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Original Article
Tumor markers and 18F-FDG PET/CT after orchiectomy in seminoma: Is there any correlation?
Marcadores tumorales y 18F-FDG PET/CT después de orquiectomía en seminoma: ¿hay alguna correlación?
Francesco Dondi
Corresponding author
f.dondi@outlook.com

Corresponding author.
, Domenico Albano, Francesco Bertagna, Raffaele Giubbini
Nuclear Medicine, University of Brescia, Spedali Civili Brescia, Brescia, Italy
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early stages are generally associated with a cure rate approaching of 100&#37;&#44; while in advanced stages the cure rate varies from 90&#37; to 50&#37; depending on histology and time of diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Routinely&#44; the diagnostic imaging work-up for testicular cancer and seminoma is based on ultrasonography for identification of the primary lesion and CT for the diagnosis of secondary lesions&#44; while MRI is performed only in selected cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Late relapse of testis cancer is relatively common and can occur more than 2 years after the completion of treatment&#44; requiring annual follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7</span></a><span class="elsevierStyleSup">18</span>F-fluorodoxyglucose positron emission tomography&#47;computed tomography &#40;<span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT&#41; is not routinely performed in the work-up of seminoma&#44; however its value in the diagnosis of primary tumor site and distant metastasis is well known in many forms of solid malignant tumors&#44; depending on its ability to give both anatomic and functional imaging&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Seminoma have shown high <span class="elsevierStyleSup">18</span>F-FDG avidity and so PET&#47;CT can be useful in the post-chemotherapy management or in the follow-up of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Tumor markers are considered useful tools to evaluate the risk of possible recurrence in several cancers&#46; Tumor markers for testicular cancer include alpha-fetoprotein &#40;AFP&#41;&#44; human chorionic gonadotropin &#40;hCG&#41; and lactate dehydrogenase &#40;LDH&#41;&#46; By definition&#44; pure seminoma can give an elevation of hCG while it does not interfere with AFP values&#46; After primary orchiectomy&#44; serum tumor markers are an integral part in restaging and in particular after a period of at least 5 half-lives they can normalize to baseline level and therefore be used to evaluate potential recurrence of disease&#46; Half-life of hCG can vary from 1 to 3 days while AFP has a half-life of 5 to 7 days&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The purpose of our study was to evaluate the accuracy of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT in detecting tumor persistence or recurrence in patients previously treated for seminoma and to search a possible correlation between <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT features and tumor markers such as AFP and hCG&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We retrospectively included a total of 65 <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scans in 41 patients with a previous diagnosis of seminoma&#44; performed in our center from May 2006 to September 2019&#46; Every PET&#47;CT scan was performed at least one month after completion of chemotherapy and at least two months after completion of radiotherapy or surgery&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A dose of 3&#46;5&#8211;4&#46;5 MBq&#47;kg of <span class="elsevierStyleSup">18</span>F-FDG was administered intravenously to the patient and images were acquired 60<span class="elsevierStyleHsp" style=""></span>min after radiotracer injection from the skull base to the midthigh on a Discovery ST or Discovery 690 PET&#47;CT tomograph &#40;General Electric Company&#44; GE&#44; Milwaukee&#44; Wisconsin&#41; with standard parameters &#40;CT&#58; 80<span class="elsevierStyleHsp" style=""></span>mA&#44; 120<span class="elsevierStyleHsp" style=""></span>kV&#59; PET&#58; 2&#46;5&#8211;4<span class="elsevierStyleHsp" style=""></span>min per bed position&#44; PET step of 15<span class="elsevierStyleHsp" style=""></span>cm&#41;&#59; the reconstruction was performed in a 256<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>256 matrix and 60-cm field of view&#46; Patients were instructed to void before imaging acquisition&#44; and no oral or intravenous contrast agents were administrated or bowel preparation used for any patient&#59; written consent was obtained before studies&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">PET&#47;CT images were analyzed visually and semi-quantitatively by two experienced nuclear medicine physicians by consensus&#46; Readers were aware about clinical history and other imaging&#59; every focal tracer uptake deviating from physiological distribution and background was regarded as suggestive of disease persistence&#46; Semiquantitative analysis was performed by measuring the maximum and mean standardized uptake value body weight max &#40;SUVbwmax&#44; SUVbwmean&#41;&#44; maximum SUV lean body mass &#40;SUVlbm&#41;&#44; maximum SUV body surface area &#40;SUVbsa&#41;&#44; metabolic tumor volume &#40;MTV&#41; and total lesion glycolysis &#40;TLG&#41; of hypermetabolic lesions&#46; MTV was measured from attenuation-corrected <span class="elsevierStyleSup">18</span>F-FDG-PET images using a SUV-based automated contouring program &#40;Advantage Workstation 4&#46;6&#44; GE HealthCare&#41; with an isocounter threshold method based on 41&#37; of the SUVmax&#44; as previously recommended by European Association of Nuclear Medicine because of its high inter-observer reproducibility&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> TLG was calculated as the sum of the product of MTV of each lesion and its SUVmean&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The tumor markers values collected in a time range of 3 months from the PET scan were registered&#46; AFP was considered as positive when higher or equal to 6 UI&#47;mL&#59; hCG was considered positive if higher or equal to 10 mUI&#47;mL&#44; according to the reference values of our institution&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A combination of clinical&#47;imaging follow-up data collected for at least 12 months and&#47;or histopathology &#40;when available&#41; was taken into account as reference standard in order to evaluate PET&#47;CT diagnostic accuracy and to select hypermetabolic lesions in order to perform semiquantitative analysis&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All statistical analysis was carried out using MedCalc Software version 17&#46;1 for Windows &#40;Ostend&#44; Belgium&#41;&#46; A <span class="elsevierStyleItalic">p</span>-value &#60;0&#46;05 was considered statistically significant&#46; The descriptive analysis of categorical variables comprised the calculation of simple and relative frequencies&#46; The numeric variables were described as mean&#44; standard deviation&#44; minimum and maximum&#46; Using final diagnosis as a reference&#44; sensitivity &#40;SE&#41;&#44; specificity &#40;SP&#41;&#44; positive predictive value &#40;PPV&#41;&#44; negative predictive value &#40;NPV&#41; and accuracy &#40;AC&#41; were calculated based on Bayes&#39;s law&#44; with 95&#37; confidence intervals &#40;Cis&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Chi Square test was performed to assess the correlation between qualitative PET&#47;CT results&#44; tumor markers positivity or negativity&#44; age &#40;considering a threshold of 35 years&#41;&#44; stage &#40;early or advanced&#41; and type of primary therapy &#40;only surgery vs surgery plus radio- or chemotherapy&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Kruskall&#8211;Wallis test was performed in order to evaluate a possible significant correlation between PET&#47;CT result and tumor makers absolute values and between tumor markers positivity or negativity and semiquantitative parameters &#40;SUVmax&#44; SUVmean&#44; SUVbsa&#44; SUVlbm&#44; MTV and TLG&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Receiver operating characteristic &#40;ROC&#41; curve analysis was then performed to identify the best tumor markers values for AFP and hCG to discriminate between patient with positive PET&#47;CT scan or patients with negative one&#46; Area under curve &#40;AUC&#41;&#44; SE and SP was obtained for each of the two values calculated with ROC analysis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">Mean age of patients was 42 &#40;standard deviation 8&#44; range 22&#8211;58&#41; years&#59; 10 of them had a stage I disease&#44; 27 had a stage II disease while stage III disease was present in 4 patients&#46; All patients&#44; except one who underwent chemotherapy only&#44; had a PET&#47;CT scan after a previous orchiectomy&#46; Of these patients&#44; 18 performed only surgery&#44; 14 performed chemotherapy after surgery&#44; 2 chemotherapy plus radiotherapy and 6 only radiotherapy after primary surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Mean time between PET&#47;CT scan and tumor markers sampling was 27 day &#40;standard deviation 21&#44; range 1&#8211;87&#41;&#46; HCG values were available in conjunction with PET&#47;CT studies in 61 patients&#58; 54 of them were under the normal limit while 7 were above that limit&#59; AFP values were collected in 43 PET&#47;CT studies&#58; 39 were under the limit while 4 were above&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Of the total of 65 PET&#47;CT scans performed&#44; 34 &#40;52&#37;&#41; were positive for persistence or recurrence while 31 &#40;48&#37;&#41; were negative&#46; All positive PET&#47;CT showed abdomino-pelvic nodal localizations and in 5 cases also thoracic or laterocervical nodal metastases &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In one case&#44; PET&#47;CT revealed a bone metastasis located to a rib &#40;this patient was excluded to the subsequent statistical analysis being the only one with distant metastasis&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Among 34 positive PET&#47;CT studies&#44; 28 were confirmed as true positive while 6 were classified as be false positive on the subsequent follow-up&#44; based on histopathological evaluation for 25 &#40;74&#37;&#41; scans and on radiological data for other scans &#40;imaging follow-up with CT or MR scans for at least 12 months&#44; in particular with a mean follow-up of 17&#46;1 months&#41;&#46; Regarding false positive scans&#44; in 4 of them we found focal uptake in the lungs subsequently defined as inflammatory disease on radiological follow-up and 2 scans revealed nodal uptake at the inguinal level&#44; subsequently defined as inflammatory disease by histopathological evaluation&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Among 31 negative scans&#44; all were confirmed as true negative on subsequent radiological follow-up &#40;imaging follow-up with CT or MR scans for at least 12 months as previously mentioned&#44; in particular with a mean follow-up of 21&#46;3 months&#41;&#46; Sensitivity&#44; specificity&#44; positive predictive value&#44; negative predictive value and accuracy of <span class="elsevierStyleSup">18</span>F-FDG-PET&#47;CT were 100&#37;&#44; 84&#37;&#44; 82&#37;&#44; 100&#37;&#37; and 91&#37;&#44; respectively&#46; Positive and negative likelihood ratios were 6&#46;17 and 0&#44; respectively&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">No significant correlation was found between PET&#47;CT results and age&#44; stage&#44; therapy and serum markers &#40;AFP and hCG&#41; findings dichotomized as positive and negative&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">No significant correlation was found between PET&#47;CT positivity or negativity and AFP or hCG values dichotomized as above or under references values&#46; Similarly&#44; no significant correlation was observed when comparing PET positivity or negativity to tumor markers absolute values &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Instead a positive significant association between hCG positivity or negativity and semiquantitative PET parameters was found &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Moreover&#44; considering hCG absolute values a significant correlation was reported with SUVmax&#44; SUVmean&#44; MTV and TLG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; but not with SUVlbm and SUVbsa&#46; No significant correlation was therefore observed comparing AFP absolute values or dichotomized as positive or negative with PET semiquantitative parameters &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Applying ROC curves analysis&#44; we found a value of 1&#46;41 UI&#47;mL for AFP &#40;AUC 0&#46;703&#44; sensitivity 87&#37;&#44; specificity 50&#37;&#41; and a value of 4&#46;9 mUI&#47;mL for hCG &#40;AUC 0&#46;675&#44; sensitivity 37&#37;&#44; specificity 91&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Comparing serum markers using aforementioned cutoff values and PET&#47;CT results&#44; no significant association were observed &#40;<span class="elsevierStyleItalic">p</span> value 0&#46;12 for AFP and <span class="elsevierStyleItalic">p</span> value 0&#46;17 for hCG&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">It has been shown that late relapse of testis cancer is relatively common and often occur more than 2 years after the completion of primary treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7</span></a> In this context&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT can be a useful tool to evaluate possible relapse of seminoma and for the follow-up of patients&#44; especially after chemotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Moreover&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT has an important prognostic value and combined with TNM staging and tumor markers&#44; helps to better stratify the risk&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Likewise&#44; serum tumor markers are worldwide accepted as a simple and reliable method for the same goal&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9&#44;11</span></a> Guidelines for follow-up of testicular seminoma underline the fact that when assessing chemotherapy in late relapse&#44; the decision of performing new therapy must be individualized also on tumor markers development&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Cook et al&#46; reported that <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT is an accurate method for localizing active disease when tumor markers are abnormal and conventional imaging &#40;CI&#59; ultrasonography&#44; CT and eventually MR&#41; is negative&#59; similar findings are also reported in another work by the same authors&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> A possible correlation between PET and tumor markers could be very helpful since it can provide metabolic information allowing the differentiation between viable residual tumor and scar tissue&#44; fibrosis or necrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In our study&#44; in all positive PET&#47;CT scans we reported at least one retroperitoneal abdomino-pelvic metastatic nodal uptake and this finding agrees with the fact that metastatic spread of testicular tumors occurs mainly through the lymphatic route to the retroperitoneal nodes via predictable lymphatic channels&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In particular&#44; right-sided tumors typically spread to inter-aorto-caval nodes&#44; while left-sided ones spread to paraortic nodes&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Our analysis confirmed the good diagnostic value of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT in the restaging of seminoma after primary therapy&#46; Most of the scans were confirmed as true positive or true negative and only 6 scans were classified as false positive&#58; in 4 of them we reported focal uptake in the lungs subsequently defined as inflammatory disease and in 2 scan we reported focal nodal uptake at inguinal level&#44; subsequently defined as inflammatory disease&#46; It is however well known that important causes of PET false positive findings are caused by inflammatory diseases&#44; according with our findings&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In a recent meta-analysis&#44; Treglia et al&#46; found an overall SE of 78&#37;&#44; SP of 86&#37;&#44; PPV of 58&#37;&#44; NPV of 94&#37; and AC of 84&#37; when evaluating the potential role of PET&#47;CT in restaging seminoma after chemotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Our results confirm this evidence&#44; highlighting the fact that negative findings in PET&#47;CT scans could avoid unnecessary therapies because of its excellent NPV&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14&#44;15</span></a> In our study we obtained a SE and a NPV of 100&#37;&#44; in absence of false-negative scans&#59; the low number of patients that were collected for the study could be an explanation to this difference between the values&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Analyzing the potential relationship between PET&#47;CT results and tumor markers&#44; we did not find any correlation between PET scan positivity or negativity and serum markers ones&#46; This fact is partially in contrast with the results obtained by Alongi et al&#46; in a recent paper focused on the role of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT in the restaging of germinal tumor cell carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> A possible explanation to these different results is the fact that we focused only on patients with a diagnosis of seminoma&#44; instead of including all types of germ cell tumors&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Moreover we did not find any influence of age&#44; type of primary therapy and stage on PET&#47;CT results&#46; Only hCG values significantly correlated with PET&#47;CT result&#59; this association could derive from the fact that the more vital the tumor mass&#44; the more marker is put into the blood-pool&#46; This point strengths the fact that <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT is useful to distinguish between residual viable tissue or necrotic one&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;14</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Alongi et al&#46; reported the influence of PET results and clinical stage on progression free survival &#40;PFS&#41; and overall survival &#40;OS&#41; in patients with seminoma&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Our results do not allow us to state that tumor markers values correlates with PET&#47;CT scan result&#44; so a possible influence of markers on PFS and OS cannot be speculate&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In agreement with several guidelines about germ cell tumors and seminoma management&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9&#44;11</span></a> AFP values did not correlate with PET results&#46; As known&#44; by definition seminoma express only hCG and not AFP but in our institute also the second marker is routinely performed&#44; so we decided to take note also of this one&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Comparing tumor markers and PET semiquantitative values&#44; we found correlation of hCG values with SUVmax&#44; SUVmean&#44; MTV and TLG&#59; this results confirm our insight of a correlation between tumor viability and marker expression&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In the past&#44; Ambrosini et al&#46; underlined the role of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT in patients with seminoma providing relevant informations that determined a changed clinical management in about 87&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">ROC curve analysis allowed us to find a discriminating value of 4&#46;9 mUI&#47;mL for hCG when searching for PET&#47;CT positivity or negativity with an AUC of 0&#46;675&#44; a sensitivity of 37&#37; and a specificity of 91&#37;&#46; For AFP we obtained a value of 1&#46;41 UI&#47;ml with an AUC of 0&#46;703&#44; a sensitivity of 87&#37; and a specificity of 50&#37;&#46; In fact&#44; among patients with hCG higher than 4&#46;9 mUI&#47;mL PET&#47;CT scan resulted positive in 17 cases &#40;67&#37;&#41;&#44; while in patients with hCG lower than 4&#46;9 mUI&#47;mL PET&#47;CT was positive only in 3 cases &#40;50&#37;&#41;&#46; Instead&#44; for AFP higher than 1&#46;41 UI&#47;ml PET&#47;CT scan resulted positive in 13 cases &#40;68&#37;&#41;&#44; while in patients with AFP lower than 1&#46;41 UI&#47;ml only in 2 cases PET&#47;CT was positive &#40;33&#37;&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Our work presents some limitations&#46; First of all&#44; this is a retrospective study with heterogeneous characteristics of the population in terms of clinical features&#46; Moreover all 65 <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scans evaluated came from 41 patients only which is a relatively low sample&#46; The low rate of patients with positive markers and the fact that definitive histopatological diagnosis was not available for all PET&#47;CT scan&#44; are important limitations&#46; Mean time between PET scan and markers sampling &#40;27 days&#41; is another limitation&#58; this long time compared to markers half-life is due to clinical and technical reasons&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">In conclusion&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT seems to be accurate diagnostic tool in evaluating patients with relapse of seminoma or with persistence of disease&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Moreover&#44; there is a significant correlation between hCG values and PET&#47;CT results &#40;qualitative and most of semiquantitative parameters&#41;&#46; On the other hand&#44; there is no correlation between AFP values and PET&#47;CT features&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of our study was to analyze the potential relationship between tumor markers and <span class="elsevierStyleSup">18</span>F-fluorodoxyglucose positron emission tomography&#47;computed tomography &#40;<span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT&#41; results in patients affected by seminoma&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">65 <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scans of 41 patients with diagnosis of seminoma were analyzed and compared to alpha-fetoprotein &#40;AFP&#41; and human chorionic gonadotropin &#40;hCG&#41;&#46; PET&#47;CT studies were analyzed qualitatively and measuring the maximum and mean standardized uptake value body weight max &#40;SUVbwmax&#44; SUVbwmean&#41;&#44; maximum SUV lean body mass &#40;SUVlbm&#41;&#44; maximum SUV body surface area &#40;SUVbsa&#41;&#44; metabolic tumor volume &#40;MTV&#41; and total lesion glycolysis &#40;TLG&#41; of hypermetabolic lesions&#46; All values were compared with serum markers&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">31 PET&#47;CT studies were true negative&#44; 28 true positive&#44; 6 false positive and 0 false negative with sensitivity of 100&#37;&#44; specificity of 84&#37;&#44; negative predictive value of 100&#37;&#44; positive predictive value of 82&#37; and accuracy of 91&#37;&#46; No correlation between PET results and tumor marker levels was found and also between AFP and PET&#47;CT semiquantitive parameters&#46; All semiquantitative PET parameters were significantly related to hCG level&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT has good accuracy in evaluating patients with relapsed seminoma&#46; HCG levels were significantly correlated with metabolic PET&#47;CT parameters&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo de nuestro estudio fue analizar la posible relaci&#243;n entre los marcadores tumorales y los resultados de la tomograf&#237;a por emisi&#243;n de positrones con <span class="elsevierStyleSup">18</span>F-fluorodoxiglucosa&#47;tomografia computarizada &#40;<span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT&#41; en pacientes afectados por seminoma&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">se analizaron 65 exploraciones PET&#47;TC <span class="elsevierStyleSup">18</span>F-FDG de 41 pacientes con diagn&#243;stico de seminoma y se compararon con alfafetoprote&#237;na &#40;AFP&#41; y gonadotropina cori&#243;nica humana &#40;hCG&#41;&#46; Los estudios PET&#47;CT se analizaron cualitativamente y midieron el valor m&#225;ximo y medio de la captacion estandarizada de peso corporal maximo &#40;SUVbwmax&#44; SUVbwmean&#41;&#44; masa corporal magra SUV maxima &#40;SUVlbm&#41;&#44; &#225;rea de superficie corporal m&#225;xima de SUV &#40;SUVbsa&#41;&#44; volumen tumoral metab&#243;lico &#40;MTV&#41; y gluc&#243;lisis de lesi&#243;n total &#40;TLG&#41; de lesiones hipermetabolicas&#46; Todos los valores se compararon con marcadores sericos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">31 estudios PET&#47;CT fueron verdaderos negativos&#44; 28 verdaderos positivos&#44; 6 falsos positivos y 0 falsos negativos con sensibilidad del 100&#37;&#44; especificidad del 84&#37;&#44; valor predictivo negativo del 100&#37;&#44; valor predictivo positivo del 82&#37; y precision de 91&#37;&#46; No se encontro correlaci&#243;n entre los resultados de PET y los niveles de marcadores tumorales y tampoco entre los par&#225;metros semicuantitativos de AFP y PET&#47;CT&#46; Todos los par&#225;metros semicuantitativos de PET se relacionaron significativamente con el nivel de hCG&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT tiene buena precisi&#243;n en la evaluaci&#243;n de pacientes con seminoma recidivante&#46; Los niveles de HCG se correlacionaron significativamente con los parametros metabolicos de PET&#47;CT&#46;</p></span>"
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            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todo"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0070">Please cite this article as&#58; Dondi F&#44; Albano D&#44; Bertagna F&#44; Giubbini R&#46; Marcadores tumorales y <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT despu&#233;s de orquiectom&#237;a en seminoma&#58; &#191;hay alguna correlaci&#243;n&#63; Rev Esp Med Nucl Imagen Mol&#46; 2021&#59;40&#58;287&#8211;292&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">MIP &#40;1&#41; of a negative <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scan performed in a patient with negative hCG and AFP&#46; Axial CT &#40;2a&#41;&#44; axial PET &#40;2b&#41;&#44; fused axial PET&#47;CT &#40;2c&#41; and MIP &#40;2d&#41; images of a <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scan demonstrating external iliac&#47;inguinal metastases in a patient with positive hCG and AFP&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">MIP &#40;a&#41;&#44; axial CT &#40;b&#41;&#44; axial PET &#40;c&#41; and axial fused PET&#47;CT &#40;d&#41; images of a <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scan demonstrating a metastatic lesion on the posterior arch of the 8th right rib in a patient with positive hCG and negative AFP&#46;</p>"
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                  \t\t\t\t">Age&#44; years &#40;mean&#44; range&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Stage</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;320&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;32&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;82&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;61&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;18&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Therapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;184&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;53&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;32&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Surgery<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>chemo&#47;radiotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;44&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;68&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Only chemotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">AFP</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;630&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;13&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;87&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">hCG</span><span class="elsevierStyleSup">c</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Positive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;19&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;81&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;97&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">AFP</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleItalic">as continuous values</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;44&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;48&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;086&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">hCG</span><span class="elsevierStyleSup">d</span><span class="elsevierStyleItalic">as continuous values</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;56&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;52&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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Article information
ISSN: 22538089
Original language: English
DOI:10.1016/j.remnie.2020.09.010
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