Surveillance for patients with stage I NSGCTs is now routine practice at many centers, and CT plays a critical role in this policy.46,47 The number of CT studies undertaken during a 5-year surveillance schedule and the timing of such CT studies vary from center to center, but in general, CT is performed every three to six months for the first 2 or 3 years. Further follow-up with CT is carried out either annually or only if there is a rise in serum markers or there is other evidence that suggests relapse. Chest radiography is omitted from the surveillance program at many centers now because there is good evidence that results from x-ray films do not contribute to management decisions, provided CT is being carried out on a regular basis.48 Although CT for staging should include the chest, abdomen, and pelvis, follow-up scanning for patients on surveillance should not include pelvic CT unless there are special risk factors, such as bulky retroperitoneal adenopathy (> 2 cm in short axis), prior history of scrotal surgery, and invasion of tunica vaginalis by a tumor.49 PET is likely to have an important role in assessing patients on surveillance as small nodal deposits or other subtle or equivocal findings on follow-up may be assessed with PET, and a definitive diagnosis of relapse can be made more quickly than by simply waiting for a further follow-up CT study. Rising markers may be observed without demonstrable CT findings, and in this group of patients, it is likely that PET will be a valuable adjunct. In this scenario, PET is very specific, having a positive predictive value in excess of 90% but a negative predictive value of only 50% (Figure 6-20).8 This reflects the fact that even functional imaging techniques cannot detect microscopic volumes of disease. Nevertheless, PET remains more sensitive than anatomic techniques and is frequently the first modality to identify the site of previously marker-positive occult disease.8
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