Coverage Policy Manual
Policy #: 1998156
Category: Radiology
Initiated: July 1998
Last Review: October 2024
  PET or PET/CT for Non-Small Cell Lung Cancer
Description:
Note:  This policy is intended for those members with contracts that do not have requirements for prior approval for imaging procedures through an independent imaging review organization.
 
 
Positron Emission Tomography (PET) imaging uses radiotracers that can reveal both anatomical and physiological information.  The glucose analog, 2-[fluorine-18]-Fluoro-2-deoxy-D-glucose (FDG) is useful in cancer imaging because it has been found that tumor cells show increased utilization of glucose compared to non-malignant tissue and is the most common radiotracer that is utilized. For certain malignancies PET scans have been shown to be more accurate than other non-invasive tests in detecting malignant disease.  However, as with all diagnostic tests, PET scans do not detect cancer 100% of the time that cancer is present (a false negative test), nor do all positive PET scans represent the presence of malignant disease (a false positive test).  A false negative test may occur because a critical volume of malignant cells is necessary for a PET scan to be positive. PET scans may be false positive in the presence of inflammation or granulomatous disease.
 
PET scans have been studied in patients with known or suspected lung cancer for the following indications:
    • to evaluate a solitary pulmonary nodule of unknown cause to determine if the nodule is malignant;
    • to stage the extent of cancer in a patient with known lung cancer prior to initiating treatment;
    • to evaluate suspected recurrence of disease; and
    • to monitor the effects of treatment.
 
Studies using PET scans to distinguish between malignant and benign pulmonary lesions have shown a sensitivity of 81% to 100%, and a specificity of 52% to 90%.  The probability that a positive PET scan represents a malignant nodule varies from 79% to 95%, and the probability that a negative scan definitely excludes malignancy ranges from 60% to 100%.  Compared to Computed Tomography (CT) the positive predictive value and specificity of PET were better than CT.
 
Studies using PET scans to stage the extent of lung cancer show that the sensitivity and specificity of PET for the detection of mediastinal disease were 91% and 86%, compared to 75% and 66% for CT.  PET also identifies distant metastases better than CT.  PET has been shown to improve the preoperative staging of patients with lung cancer.
 
Few studies have reported the results of repeat PET scans to detect recurrent disease in patients who are symptomatic at the time of the suspected recurrence, and those that are reported include only small numbers of patients.  Even fewer studies have been reported the use of PET scans to follow-up asymptomatic patients previously treated for lung cancer.  The sensitivity of PET is high, but the specificity ranges from as low as 33% to a high of 98%.  PET may be effective for identifying recurrence earlier than would have occurred with other diagnostic modalities, but whether that improves patient outcome is unknown.
 
The result of using of PET to monitor response to chemotherapy has been reported in a few series of small numbers of patients.  In these case series, the interval between tumor therapy and FDG-PET, as well as the method of quantification differ per study. Whether the result of monitoring chemotherapy or radiotherapy with PET improves health outcomes is unknown. Dynamic imaging is not a standard technique to evaluate tumor therapy.
 
Definitions
 
Screening – testing in the absence of an established or clinically suspected diagnosis
 
Diagnosis - testing based on a reasonable clinical suspicion of a particular condition or disorder
 
Diagnostic Workup – initial staging of documented malignancy
 
Management – testing to direct therapy of an established condition, which may include preoperative or postoperative imaging, or imaging performed to evaluate the response to nonsurgical intervention. In oncologic imaging, management applies to patients with measurable disease and to imaging performed before or after planned treatment intervention, therapy response, restaging or clinically suspected recurrence.
 
Surveillance – periodic assessment following completion of therapy. In oncologic imaging, surveillance applies to asymptomatic patients in remission and/or without measurable disease
 
Cannot be performed or is nondiagnostic – applies when the test:
    • Is positive or indeterminate for clinically significant pathology when the information provided about the abnormality by the test is not sufficient to direct subsequent management
    • Is negative when the negative likelihood ratio of the test is both insufficient to confidently exclude the absence of suspected disease and unable to direct subsequent management. This typically applies in scenarios with moderate to high clinical pretest probability with negative testing or low pretest probability with clear evidence for net benefit
    • Has been previously nondiagnostic because of a persistent clinical factor (e.g., body habitus, immobility) that is very likely to make retesting nondiagnostic as well Cannot be performed due to a medical contraindication (e.g., contrast nephrotoxicity, allergy, or in highly radiation sensitive populations such as pediatrics and pregnancy) or reasonable unavailability related to lack of local expertise or service availability
Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
Policy/
Coverage:
Act 583 applies to all contracts subject to AR state law (this includes fully insured contracts, self-funded church sponsored health plans, and self-funded state and local government sponsored health plans except the Arkansas State and Public School Employees program). For a list of the plans subject to AR state law, please see policy guidelines below.
 
As required by Act 583 of the Arkansas Legislature, positron emission tomography to screen for or to diagnose cancer in a patient upon the recommendation of the patient's physician when the patient has a prior history of cancer is covered when the following criteria are met:
 
a) Documentation of the malignancy by pathologic or equivalent report, and
b) Performed no more often than every 6 months, and
c) Ordered by or in consultation with a specialist trained in pediatric oncology for an individual under the age of 18 (given the enhanced risk of radiation exposure in young).
 
Special Note regarding “prior history of cancer”: In applying Act 583 to any PET scan prior approval or coverage decision for those fully-insured contracts and self-funded church or government plans to which Act 583 applies, the patient-member will be considered to have a “prior history of cancer” as referenced in Act 583 if the patient-member either (a) has active cancer at the time a prior approval request is submitted, as documented by a pathologic or equivalent report or (b) previously had cancer, whether or not in remission at the time the prior approval request is submitted, as documented by a pathologic or equivalent report.
 
For additional information, please see policy 2021004 (PET or PET/CT for Cancer Surveillance and Other Oncologic Applications)
 
Policy Guidelines
List of Plans subject to Act 583:
 
  • Fully Insured Contracts
    • Arkansas Blue Cross Blue Shield
    • Health Advantage
    • Octave
  • Self-funded State and Local Government Sponsored Health Plans
    • Arkansas State Police
    • Arkansas State University (ASU)
    • Benton County
    • City of Rogers
    • City of Siloam Springs
    • MEMS
    • Mississippi County Hospital System
    • Northwest Arkansas Community College
    • Rogers Water Utilities
    • Southern Arkansas University (grandfathered plan)
    • St. Bernards Regional Medical Center
    • University of Central Arkansas
    • Washington County
  • Self-Funded Church Sponsored Health Plans
 
As stated above, this does not apply to Arkansas State and Public School Employee health plan participants and beneficiaries. For Arkansas State and Public School Employee health plan participants and beneficiaries, please see policy 2023025 (PET or PET/CT for Oncologic Applications for ASE/PSE Contracts) for additional information.
 
For Federal Employee Health Benefit Program and Medicare Advantage plan participants please use the appropriate policy set to review.
 
For other requests for PET or PET/CT scans, the following policy/coverage criteria applies:
 
Effective April 14, 2024
 
NON-SMALL CELL LUNG CANCER
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT for Non-Small Cell Lung Cancer meets primary coverage criteria and is covered for:
Diagnostic Workup
Indicated for evaluation of the extent of disease following biopsy confirmation of non-small cell lung cancer, if not previously performed.  
 
Management
Indicated in ANY of the following scenarios:
        • Radiation planning for preoperative or definitive treatment
        • Evaluation following induction or neoadjuvant therapy, to determine eligibility for resection
        • Assessment of response to definitive chemoradiation when performed at least 12 weeks following therapy
        • Standard imaging cannot be performed or is nondiagnostic for recurrent or progressive disease
        • Surveillance CT Chest demonstrates recurrence
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for Non-Small Cell Lung Cancer does not meet member certificate of benefit Primary Coverage Criteria for effectiveness and is not covered for any indication or any circumstance other than those listed above.
 
For members with contracts without primary coverage criteria, PET/CT for Non-Small Cell Lung Cancer is considered investigational and is not covered for any indication or any circumstance other than those listed above. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
PULMONARY NODULE OR MASS
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
PET, PET-CT for evaluation of a pulmonary nodule or mass meets primary coverage criteria and is covered when BOTH of the following criteria are met:
    • Nodule is well-demarcated, solid or part solid, and lacks a benign calcification pattern.
    • Size is greater than 8 mm in greatest diameter
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for evaluation of a pulmonary nodule does not meet member certificate of benefit Primary Coverage Criteria for effectiveness and is not covered for any indication or any circumstance other than those listed above.
 
For members with contracts without primary coverage criteria, PET/CT for evaluation of a pulmonary nodule is considered investigational and is not covered for any indication or any circumstance other than those listed above. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Note: Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
Effective April 9, 2023 – April 14, 2024
NON-SMALL CELL LUNG CANCER
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
FDG-PET/CT for Non-Small Cell Lung Cancer meets primary coverage criteria and is covered for:
Diagnostic Workup
Indicated for evaluation of the extent of disease following biopsy confirmation of non-small cell lung cancer, if not previously performed.   
Management
Indicated in ANY of the following scenarios:
        • Radiation planning for preoperative or definitive treatment
        • Evaluation following induction or neoadjuvant therapy, to determine eligibility for resection
        • Assessment of response to definitive chemoradiation when performed at least 12 weeks following therapy
        • Standard imaging cannot be performed or is nondiagnostic for recurrent or progressive disease
 
For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for Non-Small Cell Lung Cancer does not meet member certificate of benefit Primary Coverage Criteria for effectiveness and is not covered for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance*
For members with contracts without primary coverage criteria, PET/CT for Non-Small Cell Lung Cancer is considered investigational and is not covered for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance*
Investigational services are Plan exclusions.
 
*For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
PULMONARY NODULE OR MASS
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
PET, PET-CT for evaluation of a pulmonary nodule or mass meets primary coverage criteria and is covered when BOTH of the following criteria are met:
    • Nodule is well-demarcated, solid or part solid, and lacks a benign calcification pattern.
    • Size is greater than 8 mm in greatest diameter
 
For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for evaluation of a pulmonary nodule does not meet member certificate of benefit Primary Coverage Criteria for effectiveness and is not covered for any indication or any circumstance other than those listed above.
 
For members with contracts without primary coverage criteria, PET/CT for evaluation of a pulmonary nodule is considered investigational and is not covered for any indication or any circumstance other than those listed above.
Investigational services are Plan exclusions.
 
For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
  
Note: Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
 
Effective Prior to March 13, 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
NON-SMALL CELL LUNG CANCER
Positron emission tomography (PET) scanning meets primary coverage criteria for effectiveness and is covered for patients with non-small cell lung cancer for:
 
Initial treatment:
    • Diagnosis when strong clinical/radiographic suspicion; OR
    • Evaluation of disease extent following biopsy confirmation
 
Subsequent treatment:
    • Following induction or neoadjuvant therapy to determine eligibility for resection; OR
    • Assess response to definitive chemoradiation at least 12 weeks post treatment; OR
    • Evaluate signs/symptoms of recurrence/progression when CT or MRI non-diagnostic; OR
    • Differentiate tumor from benign conditions (e.g. atelectasis) when CT delineates abnormal findings.
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.  
PULMONARY NODULE (SUSPECTED PRIMARY LUNG CANCER)
 
Positron emission tomography (PET) scanning meets primary coverage criteria for effectiveness for patients with a pulmonary nodule (suspected primary lung cancer) when all of the following criteria are met:  
 
    • Nodule is well-demarcated, solid or part solid, and lacks a benign calcification pattern; AND
    • Size is greater than 8 mm but less than 3 cm in greatest diameter; AND
    • Nodule is surrounded by aerated lung parenchyma; AND
    • There is no associated adenopathy, atelectasis or pleural effusion
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET scan for patients with Non-Small Cell Lung Cancer or Pulmonary Nodules does not meet member certificate of benefit Primary Coverage Criteria for effectiveness for the following:
 
    • Surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
    • Any other indication not specifically listed as covered above.
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.  
 
For members with contracts without primary coverage criteria, PET scan for patients with Non-Small Cell Lung Cancer or Pulmonary Nodules, is considered investigational and is not covered for the following:
 
    • Surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
    • Any other indication not specifically listed as covered above.
 
Investigational services are exclusions in the member certificate of coverage.
 
Effective prior to October 2019
 
“PET scan” refers to FDG PET or PET/CT.
 
 
Positron emission tomography (PET) scanning meets primary coverage criteria for effectiveness and is covered for the evaluation of a solitary pulmonary nodule of unknown cause if the PET scan is used as an alternative to surgical biopsy of the lesion.
  
PET scanning meets primary coverage criteria for effectiveness and is covered for the staging of a newly diagnosed case of cancer of the lung if the PET scan is used to influence the therapy prescribed.
  
PET scanning meets primary coverage criteria for effectiveness and is covered for patients with previously diagnosed lung cancer who have suspected recurrence of disease when laboratory studies/fluid sampling or other radiologic imaging are inconclusive.  Repeat PET scanning for patients with findings suggesting recurrent cancer meets primary coverage criteria for effectiveness and is covered only on an annual basis.
  
PET scan for Non-Small Cell Lung Cancer does not meet member certificate Primary Coverage Criteria for effectiveness for:
    • Monitoring the effectiveness of radiation therapy, chemotherapy, or combination of the two (Under study in clinical trial; NCT 00450567, and is not recommended by NCCN)
    • Surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence  for effectiveness  as there are no evidence-based studies which indicate improvement in health outcomes, and this use of PET is not recommended by NCCN.
 
 
For contracts without primary coverage criteria, PET scanning is covered for the following:
    • PET for evaluation of a solitary pulmonary nodule of unknown cause if the PET scan is used as an alternative to surgical biopsy of the lesion.
    • PET for the staging of a newly diagnosed case of cancer of the lung if the PET scan is used to influence the therapy prescribed.
    • PET for patients with previously diagnosed lung cancer who have suspected recurrence of disease when laboratory studies/fluid sampling or other radiologic imaging are inconclusive.
    • Repeat scanning for patients with findings suggesting recurrent cancer only on an annual basis.
 
 
 
For contracts without primary coverage criteria,
    • PET scanning for monitoring the effectiveness of radiation therapy, chemotherapy, or combination of the two (Under study in clinical trial; NCT 00450567, and is not recommended by NCCN)is considered investigational.
 
    • PET scanning for surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence for effectiveness as there are no evidence-based studies which indicate improvement in health outcomes is considered investigation.  This use of PET is not recommended by NCCN.
 
 
Investigational services are an exclusion in the member certificate of coverage.
 
 
Rationale:
2013 Update:
A review of literature on PubMed through December 2012 was performed.  There were no published articles identified that would prompt a change in the coverage statement.
 
Nakajima and associates (2013) evaluated the role of (18)F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) in differentiating tumor recurrence from radiation fibrosis after stereotactic ablative radiotherapy (SABR).  Sixteen of 59 patients had local failure. The SUV(max) of tumor recurrence after 12 months was significantly higher than that of radiation fibrosis (8.0 ± 3.2 vs. 2.1 ± 0.9, p < 0.001), and all tumor recurrence showed the SUV(max) > 4.5 at diagnosis of local failure.  At ≥12 months after SABR, the combination of intensity 2 and mass-like FDG uptake or SUV(max) > 4.5 acquired a significant high predictive value of local recurrence, finding sensitivity 100 % and specificity 100 % for both of them.  The authors concluded that the combination of FDG uptake patterns and SUV(max) was useful for distinguishing tumor recurrence from radiation fibrosis after SABR.
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Novello and colleagues (2012) published  the results of a study aimed to demonstrate that patients who exhibit a tumor metabolic response to first-line chemotherapy seen on FDG-PET and computed tomography (CT) would survive longer than those who did not show such a response, comparing this evaluation with the morphologic response seen on CT.  Images were acquired in 22 consecutive patients with advanced non-small-cell lung cancer (NSCLC) randomized to receive carboplatin/paclitaxel/sorafenib or placebo.  FDG-PET was performed within 4 weeks before (PET1) and 2 weeks after starting treatment (PET2). Similarly, CT (CT1) was performed at baseline and then every 2 cycles (6 weeks) during treatment (CT2). Responders and nonresponders were identified with FDG-PET, and metabolic response was then compared with morphologic changes detected by spiral CT.   In terms of progression-free survival (PFS) (45 vs. 22.2 weeks) and overall survival (OS) (77 vs. 47.7 weeks), Novello and group, observed a trend that was not statistically significant for patients whose response after 2 weeks of treatment was seen on FDG-PET (P = .22 for PFS; P = .15 for OS).  It was determined from the study that patients with advanced NSCLC who had a positive outcome, as evidenced by prolonged survival, were those who showed a tumor metabolic response seen on FDG-PET.
 
Tobaa and colleagues (2012) reported on a study done to evaluate the diagnostic capability of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in postoperative NSCLC patients without clinical and radiological evidence of recurrence, as a follow-up and surveillance program.   From 2005 – 2010, a total of 101 NSCLC patients underwent potentially curative operations and follow-up FDG-PET/CT was performed (at least once a year) in patients without clinical and radiological evidence of recurrence.  A total of 233 FDG-PET/CT studies were entered and retrospectively reviewed.  Eighteen (18%) asymptomatic patients had recurrent diseases and 22 recurrent sites were confirmed. Of 22 recurrent sites, recurrence was diagnosed by histological examination in 9 (41%) sites and by imaging examination in 13 (59%) sites. FDG-PET/CT correctly diagnosed recurrence in 17 of the 18 (94%) patients and 21 of the 22 (95%) recurrent sites.  The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 94.4, 97.6, 89.5, 98.8 and 97.0%, respectively.  On the other hand, in 3 patients, other diseases were detected and treated appropriately.  Post-recurrence therapies were performed in all patients with recurrence, but 4 (22%) patients died of the original diseases. The median post-recurrence survival was 25.2 months, and the 1- and 2-year post-recurrence survival rates were 83.3 and 69.6%, respectively.   The authors concluded that  FDG-PET/CT is a useful tool that has a high capability of detecting recurrences in asymptomatic NSCLC patients after a potentially curative operation.   However, a large-scale multi-institutional randomized control trial may be needed to ascertain the benefit of surveillance with FDG-PET/CT, including cost-effectiveness and post-recurrence survival in postoperative patients.
 
Gregory and colleagues (2012) investigated the incremental management impact and prognostic value of staging with 18F-FDG PET/CT in patients with NSCLC being considered for potentially curative therapies. Information on 168 consecutive patients with NSCLC being considered for surgery or definitive radiotherapy with curative intent before PET/CT was entered into a prospective database. The pre-PET/CT management plan, based on conventional imaging (conventional CT, appropriately supplemented by bone scintigraphy or other modalities), was defined prospectively by referring clinicians before PET/CT results became available.  After PET/CT, actual clinical management was recorded, and patients were followed up until 5 years or death. The appropriateness of PET/CT management plans was assessed by biopsy when available, clinical follow-up, and survival analysis. Both conventional imaging stage and PET/CT stage were strongly predictive of overall survival but there were greater differences between hazard rates and separations in the overall survival curves for stage groupings determined using PET/CT. Overall survival was also strongly predicted by PET/CT-directed choice of therapy (P < 0.0001). The conclusion was that PET/CT frequently affects patient management and strongly predicts overall survival in NSCLC, supporting the appropriateness of such changes.
 
Geraldson and colleagues (2012)_The ability to accurately diagnose mediastinal lymph node involvement is significantly important in patients with NSCLC. Positron emission tomography (PET) imaging has become a standard technique to assess lymph node involvement in patients with NSCLC. The purpose of this study was to evaluate the accuracy of PET scan imaging as a mediastinal staging tool in patients with NSCLC.  A single-institution, retrospective review was performed of 117 patients diagnosed with NSCLC from January 1, 2006, through December 31, 2007. Only those patients who underwent computed tomography (CT), PET, and pathologic assessment of mediastinal lymph nodes were included. Using pathologic assessment as the criterion standard, the overall accuracy, sensitivity, specificity, and positive and negative predictive values of CT and PET were calculated.  The overall accuracy was 81.2% for CT and 91.5% for PET. Sensitivity was 42.1% for CT and 52.6% for PET. Specificity was 88.8% for CT and 99.0% for PET. Positive predictive values were 42.1% for CT and 90.9% for PET; negative predictive values were 88.8% for CT and 91.5% for PET. False-negative result rates were 9.4% for CT and 7.7% for PET; false-positive result rates were 9.4% for CT and 0.9% for PET. The authors determined that the  analysis confirmed the use of PET scan imaging in the staging of patients with NSCLC.
 
Lee and colleagues_ (2012)
Radiation therapy is an important component of cancer therapy for early stage as well as locally advanced lung cancer. The use of F18 FDG PET/CT has come to the forefront of lung cancer staging and overall treatment decision-making.  FDG PET/CT parameters such as standard uptake value and metabolic tumor volume provide important prognostic and predictive information in lung cancer. Importantly, FDG PET/CT for radiation planning has added biological information in defining the gross tumor volume as well as involved nodal disease. For example, accurate target delineation between tumor and atelectasis is facilitated by utilizing PET and CT imaging. Furthermore, there has been meaningful progress in incorporating metabolic information from FDG PET/CT imaging in radiation treatment planning strategies such as radiation dose escalation based on standard uptake value thresholds as well as using respiratory-gated PET and CT planning for improved target delineation of moving targets. In addition, PET/CT-based follow-up after radiation therapy has provided the possibility of early detection of local as well as distant recurrences after treatment. More research is needed to incorporate other biomarkers such as proliferative and hypoxia biomarkers in PET as well as integrating metabolic information in adaptive, patient-centered, tailored radiation therapy.
 
The following studies were identified at www.clinicaltrials.gov:
  • NCT00450567 -  Monitoring Targeted Lung Cancer Treatments With FDG-PET/CT.  This clinical trial studied  glucose metabolism in patients with non-small cell lung cancer treated with targeted therapy and chemotherapy.  This prospective study has been completed, but results not yet published.
 
 
  • NCT00759382 - Prognostic Role of Primary Non Small Cell Lung Carcinoma Standardized F18-FDG Uptake Values (SUV and TLG) Measured With F18-fluorodeoxyglucose Positron Emission Tomography (F18-FDG-PET): a Non Interventional Study. Prospective study with estimated enrollment of 340 and completion date of January 2015.
 
 
  • NCT00732563 - Radioguided Detection of Lymph Node Metastasis in Non-Small Cell Lung Cancer.  This interventional clinical trial is studying how well fludeoxyglucose F 18 works in detecting lymph node metastasis in patients with stage I or stage II non-small cell lung cancer that can be removed by surgery.  Estimated enrollment 100 with completion date of September 2013.
 
 
  • NCT00564733 - This phase II trial studied how well fludeoxyglucose F 18 (FDG)-labeled PET scan works in planning chemotherapy in treating patients with stage IIIB or IV non-small cell lung cancer (NSCLC). Drugs used in chemotherapy, such as paclitaxel, carboplatin, gemcitabine hydrochloride, and docetaxel, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Diagnostic imaging procedures, such as FDG-labeled PET scan, may help in guiding chemotherapy and allow doctors to plan better treatment.  Study completed, but results not yet published.
 
 
  • NCT00004138 - The Utility of Positron Emission Tomography (PET) in Staging of Patients With Potentially Operable Non-Small Cell Lung Carcinoma; interventional study performed at 23 locations.  Study has been completed, but results not yet published.  
 
 
  • NCT01017133 - Assessing Hypoxia by 18F-EF5 PET Scanning and Glycolysis by 18FFDG PET Scanning in Subjects With Non-Small Cell Lung Cancer; Interventional study; RATIONALE: Diagnostic procedures, such as positron emission tomography, using the drug fluorine F18-EF5 to find oxygen and fludeoxyglucose F18 to find sugar in tumor cells may help in planning treatment for patients with non-small cell lung cancer.  Estimated enrollment 56.  Study completed, but results not yet reported.
 
NCCN Guidelines v1.2013
NCCN Guidelines v1.2013 recommends PET/CT for evaluation and staging of NSCLC in identifying stage I (peripheral and central T1-2, NO), stage II, stage III, and stage IV diseases. When patients with early stage disease are accurately staged using PET/CT, inappropriate surgery is avoided.  Positive PET/CT findings need pathologic or other radiologic confirmation (e.g. MRI of bone).  If the PET/CT is positive in the mediastinum, the lymph node status needs pathologic confirmation.
 
2014 Update
A literature search conducted through August 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
The American College of Chest Physicians issued guidelines on the diagnosis and management of lung cancer in 2013 (Silvestri, 2013). The guidelines state that RCTs support the use of PET or PET-CT scanning as a component of lung cancer treatment and recommend PET or PET-CT for staging, detection of metastases, and avoidance of noncurative surgical resections.
 
The NCCN guidelines on non-small-cell lung cancer indicate PET may be used in the staging of disease, detection of metastases, treatment planning, and detection of disease recurrence (NCCN, 2014a). However, PET is not recommended for detection of brain metastasis from lung cancers. The NCCN guidelines on SCLC indicate PET may be used in the staging of disease and treatment planning but “is not recommended for routine follow-up” (NCCN, 2014b).
 
2015 Update
 
A literature search conducted through January 2015 did not reveal any new information that would prompt a change in the coverage statement.
 
Current NCCN guidelines for non-SCLC indicate that PET may be used in the staging of disease, detection of metastases, treatment planning, and detection of disease recurrence. However, PET is not recommended for detection of brain metastasis from lung cancers. Current NCCN guidelines for SCLC indicate PET may be used in the staging of disease and treatment planning but “is not recommended for routine follow-up (NCCN, 2015).”
 
2017 Update
 
A literature search conducted using the Medline database through August 2017. There was no new information identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A 2017 systematic review by Ruilong et al evaluated the diagnostic value of 18F-FDG PET/CT for detecting solitary pulmonary nodules (Ruilong, 2017). The literature search, conducted to May 2015, identified 12 studies (1297 patients) for inclusion in the analysis. The pooled sensitivity and specificity of 18F-FDGPET/CT to detect malignant pulmonary nodules were 82% (95% CI, 76% to 87%) and 81% (95% CI, 66% to 90%), respectively.
 
Current NCCN guidelines for NSCLC indicate that PET/CT can be used in the staging of disease, detection of metastases, treatment planning, and detection of disease recurrence (NCCN, 2017). The guideline notes that PET is “best performed before a diagnostic biopsy site is chosen in cases of high clinical suspicion for aggressive, advanced-stage tumors.” However, PET is not recommended for detection of brain metastasis from lung cancers, and PET/CT is not routinely recommended for surveillance after completion of definitive therapy.
 
2018 Update
 
Annual policy review completed with a literature search using the MEDLINE database through February 2018. No new literature was identified that would prompt a change in the coverage statement.
 
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2019. No new literature was identified that would prompt a change in the coverage statement.
 
2020 Update
A literature search was conducted through February 2020.  There was no new information identified that would prompt a change in the coverage statement.
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through January 2021. No new literature was identified that would prompt a change in the coverage statement.   
 
October 2021 Update
A literature review was performed through August 2021.  Following is a summary of the key literature to date.
 
DIAGNOSTIC WORKUP
Non-small cell lung cancer is staged using the American Joint Committee on Cancer TNM system.
PET/CT for evaluation of pulmonary nodules suspected to be malignant should be limited those greater than 8 mm and of solid or part-solid composition to limit false-negative results commonly seen in nodules small in size and of low cellular density/low tumor avidity for FDG. CT can accurately evaluate the primary tumor and detect metastatic disease, but is less accurate than PET/CT in identifying mediastinal lymphadenopathy.(1, 2) Studies comparing CT and PET/CT for staging of mediastinal nodes have found accuracy rates of 80%-84% for PET/CT versus 76%-77% for CT alone.(3, 4) In one prospective trial, PET/CT prevented unnecessary surgery in 17% of patients.(5) PET/CT can be used for planning treatment volumes as well as determination of the need for extranodal irradiation. The Radiation Therapy Oncology Group 0151 showed that PET/CT-derived tumor volumes were smaller than those derived by CT alone with only a small number of patients developing nodal failures.(6) Involved field irradiation has been shown to improve overall survival in patients over extranodal irradiation in a prospective study by Yuan et al. In this prospective study, the involved field irradiation arm achieved better overall response and local control than the extranodal irradiation arm, and it allowed a dose increase from 68 to 74 Gy to be safely administered.(7) Asymptomatic metastatic central nervous system disease is seen in as many as 12% of patients, and brain imaging should always be performed for stage II or higher.(8) MRI chest with contrast should be considered to assess the spine/thoracic inlet for superior sulcus lesions abutting the spine and/or subclavian vessels in patients with stage IIB (T3 invasion N0) and stage IIIA (T4 extension N0-1; T3 N1, T4N0-1).
 
MANAGEMENT
Following treatment with concurrent chemoradiation therapy for superior sulcus non-small cell lung cancer, restaging with either CT or PET/CT is appropriate for detection of metastatic disease. For definitive treatment with chemoradiation therapy, the most appropriate follow-up imaging modality is not clear. A prospective study looking at PET/CT versus CT for the restaging of stage IIIA non-small cell lung cancer after neoadjuvant chemoradiation therapy showed PET/CT scan was more accurate than CT alone for restaging at all pathologic stages (stage 0, 92% vs 39%, P = .03: stage I, 89% vs 36%, P = .04). The authors, however, concluded that nodal biopsies are required since a persistently high maximum standardized uptake value does not equate to residual cancer.(9) Two other studies which evaluated post-treatment PET for locally advanced non-small cell lung cancer after treatment with concurrent chemoradiation therapy found PET was able to accurately predict local control and tumor response.(10, 11) Pan et al. compared conventional CT to PET/CT for locally advanced non-small cell lung cancer performed at 9 months after completion of therapy. Although PET/CT was able to identify progression of disease and recurrence in 48% of patients, no difference in survival could be demonstrated (21.6 months in CT group vs. 23.5 months in PET/CT, P= .89). (12) PET/CT may remain FDG-avid up until 2 years after radiation therapy. (13) Any suspected recurrence should be biopsied for pathologic confirmation.
 
SURVEILLANCE
NCCN recommends surveillance imaging with CT chest every 6 months for 2 to 3 years followed by annual low-dose technique CT chest for stage I/II treated with surgery. All others should undergo CT chest every 3 to 6 months for 3 years, then every 6 months for 2 years. Timing of CT scans within Guideline parameters is a clinical decision. (14)
 
PULMONARY NODULE LARGER THAN 8 mm
PET/CT for evaluation of pulmonary nodules suspected to be malignant should be limited those greater than 8 mm and of solid or part-solid composition to limit false-negative results commonly seen in nodules small in size and of low cellular density/low tumor avidity for FDG. (15)
 
 
 
Current References
    1. McLoud TC, Bourgouin PM, Greenberg RW, et al. Bronchogenic carcinoma: analysis of staging in the mediastinum with CT by correlative lymph node mapping and sampling. Radiology. 1992;182(2):319-23. PMID: 1732943
    2. Seely JM, Mayo JR, Miller RR, et al. T1 lung cancer: prevalence of mediastinal nodal metastases and diagnostic accuracy of CT. Radiology. 1993;186(1):129-32. PMID: 8416552
    3. Chin R, Jr., Ward R, Keyes JW, et al. Mediastinal staging of non-small-cell lung cancer with positron emission tomography. Am J Respir Crit Care Med. 1995;152(6 Pt 1):2090-6. PMID: 8520780
    4. Kernstine KH, Stanford W, Mullan BF, et al. PET, CT, and MRI with Combidex for mediastinal staging in non-small cell lung carcinoma. Ann Thorac Surg. 1999;68(3):1022-8. PMID: 10510001
    5. Fischer B, Lassen U, Mortensen J, et al. Preoperative staging of lung cancer with combined PET-CT. [Erratum appears in N Engl J Med. 2011 Mar 10;364(10):982]. N Engl J Med. 2009;361(1):32-9. PMID: 19571281
    6. Bradley J, Bae K, Choi N, et al. A phase II comparative study of gross tumor volume definition with or without PET/CT fusion in dosimetric planning for non-small-cell lung cancer (NSCLC): primary analysis of Radiation Therapy Oncology Group (RTOG) 0515. Int J Radiat Oncol Biol Phy s. 2012;82(1):435-41.e1. PMID: 21075551
    7. Yuan S, Sun X, Li M, et al. A randomized study of involved-field irradiation versus elective nodal irradiation in combination with concurrent chemotherapy for inoperable stage III nonsmall cell lung cancer. Am J Clin Oncol. 2007;30(3):239-44. PMID: 17551299
    8. Mintz BJ, Tuhrim S, Alexander S, et al. Intracranial metastases in the initial staging of bronchogenic carcinoma. Chest. 1984;86(6):850-3. PMID: 6094117
    9. Cerfolio RJ, Bryant AS, Ojha B. Restaging patients with N2 (stage IIIa) non-small cell lung cancer after neoadjuvant chemoradiotherapy: a prospective study.[Erratum appears in J Thorac Cardiovasc Surg. 2006 Sep;132(3):565-7]. J Thorac Cardiovasc Surg. 2006;131(6):1229-35. PMID: 16733150
    10. Ohri N, Bodner WR, Halmos B, et al. 18F-fluorodeoxyglucose/positron emission tomography predicts patterns of failure after definitive chemoradiation therapy for locally advanced non-small cell lung cancer. Int J Radiat Oncol Biol Phys. 2017;97(2):372-80. PMID: 28068244
    11. Roy S, Pathy S, Kumar R, et al. Efficacy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography as a predictor of response in locally advanced non -small-cell carcinoma of the lung. Nucl Med Commun. 2016;37(2):129-38. PMID: 26544097
    12. Pan Y, Brink C, Schytte T, et al. Planned FDG PET-CT scan in follow-up detects disease progression in patients with locally advanced NSCLC receiving curative chemoradiotherapy earlier than standard CT. Medicine (Baltimore). 2015;94(43):e1863. PMID: 26512597
    13. Ulaner GA, Lyall A. Identifying and distinguishing treatment effects and complications from malignancy at FDG PET/CT. Radiographics. 2013;33(6):1817-34. PMID: 24108564
    14. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Non -Small Cell Lung Cancer (Version 4.2021). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2021  
    15. MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology. 2017;284(1):228-43.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2022. No new literature was identified that would prompt a change in the coverage statement.
 
DIAGNOSTIC WORKUP
CT can accurately evaluate the primary tumor and detect metastatic disease, but is less accurate than PET/CT in identifying mediastinal lymphadenopathy.1, 2 Studies comparing CT and PET/CT for staging of mediastinal nodes have found accuracy rates of 80%-84% for PET/CT versus 76%-77% for CT alone.(3, 4) In one prospective trial, PET/CT prevented unnecessary surgery in 17% of patients.(5) PET/CT can be used for planning treatment volumes as well as determination of the need for extranodal irradiation. The Radiation Therapy Oncology Group 0151 showed that PET/CT-derived tumor volumes were smaller than those derived by CT alone with only a small number of patients developing nodal failures.(6) Involved field irradiation has been shown to improve overall survival in patients over extranodal irradiation in a prospective study by Yuan et al. In this prospective study, the involved field irradiation arm achieved better overall response and local control than the extranodal irradiation arm, and it allowed a dose increase from 68 to 74 Gy to be safely administered.(7)
 
MANAGEMENT
Following treatment with concurrent chemoradiation therapy for superior sulcus non-small cell lung cancer, restaging with either CT or PET/CT is appropriate for detection of metastatic disease. For definitive treatment with chemoradiation therapy, the most appropriate follow-up imaging modality is not clear. A prospective study looking at PET/CT versus CT for the restaging of stage IIIA non-small cell lung cancer after neoadjuvant chemoradiation therapy showed PET/CTscan was more accurate than CT alone for restaging at all pathologic stages (stage 0, 92% vs 39%, P = .03; stage I,89% vs 36%, P = .04). The authors, however, concluded that nodal biopsies are required since a persistently high maximum standardized uptake value does not equate to residual cancer.(8) Two other studies which evaluated posttreatment PET for locally advanced non-small cell lung cancer after treatment with concurrent chemoradiation therapy found PET was able to accurately predict local control and tumor response.(9, 10)  Pan et al. compared conventional CT to PET/CT for locally advanced non-small cell lung cancer performed at 9 months after completion of therapy. Although PET/CT was able to identify progression of disease and recurrence in 48% of patients, no difference in survival could be demonstrated (21.6 months in CT group vs. 23.5 months in PET/CT, P = .89).(11) PET/CT may remain FDG-avid up until 2 years after radiation therapy.(12) Any suspected recurrence should be biopsied for pathologic confirmation.
 
SURVEILLANCE
NCCN recommends surveillance imaging with CT chest every 6 months for 2 to 3 years followed by annual low-dose technique CT chest for stage I/II treated with surgery. All others should undergo CT chest every 3 to 6 months for 3 years, then every 6 months for 2 years. Timing of CT scans within Guideline parameters is a clinical decision. (13)
 
PULMONARY NODULE OR MASS
In 2017, the Fleischner Society, a high-quality evidence-based guideline directly applicable to American patients published recommendations and guidelines for management of incidental pulmonary nodules detected on CT images. (14) These recommendations apply to asymptomatic patients age 35 or older who are not immunocompromised, who do not have cancer, and who are not enrolled in a lung cancer screening program. Fleischner endorses the use of Lung-RADS guidelines to determine follow up when pulmonary nodules are detected as part of a lung cancer screening program.
 
SOLID PULMONARY NODULE IN ASYMPTOMATIC PATIENTS UNDER AGE 35
Primary lung cancer is rare in persons under age 35 (1% of all cases), and the risks from radiation exposure are greater. In young patients, infectious/inflammatory causes are more likely than cancer, and use of serial CT should be minimized. Exceptions may include nodules greater than 1 cm in size or with suspicious morphology. In such cases, follow-up imaging is at the ordering provider's discretion; a single 12-month follow-up CT may be considered to confirm stability.
 
Most nodules smaller than 1 cm will not be visible on chest radiographs; however, for larger solid nodules that are clearly visualized and are considered low risk, follow up with radiography rather than CT may be appropriate for lower radiation exposure.
 
NODULE SMALLER THAN 6 mm SEEN ON PREVIOUS IMAGING
Nodules of this size do not require routine follow up in low-risk patients. Since the average risk of cancer in solid nodules smaller than 6 mm in high-risk patients is less than 1%, and the relative risk of cancer in a nonsmoker is much less (0.15) than in a smoker, the risk of malignancy in low-risk patients is very low.
For high-risk patients, some nodules of this size with suspicious morphology, upper lobe location, or both may warrant follow up at 12 months. These features may increase cancer risk to 1%-5%.
 
NODULE LARGER THAN 8 mm
High-risk patients should usually proceed directly to PET-CT or biopsy. CT surveillance is recommended for nodules greater than 8 mm when:
    • Nodules have a low (less than 5%) risk of malignancy (as a rule of thumb, patients older than age 70, patients 50-70 years of age with no high-risk features, and patients younger than age 50 with only one high-risk feature)
    • Nodules with intermediate risk (5%-65%) especially when PET-CT is negative or equivocal, and the lesion is too small to biopsy
    • Patients are at high surgical risk
 
Current References
    1. McLoud TC, Bourgouin PM, Greenberg RW, et al. Bronchogenic carcinoma: analysis of staging in the mediastinum with CT by correlative lymph node mapping and sampling. Radiology. 1992;182(2):319-23. PMID:1732943
    2. Seely JM, Mayo JR, Miller RR, et al. T1 lung cancer: prevalence of mediastinal nodal metastases and diagnostic accuracy of CT. Radiology. 1993;186(1):129-32. PMID: 8416552
    3. Chin R, Jr., Ward R, Keyes JW, et al. Mediastinal staging of non-small-cell lung cancer with positron emission tomography. Am J Respir Crit Care Med. 1995;152(6 Pt 1):2090-6. PMID: 8520780
    4. Kernstine KH, Stanford W, Mullan BF, et al. PET, CT, and MRI with Combidex for mediastinal staging in non -small cell lung carcinoma. Ann Thorac Surg. 1999;68(3):1022-8. PMID: 10510001
    5. Fischer B, Lassen U, Mortensen J, et al. Preoperative staging of lung cancer with combined PET-CT.[Erratum appears in N Engl J Med. 2011 Mar 10;364(10):982]. N Engl J Med. 2009;361(1):32-9. PMID: 19571281
    6. Bradley J, Bae K, Choi N, et al. A phase II comparative study of gross tumor volume definition with or without PET/CT fusion in dosimetric planning for non-small-cell lung cancer (NSCLC): primary analysis of Radiation Therapy Oncology Group (RTOG) 0515. Int J Radiat Oncol Biol Phys. 2012;82(1):435-41.e1. PMID: 21075551
    7. Yuan S, Sun X, Li M, et al. A randomized study of involved-field irradiation versus elective nodal irradiation in combination with concurrent chemotherapy for inoperable stage III nonsmall cell lung cancer. Am J Clin Oncol. 2007;30(3):239-44. PMID: 17551299
    8. Cerfolio RJ, Bryant AS, Ojha B. Restaging patients with N2 (stage IIIa) non -small cell lung cancer after neoadjuvant chemoradiotherapy: a prospective study.[Erratum appears in J Thorac Cardiovasc Surg. 2006 Sep;132(3):565-7]. J Thorac Cardiovasc Surg. 2006;131(6):1229-35. PMID: 16733150
    9. Ohri N, Bodner WR, Halmos B, et al. 18F-fluorodeoxyglucose/positron emission tomography predicts patterns of failure after definitive chemoradiation therapy for locally advanced non-small cell lung cancer. Int J Radiat Oncol Biol Phys. 2017;97(2):372-80. PMID: 28068244
    10. Roy S, Pathy S, Kumar R, et al. Efficacy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography as a predictor of response in locally advanced non-small-cell carcinoma of the lung. Nucl Med Commun. 2016;37(2):129-38. PMID: 26544097
    11. Pan Y, Brink C, Schytte T, et al. Planned FDG PET-CT scan in follow-up detects disease progression in patients with locally advanced NSCLC receiving curative chemoradiotherapy earlier than standard CT. Medicine (Baltimore). 2015;94(43):e1863. PMID: 26512597
    12. Ulaner GA, Lyall A. Identifying and distinguishing treatment effects and complications from malignancy at FDG PET/CT. Radiographics. 2013;33(6):1817-34. PMID: 24108564
    13. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Non -Small Cell Lung Cancer (Version 3.2022). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2022.
    14. MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology. 2017;284(1):228-43.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2023. No new literature was identified that would prompt a change in the coverage statement.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2024. No new literature was identified that would prompt a change in the coverage statement.
 
NCCN Guidelines for Non-Small Cell Lung Cancer (Version 5.2023) reviewed with no change to PET applications.
CPT/HCPCS:
78811Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
78812Positron emission tomography (PET) imaging; skull base to mid thigh
78813Positron emission tomography (PET) imaging; whole body
78814Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
78815Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid thigh
78816Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body
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Al-Jahdali H, Khan AN, Loutfi S, Al-Harbi AS.(2012) Guidelines for the role of FDG-PET/CT in lung cancer management. J Infect Public Health. 2012 Dec;5 Suppl 1:S35-40

Bury T, Corhay JL, Duysinx B, et al.(1999) Value of FDG-PET in detecting residual or recurrent non-small cell lung cancer. Eur Respir J 1999; 14:1376-1380.

Bury T, Paulus P, Dowlati A.(1996) Staging of the mediastinum: value of PET imaging in non-small cell lung cancer. Eur Respir J 1996; 9:2560-2564.

Cerfolio RJ, Otha B, Mukherjee, et al.(2003) Positron emission tomography scanning with 2-fluoro-2-deoxy-d-glucose as a predictor of response of neoadjuvant treatment for non-small cell carcinoma. J Thorac Cardiovasc Surg, 2003; 125:938-944

Cook GJ, Yip C, Siddique M, Goh V, et al.(2013) Are Pretreatment 18F-FDG PET Tumor Textural Features in Non-Small Cell Lung Cancer Associated with Response and Survival After Chemoradiotherapy? J Nucl Med. 2013 Jan;54(1):19-26.

Duhaylongsod FG, Lowe VJ, Patz EF, et al.(1995) Detection of primary and recurrent lung cancer by means of FDG PET. J Thor CV Surg 1995; 110:130-140.

Frank A, Lefkowitz D, Jaeger S, et al.(1995) Decision logic for retreatment of asymptomatic lung cancer recurrence based on PET findings. Int J Radiat Oncol Biol Phys 1995; 32:1495-1512.

Gambhir SS, Shepherd JE, Shah BD, et al.(1998) Analytical decision model for the cost effective management of solitary pulmonary nodules. J Clin Oncol 1998; 16:2113-2125.

Geraldson CT, Stephenson JE, Lagrew JP, et al.(2012) Use of positron emission tomography in initial staging of nonsmall cell lung carcinoma: a regional teaching hospital experience. Am Surg. 2012 Mar;78(3):305-8.

Gupta NC, Graeber GM, Rogers JS, et al.(1999) Comparative efficacy of PET with FDG and computed tomographic scanning in preoperative staging of non-small cell lung cancer. Ann Surg 1999; 229:286-291.

Inoue T, Kim E, Komaki R, et al.(1995) Detecting recurrent or residual lung cancer with FDG-PET. J Nucl Med 1995; 36:788-793.

Lee P, Kupelian P, Czemin J, et al.(2012) Current concepts in F18 FDG PET/CT-based radiation therapy planning for lung cancer Front Oncol. 2012; 2: 71. Published online 2012 July 11.

Lowe VJ, Fletcher JW, Gobar L, et al.(1998) Prospective investigation of PET in lung nodules. J Clin Oncol 1998; 16:1075-1084.

Lu YY, Chen JH, Liang JA, et al.(2014) 18F-FDG PET or PET/CT for detecting extensive disease in small-cell lung cancer: a systematic review and meta-analysis. . Nucl Med Commun. Jul 2014;35(7):697-703. PMID 24694775

Marom EM, McAdams HP, Erasmus JJ, et al.(1999) Staging non-small cell lung cancer with whole-body PET. Radiology 1999; 212:803-809.

McCain TW, Dunagan DP, Chin R, et al.(2000) The usefulness of PET in evaluating patients for pulmonary malignancies. Chest 2000; 18:1610-1615.

Miyauchi T, Wahl RL.(1996) Regional FDG uptake varies in normal lung. Eur J Nucl Med 1996; 23:517-523.

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