology 20 of 41

21 Data Supplement Table DS6 (continued): Post-Chemotherapy STM Assays for Poor Risk, Advanced or Metastatic NSGCT, to Predict Outcome of Subsequent RPLND or other Surgery, or Response to more Chemotherapy STUDY TYPE PURPOSE N PRIMARY SITE and TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL PROGRESSION- FREE Beck et al To determine outcomes for patients with metastatic GCT with elevated STMs at postchemotherapy (cisplatin-based) RPLND st line 50 2nd line - 64 Testis 100% Histology of Residual Cancer 53.5% Terat 34.2% Fibrosis 12.3% Mean AFP (ng/ml) 1 st line vs 2 nd line Initial 15,754 vs 11,550 p=ns Pre-op vs 645 p=ns Mean hcg (mu/ml) 1 st line vs 2 nd line Initial 184,299 vs 105,312 p=ns Pre-op 35.2 vs 1057 p=ns Preop Predictors, Cancer in Surgical Specimen Increasing AFP - p Increasing hcg - p hcg>100mu/ml p<0.025 Redo RPLND - p nd line chemo p< Univariate Survival Analysis (adverse prognostic factors) Preop hcg (contin) p=0.018 Preop hcg(<100 vs >100) p=0.003 Preop hcg (<1000 vs >1000) p=0.01 Preop AFP (<100 vs >100) p=0.044 Preop AFP (< vs >1000) p= Preop hcg (incr vs decr) p= Preop-AFP (incr vs decr) p= Hx of STM normalization p< st vs 2 nd line chemo p< Redo RPLND p< Surgical Path (ca vs other) p= Unresectable disease p= Cancer in Surgical Specimen 1 st line 28% 2 nd line 73.4% p<0.0001) 5-yr 53.9% 5-yr based on pathology Ca 31.4% Terat 77.5% Fibros 85.7% 5-yr based on line of chemo 1 st 81.1% 2 nd 33.3% p= Kobayashi et al To determine the significance of preoperative elevated AFP in post-chemo RTR 68 Site Testis 88% Extrag 12% Histology Sem 10.3% Non 66.2% Not asses 7.4% Missing- 16.2% Proportion with elevated STM levels measured postchemotherapy but pre- RTR : AFP pos 79.4% hcg pos 64.7% Both neg 7.4% Viable cells in RTR specimen Overall 35% AFP pos 43% hcg pos 36% Disease- Specific Survival (DSS) viable cells in RTR assoc d w/ decrease in DSS, p=0.03 DSS signif better if preop AFP pos than preop HGC pos (p=0.02 but based on small numbers; 7 vs 4 respectively) 2010 by American Society of Clinical Oncology 21 of 41

22 Data Supplement Table DS6 (continued): Post-Chemotherapy STM Assays for Poor Risk, Advanced or Metastatic NSGCT, to Predict Outcome of Subsequent RPLND or other Surgery, or Response to more Chemotherapy STUDY TYPE PURPOSE N PRIMARY SITE and TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL PROGRESSION- FREE Spiess et al To determine predictors of outcomes after post-chemotherapy RPLND for metastatic testicular cancer 236 Testis 100% RPLND Histology (N=226) Fibros 37.6% Terat 42.9% Viabl 19.4% Pre-Orchiectomy Levels Median AFP ng/ml hcg 30.6 miu/ml LDH 485 IU/L MVA of Disease-Specific Survival HR(95%CI) Systemic symptoms at presentation 2.28( ) p=0.05 Elevated AFP prior to RPLND 1.002( ) p=0.006 Elevated hcg prior to RPLND 1.01(( ) p=0.004 Postop complic 2.49( ) p=0.03 Postop recurrence p< Recurrence-Free Survival 5-yr 75% 10-yr 73% DSS 5-yr 85% 10-yr 81% Predictive Value of Pre-RPLND STMs for Disease-Specific Death AFP >9 ng/ml p=0.03 hcg >4.1 miu/l p=0.03 Shayegan et al To evaluate outcomes and predictors after one (n=107) or two (n=50) lines of chemotherapy followed by RPLND in IGCCCG intermediate- and poor-risk metastatic NSGCT 157 Testis 100% RPLND Histology: fibrosis: 47% teratoma: 40% viable: 13% Pre-Chemo Levels; median (range): AFP: 624 ng/ml (0-92,000) hcg: 708 IU/mL (0 860,000) Post-Chemo Levels; median (range): AFP: 3.6 ng/ml (0 1,820) hcg: 0 (0 101 IU/mL) Predictors of Recurrence-Free Survival HR(95%CI) Advanced clin stage 4.67( ) p=0.001 Fibrosis vs viable in RPLND specimen 0.40( ) p=0.01 Teratoma vs viable in RPLND specimen 0.48( ) p=0.03 Predictors of Disease Progression and Relapse, Univariate HR(95%CI) pre-chemo mass, per cm: 1.05 ( ), p=0.2 post-chemo mass, per cm: 1.15 ( ), p=0.002 elevated STM at RPLND: 1.30 ( ), p=0.5 risk group (poor vs interm): 0.80 ( ), p=0.5 2 nd -line vs no 2 nd -line chemo: 1.40 ( ), p=0.3 incompl. vs complete resect.: 7.85 ( ), p<0.001 teratoma vs fibrosis, RPLND: 2.49 ( ), p=0.02 viable GCT vs fibrosis, RPLND: 6.61 ( ), p<0.001 Pre-Chemo RP Mass: median, 7.5 cm range, 0-18 cm Post-Chemo Residual RP Mass: median, 3.0 cm range, 0-15 cm residual extra-rp mass, n=74 (47%) elevated STM at RPLND, n=29 (17%) 5 yr PFP (95% CI) all: 70% (63%-78%) 1 line+rplnd: 71% (62%-80%) 2 lines+rplnd: 67% (54%-80%), p=0.3 inter. risk: 68% poor risk: 73%, p=0.5 5 yr DSS (95% CI) all: 81% (74%-88%) 1 line+rplnd: 85% (77%-93%) 2 lines+rplnd: 72% (59%-85%), p=0.02 intermed. risk: 80% poor risk: 81%, p= by American Society of Clinical Oncology 22 of 41

23 Data Supplement Table DS6 (continued): Post-Chemotherapy STM Assays for Poor Risk, Advanced or Metastatic NSGCT, to Predict Outcome of Subsequent RPLND or other Surgery, or Response to more Chemotherapy STUDY TYPE PURPOSE N PRIMARY SITE and TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL PROGRESSION- FREE Kesler et al to determine factors predicting survival after surgery for postchemotherapy residual mass(rm) in patients with 1 o mediastinal NSGCT 158 n=46 (29%) with other mets 10 operative deaths 148 evalu-able for postoperative survival mediastinal: 100% at biopsy: yolk sac 58% embryonal 26% chorio 6% unknown 10% post-chemo RM: necrosis 26% teratoma 34% persist. GCT 40% or other cancer Elevated AFP: at diagnosis 90.3% at surgery 13.5% Elevated hcg: at diagnosis 39.2% at surgery 4.1% Either STM Elevated: at diagnosis 94.0% at surgery 33.3% (rising at Sx 12.5%) post surgery 11.5% Univariate predictors for survival: AFP at Dx ( vs normal): HR = % CI: ; p = 0.80 hcg at Dx ( vs normal): HR = % CI: ; p = 0.27 AFP at Sx ( vs normal): HR = % CI: ; p = 0.51 hcg at Sx ( vs normal): HR = % CI: ; p = 0.64 either STM at Sx: but stable vs normal: HR = % CI: ; p = 0.10 rising vs normal: HR = % CI: ; p = 0.03 either STM post Sx: HR = % CI: ; p < post-chemotx RM pathology: teratoma vs necrosis: HR = % CI: ; p = 0.01 persist. cancer vs necrosis: HR = % CI: ; p < at median F-U 34 mos (range mos): N = 89 alive NED N = 3 alive with GCT N = 49 died of GCT N = 4 died of other known causes N = 3 died of unknown causes Multivariate Independent Predictors for Survival from Cox Model: STMs post Sx HR = % CI: ; p < post-chemotx RM pathology: teratoma vs necrosis: HR = % CI: ; p = 0.01 persist. cancer vs necrosis: HR = % CI: ; p < by American Society of Clinical Oncology 23 of 41

24 Data Supplement Table DS7: STM Assays at NSGCT Relapse to Predict Outcome or Monitor Response to Salvage Therapy STUDY TYPE PURPOSE N PRIMARY SITE TUMOR MARKERS PROGNOSTIC FACTORS RESPONSE OVERALL Fossa et al To determine prognostic factors for survival in patients given salvage chemo for advanced GCT that progressed after cisplatin-based chemo with or without surgery 164 testis 83% RP 12% mediast 3% unk 2% AFP at Relapse (n=110) Normal 50% <100 ku/l 30% % >1000 8% hcg at Relapse (n=110) Normal 52% <100 IU/L 21% % > % LDH Univariate Factors for Survival from Relapse MRC prog group at primary diagnosis (good vs poor) p= Response to Induction trtm p< TTP from init of primary therapy p< Year of relapse trtm (pre/post 86) p=0.08 Trtm Centre (lg/sm) p= yr OS 30% (95%CI: 23-38) Median TTP 10 mos (0-99) Hartmann et al to evaluate results of 2 nd -line chemotx in extragonadal NSGCT, and identify prognostic factors for survival 142 testis 0 RP 43% mediast 56% unk 1% AFP at relapse: median 37 ng/ml range 1 to 16,310 elevated 61% hcg at relapse: median 5 miu/ml range 0 to 58,500 elevated 45% LDH at relapse: median 306 IU/L range 112 to 3,014 elevated 70% Factors Predicting Shorter Survival, by Univariate Analyses: mediastinal tumors p = no CR or STM - PR p = 0.03 at cisplatin induction AFP at Dx p = 0.98 AFP at relapse p = 0.07 hcg at Dx p = 0.01 hcg at relapse p = 0.1 normal LDH at Dx p = 0.04 LDH at relapse p = 0.2 Factors Predicting for Mortality, by Multivariate Cox Regression: mediastinal vs RP tumors: HR = 1.9; 95% CI: ; p = sensitive/refractory vs absolute refractory to cisplatin: HR = 2.4; 95% CI: ; p = (19%) alive NED 12 (8.5%) alive w GCT 92 (65%) died of GCT 8 (5.5%) died from Tx related toxicity 3 (2%) outcome uncertain 2010 by American Society of Clinical Oncology 24 of 41