Positron Emission Tomography (PET) for Oncologic Applications
DESCRIPTION
Positron Emission Tomography (PET) scans are based on the use of positron emitting radionuclide tracers coupled to organic molecules such as glucose, ammonia, or water. The radionuclide tracers simultaneously emit two high-energy photons in opposite directions that can be simultaneously detected by a PET scanner. The PET scanner consists of multiple detectors that encircle the area of interest. A variety of tracers are used for PET scanning including oxygen-15, nitrogen-13, carbon-11, and fluorine-18. The most commonly used radiotracer in oncology imaging is fluorine-18 coupled with fluorodeoxyglucose (FDG). FDG has a metabolism related to glucose metabolism. It has been considered potentially useful in cancer imaging, since tumor cells show increased metabolism of glucose. PET usefulness is established for use in cardiac, neurological and oncologic situations. This policy will address PET for oncological applications. The indications for PET also apply to PET/CT fusion scans.
POLICY
Positron emission tomography (PET) scans for the oncological applications listed below are considered medically necessary if the medical appropriateness criteria are met. (Click on the underlined word below to be taken directly to the corresponding Medical Appropriateness.)
Adenocarcinoma of the stomach
Anal Canal Squamous Cell Carcinomas
Colorectal Cancer
Gallbladder Hepatobiliary Tree
Gastrointestinal stromal tumors (GIST)
Liver
Malignant and non-adrenal pheochromocytomas
Neuroendocrine tumor
Other GI neuroendocrine Cancers
Pancreatic Cancers
Rectal Cancers
Upper GI cancers
Cervical Cancer
Ovarian Cancer
Salivary Gland Cancers
Squamous Cell Carcinomas of the Head and Neck
Richter’s transformation Leukemia (transformation of chronic lymphocytic leukemia (CLL) into diffuse large cell lymphoma)
Hodgkin’s Lymphomas
Non Hodgkin’s Lymphoma
Adrenal lesions and Neuroendocrine Lesions
Carcinomas of Unknown Primary Sites
Generalized lymphadenopathy and Mediastinal abnormalities
Liver Lesions
Soft Tissue Sarcomas
Multiple Myeloma, Waldenstrom's Macroglobulinemia, and Plasmacytomas
Bladder Cancer
Bladder and other urinary tract transitional cell carcinomas
Penile Cancer
Prostate Cancer
Renal Cell Cancer (Kidney)
Testicular and Nonepithelial ovarian cancer (Germ Cell Tumors)
Positron emission tomography (PET) scans for the following applications is considered investigational:
General Guidelines
When imaging Metastatic disease in the central nervous system (CNS)
When Imaging lesions less than 7mm in size
When used as a routine surveillance test without prior clinical or other imaging evidence that suggest possible disease recurrence
Breast
When used for non-invasive breast cancers
When obvious multi-organ metastatic disease is present
When used for a pre-operative assessment of the response after neo-adjuvant chemotherapy
When used prior to lymph node sampling with clinical Stage I, II, or operable III a disease
When used for repeated use in Stage IV breast cancer disease
When used for re-staging when all know disease is surgically removed
Esophageal
When used for surveillance
When used for individuals receiving supportive care only
Gastrointestinal
Non-invasive carcinomas
Carcinomas contained within a polyp
Colon cancer that is completely resected and lymph node negative
Anal Margin Carcinomas
T1 gastric cancers
When the metastatic disease is already confirmed
Following complete resection of Gastrointestinal Stromal Tumor (GIST)
Cancers of the Liver, Gallbladder, and Hepatobiliary Tree including Klatskin’s tumors
Liver lesions less than 1 cm in individuals without a prior history of confirmed malignancy
When used following interventional radiology procedures involving liver lesions, such as Radiofrequency Ablation (RFA)
When used following postoperative adjuvant chemotherapy with the following:
When resection has removed all known gross disease
When markers are not elevated
When used in the setting of obvious multi-organ metastatic disease
Gynecologic Cancers
Endometrial cancer
Vulvar cancer
Vaginal cancer
Uterine cancers
Non-invasive cervical cancer
External Genitalia
Head and Neck (Squamous Cell Carcinomas of the head and neck and Salivary gland cancers)
When used to determine the need for neck dissection for individual with newly diagnosed head and neck cancer
When used for restaging of Cancers of the Head and Neck when surgery is the primary treatment modality (e.g. complete resection/ radical neck dissection)
When complete response or progression is clearly obvious on physical examination
When used for Salivary gland tumors
When used as a substitute for panendoscopy
Leukemia
When used for routine evaluation, or restaging
Lungs
When using serial PET scans to evaluate lung nodules
When other imaging modalities have confirmed skeletal disease metastasis from other primary sites (i.e. Lung, breast, prostate, renal cell and other urogenital cancers)
When other imaging shows extensive staged disease in small cell carcinoma
Following chemotherapy for small cell carcinoma
For restaging for the following:
Small cell carcinomas
When surgery was the primary treatment and all known tumor was resected
When tumors were initially treated with radiation therapy as the only treatment modality
Lymphomas
Indolent Non-Hodgkin’s lymphomas, including but not limited to the following:
Chronic Lymphocytic Leukemia (CLL)
Small Lymphocytic Lymphoma (SLL)
Gastric Mucosa-Associated Lymphoid Tissue (MALT) lymphomas
Low-grade Follicular
Melanoma and Other Skin Cancers
For routine surveillance in all skin cancers (including melanoma) for asymptomatic individuals
Miscellaneous (Carcinomas of Unknown Primary Site, Soft Tissue Sarcoma, Generalized Lymphadenopathy and Mediastinal abnormalities/ Lymphadenopathy, Liver Lesions, Adrenal Lesions and Neuroendocrine Lesions)
When used for surveillance and for routine body imaging of lymph nodes
When used following complete resection
When used for generalized lymphadenopathy and mediastinal abnormalities prior to histologic diagnosis
Multiple Myeloma, Waldenstrom’s Macroglobulinemia and Plasmachytomas
For individuals with Monoclonal Gammopathy of Unknown Significance (MGUS)
For individuals with Stage III Multiple Myeloma when standard imaging and Lab tests can define extent of disease and response to therapy
For routine monitoring of therapy by PET (or skeletal MRI)
Primary Brian Tumors
For detection, initial work up or staging for primary brain tumors
For the use of FDG-PET in the evaluation of metastatic deposits and well-differentiated brain tumors
Thyroid Cancer
For routine use in initial staging, restaging or surveillance
Urologic/ Testicular
For initial diagnosing or staging of renal cell carcinoma.
To differentiate neoplastic disease from benign prostatic hypertrophy
For routine surveillance in renal cell carcinoma
For evaluating individuals with transitional cell carcinomas of the bladder or other urinary tract sites
For diagnosis, Initial staging, or routine surveillance of testicular cancers including the following:
Testicular cancers
Extragonadal germ cell tumors
Germ cell tumors of the ovary
Non seminomatous germ cell tumors
Penile cancer
Urothelial (transitional cell) tumors
For initial staging of prostate cancer
For initial work up of testicular and nonepithelial ovarian (germ cell) cancer
Any radiopharmaceutical utilized for this procedure must have FDA approval or have been determined by the FDA to be safe and effective otherwise it will be considered investigational.
See also:
Milliman Care Guideline - PET, Myocardial
MEDICAL APPROPRIATENESS
Positron emission tomography scans for oncological applications are considered medically appropriate if ANY ONE of the following criteria are met:
For staging or evaluation of unresectable clinical Stage III, and Stage IV disease (locally advanced, or limited metastatic disease). If ALL of the following are met:
The individual has inflammatory breast cancer
The breast cancer is greater than 5 cm
When lymph node disease is found in four or more axillary lymph nodes
When axillary lymph nodes are fixed to node another or to other structures
When disease is found in lymph node sites other than the axilla
When used prior to neoadjuvant chemotherapy for locally advanced disease
When used to document response to therapy in Stage IV disease when identification of responders vs non-responders will influence future therapy decisions
For evaluation of a individual with ANY ONE of the following:
There is a recurrence documented by other imaging
There are elevations of laboratory tests
There is histologic confirmation
Use of PET is delayed a minimum of 12 weeks following radiotherapy due to the risk of a false positive FDG uptake in lethally irradiated cells
PET scan is taken before 12 weeks only for clinical situations requiring evaluation of disease outside the irradiated volume
PET is indicated if additional information about organ systems other than skeletal is clinically relevant
A biopsy has been performed prior to a PET scan
When used for an individual with biopsy proven esophageal cancer
A PET scan is done prior to a biopsy for ANY ONE of the following only:
For evaluating the feasibility of an approach to biopsy when other imaging modalities yield conflicting information
Attempted biopsy is non diagnostic
Biopsy is not technically feasible
For staging, when conventional imaging fails to find clear evidence of metastatic disease
For evaluation or restaging of an individual’s response to Radiation/ Chemotherapy with ANY ONE of the following:
After an Upper endoscopy or endoscopic ultrasound (EUS) with the ABSENCE of ALL of the following:
The UE/ EUS fails to show obvious disease progression
The UE/ EUS fails to show the individual’s continued deterioration
The UE/ EUS fails to show a complete response to Radiation/ Chemotherapy
PET is delayed as feasible to allow time for tumor response to be assessed without delaying the required surgery
PET following radiotherapy when surgery is not an option with ANY ONE of the following:
PET scan is delayed a minimum of 12 weeks, due to risk of false positive FDG uptake in lethally irradiated cells
The clinical situation requires evaluation of disease outside the irradiated volume
For the staging of identified recurrence only when an individual is a candidate for aggressive local salvage therapy
In Gastrointestinal Cancer if ANY ONE of the following are met:
There is histologic confirmation of malignancy prior to the PET scan
For the initial staging of ANY ONE of the following:
Adenocarcinoma of the stomach
Pancreatic cancers considered for resection with ANY ONE of the following:
By the Whipple procedure
By a subtotal pancreatectomy of pancreatic tail tumors
Any GI tumor where a solitary metastatic lesion is detected in a site where aggressive local therapy of the primary site and of the solitary metastasis can confer a survival advantage
Any GI tumor with an elevated CEA preoperatively, and the CEA fails to normalize after apparently curative resection
Any GI tumor where pathologic diagnosis suggests a primary site other than the GI system, and a search for a second primary site is reasonable
Malignant and non-adrenal pheochromocytomas, and any symptomatic neuroendocrine tumor when an apparently complete resection fails to resolve secretion of pathologic levels of hormones or neurotransmitter compounds, if functional nuclear imaging (MIBG or Octreoscan) is negative
Anal Canal Squamous Cell Carcinomas
Lymph node positive colorectal cancer when an abnormality on standard imaging suggests a possible solitary metastatic lesion that might be amenable to resection and positive PET results elsewhere will alter the therapy decision
Restaging of Anal Canal Squamous cell Carcinomas, if the initial staging study was PET avid and not easily evaluated on other imaging tests or by physical examination
Restaging of Colorectal cancer with ANY ONE of the following:
Postoperative CEA or LFT’s remain elevated and other imaging are negative
Recurrence is clinically suspected even with negative or equivocal results from conventional imaging
In evaluating a potentially resectable metastatic lesion in order to confirm that it is resectable and to confirm absence of other sites of disease
In differentiating local tumor recurrence from postoperative and or post radiation scarring
Gastrointestinal Stromal Tumor (GRIST) if ANY ONE of the following are met:
Baseline study prior to treatment of unresected gross disease, within 4 weeks from the start of tyrosine kinase (TK) inhibitor therapy, and every 3 months thereafter until complete response is documented, resection is accomplished, or disease progression precludes further TK therapy
In certain select cases, for evaluation of any unresectable or inoperable GI tumor following chemotherapy or radiotherapy when conventional imaging is unclear
PET should be delayed until 12 weeks following radiotherapy due to risk of false positive FDG uptake in lethally irradiated cells, unless the clinical situation requires evaluation of disease outside the irradiated volume
For any suspicious appearing lesion that cannot be characterized by CT or MRI
Restaging can be considered to evaluate abnormalities detected on other routine follow-up imaging modalities or in an individual with rising LFTs or CEA when resection or other local treatment modalities are feasible
Assess response to therapy at sites of unresectable disease
Differentiating local tumor recurrence from postoperative and or postradiation scarring
In Cervical Cancer with ANY ONE of the following:
For evaluation of newly diagnosed cervical cancers of Clinical Stage IB2 or higher (>4 cm or invasion beyond uterus, positive lymph nodes, or distant metastasis)
To evaluate abnormalities seen on other imaging modalities in lower stage invasive cancers
For cancers incidentally discovered during hysterectomy
Following radiation therapy for advanced disease with ANY ONE the following:
Delayed for 12 weeks from completion of therapy, due to risk of false positive FDG uptake in lethally irradiated cells
Given before 12 weeks when clinical situation requires evaluation of disease outside the irradiated volume
For defining and staging or restaging of suspected recurrent disease when indicated by changes reported in symptoms, found on physical examination, or reported by other imaging
In Ovarian Cancer with ANY ONE of the following:
For initial work-up of Ovarian Cancers for cases of primary peritoneal disease where the pelvic structures are normal
Following complete resection with ANY ONE of the following:
Individual with elevated CA-125 or other relevant tumor markers
Changes in physical examination
Normal conventional imaging
Evaluation of radiographic abnormalities suspicious for recurrence
Elevation of LFTs with negative abdominal imaging
For repeat scans with ANY ONE of the following:
Prior conventional imaging failed to demonstrate tumor
A persistent radiographic mass is seen
To document response to therapy with ANY ONE of the following:
Prior conventional imaging has failed to demonstrate tumor
A persistent radiographic mass is seen
In Head and Neck Cancer if ANY ONE of the following are met:
A biopsy is completed before the PET scan
PET scan may be done before a Biopsy when ALL of the following are met:
When done only to guide the direction of the biopsy in diagnostically challenging cases
When done to provide information for directing a biopsy for an individual who presents with a neck mass and the initial attempts to find a primary source is difficult
For clinical stage III-IV disease (T3 or higher; any positive lymphadenopathy)
For nasopharyngeal carcinoma
For Occult primary
When PET is used to explain radiographic findings suggestive of disease outside the head and neck when a positive PET scan demonstrating Metastatic disease will change the treatment management
For assessing response to chemo/radiotherapy if ALL of the following are met:
Clinical examination remains abnormal / equivocal
A description is provided of recent clinical examination of previously involved sites
PET performed if ANY ONE of the following are met:
Delayed a minimum of 90 days following chemo/radiotherapy to avoid false FDG positive unless the clinical situation requires evaluation of a disease outside the irradiated volume/ portal
Performed at 8-12 weeks following radiotherapy to avoid excess radiation-induced fibrosis for individuals with clinically apparent lymph nodes when the results will determine the need for a radical neck dissection
PET may be performed in suspected recurrence if ANY ONE of the following are met:
After adequate examination with indirect laryngoscopy and documentation provided of exam results
To differentiate between residual tumor and scar tissue
For a biopsy confirmed recurrence for ANY ONE of the following:
Apparent recurrent lymphadenopathy
Glottic tumors not able to be visualized by competent and adequate exam with indirect laryngoscopy
For use in Richter’s transformation aggressive type leukemia only in selected cases
Individuals must be undergoing therapy or be considered for starting therapy
In Lung Cancer and Pulmonary Nodules if ANY ONE of the following are met:
For evaluation of one or more newly discovered, distinct pulmonary nodules if ALL of the following are met:
Confirmed on CT and/or MRI
Measuring greater than or equal to 7 mm (0.7 cm) on chest CT scan
Negative PET scan requires CT done at 3,6,12, and 24 months
For initial staging for histologically proven lung cancer and mediastinal lymphadenopathy in the ABSENCE of ALL of the following:
Evidence for Stage IV disease
Bronchioalveolar carcinoma
Bronchial carcinoid
Mucinous carcinoma
For staging of limited stage disease in Small cell carcinoma after standard imaging
For restaging if ANY ONE of the following are met:
Following radiotherapy PET should be delayed a minimum of 12 weeks
PET may be done before 12 weeks following radiotherapy when the clinical situation requires evaluation of disease outside the irradiated volume
PET can differentiate persistent or recurrent tumor from necrotic or fibrotic tissue following chemotherapy or radiotherapy
PET is useful for evaluation of abnormalities that are newly discovered by CT or other imaging modalities used for re-staging
PET may help differentiate persistent or recurrent tumor from radiation-induced fibrosis or pleural thickening
PET may be considered if LFTs or tumor markers become elevated and CT scans are negative or equivocal
For Evaluating enlarged mediastinal lymph nodes with PET is done when ANY ONE of the following are met:
After a biopsy
A Biopsy is medically contraindicated or technically not feasible
PET or MRI chest scan can be performed if curative surgery is still an option
PET can be considered on a case-by-case basis if symptom response cannot be used to judge efficacy of therapy
PET is appropriate for the characterization of an SPN (Solitary Pulmonary Nodule/Node) if ALL of the following are met:
The lesion is a distinct parenchymal lung nodule
Measuring greater than or equal to 7 mm (0.7cm) on chest CT scan
ABSENCE of ALL of the following:
Lung infiltrate
Ground glass opacity
Hilar enlargement
The scan request for evaluation must clearly document ALL of the following:
Diagnosis
Cell subtype of lymphoma
Histologic confirmation of cell type is made prior to the scan
Scan may be done before biopsy only if ANY ONE of the following are met:
Biopsy can only be accomplished by ANY ONE of the following:
Mediastinoscopy
Thoracoscopy/thoracotomy (i.e. percutaneous biopsy, transbronchial biopsy, transbronchial biopsy using endobronchial ultrasound
In the ABSENCE of endoscopic ultrasound-guided Fine Needle Aspiration (FNA)
Before a biopsy of a relatively inaccessible body region with ANY ONE of the following:
To confirm the likelihood of yielding a pathologic diagnosis
To determine if a more favorable site for biopsy exists
For characterizing anterior mediastinal abnormalities
To differentiate normal or benign hypertrophic thymus tissue from pathologic mediastinal lesions
For initial diagnosis and staging of most lymphomas with ALL of the following:
The individual has ANY ONE of the following diagnoses:
Hodgkin’s lymphoma
All intermediate and aggressive sub-types of Non-Hodgkin’s lymphoma, including but not limited to the following:
Follicular
Mantle Cell
Marginal Zone
Non-Gastric MALT
Mycosis
Fungoides
Diffuse Large B-Cell (DLBCL)
DLBCL mixed with other histologies
Lymphoblastic anaplastic large cell
Peripheral T-cell lymphomas
AIDS-related lymphomas
ABSENCE of ALL of the following:
Indolent Non-Hodgkin’s lymphomas
Chronic Lymphocytic Leukemia (CLL)
Small Lymphocytic Lymphoma (SLL)
Gastric MALT lymphomas
Low-grade Follicular
PET and CT chest/abdomen/pelvis scans with contrast can be performed for initial staging of cell appropriate cancer
Interim re-staging scan for initial chemotherapy regimens for Hodgkin’s and many Non-Hodgkin’s Lymphomas to evaluate the response after 4 cycles, and a “final” re-staging when all therapies are complete for ANY ONE of the following:
Hodgkin’s Lymphomas
Non Hodgkin’s Lymphomas (NHL)
For interim re-staging, take either PET or CT scans with contrast NOT BOTH
For final re-staging of body areas previously positive, PET (or CT scans with contrast but not both) can be performed when ALL of the following are met:
ANY ONE of the following criteria are met:
Radiation therapy is planned in a patient who initially presented with bulky mediastinal adenopathy
PET only was used for interim re-staging
Variable FDG uptake by the tumor occurred
FDG activity cleared but an enlarged abnormality remains
ABSENCE of ALL the following:
Interim PET when there is no stated change in management that will be impacted by the results of the scans
Negative PET results
Detection of recurrence:
When recurrence is known or suspected based upon ANY ONE of the following:
Physical examination
Laboratory studies
Conventional imaging in an individual with ANY ONE of the following:
A history of Hodgkin’s lymphoma
An aggressive or intermediate sub-type of Non-Hodgkin’s lymphoma
Both PET and CT chest/abdomen/pelvis with contrast can be performed for evaluation of a recurrence of lymphoma that was previously in remission, especially if transformation to a more aggressive type is suspected
Surveillance if ANY ONE of the following are met:
To confirm absence of lymphoma in a radiographically persistent CT abnormality
When repeated lab tests such as LFT’s or ESR become elevated after previously being normalized
CT scans are negative
In Melanoma and other skin cancers if ANY ONE of the following are met:
For the initial evaluation of Melanoma lesions Stage II or greater including but not limited to the following:
Lesions greater than 1 mm thick with ulceration
Lesions greater than 2mm thick with no ulceration
Obvious clinical lymphadenopathy
Lymphatic disease confirmed histologically
For an individual with recurrent disease that has failed documentation of metastasis by all other imaging modalities
When other imaging studies suggest isolated metastatic disease amenable to resection/ recurrence only in lymph nodes
When the disease is initially found in a lymph node/ distant organ and the original disease site remains occult
To address specific signs and symptoms not explained by conventional imaging
For Initial staging for orbital/ ocular melanoma
In an individual with known Stage IV (metastatic) disease, if the ANY ONE of the following are met:
To determine the involvement of a specific organ
Results will change the clinical management decisions
For staging localized Merkel Cell carcinoma after standard imaging studies fail to show metastatic disease
ABSENCE of ALL of the following:
Stage I disease including the following:
Lesions less than 2 mm thick without ulceration and lymphadenopathy
Lesion less than or equal to 1 mm without lymphadenopathy
Non-melanomatous skin cancers
Obvious multi-organ Metastatic spread
CT scans demonstrate multi-organ metastasis
In Miscellaneous Cancers (Carcinomas of Unknown Primary Site, Soft Tissue Sarcoma, Generalized Lymphadenopathy and Mediastinal abnormalities/ Lymphadenopathy, Liver Lesions, and Adrenal Lesions and Neuroendocrine Lesions) if ANY ONE of the following are met:
In Carcinomas of Unknown Primary Site if ANY ONE of the following are met:
Finding a probable primary site in carcinomas of unknown primary site
Other imaging studies (i.e. CT, Bone Scans, MRI) have failed to clearly demonstrate primary site
When PET results are positive for the primary site subsequent imaging decisions are to be made according to the guidelines for that site
In Soft Tissue Sarcomas if ANY ONE of the following are met:
To solve specific clinical questions or problems for high grade sarcomas with abnormalities found on other imaging studies or physical examination
To assist in determining the grade of an unresectable lesion, when the grade of the pathologic specimen is in doubt
To assist in re-staging if needed for ANY ONE of the following:
Differentiate tumor from radiation fibrosis or surgical fibrosis
Determine response to therapy
Prior to resection of an apparent solitary metastasis
Suspected metastasis to determine ANY ONE of the following:
Eligibility for metastasectomy
Extent of resection needed
Other therapies
In Generalized Lymphadenopathy and Mediastinal abnormalities when ANY ONE of the following are met:
Histologic diagnosis done prior to PET scan
Requires an invasive surgery biopsy of a relatively inaccessible body region (by mediastinoscopy or thoracoscopy/ thoracotomy ) if ALL of the following are met:
Used to confirm the likelihood of yielding a pathologic diagnosis
Used to determine if a more favorable site for biopsy exists
Characterizing anterior mediastinal abnormalities
Study may differentiate normal or benign hypertrophic thymus tissue from pathologic mediastinal lesions
In Liver Lesions when ALL of the following are met:
Individual have a history of extra hepatic malignancy, with a cell type known to be FDG avid
There is a new finding of a liver lesion with ALL of the following:
Greater than 1 cm
Suspicious for malignancy
Adrenal Lesions and Neuroendocrine Lesions when ANY ONE of the following are met:
Histological confirmation is done before the PET scan
For Pheochromocytoma situations that are clinically determined as high risk for metastatic disease
For evaluation of an adrenal mass found on other imaging in an individual with ALL of the following:
Prior diagnosis of cancer
Predisposed to metastasize to the adrenal gland
In Multiple Myeloma Waldenstrom’s Macroglobulinemia and Plasmacytomas if ANY ONE of the following are met:
Verify a solitary plasmacytoma
Lab studies suggest that an individual with Monoclonal Gammopathy of Unknown Significance (MGUS) has possible progression to a more malignant form of disease
For unusual signs, symptoms, or unexplained radiographic abnormalities
Confirm the early stage of disease to allow for safe observation of an individual with less than “full-blown” Multiple Myeloma (MM) (Stage I or II, or so-called “smoldering” myeloma)
Evaluate for clinically suspected extraosseous plasmacytomas
Certain cases of refractory disease, to aid in determining additional therapies
PET can be approved if a negative PET will allow the oncologist to change a patient’s management plan from active treatment to surveillance
In Primary Brain Tumors if ANY ONE of the following are met:
Distinguishing high grade from low grade gliomas if ANY ONE of the following are met:
Due to indeterminate histology by biopsy
The lesion is in a surgically inaccessible location of the brain (brain stem)
Distinguishing recurrent tumor from radiation necrosis if ALL of the following are met:
Individuals with ANY ONE of the following Anaplastic tumors of glial origin:
Glioblastoma
Anaplastic astrocytoma
Anaplastic oligodendroglioma)
Prior Radiation Therapy
Recurrent disease is suspected
Imaging modalities are indeterminate/ unable to demonstrate primary site
Recent MRI shows new lesions compatible with ANY ONE of the following:
Recurrent tumor
Radiation necrosis
Findings of brain biopsy/ resection suggest a lesion is a metastasis from an unknown primary source
All other Imaging types have failed to clearly demonstrate the site of the primary tumor
Indicated for use in initial staging, re-staging, or surveillance if ANY ONE of the following are met:
When the I-131 scan (I-131 iodine uptake scan) is negative although repeated serum thyroglobulin tests demonstrate a rising thyroglobulin level
Partial thyroidectomy has been performed leaving a large thyroid remnant (> 2 grams or 2 cubic centimeters) and the I-131 whole body scan is not helpful for identifying recurrent disease
Anaplastic thyroid cancers
When abnormalities are found on other imaging studies that cannot be explained
If highly morbid surgery/ radiotherapy is contemplated for salvage or recurrence
Hurthle Cell carcinomas on a case-by-case basis
In Urologic and Testicular Cancers when ANY ONE of the following are met:
For all urologic malignancies when a prior histologically confirmed diagnosis of malignancy is obtained
In Prostate Cancer if ANY ONE of the following are met:
Hormone Refractory disease
A rising PSA
Suspicious finding on another imaging modality following initially successful local therapy
In Kidney and Renal Cell Carcinoma if ANY ONE of the following are met:
Suspicion of a metastatic lesion
Biopsy of the lesion is considered potentially less invasive than biopsy of the kidney
Less invasive than performing a nephrectomy
Clarifying findings on other imaging modalities that are suspicious for, but not diagnostic of ANY ONE of the following:
Metastatic disease
Bilateral disease
Recurrence
In conjunction with conventional imaging, will differentiate possible osseous metastasis from benign bone lesions
In individuals who have undergone complete nephrectomy will Differentiate local tumor recurrence from postoperative and/or post-radiation changes
In Testicular and Nonepithelial ovarian cancer (Germ Cell) if ANY ONE of the following are met:
Evaluation of a germ cell tumor found in a retroperitoneal and/or mediastinal mass, when testicular examination is negative
Differentiate viable tumor from fibrosis or necrosis when ANY ONE of the following are met:
Advanced seminoma
CT-documented residual mass after chemotherapy
Re-staging when the CT is positive
Following radiation therapy delayed until 12 weeks after completion of therapy due to risk of false positive FDG uptake in lethally irradiated cells
Scan done earlier when the clinical situation requires evaluation of disease outside the irradiated volume
With conventional imaging, in evaluating for germ cell tumors in individuals found to have rising tumor markers following potentially curative therapies
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
In general, the anatomic detail acquired in PET/CT is reasonable for the evaluation of many oncologic conditions; however, the diagnostic quality may be inconsistent. For initial diagnosis or staging, a diagnostic CT may be appropriate in addition to PET/CT for certain types of cancers.
The diagnostic and therapeutic decisions of breast cancer are identical for both males and females. This policy addresses breast cancer for all individuals.
PET is not intended to be a substitute for panendoscopy for squamous cell head and neck or salivary gland cancers.
Since the lack of randomized control trials or studies for the use of positron emission tomography (PET) scans to determine early response to treatment (PET scans done during a planned course of chemotherapy and/or radiation therapy) in individuals with cancer, the technology would be considered investigational because the impact of these PET scans on the net health outcome is not known.
For oncologic applications, the skull base to mid-femur (“eyes-to thighs”) procedure is most commonly used. The exceptions to this include malignant melanoma, some unusual presentation of sarcomas and lymphomas and pediatric malignancies in pre-adolescent children.
SOURCES
General Guidelines
Neyman, E., Kamel, I., & Georgiades, C., (2006).Use of combined PET/CT imaging in evaluation of the solitary pulmonary nodule: principles, techniques, and pitfalls. Applied Radiology, 35 (4), 24-43.
Breast Cancer
National Comprehensive Cancer Network. (2010). Invasive breast cancer. NCCN practice guidelines in oncology - . V.2.2010. Retrieved October 27, 2010 from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Uematsu, T., Yuen, S., Yukisawa, S., et al. (2005). Comparison of FDG PET and SPECT for detection of bone metastases in breast cancer. AJR, 184 (4), 1266-1273.
Esophageal Cancer
Cunningham, D., Allum, W. H., Stenning, S. P., Thompson, J. N., Van de Velde, C., Nicolson, M., et al. (2006). Perioperative chemotherapy versus surgery alone for respectable gastroesophageal cancer. New England Journal of Medicine, 355 (1), 11-20.
Lordick, F., Ott, K., Krause, B. J., Weber, W. A., Becker, K., Stein, H. J., et al. (2007). PET to assess early metabolic response and to guide treatment of adenocarcinoma of the oesophagogastric junction: The MUNICON phase II trial. Lancet Oncology, 8 (9), 797-805.
National Comprehensive Cancer Network (NCCN). (2010). Esophageal cancer, NCCN practice guidelines in oncology - V.1.2010. Retrieved October 27, 2010 from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Gastrointestinal Tumors
Heinrich, S., Goerres, G. W., Schafer, M., Sagmeister, M., Bauerfeind, P., Pestalozzi, P., et al. (2005). Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost-effectiveness. Annals of Surgery, 242 (2), 235-243.
Ilias, I., & Pacak, K. (2004). Anatomical and functional imaging of metastatic pheochromocytoma. Annals of the New York Academy of Sciences, 1018, 495-504.
Juweid, M., & Cheson, B. (2006). Positron emission tomography and assessment of cancer therapy. New England Journal of Medicine, 354 (5), 496-507.
National Comprehensive Cancer Network (NCCN). (2010). Gastric cancer. NCCN practice guidelines in oncology - V.2.2010. Retrieved October 27, 2010 from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Northrop, J., & Lee, H. (2007). Large bowel carcinoid tumors. Current Opinions in Gastroenterology, 23 (1), 74-78.
Gynecologic Cancers
Sironi, S., Buda, A., Picchio, M., Perego, P., Moreni, R., Pellegrino, A., et al. (2006). Lymph node metastasis in patients with clinical early stage cervical cancer: Detection with integrated FDG PET/CT. Radiology, 238 (1), 272-279.
Schwarz, J., Siegel, B., Dehdashti, F., & Grigsby, P. W. (2007). Association of post therapy positron emission tomography with tumor response and survival in cervical carcinoma. JAMA, 298 (19), 2289-2295.
Head & Neck
Canning, C. A., Gubbels, S., Chinn, C., Wax, M., & Holland, J. M. (2005). Positron emission tomography scan to determine the need for neck dissection after chemoradiation for head and neck cancer: Timing is everything. Laryngoscope, 115 (12), 2206-2208.
Nahmias, C., Carlson, E., Duncan, L., Blodgett, T., Kennedy, J., Long, M., et al. (2007). Positron emission tomography/computerized tomography (PET/ CT) scanning for preoperative staging of patients with oral/head and neck cancer. Journal of Oral Maxillofacial Surgery, 65 (12), 2524-2535.
National Comprehensive Cancer Network (NCCN). (2010). Head & neck cancers. NCCN practice guidelines in oncology V.2.2009. Retrieved October 27, 2010 from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Pellitteri, P. K., Ferlito, A., Rinaldo, A., Shah, J. P., Weber, R. S., Lowry, J., et al. (2006). Planned neck dissection following chemoradiotherapy for advanced head and neck cancer: Is it necessary for all? Head & Neck, 28 (2), 166-175.
Lung Cancer and Pulmonary Nodules
Al-Sarraf, N., Gately, K., Lucey, J., Wilson, L., McGovern, E., & Young, V. (2008). Lymph node staging by means of positron emission tomography is less accurate in non-small cell lung cancer patients with enlarged lymph nodes: Analysis of 1145 lymph nodes. Lung Cancer, 60 (1), 62-68.
Line, B., Maragh, M., & Ahamed, T. (2002). Positron emission tomography imaging of lung and esophageal cancer. Applied Radiology, 31 (6), 9-17.
Lymphomas
Blake, M., Slattery, J., Sahani, D., & Kaira, M. (2005). Practical issues in abdominal PET/CT. Applied Radiology, 34 (11), 8-18.
Kazama, T., Faria, S. C., Varavithya, V., Phongkitkarun, S., Ito, H., & Macapinlac, H. A. (2005). FDG PET in the evaluation of treatment for lymphoma: Clinical usefulness and pitfalls. RadioGraphics, 25 (1), 191-207.
Melanoma
Gulec, S. A., Faries, M. B., Lee, C. C., Kirgan, D., Glass, C., Morton, D. L., et al. (2003). The role of fluorine-18 deoxyglucose positronemission tomography in the management of patients with metastatic melanoma: Impact on surgical decision making. Clinical Nuclear Medicine, 28 (12), 961-965.
Kumar, R., & Alavi, A. (2005). Clinical applications of fluorodeoxyglucose-positron emission tomography in the management of malignant melanoma. Current Opinion in Oncology, 17 (2), 154-159.
Miscellaneous
American College of Radiology. (2007, October). ACR practice guideline for performing FDG-PET/CT in oncology. Retrieved February 23, 2010 from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/nuc_med/fdg_pet_ct.aspx.
American College of Radiology. (2008, October). ACR appropriateness criteria®. Follow-up of malignant or aggressive musculoskeletal tumors. Retrieved February 23, 2010 from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/FollowUpofMalignantorAggressiveMusculoskeletalTumorsDoc11.aspx.
American College of Radiology. (2008, October). ACR appropriateness criteria®. Suspected liver metastases. Retrieved February 23, 2010 from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/SuspectedLiverMetastasesDoc14.aspx.
Boland, G., Blake, M., Holalkere, N., & Hahn, P. (2009). PET/ CT for the characterization of adrenal masses in patients with cancer: Qualitative versus quantitative accuracy in 150 consecutive patients. American Journal of Roentgenology, 192 (4), 956-962.
Iagaru, A., Quon, A., McDougall, I. R., Gambhir, S. S. (2006). F-18 FDG PET/CT evaluation of osseous and soft tissue sarcomas. Clinical Nuclear Medicine, 31 (12), 754-760.
National Comprehensive Cancer Network (NCCN). (2010). Occult primary. NCCN practice guidelines in oncology - V.1.2010. Retrieved October 27, 2010 from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Multiple Myeloma Waldenstrom’s Macroglobulinemia, and Plasmacytomas
Angtuaco, E. J., Fassas, A. B., Walker, R., Sethi, R., & Barlogie, B. (2004). Multiple myeloma: Clinical review and diagnostic imaging. Radiology, 231 (1), 11-23.
National Comprehensive Cancer Network (NCCN). (2009). Multiple Myeloma. NCCN practice guidelines in oncology - V.2.2009. Retrieved February 23, 2010 from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Thyroid Cancer
Khan, N., Oriuchi, N., Higuchi, T., & Endo, K. (2005). Review of fluorine-18-2-fluoro-2-deoxy-Dglucose positron emission tomography (FDG-PET) in the follow-up of medullary and anaplastic thyroid carcinomas. Cancer Control, 12(4), 254-260.
Lansford, C. & Teknos, T. (2006). Evaluation of the thyroid nodule. Cancer Control, 13 (2), 89-98.
National Comprehensive Cancer Network (NCCN). (2010). Thyroid carcinoma. NCCN practice guidelines in oncology, - V.1.2010. Retrieved February 23, 2010 from http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Urologic and Testicular Cancers
Becherer, A., De Santis, M., Karanikas, G., Szabo, M., Bokemeyer, C., & Dohmen, B. M. (2005). FDG PET is superior to CT in the prediction of viable tumour in post-chemotherapy seminoma residuals. European Journal of Radiology, 54 (2), 284-288.
de Wit, M., Brenner, W., Hartmann, M., Kotzerke, J., Hellwig, D., Lehmann, J., et al. (2008). [18F]-FDG-PET in clinical stage I/II non-seminomatous germ cell tumors: Results of the German multicenter trial. Annals of Oncology, 19 (9), 1619-1623.
Fogelman, I., Cook, G., Israel, O., & Van der Wall, H. (2005). Positron emission tomography and bone metastases. Seminars in Nuclear Medicine, 35 (2), 135-142.
Kang, D. E., White, R. L., Zuger, J. H., Sasser, H. C., & Teigland, C. M. (2004). Clinical use of fluorodeoxyglucose F18 positron emission tomography for detection of renal cell carcinoma. Journal of Urology, 171 (5), 1806-1809.
Martorana, G., Schiavina, R., Corti, B., Farsad, M., Salizzoni, E., Brunocilla, E., et al. (2006). 11C-Choline positron emission tomography/computed tomography for tumor localization of primary prostate cancer in comparison with 12-core biopsy. Journal of Urology, 176 (3), 954-960.
Oechsle, K., Hartmann, M., Brenner, W., Venz, S., Weissbach, L., Franzius, C., et al. (2008). [18 F] Fluorodeoxyglucose positron emission tomography in nonseminomatous germ cell tumors after chemotherapy: The German multicenter positron emission tomography study group. Journal of Clinical Oncology, 26 (36), 5930-5935.
ORIGINAL EFFECTIVE DATE: 9/1/2000
MOST RECENT REVIEW DATE: 12/1/2010
ID_MS
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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