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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer Statistics, 2021. CA Cancer J Clin 2021;71:7-33. Review/Other-Dx N/A Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence. Incidence data (through 2017) were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2018) were collected by the National Center for Health Statistics. In 2021, 1,898,160 new cancer cases and 608,570 cancer deaths are projected to occur in the United States. After increasing for most of the 20th century, the cancer death rate has fallen continuously from its peak in 1991 through 2018, for a total decline of 31%, because of reductions in smoking and improvements in early detection and treatment. This translates to 3.2 million fewer cancer deaths than would have occurred if peak rates had persisted. Long-term declines in mortality for the 4 leading cancers have halted for prostate cancer and slowed for breast and colorectal cancers, but accelerated for lung cancer, which accounted for almost one-half of the total mortality decline from 2014 to 2018. The pace of the annual decline in lung cancer mortality doubled from 3.1% during 2009 through 2013 to 5.5% during 2014 through 2018 in men, from 1.8% to 4.4% in women, and from 2.4% to 5% overall. This trend coincides with steady declines in incidence (2.2%-2.3%) but rapid gains in survival specifically for nonsmall cell lung cancer (NSCLC). For example, NSCLC 2-year relative survival increased from 34% for persons diagnosed during 2009 through 2010 to 42% during 2015 through 2016, including absolute increases of 5% to 6% for every stage of diagnosis; survival for small cell lung cancer remained at 14% to 15%. Improved treatment accelerated progress against lung cancer and drove a record drop in overall cancer mortality, despite slowing momentum for other common cancers. No results stated in abstract. 4
2. Bahrami A, Ro JY, Ayala AG. An overview of testicular germ cell tumors. Arch Pathol Lab Med 2007;131:1267-80. Review/Other-Dx N/A To help the readers distinguish various subtypes of GCTs, to highlight the clinical manifestations and pathologic features of these tumors, and to review several newly developed immunohistochemical markers for GCTs. No results stated in abstract. 4
3. Brenner H, Gondos A, Arndt V. Recent major progress in long-term cancer patient survival disclosed by modeled period analysis. J Clin Oncol. 2007; 25(22):3274-3280. Review/Other-Dx N/A To disclose most recent trends in long-term cancer patient survival. Statistically significant and partly very substantial improvement in 5- and 10-year relative survival in the 1998 to 2003 period was seen for 14 of 24 of the assessed common forms of cancer, including breast and colorectal cancer. Improvement was most pronounced for patients with regional tumor spread and somewhat less so for patients with localized tumors, whereas hardly any improvement was achieved for patients with distant tumor spread. Study analysis discloses further major improvement in prognosis for most, but not all forms of cancer in recent years. The largest contribution to this improvement comes from improved prognosis of patients with regional tumor spread. 4
4. Pano B, Sebastia C, Bunesch L, et al. Pathways of lymphatic spread in male urogenital pelvic malignancies. Radiographics. 2011; 31(1):135-160. Review/Other-Dx N/A To describe the anatomy and nomenclature of the iliopelvic and paraaortic lymph nodes and outline common pathways of metastasis from tumors of the male urogenital system to these regional nodes. The advantages and limitations of anatomic and functional imaging techniques for the detection and classification of nodal disease are discussed in detail. Functional imaging techniques, such as diffusion-weighted MRI performed with or without a lymphotropic contrast agent and PET, may allow a more accurate nodal assessment based on molecular or physiologic activity. 4
5. Amin MB, Edge S, Greene F, et al. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017. Review/Other-Dx N/A To classify patients with cancer, define prognosis, and determine the best treatment approaches. No abstract available. 4
6. Hedgire SS, Pargaonkar VK, Elmi A, Harisinghani AM, Harisinghani MG. Pelvic nodal imaging. Radiol Clin North Am 2012;50:1111-25. Review/Other-Dx N/A To review the clinical anatomy, pathways of lymphatic spread of malignancies, current criteria, and newer advances in imaging of male pelvic nodes. No results stated in abstract. 4
7. Epstein BE, Order SE, Zinreich ES. Staging, treatment, and results in testicular seminoma. A 12-year report. Cancer. 1990; 65(3):405-411. Observational-Tx 61 patients A 12-year report on staging, treatment, and results in testicular seminoma. Median follow-up for these patients is 5.5 years. Overall actuarial survival (Kaplan-Meier method) was 97% at 5 years and 92% at 10 years. Five-year survival corrected for intercurrent disease was 100% for Stage I, 100% for Stage IIA, and two of three in Stage IIB patients. There were two distant treatment failures among the entire cohort. One patient who had Stage I disease was salvaged with local-field radiation and chemotherapy and is now without evidence of disease for 6 years. The second patient with Stage IIB seminoma receiving the same treatments disseminated and died. There were no significant acute toxicities or serious complications. In summary, proper staging with information gained from LAG and adequate radiation dose led to a 92% 10-year disease-free survival. 3
8. NCCN Clinical Practice Guidelines in Oncology. Testicular Cancer. Version 3.2020.  Available at: https://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf. Review/Other-Tx N/A Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Testicular Cancer focuses on the diagnosis and management of nonseminomatous GCTs No results stated in abstract. 4
9. Aparicio J, Terrasa J, Duran I, et al. SEOM clinical guidelines for the management of germ cell testicular cancer (2016). Clin Transl Oncol. 18(12):1187-1196, 2016 Dec. Review/Other-Tx N/A To define current ‘‘state-of-the-art’’ in the treatment of this malignancy using the methodology of evidence-based medicine. No results stated in abstract. 4
10. Roth BJ.. Management of Clinical Stage I Germ Cell Tumors. [Review]. Urol Clin North Am. 46(3):353-362, 2019 Aug. Review/Other-Tx N/A To describe the noninterventional approach to managing stage I germ cell tumors. No results stated in abstract. 4
11. Stephenson A, Eggener SE, Bass EB, et al. Diagnosis and Treatment of Early Stage Testicular Cancer: AUA Guideline. J Urol. 202(2):272-281, 2019 08. Review/Other-Tx N/A To provide a useful reference (guideline) on the effective evidence-based treatment of early stage testicular cancer. No results stated in abstract. 4
12. Braga FJ, Arbex MA, Haddad J, Maes A. Bone scintigraphy in testicular tumors. Clin Nucl Med. 2001; 26(2):117-118. Review/Other-Dx 28 patients To identify the role of bone scan in staging and restaging bone disease in testicular cancer. Early detection of metastases is very important to ensure the efficacy of radiotherapy and chemotherapy. Bone scintigraphy may play an important role in such cases and seems to be more sensitive than conventional radiography. Testicular tumor metastases should be considered when iliac involvement is observed. Paget's disease should be included in a differential diagnosis. 4
13. Dixon AK, Ellis M, Sikora K. Computed tomography of testicular tumours: distribution of abdominal lymphadenopathy. Clin Radiol. 37(6):519-23, 1986 Nov. Review/Other-Dx 145 total patients; 55 patients with definite evidence of nodal enlargement on CT To assess testicular tumors referred for staging by CT. Findings which correlate well with data from anatomical, surgical and direct lymphographic studies should assist in the CT interpretation of equivocal nodal enlargement and aid decisions on the optimal interval for CT follow-up during surveillance. 4
14. MacVicar D.. Staging of testicular germ cell tumours. [Review] [76 refs]. Clin Radiol. 47(3):149-58, 1993 Mar. Review/Other-Dx Referred to 1,000+ patients from 1976-present To review radiological staging methods for testicular GCTs. Whole body CT and CXR are the central and essential investigations, and subsidiary techniques such as MRI, US and lymphography may be of benefit in individual patients. 4
15. Rowland RG, Weisman D, Williams SD, Einhorn LH, Klatte EC, Donohue JP. Accuracy of preoperative staging in stages A and B nonseminomatous germ cell testis tumors. J Urol. 127(4):718-20, 1982 Apr. Observational-Dx 64 patients To assess the value of US and CT when combined with tumor marker determination in patients with nonseminomatous testes tumors. Correct staging in 24/32 patients with stage A 21/32 with stage B. Overall, the correct results were obtained in 61% of the patients with alpha-feprotein, 64% with beta-huma chorioic gonadotropin, 53% with US and 67% with CT. US is not of additional benefit. 3
16. McMahon CJ, Rofsky NM, Pedrosa I. Lymphatic metastases from pelvic tumors: anatomic classification, characterization, and staging. [Review] [98 refs]. Radiology. 254(1):31-46, 2010 Jan. Review/Other-Dx N/A To illustrate the anatomic location and the nomenclature of pelvic lymph node groups and to review the patterns of nodal spread from individual pelvic tumors with a description of the effect of the location and number of nodal metastases on staging and management. The spread of pelvic tumors to lymph nodes is an important means of tumor dissemination and substantially affects prognosis and management. 4
17. Hilton S, Herr HW, Teitcher JB, Begg CB, Castellino RA. CT detection of retroperitoneal lymph node metastases in patients with clinical stage I testicular nonseminomatous germ cell cancer: assessment of size and distribution criteria. AJR Am J Roentgenol. 169(2):521-5, 1997 Aug. Observational-Dx 70 patients; 3 observers To retrospectively determine the accuracy of CT for revealing retroperitoneal lymph node metastases in patients with clinical stage I testicular nonseminomatous germ cell cancer: assessment of size and distribution criteria. Using a criterion of 10 mm or larger for metastases, sensitivity was 37% and specificity 100%; with a 4 mm criterion, the sensitivity was 93% and the specificity 58%. False-negative rates were decreased from 63% using a size criterion of 10 mm to as low as 7% using a size criterion of 4 mm, with a corresponding decrease in specificity. Lymph nodes measuring larger than or equal to 4 mm, especially those located anterior to the mid portion of the aorta, should raise a suspicion of metastases. 2
18. Husband JE, Barrett A, Peckham MJ. Evaluation of computed tomography in the management of testicular teratoma. Br J Urol. 53(2):179-83, 1981 Apr. Review/Other-Dx 100 patients To define the role of CT in staging patients with testicular teratoma and comparing these findings with other staging modalities. CT led to a change in stage in 12% of patients compared to conventional techniques (US, lymphangiography, CXR, whole lung tomography, intravenous urography, liver-spleen scanning. Although these tumors are rare, their pattern of metastasis to the retroperitoneum, mediastinum, lungs and liver is consistent. Thus the value of CT scanning can be tested in all of these sites in each patient and the indications for scanning clearly defined. 4
19. Jing B, Wallace S, Zornoza J. Metastases to retroperitoneal and pelvic lymph nodes: computed tomography and lymphangiography. [Review] [61 refs]. Radiol Clin North Am. 20(3):511-30, 1982 Sep. Review/Other-Dx N/A To review roles of CT and lymphangiography in the evaluation of retroperitoneal and pelvic lymph node metastases. CT and lymphangiography are complementary. Lymphangiography is recommended for the evaluation of the internal architecture of the lymph node while CT is indicated to visualize large non-opacified masses. CT can be a substitute when lymphangiography is contraindicated. 4
20. Richie JP, Garnick MB, Finberg H. Computerized tomography: how accurate for abdominal staging of testis tumors?. J Urol. 127(4):715-7, 1982 Apr. Observational-Dx 30 patients A prospective study to determine the ability of CT to predict correctly the presence of retroperitoneal lymphadenopathy. Sensitivity 90%, for an over-all accuracy of 73%. 7/16 CT scans interpreted as normal were false negative. False negative rate limits the reliability of a negative CT to exclude metastases. The CT scan, when positive, is highly likely to detect metastatic nodal involvement. However, the false negative rate, even in patients with tumor-filled lymph nodes 2 to 3 cm in diameter, limits the reliability of a negative CT scan to exclude metastases. Technological improvements are needed to refine the technique and, thus, to reduce the false negative rate. 3
21. Strohmeyer T, Geiser M, Ackermann R, Mumperow E, Hartmann M. Value of computed tomography in the staging of testicular tumors. Urol Int. 1988; 43(4):198-200. Observational-Dx 56 patients; 2 groups of 28 patients To determine the value of CT for the exact staging of testicular tumors. Stage found by CT was correct but 3 (5%) false-positive and 13 false-negative results were obtained. CT should be restricted to certain centers with guaranteed long-term standardized patient observation and extremely high patient compliance. 4
22. Thomas JL, Bernardino ME, Bracken RB. Staging of testicular carcinoma: comparison of CT and lymphangiography. AJR Am J Roentgenol. 137(5):991-6, 1981 Nov. Observational-Dx 27 patients To compare clinical staging by CT and lymphangiography in pathologically staged testicular carcinoma, primarily nonseminomatous tumors. Accuracy of CT 89%; sensitivity, 90%; specificity, 83%. The accuracy of lymphangiography 70%; sensitivity, 71%; specificity, 67%. CT provided better delineation of tumor margins in 48% of cases. 3
23. Hansen J, Jurik AG. Diagnostic value of multislice computed tomography and magnetic resonance imaging in the diagnosis of retroperitoneal spread of testicular cancer: a literature review. [Review] [64 refs]. Acta Radiol. 50(9):1064-70, 2009 Nov. Review/Other-Dx 44 publications To analyze whether there is evidence to recommend a substitution of multislice CT with MRI in the diagnosis of retroperitoneal spread of testicular cancer. None of the publications reviewed encompassed diagnostic specificity and sensitivity of multislice CT, and they lacked systematic comparison of multislice CT and MRI. Only one study included sensitivity and specificity of MRI compared to single-slice CT. Both methods had sensitivity and a specificity of approximately 70%. The literature review did not reveal valid data regarding diagnostic accuracy of MRI compared with multislice CT for diagnosing retroperitoneal spread of testicular cancer. A prospective blinded comparative study is needed to provide valid evidence. 4
24. Hudolin T, Kastelan Z, Knezevic N, Goluza E, Tomas D, Coric M. Correlation between retroperitoneal lymph node size and presence of metastases in nonseminomatous germ cell tumors. Int J Surg Pathol. 20(1):15-8, 2012 Feb. Observational-Dx 85 patients To investigate/correlate the lymph node size and presence of metastases in them in order to find out how sure one can be when deciding on treatment options based on the lymph node size. A total of 1139 lymph nodes have been removed and in 27 (31.8%) patients, metastases in one or more lymph nodes were detected. There were 338 (29.7%) hilar, 259 (22.7%) paraaortic, 221 (19.4%) interaortocaval, 171 (15%) paracaval, 133 (11.7%) preaortic and 17 (1.5%) precaval lymph nodes. The total number of lymph nodes with metastases was 74 (6.5%), and 1065 (93.5%) nodes did not have any metastases. The average size of a lymph node with metastases was 1.05 (0.3-3), and without metastases it was 0.55 (0.1-2.5) cm, (p<0.001). If we use > 1 cm size of a lymph node as a “cut-off” value for enlargement and presence of metastases, 60% of metastatic lymph nodes would be missed since they were all = 1 cm. 3
25. Coursey Moreno C, Small WC, Camacho JC, et al. Testicular tumors: what radiologists need to know--differential diagnosis, staging, and management. Radiographics. 35(2):400-15, 2015 Mar-Apr. Review/Other-Dx N/A To describe the anatomy of the testes and review the risk factors for testicular cancer. An approach to the differential diagnosis of a testicular mass is presented, with a review of the staging and management of testicular malignancies. No results stated in abstract. 4
26. Howard SA, Gray KP, O'Donnell EK, Fennessy FM, Beard CJ, Sweeney CJ. Craniocaudal retroperitoneal node length as a risk factor for relapse from clinical stage I testicular germ cell tumor. AJR Am J Roentgenol. 203(4):W415-20, 2014 Oct. Observational-Dx 118 patients To investigate whether retroperitoneal craniocaudal nodal length or nodal volume predicts relapse risk in stage I testicular cancer. Sixty-six (56%) of 118 patients had nonseminomatous germ cell tumor and 52 (44%) had seminomatous germ cell tumor. Craniocaudal nodal length proved to be an independent risk factor in nonseminomatous germ cell tumors using a multivariable logistic regression model adjusting for other potential known risk factors of embryonal predominance and lymphovascular invasion. For every 3-mm increase in craniocaudal nodal length, the risk of relapse increased by 52% (odds ratio [OR], 1.52; 95% CI, 1.03-2.25). For patients with seminomas, only primary tumor size was an independent risk factor for relapse (1.34, 1.02-1.75). 3
27. Maakaron JE, Gasparis PT, Althouse S, et al. Three-dimensional lymph node volume and craniocaudal lymph node length as an independent risk factor for recurrence or presence of micrometastatis in clinical stage I non-seminomatous germ cell tumors: A retrospective study. J Clin Oncol 2015;33:e15547-e47. Observational-Dx 37 patients To validate if three-dimensional lymph node volume and craniocaudal lymph node length are predictors for the risk of micrometastasis or recurrence in clinical stage I testicular cancer. Fifty-one percent (19/37) had either relapsed or had pathologically positive lymph nodes after virgin retroperitoneal lymph node dissection. Logistic univariate analysis revealed a statistically significant correlation between relapse and the craniocaudal lymph node length (p=0.01). The correlation between nodal volume and relapse was not significant, but trended towards significance (p=0.09). 4
28. Ozturk C, Velleman T, Bongaerts AH, et al. Assessment of Volumetric versus Manual Measurement in Disseminated Testicular Cancer; No Difference in Assessment between Non-Radiologists and Genitourinary Radiologist. PLoS ONE [Electronic Resource]. 12(1):e0168977, 2017. Observational-Dx 21 patients To assess the suitability and reproducibility of semi-automated volumetric analysis when applied to retroperitoneal lymph nodes in patients with disseminated TC, compared to 2D measurements based on RECIST between non-radiologists and a genitourinary radiologist.a. Assessment of intra observer and inter observer variance proved non-significant in both measurement modalities. In particularly all intraclass correlation (ICC) values for the volumetric analysis were > .99 per observer and between observers. 2
29. Einstein DM, Singer AA, Chilcote WA, Desai RK. Abdominal lymphadenopathy: spectrum of CT findings. Radiographics. 11(3):457-72, 1991 May. Review/Other-Dx N/A To discuss a regional approach for the diagnosis of lymphadenopathy with CT No results stated in abstract. 4
30. Harvey ML, Geldart TR, Duell R, Mead GM, Tung K. Routine computerised tomographic scans of the thorax in surveillance of stage I testicular non-seminomatous germ-cell cancer--a necessary risk?. Ann Oncol. 13(2):237-42, 2002 Feb. Review/Other-Dx 168 patients; 42 had relapse during follow-up Retrospective review to evaluate the contribution of routine thoracic CT imaging in the management of stage I testicular non-seminomatous germ-cell tumors. 19% of relapsed lesions were in the chest and were detected by chest CT. In retrospect many of these could be found on CXR but CT was capable of detecting them at a smaller size. The elimination of chest CT did not compromise outcome but significantly reduced radiation exposure thereby minimizing the risk of radiation-induced secondary malignancy. Continued review of surveillance programs is essential if we are to optimize management of this disease. 4
31. Meyer CA, Conces DJ. Imaging of intrathoracic metastases of nonseminomatous germ cell tumors. Chest Surg Clin N Am. 2002; 12(4):717-738. Review/Other-Dx N/A To review the imaging of intrathoracic metastases of NSGCT. CT is the workhorse of staging for testicular cancer. The addition of FDG-PET is useful in assessing thoracic masses in select, high-risk patients. 4
32. Horan G, Rafique A, Robson J, Dixon AK, Williams MV. CT of the chest can hinder the management of seminoma of the testis; it detects irrelevant abnormalities. Br J Cancer 2007;96:882-5. Observational-Dx 182 patients To evaluate the role of initial CT chest in the staging work-up of seminomatous germ cell tumours. Most patients had stage I disease (86%). Twenty-four patients had abnormal abdominal CT findings. One hundred and fifty-eight had normal abdominal CT findings but, on initial staging, chest CT reported abnormalities in 13 patients, which, on further follow-up CT were deemed to be irrelevant to the diagnosis of seminoma. There was a further patient with a normal CT abdomen in whom chest CT detected obvious metastatic disease, which was seen on chest x-ray. Overall 18 cases required additional investigations and follow-up for abnormalities subsequently found to be benign. There was a false-positive rate of 10% for initial staging with chest CT. 3
33. Cascade PN, Gross BH, Kazerooni EA, et al. Variability in the detection of enlarged mediastinal lymph nodes in staging lung cancer: a comparison of contrast-enhanced and unenhanced CT. AJR Am J Roentgenol. 170(4):927-31, 1998 Apr. Observational-Dx 50 patients with known or suspected bronchogenic carcinoma To evaluate intra- and interobserver agreement in the detection of enlarged mediastinal lymph nodes, comparing i.v. contrast-enhanced and unenhanced CT. The number of enlarged lymph nodes with enhanced CT was 11% higher than on unenhanced studies (418 versus 377; p = .044). Numbers of enlarged lymph nodes were different for five stations; however, the numbers were small except for the right upper paratracheal station (2R) (contrast-enhanced, 68 enlarged lymph nodes; unenhanced, 44 enlarged lymph nodes; p = .014). With regard to all stations together, intraobserver agreement between contrast-enhanced and unenhanced studies was almost perfect (kappa range, .85-.94), and no difference was found for any observer in the proportion of patients with at least one enlarged lymph node. Interobserver agreement was substantial or almost perfect for the total number of enlarged lymph nodes. For specific stations, the lowest kappa value was .48 at 2R. One observer reported more patients with at least one enlarged lymph node with contrast enhancement at station 2R (p = .031). Greater agreement existed between two observers at station 2R with contrast enhancement versus no enhancement (kappa = .85 versus .48; p = .02). 3
34. Cremerius U, Effert PJ, Adam G, et al. FDG PET for detection and therapy control of metastatic germ cell tumor. J Nucl Med. 1998; 39(5):815-822. Observational-Dx 87 total patients: 54 PET, 33 CT To examine the use of FDG-PET for detection and therapy control of metastatic germ cell cancer as compared to CT. While sensitivities of PET and CT did not differ markedly, PET was significantly more specific than CT. FDG-PET is superior to CT for assessment of residual disease after chemotherapy for germ cell cancer. 3
35. Cremerius U, Wildberger JE, Borchers H, et al. Does positron emission tomography using 18-fluoro-2-deoxyglucose improve clinical staging of testicular cancer?--Results of a study in 50 patients. Urology. 1999; 54(5):900-904. Observational-Dx 50 patients To compare PET and CT for staging in unselected patients with germ cell cancer. PET: 87% sensitivity, 97% specificity. CT: 73% sensitivity, 94% specificity. PET is superior to CT for staging. FDG-PET has the potential to improve clinical staging of testicular cancer. However, PET, as well as CT, is limited in the detection of small retroperitoneal lymph node metastases. 3
36. de Wit M, Brenner W, Hartmann M, et al. [18F]-FDG-PET in clinical stage I/II non-seminomatous germ cell tumours: results of the German multicentre trial. Ann Oncol. 2008; 19(9):1619-1623. Observational-Dx 72 patients To determine the predictive values of FDG-PET in primary staging in patients with newly diagnosed NSGCT clinical stage I/II. The prevalence of nodal involvement was 26%. Correct nodal staging by FDG-PET was achieved in 83% compared with correct CT staging in 71%. CT had a sensitivity and specificity of 41% and 95%, respectively. PPV and NPV were 87% and 67%, respectively. FDG-PET had a sensitivity and specificity of 66% and 98%, respectively. PPV was 95%. The primary end point was not reached, with an NPV of 78%. FDG-PET as a primary staging tool for NSGCT yielded only slightly better results than CT. Both methods had a high specificity while false-negative findings were more frequent with CT. FDG-PET is mostly useful as a diagnostic tool in case of questionable CT scan. 2
37. Hain SF, O'Doherty MJ, Timothy AR, Leslie MD, Partridge SE, Huddart RA. Fluorodeoxyglucose PET in the initial staging of germ cell tumours. Eur J Nucl Med. 2000; 27(5):590-594. Observational-Dx 31 patients A retrospective study to determine if FDG-PET is useful for staging testicular cancer. The PPV was 100%. The NPV was 76%. It may be concluded that FDG-PET is capable of detecting metastatic disease at diagnosis that is not identified by other imaging techniques. These preliminary results are sufficient to suggest that a large prospective study should be performed to evaluate the role of FDG-PET in primary staging of disease. 3
38. Lassen U, Daugaard G, Eigtved A, Hojgaard L, Damgaard K, Rorth M. Whole-body FDG-PET in patients with stage I non-seminomatous germ cell tumours. Eur J Nucl Med Mol Imaging. 2003; 30(3):396-402. Observational-Dx 46 patients To compare FDG-PET and CT in patients with stage I NSGCT. The sensitivity, specificity and accuracy of PET were 70%, 100% and 93%, respectively. The sensitivity of detecting small retroperitoneal metastases was 88%. The negative and PPV were 92% and 100%, respectively, whereas the NPV of standard staging procedures was 78%. FDG-PET thus seems to be superior to conventional staging (P=0.06) in stage I NSGCT. This non-invasive method may improve the overall management of patients with NSGCT. 2
39. Spermon JR, De Geus-Oei LF, Kiemeney LA, Witjes JA, Oyen WJ. The role of (18)fluoro-2-deoxyglucose positron emission tomography in initial staging and re-staging after chemotherapy for testicular germ cell tumours. BJU Int. 2002; 89(6):549-556. Review/Other-Dx 50 patients To investigate the role of FDG-PET in the initial staging of clinical stage I and II NSGCT and in re-staging NSGCT after chemotherapy. FDG-PET performed equally well with CT on initial staging but was superior to CT on restaging. It could be useful to predict fibrotic residual mass in NSGCT in those patients with no teratoma component in their primary tumor. 4
40. NCCN Clinical Practice Guidelines in Oncology. Testicular Cancer. NCCN Evidence Blocks. Version 2.2021.  Available at: https://www.nccn.org/professionals/physician_gls/pdf/testicular_blocks.pdf. Review/Other-Dx N/A To provide recommendations for the management of adult patients with nonseminomatous GCTs. No results stated in abstract. 4
41. Ellis JH, Bies JR, Kopecky KK, Klatte EC, Rowland RG, Donohue JP. Comparison of NMR and CT imaging in the evaluation of metastatic retroperitoneal lymphadenopathy from testicular carcinoma. J Comput Assist Tomogr. 8(4):709-19, 1984 Aug. Observational-Dx 25 patients To compare CT and nuclear MR in the evaluation of metastatic retroperitoneal lymphadenopathy from testicular carcinoma. CT correctly predicted the presence or absence of adenopathy in 88% and assigned the correct stage in 84%. Nuclear MR had comparable figures of 84% and 80%. 3
42. Glazer HS, Lee JK, Levitt RG, et al. Radiation fibrosis: differentiation from recurrent tumor by MR imaging. Radiology. 1985; 156(3):721-726. Review/Other-Dx 36 total patients: 21 had RT; 15 no RT To analyze the MRI of patients who had RT and compare with those who had no RT to determine differentiation of radiation fibrosis from recurrent tumor by MRI. T2-weighted images (TR = 1,500 msec, TE = 90 msec) were most helpful in distinguishing recurrent tumor from radiation fibrosis. Relatively high signal intensity on T2-weighted images is not specific for tumor recurrence. 4
43. Hogeboom WR, Hoekstra HJ, Mooyaart EL, et al. The role of magnetic resonance imaging and computed tomography in the treatment evaluation of retroperitoneal lymph-node metastases of non-seminomatous testicular tumors. Eur J Radiol. 1991; 13(1):31-36. Review/Other-Dx 10 consecutive patients To prospectively compare MRI with CT in staging retroperitoneal metastases. MRI and CT were equivalent in detecting and determining the anatomical localization and size of the retroperitoneal lymph node metastases. Unlike CT, MRI revealed unmistakable changes in the structure of the retroperitoneal lymph-node metastases during chemotherapy, for which no histological cause was found except in mature teratoma. On the basis of tumor consistency and signal intensity in the T1- and T2-weighted images, MRI cannot yet warrant any conclusion about the ultimate effect of chemotherapy. 4
44. Harisinghani MG, Saksena M, Ross RW, et al. A pilot study of lymphotrophic nanoparticle-enhanced magnetic resonance imaging technique in early stage testicular cancer: a new method for noninvasive lymph node evaluation. Urology. 2005; 66(5):1066-1071. Observational-Dx 18 patients (42 nodes sampled; 25 benign and 17 malignant) To prospectively evaluate whether lymphotrophic nanoparticle-enhanced MRI can be used as a method for detecting metastatic disease within retroperitoneal nodes in patients with testicular cancer. Sensitivity of lymphotrophic nanoparticle-enhanced MRI for malignant lymph node involvement was 88.2%, specificity was 92%, and the accuracy was 90.4%. On the other hand, the sensitivity of size criteria for detecting malignant nodes was 70.5%, the specificity was 68%, and the accuracy was 69%. Lymphotrophic nanoparticle-enhanced MRI is safe and accurate for detecting nodal metastases in patients with testicular cancer. Lymphotrophic nanoparticle-enhanced MRI yields higher sensitivity and specificity when compared with unenhanced MRI or conventional CT scanning. Although the results are encouraging, the precise role of this tool in early stage testicular cancer remains to be determined. 2
45. Sohaib SA, Koh DM, Barbachano Y, et al. Prospective assessment of MRI for imaging retroperitoneal metastases from testicular germ cell tumours. Clin Radiol. 2009; 64(4):362-367. Observational-Dx 52 patients; 3 independent observers Prospective study to determine the sensitivity of MRI in the detection of retroperitoneal lymph nodes in patients with testicular GCT. 22 (42%) of the 52 patients had no retroperitoneal disease; in remaining 30 patients 51 enlarged nodes were identified. On a per patient basis, readers 1, 2, and 3 identified nodal disease in 28/29, 29/30, and 24/30 patients, respectively, using MRI compared to CT. Thus for experienced radiologists (readers 1 and 2) MRI is comparable to CT for nodal detection (ie, this study excludes MRI being inferior to CT with 80% power and 5% type 1 error). MRI offers an alternative method for staging the retroperitoneum in young patients being followed for testicular GCT and has the major advantage of avoiding exposure to ionizing radiation. 2
46. Rud E, Langberg CW, Baco E, Lauritzen P, Sandbaek G. MRI in the Follow-up of Testicular Cancer: Less is More. Anticancer Research. 39(6):2963-2968, 2019 Jun. Review/Other-Dx 2,315 MRI examinations To report the location of abdominal relapse in patients with testicular cancer. Relapse was detected in 0.7% (95% CI=0.4-1.1) of the examinations. Among these, 75% were seminomas and 25% were non-seminomas. Retroperitoneal lymph nodes were affected in 88% of cases, and pelvic and inguinal lymph nodes affected in 12% of cases. No metastases were found in parenchymatous organs or bony structures. 4
47. Laukka M, Mannisto S, Beule A, Kouri M, Blomqvist C. Comparison between CT and MRI in detection of metastasis of the retroperitoneum in testicular germ cell tumors: a prospective trial. Acta Oncologica. 59(6):660-665, 2020 Jun. Experimental-Dx 50 patients To examine whether abdominal MRI is as effective as computed tomography (CT) in the detection of retroperitoneal metastases of testicular cancer. There was no significant difference in the detection of retroperitoneal metastasis between CT and MRI. The sensitivity of MRI was 0.98. There was no statistically significant difference in the sizes of lymph nodes found in CT and MRI, and even very small lymph nodes could be detected in MRI as well as in CT. 2
48. Fernandez EB, Colon E, McLeod DG, Moul JW. Efficacy of radiographic chest imaging in patients with testicular cancer. Urology. 1994; 44(2):243-248; discussion 248-249. Observational-Dx 362 patient records (119 excluded); 201 had both CXR and chest CT; 24 CXR alone; 20 CT of the chest alone To determine the efficacy of CT of the chest and CXR in the initial staging process of testicular GCTs. CXR alone is preferable for initial chest staging in all patients with seminomas and in patients with NSGCT with negative findings on CTA. Chest CT remains of slight benefit for patients with clinical stage II and greater NSGCT and to evaluate further suspicious CXR findings in any patient, although it appears not to be necessary in patients who have clinical stage I disease determined by CTA. These findings have important cost-saving implications. 3
49. Steinfeld AD, Macher MS. Radiologic staging of chest in testicular seminoma. Urology. 1990; 36(5):428-430. Review/Other-Dx N/A To review the benefits of CXR, conventional planar tomography, and computerized axial tomography in evaluating patients with stages I and II testicular seminoma. Routine use of computerized axial tomography or conventional planar tomography is not indicated in staging. 4
50. Mao Y, Hedgire S, Harisinghani M. Radiologic Assessment of Lymph Nodes in Oncologic Patients. Current Radiology Reports 2013;2. Review/Other-Dx N/A to focus on the conventional methods such as ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and some novel methods like diffusion weighted imaging of MRI, positron emission tomography (PET) or PET/CT and MRI and novel MR contrasts with reference to characterization of lymph nodes. No results stated in abstract. 4
51. See WA, Hoxie L. Chest staging in testis cancer patients: imaging modality selection based upon risk assessment as determined by abdominal computerized tomography scan results. J Urol. 1993; 150(3):874-878. Review/Other-Dx 74 patients To compare chest CT with CXR as staging modalities in patients with testicular cancer, on the basis of abdominal CT findings. In the series of patients undergoing CXR and chest CT concurrently, staging abdominal CT scans were negative in 42 patients and positive in 32 patients. Among the 42 patients with negative abdominal CT scans, chest imaging findings were discordant in 4 patients, including 3 with lesions seen only on chest CT (false positive rate of 2.3%). Among the 32 patients with positive abdominal CT, chest CT allowed detection of pulmonary metastases not seen on the CXR in 4 (12.5%) cases. CXR may be the preferred initial chest staging study in patients with negative abdominal CT, whereas chest CT is indicated in patients with a positive abdominal CT examination. 4
52. Huddart RA, O'Doherty MJ, Padhani A, et al. 18fluorodeoxyglucose positron emission tomography in the prediction of relapse in patients with high-risk, clinical stage I nonseminomatous germ cell tumors: preliminary report of MRC Trial TE22--the NCRI Testis Tumour Clinical Study Group. J Clin Oncol. 2007; 25(21):3090-3095. Observational-Dx 116 total registered patients: 111 underwent PET scans; 87 proceeded to surveillance To examine whether an FDG-PET scan could identify patients without occult metastatic disease for whom surveillance is an attractive option. For 12 months follow-up, 33/87 patients on surveillance relapsed (1-year relapse-free rate, 63%; 90% CI, 54% to 72%). Relapse rate among PET negative patients is high. Results indicate that FDG PET scanning is not sufficiently sensitive to identify patients at low risk of relapse in this setting. 2
53. Sohaib SA, Koh DM, Husband JE. The role of imaging in the diagnosis, staging, and management of testicular cancer. [Review] [45 refs]. AJR Am J Roentgenol. 191(2):387-95, 2008 Aug. Review/Other-Dx N/A To describe recent developments in imaging patients with testicular GCTs. Most patients with testicular GCTs can now be expected to be cured, so the focus on management moves toward identifying patients who need more aggressive treatment and avoiding long-term complications. CT remains central in the selection of a management strategy, although the roles of MRI and PET continue to evolve. 4
54. White PM, Adamson DJ, Howard GC, Wright AR. Imaging of the thorax in the management of germ cell testicular tumours. Clin Radiol. 1999; 54(4):207-211. Observational-Dx 623 chest CT examinations on 207 patients To evaluate role of chest CT and CXR in management of patients with testicular GCT. Intrathoracic metastases were identified in 1% of seminoma patients compared with 20% of non-seminoma GCT patients. Chest CT was more accurate than CXR in the detection of intrathoracic metastases at 0.97, 0.96-0.98 (95% CI) compared with 0.91, 0.89-0.93. The agreement between imaging techniques and the standard of reference (determined by Kappa statistic) was respectively 0.96 for chest CT and 0.65 for CXR. In GCT patients undergoing re-assessment with both CXR and chest CT, CXR never detected unknown intrathoracic metastatic disease. Abdominopelvic lymphadenopathy was associated with intrathoracic metastases (P<0.001), however re-assessment chest CT did identify intrathoracic metastases in 27 cases without concurrent abdominopelvic disease. CXR was negative in 19 of these. Routine interval CXRs are unnecessary in non-seminoma GCT patients undergoing regular re-assessment chest CT due to the low additional yield and limited effect on management. Re-assessment should still include chest CT. In low risk, pure seminoma patients (abdominal CT and marker negative) re-assessment chest CT can be safely avoided. Baseline chest CT is advocated with CXR alone for re-assessment. 3
55. Sadow CA, Maurer AN, Prevedello LM, Sweeney CJ, Silverman SG. CT restaging of testicular germ cell tumors: The incidence of isolated pelvic metastases. European Journal of Radiology. 85(8):1439-44, 2016 Aug. Review/Other-Dx 560 men To determine the incidence of isolated pelvic metastases at restaging computed tomography (CT) in patients with testicular germ cell tumors to consider if imaging the pelvis could be omitted. Isolated pelvic metastases were detected in nine (1.6%) of 560 men. Neither bulky abdominal disease (p=0.85) nor extratesticular invasion by the primary tumor (p=0.37) were statistically significant in predicting which patients were more likely to have isolated pelvic metastases. Among the nine patients with isolated pelvic recurrence, only three (0.7%) of 408 men with no known pelvic disease at initial staging and no tumor marker elevation at restaging had isolated pelvic metastases. 4
56. Rustin GJ, Mead GM, Stenning SP, et al. Randomized trial of two or five computed tomography scans in the surveillance of patients with stage I nonseminomatous germ cell tumors of the testis: Medical Research Council Trial TE08, ISRCTN56475197--the National Cancer Research Institute Testis Cancer Clinical Studies Group. J Clin Oncol 2007;25:1310-5. Experimental-Dx 414 patients To determine whether the number of scans influenced the proportion of patients relapsing with intermediate- or poor-prognosis disease at relapse. Two hundred forty-seven patients were allocated to a two-scan and 167 to five-scan policy. With a median follow-up of 40 months, 37 relapses (15%) have occurred in the two-scan arm and 33 (20%) in the five-scan arm. No patients had poor prognosis at relapse, but two (0.8%) of those relapsing in the two-scan arm had intermediate prognosis compared with 1 (0.6%) in the five-scan arm, a difference of 0.2% (90% CI, -1.2% to 1.6%). No deaths have been reported. 1
57. De La Pena H, Sharma A, Glicksman C, et al. No longer any role for routine follow-up chest x-rays in men with stage I germ cell cancer. Eur J Cancer. 84:354-359, 2017 10. Review/Other-Dx 159 relapses To evaluate the role of CXRs in the 21st century for the follow-up of men with stage I testicular cancer. From a total of 1447 patients, we identified 159 relapses. All relapses were detected either by rising tumour markers or planned follow-up CT scans. Not a single relapse was identified on CXR. 4
58. Kollmannsberger C, Tandstad T, Bedard PL, et al. Patterns of relapse in patients with clinical stage I testicular cancer managed with active surveillance. J Clin Oncol 2015;33:51-7. Review/Other-Dx 2,483 clinical stage I (CSI) patients, 1,139 CSI nonseminoma and 1,344 CSI seminoma managed with active surveillance To evaluate the performance of active surveillance as a management strategy in broad populations and to inform the development of surveillance schedules by individual patient data regarding timing and type of relapse. Relapse occurred in 221 (19%) CSI-nonseminoma and 173 (13%) CSI-seminoma patients. Median time to relapse was 4 months (range, 2-61 months), 8 months (range, 2-77 months) and 14 months (range, 2-84 months) for lymphovascular invasion-positive CSI nonseminoma, lymphovascular invasion-negative CSI nonseminoma and CSI seminoma. Most relapses were observed within the first 2 years/3 years after orchiectomy for CSI nonseminoma (90%)/CSI seminoma (92%). Relapses were detected by computed tomography scan/tumor-markers in 87%/3% of seminoma recurrences, in 48%/38% of lymphovascular invasion-negative and 41%/61% of lymphovascular invasion-positive patients, respectively. 90% of CSI-nonseminoma and 99% of CSI-seminoma relapses exhibited International Germ Cell Collaborative Group good-risk features. Three patients with CSI nonseminoma died of disease (0.3%). One patient with CSI seminoma and two patients with CSI nonseminoma died because of treatment-related events. Overall, advanced disease was seen in both early- and late-relapse patients. All late recurrences were cured with standard therapy. Five-year disease-specific survival was 99.7% (95% CI, 99.24% to 99.93%). 4
59. Tolan S, Vesprini D, Jewett MA, et al. No role for routine chest radiography in stage I seminoma surveillance. Eur Urol 2010;57:474-9. Observational-Dx 527 patients To identify the modality that first detected relapse and to assess the value of the CXR in this setting. The 5-yr disease-free survival and overall survival were 85.7% and 98.6%, respectively. Seventy-three patients (97.3%) had an abnormal CT-AP and a normal CXR at relapse. One patient (1.3%) had an abnormal CT-AP with pulmonary metastasis on CXR and CT chest scan, and one patient (1.3%) had a biopsy-proven inguinal node metastasis with a normal CXR. No patient had a normal CT-AP or physical examination with an abnormal CXR at relapse. 4
60. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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