This Article Abstract Full Text (PDF) Erratum (v19,p4355) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by De Santis, M. Articles by Pont, J. Search for Related Content PubMed PubMed Citation Articles by De Santis, M. Articles by Pont, J. Social Bookmarking                            What's this?

Predictive Impact of 2-¹⁸Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography for Residual Postchemotherapy Masses in Patients With Bulky Seminoma

From the Department of Medical Oncology and Luwdig Boltzmann Institute for Applied Cancer Research, Kaiser Franz Josef Spital; Department of Nuclear Medicine, University of Vienna Medical School; and Austrian Study Group on Urologic Oncology, Vienna, Austria; and Department of Medical Oncology and Institute of Nuclear Medicine, University of Tübingen, Tübingen, Germany.

Address reprint requests to Jörg Pont, MD, 3.Medizinische Abteilung mit Onkologie, Kaiser Franz Josef Spital, Kundratstrasse 3, A-1100 Wien, Austria; email: joerg.pont{at}univie.ac.at

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To establish the predictive potential of 2-¹⁸fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET) for detecting viable tumor tissue in residual postchemotherapy masses of seminoma patients.

PATIENTS AND METHODS: In this prospective multicenter trial, results of FDG PET studies in seminoma patients with postchemotherapy masses 1 cm were correlated with either the histology of the resected lesion or the clinical outcome on follow-up without resection. Negative PET scans of residual lesions that were devoid of viable tumor tissue on resection or disappeared, shrunk, or remained stable in size for at least 2 years were rated as true-negative (TN). Positive scans without histologic or clinical evidence of tumor tissue were classified as false-positive. In patients with histologically positive or progressive lesions, positive PET scans were defined as true-positive (TP) and negative scans, false-negative (FN).

RESULTS: Thirty-seven PET scans of 33 patients were assessable at a median follow-up time of 23 months (range, 2 to 46 months). Histologic data were available from nine patients who had undergone resection. Twenty-eight patients were followed-up clinically and radiologically. Twenty-eight scans were TN, eight were TP, and one was FN. All 14 residual lesions more than 3 cm and 22 (96%) of the 23 3 cm were correctly predicted by FDG PET. The specificity (100%; 95% confidence interval [CI], 87.7% to 100%), sensitivity (89%; 95% CI, 51.7% to 99.7%), positive predictive value (100%), and the negative predictive value (97%) of FDG PET were superior to data obtained by assessing residual tumor size ( or > 3 cm).

CONCLUSION: FDG PET is a clinically useful predictor of viable tumor in postchemotherapy residuals of pure seminoma, especially those greater than 3 cm.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
OF ALL PATIENTS WITH bulky metastatic seminoma, 56% to 78% are found to have radiologically detectable residual lesions after chemotherapy.^1-6 On resection and histologic analysis, most of these lesions consist of necrotic tissue, whereas viable tumor tissue is absent.^3-5,7 The removal of residual postchemotherapy seminomas is technically demanding and associated with considerable morbidity caused by desmoplastic reaction and fibrosis.^7,8

This explains why the management of residual postchemotherapy lesions of bulky seminoma is controversial. Strategies range from surgical resection to observation only. In a large European retrospective multicenter trial, radiotherapy failed to show any significant benefits.⁶ After the recommendations of the Memorial Sloan-Kettering Cancer Center (MSKCC),^2,3,9 many centers currently reserve surgery for patients with lesions greater than 3 cm. In some centers, residual lesions are observed for several months and only resected if they fail to shrink¹⁰ or if they grow.¹¹

2-¹⁸fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET) is a noninvasive diagnostic imaging technique that is capable of detecting the differential glucose utilization of benign and malignant tissues. It is known to predict the presence of viable tumor tissue in posttreatment residual lesions of some malignancies with considerable reliability.¹² The purpose of our study was to shed light on the specificity, sensitivity, and predictive values of FDG PET for viable tumor tissue in residual postchemotherapy masses of seminoma patients and to establish whether the predictive impact of FDG PET is superior to that of the size ( or > 3 cm) of the residual masses.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Patients
Inclusion criteria. Patients with metastases of pure testicular or extragonadal seminomas who had negative tumor markers (beta-human chorionic gonadotropin [ß-HCG] and lactate dehydrogenase [LDH]) on completion of platinum-containing first-line or salvage chemotherapy but who showed computed tomography (CT) evidence of clearly defined and measurable residual masses at least 1 cm in diameter were eligible for this study.

Exclusion criteria. Patients with nonseminomatous elements in the primary tumor and/or elevated serum alpha-fetoprotein (AFP) levels at the time of the diagnosis or at any subsequent point in time were excluded from this study, as were patients without clearly defined and measurable residual lesions after chemotherapy or with residual masses less than 1 cm in diameter. Patients who had completed or were scheduled for radiotherapy at the site of the residual lesion of interest were also not eligible for this study.

Patients were told that the PET study proposed to them was not yet an established standard diagnostic tool for residual seminomatous lesions and was being offered to them in the context of a clinical trial. The ethics committee of the trial coordinating center at Kaiser Franz Josef Spital, Vienna, Austria, felt that formal approval was unnecessary, because FDG PET was a recognized diagnostic imaging technique for other tumor entities. The study was approved by the Tübingen University Ethics Committee.

Methods
After completing chemotherapy, all patients underwent FDG PET and chest and abdominal CT. The studies were scheduled 4 to 12 weeks after chemotherapy, with an interval of no more than 2 weeks between them.

On CT the transverse diameter of all residual lesions was measured and the largest diameter was recorded. Only well-defined masses 1 cm in their largest diameter were considered. If deemed necessary for consistency and plausibility, the CT radiographs were reviewed by the reference radiologist of the coordinating center.

FDG PET scans were obtained with a dedicated PET system (GE Advance, General Electric, Milwaukee, WI) covering an axial field of view of 15.2 cm. At the center the system had an axial resolution of 4 mm and a transaxial resolution of 3.8 mm.¹³ One patient was scanned with a rotating partial ring system (ECAT ART, Siemens/CTI, Knoxville, TN) with an axial field of view of 16.2 cm and maximal axial and transaxial resolutions of 6 mm.¹⁴

After fasting for at least 4 hours, patients received 370 MBq (10 mCi) of FDG by intravenous injection. Blood glucose levels were determined and found to be within normal limits in all cases. Scans from the chin to the thighs and of the brain, if indicated, were recorded after an uptake time of at least 45 minutes.

Attenuation-corrected scan data were reconstructed by filtered backprojection and iterative algorithms and reformatted in coronal and transaxial slices. The scans were interpreted visually. Interpretation criteria included the localization, shape, and intensity of the increased uptake. Scans were classified as negative or positive for malignancy. The standard uptake values (SUVs) of positive lesions from attenuation-corrected scans were recorded.

The postchemotherapy management of the residual lesions, ie, surgery or observation, depended on the policy of the contributing centers and on the patient’s preference. A point was made not to consider the outcome of the PET study in the decision-making process. The type of surgery performed and the extent of resection (complete v incomplete) were recorded. Follow-up studies were scheduled at 3-month intervals in the first 2 years and at intervals of 6 months thereafter. For these studies, chest and abdominal CTs were used alternately with chest x-rays and abdominal ultrasound.

PET scans (positive or negative) were correlated with the histology of the resected lesion (presence or absence of viable tumor tissue) or the radiologic and clinical course (presence or absence of progressive disease). Positive PET scans of residual lesions containing viable tumor tissue on resection or progressing during follow-up were rated as true-positive (TP). Those not meeting these criteria were considered false-positive (FP). Negative PET scans of lesions containing only necrotic tissue without viable tumor elements on resection or of lesions disappearing or shrinking on radiologic follow-up were rated as true-negative (TN). Considering the slow growth rate of seminomas, negative PET scans of lesions remaining stable in size did not qualify for the rating of TN until a progression-free follow-up period of at least 24 months was documented. Negative PET scans of lesions with persistent viable tumor tissue on histology or progression during follow-up were considered to be false-negative (FN).

All patient data of this multicenter trial were recorded on case report forms and examined for consistency and plausibility by M.D. and J.P. If deemed necessary, original data were reviewed.

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Thirty-seven patients from five centers in Austria and one in Germany were enrolled onto the trial. Because three patients were repeatedly evaluated for residual lesions after second- or third-line therapies, a total of 41 residual masses were scanned. PET scans were recorded at a median interval of 44 days after chemotherapy.

The predictive power of four PET studies, all of them negative, was not or not yet assessed. One patient died 2 weeks after undergoing PET. The apparent cause of death was bleomycin-induced pneumonitis. As autopsy was omitted, the PET scans could not be classified as TN or FN. In violation of the trial protocol, the residual lesion of another patient was irradiated. Two patients with residual lesions that did not change in size during a follow-up of 14 and 20 months were not yet assessable at the time the data were analyzed because they had not yet completed the per protocol follow-up time of 2 years. Thus assessable PET scans of 37 residual lesions in 33 patients remained. The characteristics are listed in Table 1.

Nine residual lesions with a maximum transverse diameter of 2 to 10 cm (median diameter, 5 cm) were evaluated histologically. These lesions, all of them retroperitoneal, were resected at a median interval of 21 days (range, 4 to 55 days) from the date of the PET study. The PET scans were correlated with the histology of the resected mass. Resections were complete in seven cases and incomplete in two.

Twenty-eight PET scans were evaluated only by clinical and radiologic follow-up studies and not by surgery. In 12 patients of this group with residual postchemotherapy masses of 1 to 10 cm in diameter (median diameter, 1.75 cm), the radiologically confirmed lesions completely disappeared during follow-up and the patients went into complete remission. Ten residual lesions with diameters between 1.2 and 3.5 cm (median diameter, 2.3 cm) clearly shrunk during follow-up, whereas six lesions measuring 1.3 to 5 cm in diameter (median diameter, 4.5 cm) clearly increased in size within 1 to 4 months signaling progressive disease. In two patients with residual lesions of 2 and 3.5 cm, no change in size was recorded up to the time of data analysis. But as they had not yet completed the per protocol follow-up time of 2 years, they were not considered for data analysis as specified under Methods.

In Table 2, FDG PET data and residual tumor sizes are correlated with the histologic and clinical evidence of viable tumor tissue. Table 3 lists the specificity, sensitivity, and the positive and negative predictive values of FDG PET and tumor size ( or > 3 cm) for predicting residual viable tumor tissue.

View this table: [in this window] [in a new window]   Table 2.  Correlation of FDG PET Results and Maximum Transverse Diameter of Residual Masses ( or > 3 cm) With Histologically or Clinically Documented Persistence of Viable Tumor Tissue in Residual Postchemotherapy Lesions

View this table: [in this window] [in a new window]   Table 3.  Specificity, Sensitivity, and Positive and Negative Predictive Value for Detecting Viable Tumor in Residual Postchemotherapy Lesions by FDG PET and Maximum Transverse Diameter of the Residual Lesion ( 3 cm or > 3 cm)

Twenty-eight FDG PET scans were classified as TN. Eight lesions in seven patients were found to be TP. Five of these lesions were evaluated after first-line chemotherapy and three after salvage chemotherapy. First-line chemotherapies consisted of three to five courses of standard cisplatin, etoposide, and bleomycin chemotherapy. As salvage chemotherapy regimens, three courses of conventional-dose paclitaxel, ifosfamide, and cisplatin were given in one patient. Two patients underwent three courses of conventional-dose paclitaxel, ifosfamide, and cisplatin followed by one course of high-dose etoposide, carboplatin, and thiotepa. In five of the eight TP lesions, progressive disease was confirmed clinically and radiologically. In two, the resected lesion was found to contain viable seminoma tissue on histology. In the remaining patient, the retroperitoneal lesion surprisingly turned out to be a paraganglioma rather than a seminoma. The FDG PET activity of paragangliomas is well knwon.¹⁵ Because the PET scan was highly positive for viable tumor tissue in need of treatment, it was rated as TP although the lesion was not a germ cell tumor.

All 14 residual lesions greater than 3 cm and 22 (96%) of the 23 lesions 3 cm were correctly predicted by FDG PET.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
The optimal management of residual postchemotherapy masses in patients with bulky seminoma is still controversial. Although there is general agreement that residual lesions smaller than 3 cm need no more than observation, the available evidence, albeit retrospective in nature, on larger lesions has given rise to diverging views. The Indiana University data argue in favor of simply following-up seminoma patients with postchemotherapy masses irrespective of their size and to reserve treatment for patients with progressive disease.¹¹ But retrospective analyses at the MSKCC suggest that, of the residual lesions more than 3 cm, 27% to 41% contain viable tumor tissue clinically or histologically versus only 3% of those less than 3 cm.^2,3,9

Acting on these data, many centers have come to resect residual lesions larger than 3 cm, although resections are technically demanding and associated with considerable morbidity.^7,8 The underlying rationale is to give the patients at least a chance of cure by surgery and/or early salvage chemotherapy because, once recurrent seminoma has become clinically manifest, second-line chemotherapy cannot be expected to produce long-term remission in more than 54% of cases.¹⁶ This explains why it would be desirable to predict the presence of viable tumor tissue in residual postchemotherapy masses with a higher measure of accuracy.

FDG PET is capable of detecting viable tumor tissue in residual postchemotherapy masses of nonseminomatous germ cell tumors. However, it fails to differentiate between necrosis/fibrosis and adult teratoma,¹⁷ which is known to be present in more than 40% of resected masses.¹⁸ This differentiation would, however, be essential to deciding for or against surgery. For patients with pure seminomatous primary tumors this is irrelevant, because only 4% of the residual lesions of these malignancies are adult teratoma.³

The results of our prospective multicenter trial showed FDG PET to have a high specificity and sensitivity for detecting viable tumor tissue in residual postchemotherapy masses of metastatic seminoma. FDG PET data were FN in no more than a single case. FP findings were absent throughout. All residual lesions more than 3 cm were correctly predicted. In the clinical setting, this implies that persistent viable tumor tissue should be expected if PET scans are positive and that patients with positive scans should be considered candidates for surgery or salvage chemotherapy. Patients with residual masses more than 3 cm who are followed-up at centers where resection is routinely performed on patients with residual lesions of this size, by contrast, can be spared demanding surgery with all its complications if their FDG PET scans are negative. For patients with residual masses 3 cm and negative FDG PET scans, the risk of residual viable tumor tissue is less than 5%.

The prospectively yielded data in Table 2 confirm the retrospective evidence gathered by the MSKCC.^2,3,9 This suggested that residual lesions 3 cm were far less likely to contain viable tumor tissue (two of 23 in our trial) than those more than 3 cm (seven of 14 in our trial). However, the MSKCC data are, at best, negatively predictive, while they lack a positive predictive relevance. The sensitivity, specificity, and the negative and positive predictive value of FDG PET were clearly superior to an evaluation of residual masses according to their size (Table 3).

To date, only a single systematic prospective trial has been published on FDG PET for evaluating residual postchemotherapy masses in seminoma patients, ie, the Indiana University trial.¹⁹ In this single-center trial of 29 patients undergoing PET with a median follow-up of 11.5 months, only one scan was positive for a residual mass in the posterior mediastinum, with an SUV of 4.2 at an SUV cutoff of 4. This was rated as FP, because no more than necrotic tissue was found on mediastinal resection. A retroperitoneal mass of the same patient, which did not show FDG uptake on PET and was left in place, increased in size during the follow-up time. Like the negative scans of four other patients who relapsed later, this scan was considered FP. The authors concluded that PET scanning was not beneficial in distinguishing necrosis from viable seminoma. At the time of the first report on the Indiana University trial at the Thirty-Fifth Annual Meeting of the American Society of Clinical Oncology in 1999, our multicenter trial had already been underway and was continued as planned despite the Indiana University data.

Why the outcome of the two trials and the conclusions drawn are contradictory can at best be speculated. Discounting chance, which cannot be ruled out in view of the small number of patients in both trials, several factors may have played a role. First, in the past few years, the technology underlying PET scanning has been revolutionized. Computational reconstruction was improved by short transmission scans in combination with iterative reconstruction algorithms less prone to disturbances by artifacts due to neighboring high-activity areas like the kidneys and the bladder. Unfortunately, the technical specifications of the PET scanner used in the Indiana University trial were not reported.¹⁹

Second, in our trial, which was multicentric by design, PET scans were visually interpreted and classified as positive or negative, because SUVs computed by different contributing centers were not felt to be reliable enough. The reservations generally held about SUV alone as the sole criterion for classifying PET scans were another factor.^20,21 In the Indiana University trial, patients with an SUV 4 were considered positive, as per the previous Indiana University experience in nonseminomatous germ cell tumors.^17,19

Third, intervals of less than 14 days between chemotherapy and PET scanning may lead to both FP and FN results. The former are caused by an increased macrophage activity during the absorption of necrotic tissue,^12,22 whereas the latter are caused by a putative transient suppression of metabolic activity in germ cell tumors shortly after chemotherapy regardless of their final therapy response.²³ This prompted us to opt for an interval of 4 to 12 weeks after chemotherapy. The median interval in our trial was 44 days. In the Indiana University report, no reference is made to the interval between chemotherapy and PET scanning.

In conclusion, the results of our trial document that FDG PET is a clinically useful predictor in patients with residual postchemotherapy seminoma. But in view of the conflicting results obtained in the Indiana University trial,¹⁹ more research is undoubtedly needed.

	ACKNOWLEDGMENTS

 
We thank Alois Lang and Saskia Pfefferkorn, Landeskrankenhaus Feldkirch; Klaus Jeschke and Peter Lind, Landeskrankenhaus Klagenfurt; and Georg Hopfinger, Hanuschkrankenhaus, Vienna, Austria, for their contributions. We thank Jutta Gampe for statistical assistance, Günter Strau, Kaiser Franz Josef Spital, Vienna, Austria, for radiologic expertise, and Walter Albrecht, president of the Austrian Study Group on Urologic Oncology, for review of the manuscript.

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
1. Peckham MJ, Horwich A, Hendry WF, et al: Advanced seminoma: Treatment with cisplatinum-based combination chemotherapy or carboplatinum(JM 8). Br J Cancer 52: 7-13, 1985[Medline]

2. Motzer R, Bosl G, Heelan , et al: Residual mass: An indication for further therapy in patients with advanced seminoma following systemic chemotherapy. J Clin Oncol 5: 1065-1070, 1987

3. Puc HS, Heelan R, Mazumdar M, et al: Management of residual mass in advanced seminoma: Results and recommendations from the Memorial Sloan-Kettering Cancer Center. J Clin Oncol 14: 454-460, 1996[Abstract/Free Full Text]

4. Horwich A, Paluchowska B, Norman A, et al: Residual mass following chemotherapy of seminoma. Ann Oncol 8: 37-40, 1997[Abstract/Free Full Text]

5. Fossa SD, Oliver RTD, Stenning SP, et al: Prognostic factors for patients with advanced seminoma treated with platinum-based chemotherapy. Eur J Cancer 33: 1380-1387, 1997

6. Duchesne GM, Stenning SP, Aass N, et al: Radiotherapy after chemotherapy for metastatic seminoma: A diminishing role. Eur J Cancer 33: 829-835, 1997

7. Stanton GF, Bosl GJ, Whitmore WF, et al: VAB-6 as initial treatment of patients with advanced seminomas. J Clin Oncol 3: 336-339, 1985[Abstract]

8. Friedmann EL, Garnick MB, Stomper PC, et al: Therapeutic guidelines and results in advanced seminoma. J Clin Oncol 3: 1325-1332, 1985[Abstract/Free Full Text]

9. Herr HW, Sheinfeld J, Puc HS, et al: Surgery for a post-chemotherapy residual mass in seminoma. J Urol 157: 860-862, 1997[Medline]

10. Fossa SD: Response evaluation in seminoma, in Horwich A (ed): Testicular Cancer, Investigation and Management. London, United Kingdom, Chapman & Hall, pp 155-161, 1996

11. Schultz SM, Einhorn LH, Conces DJ, et al: Management of postchemotherapy residual mass in patients with advanced seminoma: Indiana University experience. J Clin Oncol 7: 1497-1503, 1989[Abstract]

12. Eary J: Nuclear medicine in cancer diagnosis. Lancet 354: 853-857, 1999[Medline]

13. De Grado TR, Turkington TG, Williams JJ, et al: Performance characteristics of a whole-body PET scanner. J Nucl Med 35: 1398-1406, 1994[Abstract/Free Full Text]

14. Bailey DL, Young H, Bloomfield PM, et al: ECAT ART: A continuously rotating PET camera—Performance characteristics, initial clinical studies, and installation considerations in a nuclear medicine department. Eur J Nucl Med 24: 6-15, 1997[Medline]

15. Macfarlane DJ, Shulkin BL, Murphy K, et al: FDG PET imaging of paragangliomas of the neck: Comparison with MIBG SPET. Eur J Nucl Med 22: 1347-1350, 1995[Medline]

16. Miller KD, Loehrer PJ, Gonin R, et al: Salvage chemotherapy with vinblastine, ifosfamide and cisplatin in recurrent seminoma. J Clin Oncol 15: 1427-1431, 1997[Abstract]

17. Stephens AW, Gonin R, Hutchins GD, et al: Positron emission tomography evaluation of residual radiographic abnormalities in postchemotherapy germ cell tumor patients. J Clin Oncol 14: 1637-1641, 1996[Abstract/Free Full Text]

18. Sheinfeld J, Bajorin D: Management of the postchemotherapy residual mass. Urol Clin North Am 20: 133-143, 1993[Medline]

19. Ganjoo KN, Chan RJ, Sharma M, et al: Positron emission tomography scans in the evaluation of postchemotherapy residual masses in patients with seminoma. J Clin Oncol 17: 3457-3460, 1999[Abstract/Free Full Text]

20. Keyes JW: SUV: Standard uptake or silly useless value? J Nucl Med 36: 1836-1839, 1995[Free Full Text]

21. Wu HS, Hoh CK, Huang SC, et al: Quantifications of serial tumor glucose metabolism. J Nucl Med 37: 506-513, 1996[Abstract/Free Full Text]

22. Nuutinen JM, Leskinen S, Elooma I, et al: Detection of residual tumours in postchemotherapy testicular cancer by FDG-PET. Eur J Cancer 33: 1234-1241, 1997

23. Cremerius U, Effert PJ, Adam G, et al: FDG PET for detection and therapy control of metastatic germ cell tumor. J Nucl Med 39: 815-822, 1998[Abstract/Free Full Text]

Submitted February 23, 2001; accepted May 8, 2001.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				K. Oechsle, M. Hartmann, W. Brenner, S. Venz, L. Weissbach, C. Franzius, S. Kliesch, S. Mueller, S. Krege, R. Heicappell, et al. [18F]Fluorodeoxyglucose Positron Emission Tomography in Nonseminomatous Germ Cell Tumors After Chemotherapy: The German Multicenter Positron Emission Tomography Study Group J. Clin. Oncol., December 20, 2008; 26(36): 5930 - 5935. [Abstract] [Full Text] [PDF]

				H. J. Schmoll, R. Souchon, S. Krege, P. Albers, J. Beyer, C. Kollmannsberger, S. D. Fossa, N. E. Skakkebaek, R. de Wit, K. Fizazi, et al. European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG) Ann. Onc., September 1, 2004; 15(9): 1377 - 1399. [Abstract] [Full Text] [PDF]

				N. P. Lenzo, G. Moschilla, and A. Patrikeos Diffuse Splenic Metastases from Seminoma Visualized on FDG PET Am. J. Roentgenol., August 1, 2004; 183(2): 525 - 527. [Full Text] [PDF]

				M. De Santis, A. Becherer, C. Bokemeyer, F. Stoiber, K. Oechsle, F. Sellner, A. Lang, K. Kletter, B. M. Dohmen, C. Dittrich, et al. 2-18fluoro-deoxy-D-glucose Positron Emission Tomography Is a Reliable Predictor for Viable Tumor in Postchemotherapy Seminoma: An Update of the Prospective Multicentric SEMPET Trial J. Clin. Oncol., March 15, 2004; 22(6): 1034 - 1039. [Abstract] [Full Text] [PDF]

				J. Oldenburg, G. C. Alfsen, H. H. Lien, N. Aass, H. Waehre, and S. D. Fossa Postchemotherapy Retroperitoneal Surgery Remains Necessary in Patients With Nonseminomatous Testicular Cancer and Minimal Residual Tumor Masses J. Clin. Oncol., September 1, 2003; 21(17): 3310 - 3317. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Erratum (v19,p4355) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by De Santis, M. Articles by Pont, J. Search for Related Content PubMed PubMed Citation Articles by De Santis, M. Articles by Pont, J. Social Bookmarking                            What's this?