Germ Cell Tumours: Difference between revisions

Line 203:

=== Imaging ===

* '''Local~~: scrotal ultrasound with doppler~~~~'''~~

=== Local ===

** '''~~Important to evaluate both testicles given~~''' '''~~2% incidence of bilateral GCT~~'''

~~***~~'''~~In cases~~ of bilateral GCT, a metachronous lesion is the most common presentation.'''

==== '''Scrotal ultrasound with doppler''' ====

** '''High-frequency transducers (5 to 10 MHz)''' can readily identify and distinguish intratesticular lesions a few millimeters in size from extra-testicular pathology

** '''Indications in the context of suspected GCT (3)'''

* '''Important to evaluate both testicles given''' '''2% incidence of bilateral GCT'''

**# '''Scrotal mass'''

**'''In cases of bilateral GCT, a metachronous lesion is the most common presentation.'''

**# '''Suspected metastatic GCT with a normal testicular examination'''

* '''High-frequency transducers (5 to 10 MHz)''' can readily identify and distinguish intratesticular lesions a few millimeters in size from extra-testicular pathology

**#* '''A small, impalpable scar or calcification indicates a “burned-out” primary testis tumor.'''

* '''Indications in the context of suspected GCT (3)'''

**#** '''If sonographic evidence of intratesticular lesions (discrete nodule, stellate scar, coarse calcification), perform radical orchiectomy because GCNIS and residual teratoma are frequently encountered.'''

*# '''Scrotal mass'''

**# '''Suspected primary extra-gonadal GCT'''

*# '''Suspected metastatic GCT with a normal testicular examination'''

**#* '''Males with advanced GCT with normal testes on physical examination and ultrasound scan are considered to have primary extragonadal GCT.'''

*#* '''A small, impalpable scar or calcification indicates a “burned-out” primary testis tumor.'''

*** '''Patients with normal serum tumor markers (hCG and AFP) and indeterminate findings on physical exam or testicular ultrasound for testicular neoplasm should undergo repeat imaging in 6-8 weeks.'''

*#** '''If sonographic evidence of intratesticular lesions (discrete nodule, stellate scar, coarse calcification), perform radical orchiectomy because GCNIS and residual teratoma are frequently encountered.'''

** '''Imaging findings'''

*# '''Suspected primary extra-gonadal GCT'''

*** '''Typical GCT is hypoechoic'''

*#* '''Males with advanced GCT with normal testes on physical examination and ultrasound scan are considered to have primary extragonadal GCT.'''

*** 2 or more discrete lesions may be identified

** '''Patients with normal serum tumor markers (hCG and AFP) and indeterminate findings on physical exam or testicular ultrasound for testicular neoplasm should undergo repeat imaging in 6-8 weeks.'''

*** INSERT IMAGE

* '''Imaging findings'''

*** '''Testicular microlithiasis'''

** '''Typical GCT is hypoechoic'''

**** '''Unclear significance''' '''in the general population'''

** 2 or more discrete lesions may be identified

***** If no history of GCT, risk of GCT is only increased if an additional established risk factor (see above) is present

** INSERT IMAGE

***** If history of GCT, microlithiasis on ultrasound of the contralateral testis is associated with an increased risk of ITGCN.

** '''Testicular microlithiasis'''

**** '''Management'''

*** '''Unclear significance''' '''in the general population'''

***** '''No further evaluation or screening in incidentally detected microlithiasis'''

**** If no history of GCT, risk of GCT is only increased if an additional established risk factor (see above) is present

***** '''If established risk factor and testicular microlithiasis, counsel patient about the potential increased risk of GCT, need for periodic self-examination and follow-up with a medical professional'''

**** If history of GCT, microlithiasis on ultrasound of the contralateral testis is associated with an increased risk of ITGCN.

**** insert image

*** '''Management'''

** '''MRI'''

**** '''No further evaluation or screening in incidentally detected microlithiasis'''

*** '''Can be considered an adjunct to scrotal ultrasound in patients with lesions suspicious for benign etiology'''

**** '''If established risk factor and testicular microlithiasis, counsel patient about the potential increased risk of GCT, need for periodic self-examination and follow-up with a medical professional'''

*** '''Should not delay orchiectomy in patients in whom malignancy is suspected'''

*** insert image

* '''Metastasis~~'''~~

** '''Regional'''

==== '''MRI''' ====

*** Regional lymph nodes comprises (7):

* '''Can be considered an adjunct to scrotal ultrasound in patients with lesions suspicious for benign etiology'''

***# Inter-aortocaval

* '''Should not delay orchiectomy in patients in whom malignancy is suspected'''

***# Para-aortic

***# Para-caval

=== Metastasis ===

***# Pre-aortic

* '''Regional'''

***# Pre-caval

** Regional lymph nodes comprises (7):

***# Retro-aortic

**# Inter-aortocaval

***# Retro-caval

**# Para-aortic

*** '''Modality'''

**# Para-caval

**** '''CT abdomen/pelvis with oral and IV contrast'''

**# Pre-aortic

***** '''Most effective imaging modality for regional staging'''

**# Pre-caval

**** MRI

**# Retro-aortic

***** Alternative to CT

**# Retro-caval

*** '''Imaging findings'''

** '''Modality'''

**** '''Retroperitoneal lymph nodes'''

*** '''CT abdomen/pelvis with oral and IV contrast'''

***** '''Pattern of lymph drainage in the retroperitoneum is from right to left.'''

**** '''Most effective imaging modality for regional staging'''

****** '''For right testis tumors, the primary drainage site is the inter-aortocaval lymph nodes inferior to the renal vessels, followed by the paracaval and para-aortic nodes.'''

*** MRI

****** '''For left testis tumors, the primary drainage site is the para-aortic lymph nodes, followed by the inter-aortocaval nodes.'''

**** Alternative to CT

***** [[File:Retroperitoneal lymph flow.jpg|thumb|Direction of lymphatic flow in the retroperitoneum]]

** '''Imaging findings'''

**** '''"Borderline" retroperitoneal lymph nodes'''

*** '''Retroperitoneal lymph nodes'''

***** '''Lymph nodes 5-9 mm in the primary landing zone should be viewed with suspicion for regional lymph node metastasis, particularly if they are anterior to the great vessels'''

**** '''Pattern of lymph drainage in the retroperitoneum is from right to left.'''

**** Limitations

***** '''For right testis tumors, the primary drainage site is the inter-aortocaval lymph nodes inferior to the renal vessels, followed by the paracaval and para-aortic nodes.'''

***** Understaging

***** '''For left testis tumors, the primary drainage site is the para-aortic lymph nodes, followed by the inter-aortocaval nodes.'''

****** 25-35% of patients with CSI NSGCT and a “normal” CT scan will be found to have pathologically involved retroperitoneal lymph nodes at RPLND

**** [[File:Retroperitoneal lymph flow.jpg|thumb|Direction of lymphatic flow in the retroperitoneum]]

***** Overstaging

*** '''"Borderline" retroperitoneal lymph nodes'''

****** 12-40% of patients with CS IIA and IIB disease will be found to have pathologically negative lymph nodes at RPLND

**** '''Lymph nodes 5-9 mm in the primary landing zone should be viewed with suspicion for regional lymph node metastasis, particularly if they are anterior to the great vessels'''

** '''Distant'''

*** Limitations

*** '''Chest'''

**** Understaging

**** '''Timing'''

***** 25-35% of patients with CSI NSGCT and a “normal” CT scan will be found to have pathologically involved retroperitoneal lymph nodes at RPLND

***** '''Necessary to complete staging in patients with confirmed GCTs'''

**** Overstaging

***** '''Should not delay orchiectomy'''

***** 12-40% of patients with CS IIA and IIB disease will be found to have pathologically negative lymph nodes at RPLND

**** '''Modality: plain-film chest x-ray vs. CT'''

* '''Distant'''

***** '''Chest x-ray'''

** '''Chest'''

****** '''Indications''' (AUA 2019 Guidelines)

*** '''Timing'''

******* '''Suspected clinical stage I seminoma'''; preferred over CT

**** '''Necessary to complete staging in patients with confirmed GCTs'''

******** '''When tumor markers are normal, the rate of skip metastasis to the thorax in seminoma is close to 0%,''' and the addition of CT chest to chest x-ray is very unlikely to alter treatment decisions.

**** '''Should not delay orchiectomy'''

***** '''CT scan'''

*** '''Modality: plain-film chest x-ray vs. CT'''

****** '''Indications (3)''' (AUA 2019 Guidelines)

**** '''Chest x-ray'''

******# '''NSGCT'''

***** '''Indications''' (AUA 2019 Guidelines)

******#* '''Skip metastases are more common in non-seminoma than seminoma.'''

****** '''Suspected clinical stage I seminoma'''; preferred over CT

******# '''Elevated and rising post-orchiectomy markers (hCG and AFP)'''

******* '''When tumor markers are normal, the rate of skip metastasis to the thorax in seminoma is close to 0%,''' and the addition of CT chest to chest x-ray is very unlikely to alter treatment decisions.

******# '''Any evidence of metastases on abdominal/pelvic imaging, chest x-ray or physical exam.'''

**** '''CT scan'''

*** '''Other'''

***** '''Indications (3)''' (AUA 2019 Guidelines)

**** '''Bone scan and CT brain'''

*****# '''NSGCT'''

*****'''No role for routine bone scintigraphy or brain CT imaging at the time of diagnosis.'''

*****#* '''Skip metastases are more common in non-seminoma than seminoma.'''

****** In the absence of symptoms or other clinical indicators of disease, visceral metastasis to bone and brain is uncommon in GCT

*****# '''Elevated and rising post-orchiectomy markers (hCG and AFP)'''

****** '''Indications for bone scan and CT brain (3):'''

*****# '''Any evidence of metastases on abdominal/pelvic imaging, chest x-ray or physical exam.'''

******#'''Symptoms suggestive of central nervous system or bone involvement'''

** '''Other'''

******# '''Poor prognosis disease.'''

*** '''Bone scan and CT brain'''

******#'''Highly elevated hCG (>10,000 mU/mL)'''

****'''No role for routine bone scintigraphy or brain CT imaging at the time of diagnosis.'''

******#*'''Highly elevated hCG are often associated with metastatic choriocarcinoma, which has a propensity for brain metastases.'''

***** In the absence of symptoms or other clinical indicators of disease, visceral metastasis to bone and brain is uncommon in GCT

**** '''FDG-PET'''

***** '''Indications for bone scan and CT brain (3):'''

***** '''Currently, no role in the routine evaluation of NSGCT and seminoma at the time of diagnosis.'''

*****#'''Symptoms suggestive of central nervous system or bone involvement'''

* '''Timing~~'''~~

*****# '''Poor prognosis disease.'''

** '''Management decisions should be based on imaging studies performed within 4 weeks of the initiation of treatment''' due to the rapid growth of GCTs.

*****#'''Highly elevated hCG (>10,000 mU/mL)'''

*****#*'''Highly elevated hCG are often associated with metastatic choriocarcinoma, which has a propensity for brain metastases.'''

*** '''FDG-PET'''

**** '''Currently, no role in the routine evaluation of NSGCT and seminoma at the time of diagnosis.'''

=== Timing ===

* '''Management decisions should be based on imaging studies performed within 4 weeks of the initiation of treatment''' due to the rapid growth of GCTs.

=== Other ===

@@ Line 203: / Line 203: @@
 === Imaging ===
-* '''<span style="color:#ff0000">Local: scrotal ultrasound with doppler</span>'''
+=== <span style="color:#ff0000">Local</span> ===
-** '''<span style="color:#ff0000">Important to evaluate both testicles given</span>''' '''<span style="color:#ff0000">2% incidence of bilateral GCT</span>'''
-***'''In cases of bilateral GCT, a metachronous lesion is the most common presentation.'''
+==== '''<span style="color:#ff0000">Scrotal ultrasound with doppler</span>''' ====
-** '''High-frequency transducers (5 to 10 MHz)''' can readily identify and distinguish intratesticular lesions a few millimeters in size from extra-testicular pathology
-** '''<span style="color:#ff0000">Indications in the context of suspected GCT (3)</span>'''
+* '''<span style="color:#ff0000">Important to evaluate both testicles given</span>''' '''<span style="color:#ff0000">2% incidence of bilateral GCT</span>'''
-**# '''<span style="color:#ff0000">Scrotal mass</span>'''
+**'''In cases of bilateral GCT, a metachronous lesion is the most common presentation.'''
-**# '''<span style="color:#ff0000">Suspected metastatic GCT with a normal testicular examination</span>'''
+* '''High-frequency transducers (5 to 10 MHz)''' can readily identify and distinguish intratesticular lesions a few millimeters in size from extra-testicular pathology
-**#* '''A small, impalpable scar or calcification indicates a <span style="color:#ff0000">“burned-out” primary testis tumor.</span>'''
+* '''<span style="color:#ff0000">Indications in the context of suspected GCT (3)</span>'''
-**#** '''<span style="color:#ff0000">If sonographic evidence of intratesticular lesions (discrete nodule, stellate scar, coarse calcification), perform radical orchiectomy because GCNIS and residual teratoma are frequently encountered.</span>'''
+*# '''<span style="color:#ff0000">Scrotal mass</span>'''
-**# '''<span style="color:#ff0000">Suspected primary extra-gonadal GCT</span>'''
+*# '''<span style="color:#ff0000">Suspected metastatic GCT with a normal testicular examination</span>'''
-**#* '''<span style="color:#ff0000">Males with advanced GCT with normal testes on physical examination and ultrasound scan are considered to have primary extragonadal GCT.</span>'''
+*#* '''A small, impalpable scar or calcification indicates a <span style="color:#ff0000">“burned-out” primary testis tumor.</span>'''
-*** '''Patients with normal serum tumor markers (hCG and AFP) and indeterminate findings on physical exam or testicular ultrasound for testicular neoplasm should undergo repeat imaging in 6-8 weeks.'''
+*#** '''<span style="color:#ff0000">If sonographic evidence of intratesticular lesions (discrete nodule, stellate scar, coarse calcification), perform radical orchiectomy because GCNIS and residual teratoma are frequently encountered.</span>'''
-** '''Imaging findings'''
+*# '''<span style="color:#ff0000">Suspected primary extra-gonadal GCT</span>'''
-*** '''Typical GCT is hypoechoic'''
+*#* '''<span style="color:#ff0000">Males with advanced GCT with normal testes on physical examination and ultrasound scan are considered to have primary extragonadal GCT.</span>'''
-*** 2 or more discrete lesions may be identified
+** '''Patients with normal serum tumor markers (hCG and AFP) and indeterminate findings on physical exam or testicular ultrasound for testicular neoplasm should undergo repeat imaging in 6-8 weeks.'''
-*** INSERT IMAGE
+* '''Imaging findings'''
-*** '''<span style="color:#ff0000">Testicular microlithiasis</span>'''
+** '''Typical GCT is hypoechoic'''
-**** '''Unclear significance''' '''in the general population'''
+** 2 or more discrete lesions may be identified
-***** If no history of GCT, risk of GCT is only increased if an additional established risk factor (see above) is present
+** INSERT IMAGE
-***** If history of GCT, microlithiasis on ultrasound of the contralateral testis is associated with an increased risk of ITGCN.
+** '''<span style="color:#ff0000">Testicular microlithiasis</span>'''
-**** '''<span style="color:#ff0000">Management</span>'''
+*** '''Unclear significance''' '''in the general population'''
-***** '''<span style="color:#ff0000">No further evaluation or screening in incidentally detected microlithiasis</span>'''
+**** If no history of GCT, risk of GCT is only increased if an additional established risk factor (see above) is present
-***** '''<span style="color:#ff0000">If established risk factor and testicular microlithiasis, counsel patient about the potential increased risk of GCT, need for periodic self-examination and follow-up with a medical professional</span>'''
+**** If history of GCT, microlithiasis on ultrasound of the contralateral testis is associated with an increased risk of ITGCN.
-**** insert image
+*** '''<span style="color:#ff0000">Management</span>'''
-** '''<span style="color:#ff0000">MRI</span>'''
+**** '''<span style="color:#ff0000">No further evaluation or screening in incidentally detected microlithiasis</span>'''
-*** '''<span style="color:#ff0000">Can be considered an adjunct to scrotal ultrasound in patients with lesions suspicious for benign etiology</span>'''
+**** '''<span style="color:#ff0000">If established risk factor and testicular microlithiasis, counsel patient about the potential increased risk of GCT, need for periodic self-examination and follow-up with a medical professional</span>'''
-*** '''Should not delay orchiectomy in patients in whom malignancy is suspected'''
+*** insert image
-* '''<span style="color:#ff0000">Metastasis</span>'''
-** '''<span style="color:#ff0000">Regional</span>'''
+==== '''<span style="color:#ff0000">MRI</span>''' ====
-*** Regional lymph nodes comprises (7):
+* '''<span style="color:#ff0000">Can be considered an adjunct to scrotal ultrasound in patients with lesions suspicious for benign etiology</span>'''
-***# Inter-aortocaval
+* '''Should not delay orchiectomy in patients in whom malignancy is suspected'''
-***# Para-aortic
-***# Para-caval
+=== <span style="color:#ff0000">Metastasis</span> ===
-***# Pre-aortic
+* '''<span style="color:#ff0000">Regional</span>'''
-***# Pre-caval
+** Regional lymph nodes comprises (7):
-***# Retro-aortic
+**# Inter-aortocaval
-***# Retro-caval
+**# Para-aortic
-*** '''<span style="color:#ff0000">Modality</span>'''
+**# Para-caval
-**** '''<span style="color:#ff0000">CT abdomen/pelvis with oral and IV contrast</span>'''
+**# Pre-aortic
-***** '''<span style="color:#ff0000">Most effective imaging modality for regional staging</span>'''
+**# Pre-caval
-**** MRI
+**# Retro-aortic
-***** Alternative to CT
+**# Retro-caval
-*** '''<span style="color:#ff0000">Imaging findings</span>'''
+** '''<span style="color:#ff0000">Modality</span>'''
-**** '''<span style="color:#ff0000">Retroperitoneal lymph nodes</span>'''
+*** '''<span style="color:#ff0000">CT abdomen/pelvis with oral and IV contrast</span>'''
-***** '''<span style="color:#ff0000">Pattern of lymph drainage in the retroperitoneum is from right to left.</span>'''
+**** '''<span style="color:#ff0000">Most effective imaging modality for regional staging</span>'''
-****** '''<span style="color:#ff0000">For right testis tumors, the primary drainage site is the inter-aortocaval lymph nodes inferior to the renal vessels, followed by the paracaval and para-aortic nodes.</span>'''
+*** MRI
-****** '''<span style="color:#ff0000">For left testis tumors, the primary drainage site is the para-aortic lymph nodes, followed by the inter-aortocaval nodes.</span>'''
+**** Alternative to CT
-***** [[File:Retroperitoneal lymph flow.jpg|thumb|Direction of lymphatic flow in the retroperitoneum]]
+** '''<span style="color:#ff0000">Imaging findings</span>'''
-**** '''<span style="color:#ff0000">"Borderline" retroperitoneal lymph nodes</span>'''
+*** '''<span style="color:#ff0000">Retroperitoneal lymph nodes</span>'''
-***** '''<span style="color:#ff0000">Lymph nodes 5-9 mm in the primary landing zone should be viewed with suspicion for regional lymph node metastasis,</span> particularly if they are anterior to the great vessels'''
+**** '''<span style="color:#ff0000">Pattern of lymph drainage in the retroperitoneum is from right to left.</span>'''
-**** Limitations
+***** '''<span style="color:#ff0000">For right testis tumors, the primary drainage site is the inter-aortocaval lymph nodes inferior to the renal vessels, followed by the paracaval and para-aortic nodes.</span>'''
-***** Understaging
+***** '''<span style="color:#ff0000">For left testis tumors, the primary drainage site is the para-aortic lymph nodes, followed by the inter-aortocaval nodes.</span>'''
-****** 25-35% of patients with CSI NSGCT and a “normal” CT scan will be found to have pathologically involved retroperitoneal lymph nodes at RPLND
+**** [[File:Retroperitoneal lymph flow.jpg|thumb|Direction of lymphatic flow in the retroperitoneum]]
-***** Overstaging
+*** '''<span style="color:#ff0000">"Borderline" retroperitoneal lymph nodes</span>'''
-****** 12-40% of patients with CS IIA and IIB disease will be found to have pathologically negative lymph nodes at RPLND
+**** '''<span style="color:#ff0000">Lymph nodes 5-9 mm in the primary landing zone should be viewed with suspicion for regional lymph node metastasis,</span> particularly if they are anterior to the great vessels'''
-** '''<span style="color:#ff0000">Distant</span>'''
+*** Limitations
-*** '''<span style="color:#ff0000">Chest</span>'''
+**** Understaging
-**** '''<span style="color:#ff0000">Timing</span>'''
+***** 25-35% of patients with CSI NSGCT and a “normal” CT scan will be found to have pathologically involved retroperitoneal lymph nodes at RPLND
-***** '''<span style="color:#ff0000">Necessary to complete staging in patients with confirmed GCTs</span>'''
+**** Overstaging
-***** '''<span style="color:#ff0000">Should not delay orchiectomy</span>'''
+***** 12-40% of patients with CS IIA and IIB disease will be found to have pathologically negative lymph nodes at RPLND
-**** '''Modality: plain-film chest x-ray vs. CT'''
+* '''<span style="color:#ff0000">Distant</span>'''
-***** '''Chest x-ray'''
+** '''<span style="color:#ff0000">Chest</span>'''
-****** '''Indications''' (AUA 2019 Guidelines)
+*** '''<span style="color:#ff0000">Timing</span>'''
-******* '''Suspected clinical stage I seminoma'''; preferred over CT
+**** '''<span style="color:#ff0000">Necessary to complete staging in patients with confirmed GCTs</span>'''
-******** '''When tumor markers are normal, the rate of skip metastasis to the thorax in seminoma is close to 0%,''' and the addition of CT chest to chest x-ray is very unlikely to alter treatment decisions.
+**** '''<span style="color:#ff0000">Should not delay orchiectomy</span>'''
-***** '''CT scan'''
+*** '''Modality: plain-film chest x-ray vs. CT'''
-****** '''Indications (3)''' (AUA 2019 Guidelines)
+**** '''Chest x-ray'''
-******# '''NSGCT'''
+***** '''Indications''' (AUA 2019 Guidelines)
-******#* '''Skip metastases are more common in non-seminoma than seminoma.'''
+****** '''Suspected clinical stage I seminoma'''; preferred over CT
-******# '''Elevated and rising post-orchiectomy markers (hCG and AFP)'''
+******* '''When tumor markers are normal, the rate of skip metastasis to the thorax in seminoma is close to 0%,''' and the addition of CT chest to chest x-ray is very unlikely to alter treatment decisions.
-******# '''Any evidence of metastases on abdominal/pelvic imaging, chest x-ray or physical exam.'''
+**** '''CT scan'''
-*** '''Other'''
+***** '''Indications (3)''' (AUA 2019 Guidelines)
-**** '''Bone scan and CT brain'''
+*****# '''NSGCT'''
-*****'''No role for routine bone scintigraphy or brain CT imaging at the time of diagnosis.'''
+*****#* '''Skip metastases are more common in non-seminoma than seminoma.'''
-****** In the absence of symptoms or other clinical indicators of disease, visceral metastasis to bone and brain is uncommon in GCT
+*****# '''Elevated and rising post-orchiectomy markers (hCG and AFP)'''
-****** '''Indications for bone scan and CT brain (3):'''
+*****# '''Any evidence of metastases on abdominal/pelvic imaging, chest x-ray or physical exam.'''
-******#'''Symptoms suggestive of central nervous system or bone involvement'''
+** '''Other'''
-******# '''Poor prognosis disease.'''
+*** '''Bone scan and CT brain'''
-******#'''Highly elevated hCG (>10,000 mU/mL)'''
+****'''No role for routine bone scintigraphy or brain CT imaging at the time of diagnosis.'''
-******#*'''<span style="color:#ff0000">Highly elevated hCG are often associated with metastatic choriocarcinoma, which has a propensity for brain metastases.</span>'''
+***** In the absence of symptoms or other clinical indicators of disease, visceral metastasis to bone and brain is uncommon in GCT
-**** '''<span style="color:#ff0000">FDG-PET</span>'''
+***** '''Indications for bone scan and CT brain (3):'''
-***** '''<span style="color:#ff0000">Currently, no role in the routine evaluation of NSGCT and seminoma at the time of diagnosis.</span>'''
+*****#'''Symptoms suggestive of central nervous system or bone involvement'''
-* '''Timing'''
+*****# '''Poor prognosis disease.'''
-** '''Management decisions should be based on imaging studies performed within 4 weeks of the initiation of treatment''' due to the rapid growth of GCTs.
+*****#'''Highly elevated hCG (>10,000 mU/mL)'''
+*****#*'''<span style="color:#ff0000">Highly elevated hCG are often associated with metastatic choriocarcinoma, which has a propensity for brain metastases.</span>'''
+*** '''<span style="color:#ff0000">FDG-PET</span>'''
+**** '''<span style="color:#ff0000">Currently, no role in the routine evaluation of NSGCT and seminoma at the time of diagnosis.</span>'''
+=== Timing ===
+* '''Management decisions should be based on imaging studies performed within 4 weeks of the initiation of treatment''' due to the rapid growth of GCTs.
 === Other ===