PET CT SCANS CLINICAL GUIDELINES

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					PET / CT SCANS CLINICAL GUIDELINES

Produced by: Address:

Yorkshire Cancer Network Imaging / PET CT Group Arthington House, Cookridge Hospital, Hospital Lane, Leeds, LS16 6QB

Telephone: Fax: Website: Document Version Publication Date Review Date

0113 3924033 0113 3924131 www.ycn.nhs.uk 3 October 2007 October 2008

Contents
1 2 3 4 5 6 7 8
8.1 8.2

INTRODUCTION................................................................................................. 3 LUNG CANCER ................................................................................................... 4 HAEMATOLOGICAL CANCER....................................................................... 5 COLORECTAL CANCER .................................................................................. 7 OESOPHAGO-GASTRIC CANCER ................................................................. 8 HEAD AND NECK (EXCLUDING THYROID) CANCER............................. 9 SELECTED PATIENT INDICATIONS........................................................... 10 ROLES OF NETWORK GROUPS................................................................... 12
ROLES OF THE NETWORK SITE SPECIFIC GROUPS............................................................................ 12 ROLE OF THE IMAGING GROUP ........................................................................................................ 12

9

APPENDIX 1 ....................................................................................................... 13

1 Introduction
PET CT scanning has made an impact on the ability to improve cancer diagnosis. The four main tumour sites, where PET CT scanning has influenced clinical decision making are: lung, lymphoma, colorectal and oesophago-gastric cancers…A summary of the potential numbers of scans by tumour site is attached in Appendix 1. These numbers constitute an assessment based on broad indications and clinical opinion. The impact of the introduction of a limited PET CT service in Hull has found that over a sixmonth period the most frequent indications for scanning were for lung and colorectal cancers. In 21% of case the assessment led to a down-staging of disease (and subsequent avoidance of any intervention is presumed). In 34% of cases the tumour was upstaged and unnecessary surgery thus avoided. Clinical Indications The following guidance is the current position for the use of PET CT scanning for the Yorkshire Cancer Network. MDT Support It is proposed until a national framework is in place, that the roles and responsibilities of the MDT radiologist with regard to PET/CT would be: To present the scan findings as reported To liase with the PET/CT reporter (or other PET trained individual) in the case of a suspected discrepancy or if clarification is required To have an understanding of the technique including its limitations and knowledge of the appropriate indications within the spectrum of disease covered by their particular MDT. To seek advice from a suitably trained colleague if any question arises within the MDT with regard to PET/CT which is outside the area of competence.

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2 Lung cancer
Rationale: For NSCLC to help decide if radical surgery or radiotherapy is required or not by staging for mediastinal nodes and distant metastasis. To help in cases where biopsy is not appropriate and therefore help diagnose suspected malignancy. Indication: All patients judged as operable or for radical radiotherapy by conventional CT staging In cases where conventional CT raises the possibility of distant metastasis In cases of a single operable pulmonary nodule where biopsy is not appropriate or has failed. Patients with mesothelioma who are candidates for radical surgery on CT All cases to be referred for PET CT only after MDT discussion Numbers: 20% NSCLC 362 patients per year Audit: Indications for scan Change in stage and clinical decision

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3 Haematological cancer
Rationale: PET-CT has been used initially to stage disease and to assess response to treatment in nonHodgkin’s lymphoma and Hodgkin lymphoma, although the latter has been more extensively studied. It can identify disease in normal sized nodes and at exta-nodal sites. It can be used for early assessment of reponse after 2 cycles of chemotherapy and at the end of treatment to confirm response. It can, also, to identify whether metabolically active disease is present in residual masses.. Indications: Currently evidence would suggest that if access to PET-CT were unlimited, it would be helpful in managing, all patients being treated with curative intent: with Hodgkin’s disease should be scanned at diagnosis, at the end of treatment and possibly after 2 cycles of chemotherapy with large cell lymphoma should be scanned at diagnosis and at the end of treatment with stage IA follicular lymphoma should be scanned at diagnosis where relapse of Hodgkin’s disease or large cell lymphoma is suspected In the current situation where access to CT-PET is limited, it is suggested that patient’s should have access to PET-CT in the following order of priority: 1. Women under the age of 35 years with mediastinal Hodgkin’s disease. This may help to determine whether any residual mediastinal mass at the end of chemotherapy contains active Hodgkin’s disease. Patients with negative PET scans may not need adjuvant radiotherapy. Patients with Hodgkin’s disease receiving treatment aimed at cure (including adolescents) To characterise residual disease when conventional imaging is equivical and there is a significant risk to further treatment Patients with large cell lymphoma receiving treatment aimed at cure.Patients with seemingly stage IA follicular lymphoma being planned for radical radiotherapy.

2. 3. 4.

All cases to be referred for PET CT only after discussion in a Lymphoma MDT Numbers: New patients diagnosed per year in the YCN with: Hodgkin’s disease 75 (including 20 women age <35 years) Large cell lymphoma 200 Stage IA follicular lymphoma 15 Audit: Use (reduction) of CT imaging at staging

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Proportion of patients where management decision is changed. Success of second line treatment Use of additional PET CT (after second line treatment)

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4 Colorectal cancer
Rationale: To help differentiate between suspected recurrence and post therapy fibrosis. To exclude distant metastasis if considering hepatic or lung secondary resection Indications: A raised CEA tumour marker on follow-up with normal or equivical conventional imaging and colonoscopy who are fit for further treatment Suspected recurrence found at pelvic CT Potentially resectable hepatic or lung secondaries on CT All cases to be referred for PET CT only after discussion in a Colorectal, Hepatobiliary or Lung MDT Numbers: Approximately 30% recurrence rate in colorectal cancer 450 patients per year Audit: Indication for scan Change in patient status Change in clinical decision

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5 Oesophago-gastric cancer
Rationale: Will help to identify patients who do not require radical surgery as the disease may be too extensive for surgery to be successful. Indication: All patients with oesophageal or gastro-oesophageal junction tumours being considered for radical surgery including those who have had neo-adjuvant chemo-radiotherapy All cases to be referred for PET CT only after discussion in an Upper GI MDT Numbers: 33% of all cancers 92 patients per year Audit: Stratify for those patients who do not receive neoadjuvant treatment Assess change in stage of disease Assess change in clinical decision

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6 Head and Neck (excluding Thyroid) cancer
Rationale: Helps in the decision whether or not to operate unilaterally or bilaterally by detecting sub clinical disease. Helps determine whether suspicious recurrence is fibrosis due to post-therapy reaction or true cancer recurrence. Indication: All patients where unilateral or bilateral surgery is contemplated To help identify the primary site in patients with proven metastatic squamous cell carcinoma in cervical lymph nodes To distinguish between fibrosis and local recurrence in patients where cross-sectional imaging is equivical and the result of the PET would significantly alter patient management All cases to be referred for PET CT only after discussion in a Head & Neck MDT Numbers: 1 - 2 per month, 12 – 24 patients per year Audit: Indications for scan Change in management plan or surgery

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7 Selected patient indications
Rationale: Evaluation of response to therapy and detection of recurrence Indication: Thyroid cancer Patients with treated differentiated thyroid carcinoma with an elevated thyroglobulin (> 10ng/ml), negative whole body iodine scintigraphy and equivical or normal cross-sectional imaging Patients with treated medullary thyroid carcinoma, elevated calcitonin levels (> 1000pg/ml), equivical or normal cross-sectional imaging, bone and octreotide scintigraphy All cases to be referred for PET CT only after discussion in a Thyroid/Endocrine MDT Testicular cancer Assessment of patients with metastatic seminoma or teratoma with a residual mass following treatment Assessment of patients with suspected recurrence of seminoma or teratoma and equivical or normal conventional imaging All cases to be referred for PET CT only after discussion in a Urology/Germ-Cell MDT Melanoma To exclude metastatic disease in patients fit for curative surgical resection and equivical findings on cross-sectional imaging All cases to be referred for PET CT only after discussion in a Melanoma MDT Sarcoma Assessment of disease extent in patients with metastatic sarcoma potentially suitable for liver or lung metastatectomy where clinical doubt remains following conventional imaging or cross-sectional imaging has not identified any extra-thoracic or extra-hepatic disease which would preclude surgery All cases to be referred for PET CT only after discussion in a Sarcoma, Lung or Hepatobiliary MDT

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Gynaecological tumours Patients with gynaecological malignancy who are being considered for radical curative surgery to exclude extra-pelvic disease which would preclude surgical treatment Patients with suspected recurrence of treated gynaecological malignancy, raised tumour markers and equivical or normal conventional imaging All cases to be referred for PET CT only after discussion in a Gynae MDT Pancreatico-biliary cancers Patients with potentially operable pancreatic adenocarcinoma and conventional imaging which is equivical for metastatic disease who are fit for resection and a positive PET would lead to a decision not to operate Patients with potentially operable cholangiocarcinoma and conventional imaging which is equivical for metastatic disease who are fit for resection and a positive PET would lead to a decision not to operate All cases to be referred for PET CT only after discussion in a Hepatobiliary MDT Suspected Paraneoplastic Neurological Syndrome (PNS) In patients with suspected PNS where conventional imaging has failed to make a diagnosis and the PET result would make a significant difference to patient management All cases to be referred for PET CT only after discussion in a Neurology MDT Breast Carcinoma Assessment of suspected malignant infiltration in patients with a painful brachial plexopathy and known breast carcinoma where conventional imaging is equivical and the result of the PET would make a significant difference to patient outcome All cases to be referred for PET CT only after discussion in a Breast MDT.

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8 Roles of Network Groups

8.1

Roles of the Network Site Specific Groups

Once the clinical indications for PET scanning have been agreed, the relevant NSSG will produce a flow chart of the place within the patient pathway that scanning should appear. In addition, the NSSG will conduct, in collaboration with the PET scan provider, a rolling sixmonthly audit as set out above. This audit will be disseminated to the NSSG group, MDT leads, and commissioners.

8.2

Role of the Imaging Group

A competency framework for training in PET CT imaging and reporting will be developed by the Imaging CCG in order to faciliate a network wide experience in the interpretation and use of PET CT scanning across the region.

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9 Appendix 1
Numbers of PET CT scans per tumour site for the Yorkshire Cancer Network Tumour site Colorectal Lung Lymphoma Oesophago-gastric Selected patients * Total Reason 30 % patients 20% lung cancer patients 2 scans per patient 33% new patients Number 450 362 844 92 400 2148

* Denotes: Sarcoma Breast Melanoma Haed and Neck Testicular Thyroid / endocrine Brain

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