Summary of results

The following cancers have been considered:

(1) Non-small cell lung cancer (NSCLC) (2) Small cell lung cancer (SCLC) (3) Lymphoma

(4) Breast cancer (5) Melanoma (6) Ovarian cancer

(7) Cancer of the uterus and cervix (8) Head and neck cancers

(9) Kidney cancer (10) Germinal tumours

(11) Cancer of unknown primary (CUP) (12) Colorectal cancer

(13) Gastric carcinoma

(14) Sarcomas (soft tissue and bone)

(15) Primary tumours of the central nervous system (16) Nasopharyngeal carcinomas

Cancers for which FDG-PET has no established role, such as prostate and hepatocellular carcinoma, are not discussed in this publication. Also, as most gastro-entero-pancreatic tumours (GEPTs) and mucinous adenocarcinomas are not FDG avid, FDG-PET is usually inappropriate for them.

Tables 1–4 summarize clinical indications for which the use of FDG-PET is recognized as appropriate, potentially appropriate, possibly appropriate and inappropriate, respectively.

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TABLE 1. INDICATIONS CONSIDERED APPROPRIATE Type of cancerDiagnosisStagingResponse evaluationRestagingSuspected recurrenceFollow-upRT planning Lung cancerCharacterization of SPNNSCLC considered for curative treatment LymphomaHD, aggressive NHL Assess FDG avidityHD and NHL with proven FDG avidity HD and NHL with proven FDG avidity

Characterize masses after treatment of HD and NHL with proven FDG avidity MelanomaOperable versus inoperable recurrence Ovarian cancerComplementary to MRI Cancer of the uterus and cervix

N staging in tumours invading beyond uterus

Confirmed recurrenceYes Head and neck cancersCUPAfter chemotherapy and/or radiotherapy End of treatmentAfter surgery and/or radiotherapy

Colorectal cancerIn apparently isolated local recurrence or metastases prior to surgery

In case of rising tumour markers and non-diagnostic conventional imaging Naso- pharyngeal carcinomas

N, M stagingYesEnd of treatment Confirmed recurrence Gastrointestinal stromal tumours (GISTs) YesYesViability assessment of confirmed recurrent tumour Viability assessment of suspected recurrent tumour

Yes Oesophageal cancerM staging Thyroid cancerIn patients with positive Tg and negative131I whole body scan

Rising tumour markers (Tg, calcitonine) to detect lesions accessible to surgery Note: CUP: cancer of unknown primary;FDG: 2-fluoro-2-deoxy-D-glucose; HD: Hodgkin’s disease; MRI: magnetic resonance imaging; NHL: non- Hodgkin’s lymphoma; NSCLC: non-small cell lung cancer; RT: radiotherapy; SPN: solitary pulmonary nodule; Tg: thyroglobulin.

TABLE 1. INDICATIONS CONSIDERED APPROPRIATE (cont.) Type of cancerDiagnosisStagingResponse evaluationRestagingSuspected recurrenceFollow-upRT planning

TABLE 2. INDICATIONS CONSIDERED POTENTIALLY APPROPRIATE Type of cancerDiagnosisStagingResponse evaluationRestagingSuspected recurrenceFollow-upRT planning Lung cancerNSCLC: Following neoadjuvant CXT to evaluate operability During definite RT/CXT to adapt dose according to response

NSCLC: Define RT treatment fields Breast cancerLocally advanced diseaseAdvanced/metastatic diseaseConfirmed recurrenceIn case of rising tumour markers MelanomaAdvanced (stage III–IV) disease Ovarian cancerYesConfirmed recurrence Cancer of the uterus and cervixEnd of treatmentRT planning (para-aortic nodal involvement in cervical carcinoma) Head and neck cancersDetect nodal involvement, distant metastases, synchronous tumours

Confirmed recurrenceAssist in defining target volume

Kidney cancerConfirmed recurrence Cancer of unknown primary, non-ENT

Detect primaryEvaluate extent of disease Colorectal cancerYes Nasopharyngeal carcinomasIdentify site(s)  of recurrence Pancreatic adenocarcinomaAssess FDG avidity to characterize pancreatic mass

Distinguish recurrence from post-treatment changes Oesophageal cancerAssess response after neoadjuvant therapy prior to surgery Identify disease amenable to locoregional therapy Assist in defining target volume Note: CXT: chemotherapy; ENT: ear–nose–throat; FDG: 2-fluoro-2-deoxy-D-glucose; NSCLC: non-small cell lung cancer; RT: radiotherapy.

TABLE 2. INDICATIONS CONSIDERED POTENTIALLY APPROPRIATE (cont.) Type of cancerDiagnosisStagingResponse evaluationRestagingSuspected recurrenceFollow-upRT planning

TABLE 3. INDICATIONS CONSIDERED POSSIBLY APPROPRIATE Type of cancerDiagnosisStagingResponse evaluation RestagingSuspected recurrenceFollow-upRT planning Lung cancerSCLCGuide selection of appropriate therapy in case of solitary metastases or local recurrence of NSCLC

NSCLC SCLCSCLC NSCLC: Define total dose Breast cancerAssist in defining target volume MelanomaAssess FDG avidity in lesions not easily amenable to biopsy Ovarian cancerYesEnd of treatmentYes Cancer of the uterus and cervix

Yes Kidney cancerIn advanced disease Germinal tumoursExcept for mature teratomaElevated tumour markers/equivocal CT Cancer of unknown primary, non-ENT

Raised tumour markers and normal/ inconclusive conventional workup Evaluate extent of disease

Colorectal cancerYesYesYes Gastric carcinomaYesAfter neoadjuvant therapyYes Sarcomas (soft tissue/bone)Guide biopsyYes (extra- pulmonary metastases) Potentially change CXT in case of non-response Yes (extra- pulmonary metastases)

Guide biopsyYesYes Primary CNS tumoursGuide biopsyYesDistinguish recurrence from radionecrosisLow grade tumourGuide RT dose escalation Naso- pharyngeal carcinomas

YesAssist in defining target volume Pancreatic adenocarcinomaM stagingYesAssist in defining target volume; dose intensification Cholangio-/ gallbladder carcinoma

Differentiate benign from malignant lesions N, M stagingYes Note: CNS: central nervous system; CT: computed tomography; CXT: chemotherapy; ENT: ear–nose–throat; FDG: 2-fluoro-2-deoxy-D-glucose; NSCLC: non-small cell lung cancer; RT: radiotherapy; SCLC: small cell lung cancer.

TABLE 3. INDICATIONS CONSIDERED POSSIBLY APPROPRIATE (cont.) Type of cancerDiagnosisStagingResponse evaluation RestagingSuspected recurrenceFollow-upRT planning

TABLE 4. INDICATIONS CONSIDERED INAPPROPRIATE Type of cancerDiagnosisStagingResponse evaluation RestagingSuspected recurrenceFollow-upRT planning Lung cancerSCLCNSCLC after definitive CXT/RT SCLC NSCLC at end of treatment SCLC

NSCLC SCLC LymphomaHD and NHLNon-follicular low grade NHLYesYes Breast cancerYesAxilla in the absence of palpable nodes

End of treatmentYes MelanomaYesStaging of stage I–II melanomasYesEnd of treatmentYesYes Ovarian cancerYesYes Cancer of the uterus and cervixYesYes Head and neck cancersCharacterize lesion Guide biopsy (except CUP)

Yes Kidney cancerYesYes (except advanced disease)YesEnd of treatmentYesYesYes Germinal tumoursYesYesYesYesYes Cancer of unknown primary (CUP) with metastases outside neck

NANANANANA

Colorectal cancerYes Gastric carcinomaCharacterize lesion Guide biopsyEnd of treatmentYesYes Sarcomas (soft tissue/bone)Characterize lesion Primary CNS tumoursYesYesEnd of treatment Confirmed recurrence Nasopharyngeal carcinomasYes Gastrointestinal stromal tumours (GISTs)

YesAfter curative surgeryYes Pancreatic adenocarcinomaEnd of treatment Confirmed recurrenceYes Cholangio-/ gallbladder carcinomaEnd of treatment Confirmed recurrenceYesYesYes Oesophageal cancerCharacterize lesion Guide biopsyEnd of treatmentYes Thyroid cancerYesYesYesYesYes Note: CNS: central nervous system; CUP: cancer of unknown primary; CXT/RT: chemotherapy/radiotherapy; HD: Hodgkin’s disease; NA: not applicable; NHL: non-Hodgkin’s lymphoma; NSCLC: non-small cell lung cancer; RT: radiotherapy; SCLC: small cell lung cancer.

TABLE 4. INDICATIONS CONSIDERED INAPPROPRIATE (cont.) Type of cancerDiagnosisStagingResponse evaluation RestagingSuspected recurrenceFollow-upRT planning

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