• Ung YC, Maziak DE, Vanderveen JA, Smith CA, Gulenchyn K, Evans WK, Lung Cancer Disease Site Group. 18-fluorodeoxyglucose positron emission tomography in the diagnosis and staging of lung cancer: a clinical practice guideline. Toronto (ON): Cancer Care Ontario (CCO); 2007 Apr 27. 54 p. (Evidence-based series; no. 7-20). [135 references]

There is limited randomized controlled trial evidence related to the impact of positron emission tomography (PET) on the clinical management of the lung cancer patient. In addition, PET technology has evolved significantly over time making it difficult to make recommendations based on studies using out-of-date imaging technologies. However, based on the interpretation of available evidence and expert consensus opinion, the Lung Cancer Disease Site Group (DSG) recommends the following:

Diagnosis of Solitary Pulmonary Nodules (SPN)

• Fine needle aspiration (FNA) biopsy is recommended as the first-line diagnostic approach in the workup of solitary pulmonary nodules. PET should be reserved for those situations in which a biopsy is inconclusive or contraindicated
  • PET appears to have a high sensitivity and specificity to differentiate benign from malignant lesions as small as 1 cm in size. Lesions less than 1 cm are difficult to categorize as they lack a sufficient mass of metabolically active cells. False-negative results can occur with low-grade malignant tumours due to their lower metabolic activity or with ground-glass opacities as may be seen in bronchoalveolar carcinomas.

Staging of Primary Non-Small Cell Lung Cancer (NSCLC)

• In the opinion of the Lung Disease Site Group, the evidence on whether the addition of PET to conventional staging or the up-front use of PET in mediastinal and extrathoracic staging changes clinical management in patients with non-small cell lung cancer is conflicting.
• Prospective studies have found that PET detects unexpected distant metastases in up to 15% of patients, which may lead to changes in patient management.
• For potential surgical candidates, mediastinoscopy is recommended to verify that PET positive mediastinal lesions are due to cancer in view of the potential for false positive results. Mediastinoscopy is necessary to ensure that a patient is not denied potentially curative surgery. A solitary extrathoracic site should also be confirmed to be metastatic, if possible, in order that a patient not be denied the chance of curative therapy.

Staging of Small Cell Lung Cancer (SCLC)

There is limited evidence on the use of PET in the staging of small cell lung cancer but three prospective trials showed good accuracy in differentiating limited from extensive stage disease.

A clinical algorithm is provided in the original guideline document for the diagnosis of solitary pulmonary nodules.

The recommendations are supported by systematic reviews, meta-analyses, heath technology assessments, practice guidelines, and prospective studies (including randomized controlled trials).

• Ung YC, Maziak DE, Vanderveen JA, Smith CA, Gulenchyn K, Evans WK, Lung Cancer Disease Site Group. 18-fluorodeoxyglucose positron emission tomography in the diagnosis and staging of lung cancer: a clinical practice guideline. Toronto (ON): Cancer Care Ontario (CCO); 2007 Apr 27. 54 p. (Evidence-based series; no. 7-20). [135 references]

Not applicable: The guideline was not adapted from another source.

2007 Apr

Program in Evidence-based Care - State/Local Government Agency [Non-U.S.]

The Program in Evidence-based Care (PEBC) is a Province of Ontario initiative sponsored by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Cancer Care Ontario
Ontario Ministry of Health and Long-Term Care

Lung Cancer Disease Site Group

The members of the Lung Disease Site Group (DSG) disclosed potential conflict of interest relating to this practice guideline. Two of the guideline lead authors are primary investigators for the Ontario Clinical Oncology Group (OCOG) positron emission tomography imaging in stage III non-small cell lung cancer (PET-START) and PET imaging in potentially surgically resectable non-small cell lung cancers (ELPET) trials.

The following is available:

• Browman GP, Levine MN, Mohide EA, Hayward RSA, Pritchard KI, Gafni A, et al. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995;13(2):502-12.

None available

This summary was completed by ECRI Institute on April 8, 2008.