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Oncology Indications for PET Scans

The following oncology indications are funded for PET scanning in Ontario based on the eligibility criteria listed.

For patients who may benefit from a PET scan, but do not meet the eligibility criteria to receive a PET scan for one of the listed indications, referring physicians may wish to apply for a PET scan for their patient through the PET Access Program (see sidebar for referral form).

Breast Cancer

Advanced breast cancer 

Eligibility criteria: PET for the staging of patients with clinical stage III breast cancer; for information on how to enrol your patient, please visit the clinical trials website for the PET ABC Trial.

Dermatology

(See sidebar for Melanoma Requisition.)

Melanoma (Staging)

Eligibility Criteria: PET for the staging of patients with localized “high risk” melanoma, or for the evaluation of patients with isolated melanoma metastases when surgery or other ablative therapies are being considered.

Metastatic Melanoma (Immunotherapy)

Eligibility criteria:

  • Baseline staging: PET for the staging of patients before starting immunotherapy
  • Early response assessment: PET after 2 to 4 cycles of immunotherapy for early response assessment of patients with metastatic melanoma currently receiving immunotherapy
  • End of therapy response assessment: PET for response assessment of patients with metastatic melanoma at end of immunotherapy

Gastrointestinal Cancers

(See sidebar for Gastrointestinal Requisition.)

Esophageal or GE Junction

Eligibility Criteria: PET for baseline staging assessment of those patients diagnosed with esophageal/GE Junction cancer being considered for curative therapy and/or repeat PET/CT scan on completion of pre-operative/ neoadjuvant therapy, prior to surgery; or for re-staging of patients with locoregional recurrence, after primary treatment, being considered for definitive salvage therapy.

Colorectal (apparent limited metastatic)

Eligibility Criteria: PET for the staging or re-staging of patients with apparent limited metastatic disease (e.g., organ-restricted liver or lung metastases) or limited local recurrence, who are being considered for radical intent therapy

Note: as chemotherapy may affect the sensitivity of the PET scan, it is strongly recommended to schedule PET at least 6 weeks after last chemotherapy, if possible.

Colorectal (Recurrent)

Eligibility Criteria: PET where recurrent disease is suspected on the basis of an elevated and/or rising carcinoembryronic antigen (CEA) level(s) during follow-up after surgical resection but standard imaging tests are negative or equivocal.

Anal canal (staging or re-staging)

Eligibility criteria: PET for the initial staging of patients with T2-4 (or node positive) squamous cell carcinoma of the anal canal with or without evidence of nodal involvement on conventional anatomical imaging.

Genitourinary (GU) Cancers

Bladder (muscle invasive)

Eligibility criteria: PET for the staging of patients with muscle-invasive urothelial carcinoma of the bladder; for more information on how to enrol your patient, please visit the clinical trials website for the PET MUSE Trial.

Germ cell tumours (recurrent/persistent disease)

(See sidebar for Genitourinary Requisition.)

Eligibility criteria: 

  • PET where recurrent disease is suspected on the basis of elevated tumour marker(s) - (beta human chorionic gonadotrophin (HCG) and/or alpha fetoprotein) and standard imaging tests are negative
    OR
  • Where persistent disease is suspected on the basis of the presence of a residual mass after primary treatment for seminoma when curative surgical resection is being considered

Prostate (recurrent) (PSMA PET)

PET PREP Registry

(See sidebar for PET PREP Request Form and Eligibility Checklist. For cohort 7 patients, PREP PET Access Program Request Form and supporting documentation are also required).

Eligibility Criteria: Prostate Specific Membrane Antigen (PSMA) PET in the following patient populations with recurrent prostate cancer:

  • Post-prostatectomy node positive disease or persistently detectable PSA
  • Biochemical failure post-prostatectomy
  • Biochemical failure following radical prostatectomy followed by adjuvant or salvage radiotherapy
  • Rising PSA post-prostatectomy despite salvage hormone therapy
  • Biochemical failure following treatment for oligometastatic disease
  • Biochemical failure following primary radiotherapy
  • Where confirmation of site of disease and/or disease extent may impact clinical management over and above the information provided by conventional imaging (requires a case-by-case review)

Locations

PET CENTRE LOCATION

PHONE NUMBER

STATUS

St. Joseph’s Health Care in London

519-646-6100 ext. 64139

Active

University Health Network

416-946-4501 ext. 3172

Active

St. Joseph’s Health Care in Hamilton

905-522-1155 ext. 32746

Active

The Ottawa Hospital

613-737-8899 ext. 72110 or ext. 70060

Active

Sunnybrook Health Sciences Centre

416-480-6100 ext. 2271

Active

Thunder Bay Regional Health Sciences Centre

807-684-6357

Active

 

Gynecological Cancers

(See sidebar for Gynecology Oncology Requisition.)

Cervical cancer (staging)

Eligibility criteria: PET for the staging of locally advanced cervical cancer when:

  • CT/MR shows positive or indeterminate pelvic nodes (>7mm and/or suspicious morphology)
    OR
  • CT/MR shows borderline or suspicious para-aortic
    OR
  • CT/MR shows suspicious or indeterminate distant metastases (e.g., chest nodules)

Gynecology (recurrent, prior to salvage therapy)

Eligibility criteria: PET for re-staging of patients with recurrent gynecologic malignancies under consideration for radical salvage surgery (e.g., pelvic exenteration)

Head & Neck Cancers

(See sidebar for Head & Neck PET Request Form.)

Unknown primary

Eligibility criteria: PET for the evaluation of metastatic squamous cell carcinoma in neck nodes when the primary disease site is unknown after standard radiologic and clinical investigation 

Note: a panendoscopy is NOT required prior to the PET scan

Nasopharyngeal (baseline staging)

Eligibility criteria: PET for the staging of nasopharyngeal cancer

Note: for cervical esophageal cancer, see Gastrointestinal Cancers.

Head & Neck node positive (baseline staging)

Eligibility criteria: PET for the baseline staging of node positive (N1-N3) H&N cancer where PET will impact radiation therapy (e.g., radiation volume or dose)

Head & Neck (re-staging after chemoradiotherapy)

Eligibility criteria: PET to assess patients with N1-N3 metastatic squamous-cell carcinoma of the head and neck after chemoradiation (HPV negative); or who have residual neck nodes equal to or greater than 1.5 cm on re-staging CT performed 10 to12 weeks post therapy (HPV positive).

Thyroid (recurrent)

Eligibility criteria: PET where recurrent or persistent disease is suspected on the basis of elevated and/or rising tumour markers (e.g., thyroglobulin) with negative or equivocal conventional imaging work-up.

Anaplastic Thyroid (staging)

Eligibility Criteria: PET for the staging of histologically proven anaplastic thyroid cancer with negative or equivocal conventional imaging work-up.

Medullary Thyroid (staging & recurrent)

Eligibility Criteria: PET for the baseline staging of histologically proven medullary thyroid cancer being considered for curative intent therapy  or where recurrent disease is suspected on the basis of elevated and/or rising tumour markers (e.g., calcitonin) with negative or equivocal conventional imaging work-up.

Esophageal or GE Junction

Eligibility Criteria: PET for baseline staging assessment of those patients diagnosed with esophageal/GE Junction cancer being considered for curative therapy and/or repeat PET/CT scan on completion of pre-operative/ neoadjuvant therapy, prior to surgery; or for re-staging of patients with locoregional recurrence, after primary treatment, being considered for definitive salvage therapy.

Hematological Cancers

Lymphoma

(See sidebar for Lymphoma Requisition.)

Eligibility criteria:

  • Staging: PET for the baseline staging of patients with Hodgkin’s or non-Hodgkin’s lymphoma
  • Interim response assessment:
    • Adults (18 years or older): PET for the assessment of response in Hodgkin's lymphoma following two (2) or three (3) cycles of chemotherapy when curative therapy is being considered.
    • Pediatric (under 18 years old; or 18 to 20 years old and treated at a pediatric centre): PET for the assessment of response in Hodgkin’s or non-Hodgkin’s lymphoma after a minimum of two (2) cycles of chemotherapy when curative therapy is being considered.
  • End of therapy response assessment: PET for the evaluation of residual mass(es) or lesion(s) (e.g., bone) following chemotherapy in a patient with Hodgkin's or non-Hodgkin's lymphoma when further potentially curative therapy (such as radiation or stem cell transplantation) is being considered

Myeloma or plasmacytoma

(See sidebar for Multiple Myeloma/Plasmacytoma Requisition.)

Eligibility criteria: To evaluate the impact of PET on the management of patients with plasmacytoma or myeloma for the following indications:

  • Solitary plasmacytoma: For patients with presumed solitary plasmacytoma who are candidates for curative intent radiotherapy [to determine whether solitary or multifocal/extensive disease]
  • Smoldering myeloma: Workup of patients with smoldering myeloma and negative or equivocal skeletal survey [to determine whether smoldering or active myeloma]
  • Nonsecretory myeloma, oligosecretory myeloma, or POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes): Baseline staging and response assessment
  • Newly-Diagnosed Secretory Multiple Myeloma: Workup of patients with newly-diagnosed secretory multiple myeloma and negative or equivocal skeletal survey

Neuroendocrine Tumours (NETs)

Neuroendocrine tumours (Ga68-DOTATATE PET)

PET NET Registry

(See sidebar for Neuroendocrine [Ga68-DOTATATE] Requisition. For patients in the “Other” cohort, the Ga68-DOTATATE PET Access Request Form and supporting documentation are also required.)

Eligibility criteria:

  • Diagnosis: PET for identification of primary tumour when there is clinical suspicion of NET and primary tumour site is unknown or uncertain. Patients should have elevated biochemical markers (e.g., 5-HIAA ± elevated chromogranin A) and no definitive evidence of disease on CT.
  • Initial staging (NET): PET for the staging of patients upon initial diagnosis of NET
  • Re-staging (NET): PET for the re-staging of patients with NET when clinical intervention is being considered
  • Other (requires case-by-case review through the PET Access Program): PET as a problem-solving tool in patients with NET when confirmation of site of disease and/or disease extent may impact clinical management

Sarcoma

(See sidebar for Sarcoma Requisition.)

Diagnosis (plexiform neurofibromas)

Eligibility criteria: PET for patients with suspicion of malignant transformation of plexiform neurofibromas

Initial staging

Eligibility criteria: PET in patients with high grade (≥ Grade 2), or ungradable, soft tissue or bone sarcomas, with negative or equivocal findings for nodal or distant metastases on conventional imaging, prior to curative intent therapy

Re-staging

Eligibility criteria: PET in patients with history of treated sarcoma with suspicion of, or confirmed, recurrent sarcoma (local recurrence or limited metastatic disease) being considered for curative intent or salvage therapy

Thoracic Cancers

(See sidebar for Thoracic Requisition.)

Esophageal or GE Junction

Eligibility criteria: PET for baseline staging assessment of those patients diagnosed with esophageal/GE Junction cancer being considered for curative therapy and/or repeat PET/CT scan on completion of pre-operative/ neoadjuvant therapy, prior to surgery; or for re-staging of patients with locoregional recurrence, after primary treatment, being considered for definitive salvage therapy.

Lung – non-small cell lung cancer (NSCLC; clinical stage I-III)

Eligibility criteria:

  • PET for initial staging of patients with NSCLC (clinical stage I – III) being considered for potentially curative therapy
    OR
  • for re-staging of patients with locoregional recurrence, after primary treatment, being considered for definitive salvage therapy

Note: Histological proof is not required prior to PET if there is high clinical suspicion for NSCLC (e.g., based on patient history and/or prior imaging)

Note: PET is appropriate for patients with either histological proof of locoregional recurrence or strong clinical and radiological suspicion of recurrence who are being considered for definitive salvage therapy

Lung – small cell lung cancer (SCLC; clinical stage I-III)

Eligibility criteria: PET for initial staging of patients with limited disease SCLC where combined modality therapy with chemotherapy and radiotherapy is being considered

Lung – solitary pulmonary nodule (SPN)

Eligibility criteria: PET for a semi-solid or solid lung nodule for which a diagnosis could not be established by a needle biopsy due to unsuccessful attempted needle biopsy; the SPN is inaccessible to needle biopsy; or the existence of a contra-indication to the use of needle biopsy

Lung – mesothelioma

Eligibility criteria: PET for the staging of patients with histologic confirmation of malignant mesothelioma

Pediatric Oncology

Pediatric Oncology Registry

To submit Pediatric Oncology Registry referrals, you must log in to the PET Scans Ontario E-Tool.

Eligibility criteria: Pediatric Registry Indications (data collection/partnership with the Pediatric Oncology Group of Ontario):

  • For the following cancer types (ICCC – International Classification of Childhood Cancer):
    • Bone/cartilage – osteosarcoma, Ewing sarcoma
    • Connective/other soft tissue – rhabdomyosarcoma, other
    • Kidney – renal tumour
    • Liver – hepatic tumour
    • Primary brain – astrocytoma, medulloblastoma, ependymoma, other
    • Reproductive – germ cell tumour
    • Sympathetic nervous system – neuroblastoma MIBG negative
    • Other – LCH, melanoma of the skin, thyroid
  • For the following indications:
    • Initial staging
    • Monitoring response during treatment or determine response-based therapy
    • Rule out progression prior to further therapy
    • Suspected recurrence or relapse
    • Rule out persistent disease
    • Select optimal biopsy site