Journal of Experimental & Clinical Cancer Research 2009, 28:120 http://www.jeccr.com/content/28/1/120 Table 2: Serum tumor markers prior to surgery (101 patients) Serum tumor markers AFP (ng/mL) ≤1,000 1,000–10,000 ≥10,000 hCG (mIU/mL) ≤5,000 5,000–50,000 ≥50,000 LDH (IU/L) <1.5 × N 1.5–10 × N >10 × N % 89.1 8.9 2.0 90.1 5.0 5.0 31.5 59.8 8.7 Mean ± SD 1214.3 ± 5892.2 25% 1.85 50% (min-max) 75% 90% 95% 97.5% 14.7 (0–53800) 307.5 1748.6 5924.9 14182.0 14772 ± 71503 0.0 25.0 (0–479000) 271.0 5000.0 66446.0 352040.0 834 ± 929.1 253.5 475.0 (37–4568) 1070.0 1975.3 3247.2 4156.7 SD = standard deviation; AFP = alpha-fetoprotein; hCG = human chorionic gonadotropin; LDH = lactate dehydrogenase Vascular density (VD) was determined in all samples. Median VD was 19.0 ± 28.9 (95% Confidence interval [95% CI], 5–75). Factors associated with higher VD were the following: AFP serum levels >14.7 ng/mL (p = 0.0001); serum hCG levels ≥ 25 mIU/mL (p = 0.0001), and non-seminomatous histologic type (p = 0.016) (Table 3 and 4). However, the sole factor independently related Table 3: Factors associated with vascular density Variable Age (years) <26 >26 AFP (ng/mL) <14.7 ≥14.7 LDH (IU/L) <475 >475 hCG (mIU/mL) <25 >25 TNM I II III Metastases (N or M) Absent Present VD Mean ± SD 30.58 ± 25.57 26.02 ± 31.29 17.23 ± 10.39 38.57 ± 36.52 23.43 ± 24.61 34.01 ± 34.09 18.27 ± 9.04 37.93 ± 37.7 23.84 ± 24.49 22.99 ± 18.49 41.49 ± 40.55 23.31 ± 24.10 32.88 ± 32.75 p 0.434 0.0001 0.092 0.0001 0.876 I vs. II 0.024 I vs. III 0.036 II vs. III 0.103 SD = standard deviation; AFP = alphafetoprotein; hCG = human chorionic gonadotropin; LDH = lactate dehydrogenase; TNM = tumor, nodes, metastasis. with VD was hCG elevation above the median (p = 0.04) (Table 5). When hCG levels were divided as <25 and ≥ 25 mIU/mL, we found that the latter were related with an increase in vascular neoformation (p = 0.0001) (Figure 1). VEGF expression was determined in 57 biopsies due to insufficient material. Its expression was present in 56% of the samples. Average percentage of expression was 19 ± 3% (minimum, 0%; maximum, 80%). Intensity was absent in 44%, mild in 48%, and moderate in 8%. Quali- tative VEGF expression and expression intensity were not associated with either VD or hCG serum levels (Table 6). Median follow-up time was 43 ± 27 months. Recurrence was observed in 7.5% and death in 11.5% of patients. Dis- ease-free survival (DFS) at 2 and 5 years was 93.7% (95% CI, 88–98) and 83% (95% CI, 68–98), respectively. By analyzing DFS-related factors, only high international risk correlated with worse prognosis (p = 0.005). VD and VEGF expression were not associated with recurrence. Discussion hCG is considered an extremely sensitive and specific marker of germ cell testicular tumors. Its increased serum levels usually correlate with the existence of viable cancer cells and it is often associated with disease progression, recurrence, and a worse prognosis [7,21,22]. Therefore, hCG levels are part of the international risk factor assess- ment [23]. In the present study, hCG is associated with elevated VD in testicular tumors. hCG has been associated with angio- genesis in normal tissues; this has been confirmed in vivo and in vitro by increasing capillary formation and endothelial cell migration [16,18], and in regulation of placental angiogenesis [24]. Elevated hCG serum levels Page 4 of 7 (page number not for citation purposes)