Joint EANM/SNMMI/ESTRO practice recommendations for the use of 2-[18F]FDG PET/CT external beam radiation treatment planning in lung cancer V1.0

Sofia C Vaz,Yolande Lievens,Lioe-Fee De Geus-Oei,Esther G C Troost,Rodney J Hicks,Roberto C Delgado Bolton,Ken Herrmann,Andrea Santos,Bernard Dubray,Heiko Schöder,Pierre Vera,Judit A Adam,Dimitris Visvikis,Wouter Van Elmpt

doi:10.1007/s00259-021-05624-5

Abstract

Purpose2-[18F]FDGPET/CT is of utmost importance for radiation treatment (RT) planning and response monitoring in lung cancer patients, in both non-small and small cell lung cancer (NSCLC and SCLC). This topic has been addressed in guidelines composed by experts within the field of radiation oncology. However, up to present, there is no procedural guideline on this subject, with involvement of the nuclear medicine societies.MethodsA literature review was performed, followed by a discussion between a multidisciplinary team of experts in the different fields involved in the RT planning of lung cancer, in order to guide clinical management. The project was led by experts of the two nuclear medicine societies (EANM and SNMMI) and radiation oncology (ESTRO).Results and conclusionThis guideline results from a joint and dynamic collaboration between the relevant disciplines for this topic. It provides a worldwide, state of the art, and multidisciplinary guide to 2-[18F]FDG PET/CT RT planning in NSCLC and SCLC. These practical recommendations describe applicable updates for existing clinical practices, highlight potential flaws, and provide solutions to overcome these as well. Finally, the recent developments considered for future application are also reviewed.

Highlights

Radiotherapy in lung cancer Lung cancerLung cancer is a major cause of cancer death in both men and women, with an incidence of 11.6% and mortality of 18.4% worldwide (World Health Organization cancer report 2020 [1])
Since 2017, non-small cell lung cancer (NSCLC) is staged according to the eighth edition of the IASLC (International Association for the Study of Lung Cancer) in tumour, nodes, and metastases (TNM) based on the American Joint Committee on Cancer (AJCC) staging system [4]
In NSCLC, radiation treatment (RT) is recommended in the following situations: Early-stage disease — Stereotactic body radiation therapy (SBRT) as primary treatment in stage I and selected node-negative stage IIA disease when patients are medically inoperable or when patients refuse surgery

Summary

Introduction

Lung cancer is a major cause of cancer death in both men and women, with an incidence of 11.6% and mortality of 18.4% worldwide (World Health Organization cancer report 2020 [1]). The joint guideline by the European Society of Gastrointestinal Endoscopy (ESGE), together with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS) [40], for the diagnosis and staging of lung cancer, recommends that EBUS be performed in peripheral NSCLC without clear mediastinal involvement on CT or PET/CT if at least one of the following apply: (i) enlarged or 2-[18F]FDG-avid ipsilateral hilar nodes [since proven nodal involvement may change the target volume], (ii) primary tumour without 2-[18F]FDG uptake [since 2-[18F] FDG is not reliable for staging], or (iii) tumour size ≥ 3 cm (a priori higher risk for metastatic nodal disease). Pathological confirmation was not systematically obtained in every study, several authors concluded nodal staging by 2-[18F]FDG PET improved GTV definition and delineation, enabling dose intensification to involved nodes, while reducing irradiation and resultant toxicity to normal tissues. The physical RT planning and the dose calculation should be reviewed by a dedicated physicist before the final treatment plan has been approved

Procedure and specifications of the examination

Findings

Segmentation methods