Introduction Introduction Cost Cost ... · - It emphasizes that PET is a revolution in medical...

IntroductionIntroductionCostCost--effectivenesseffectivenessProtocolsProtocolsCodes & FeesCodes & Fees

StructurStructural imagingal imaging

MetabolMetabolic Imagingic Imaging

RadiologyGeneral XrayCTUltrasoundMagnetic Resonance Imaging

Nuclear MedicinePlanar scintigraphySPECTPET

FDGFDG--PET PET -- the “smart” imagethe “smart” image

FDG FluorodeoxyFDG Fluorodeoxy--GlucoseGlucose

FDG FluorodeoxyFDG Fluorodeoxy--GlucoseGlucoseMetabolically behaves like Metabolically behaves like glucoseglucoseMeasure rate of metabolismMeasure rate of metabolismDue to the relatively long halfDue to the relatively long half--life, life, it can be distributedit can be distributedTherefore it can apply to:Therefore it can apply to:–– Cancer Search (Higher Cancer Search (Higher

Metabolism)Metabolism)–– Brain (Main user of energy)Brain (Main user of energy)

FDG is produced automatically from 18F

Glucose6-phosphatase


HexokinaseGlycolyticpathway

1818FDGFDG

DD--glucoseglucose

G6P

FDG-6-P



HexokinaseGlycolyticpathway

G6P

FDG-6-P

FDG uptake in cancer cellsNormal CelNormal Celll NeoplastiNeoplasticc CelCelll

(infla(inflammatory cells)mmatory cells)

CURRENT INTERNATIONAL TRENDSCURRENT INTERNATIONAL TRENDS

PET shows the fastest procedure growth of any diagnostic modalitPET shows the fastest procedure growth of any diagnostic modalitiesies

Oncology accounts for 82%Oncology accounts for 82%

THE GREATEST VALUE IS DIAGNOSTIC ONCOLOGYTHE GREATEST VALUE IS DIAGNOSTIC ONCOLOGY

THIS INCLUDESTHIS INCLUDES::

Hogkins and NonHogkins and Non--Hodgkins LymphomaHodgkins LymphomaThyroid/head and neck cancerThyroid/head and neck cancerBreast cancerBreast cancerGastroGastro--intestinal tumors especially colointestinal tumors especially colo--rectal cancerrectal cancerUrological malignanciesUrological malignanciesOesophageal malignanciesOesophageal malignanciesMelanomaMelanomaNonNon--small cell lung carcinomasmall cell lung carcinoma

HOW DOES IT HELP ?HOW DOES IT HELP ?-- Characterisation of disease (SPN)Characterisation of disease (SPN)-- Initial staging (not all cancers)Initial staging (not all cancers)-- Restaging and monitoring of therapyRestaging and monitoring of therapy

CONDITIONS:CONDITIONS:-- There would have to be standardized protocols based on InternatiThere would have to be standardized protocols based on International onal

models models (Europe (Europe and the US)and the US)-- The use of PET in aiding in a diagnosis if PET assists inThe use of PET in aiding in a diagnosis if PET assists in

** in avoiding invasive diagnostic proceduresin avoiding invasive diagnostic procedures** in determining optimal anatomical location for invasive in determining optimal anatomical location for invasive

diagnostic proceduresdiagnostic procedures-- The use in staging and restaging whenThe use in staging and restaging when

** Doubt remains after a standard clinical workupDoubt remains after a standard clinical workup** PET can replace on or more conventional imaging studies to give PET can replace on or more conventional imaging studies to give

better information for clinical managementbetter information for clinical management-- Monitoring the response to therapyMonitoring the response to therapy

** If it assists in avoiding surgery and improves patient outcomeIf it assists in avoiding surgery and improves patient outcome

Examples from current literatureExamples from current literature

A Net search on the website of the Radiological Society of NorthA Net search on the website of the Radiological Society of NorthAmerica shows 481 articles in the past 3 years in which PET was America shows 481 articles in the past 3 years in which PET was the the main topic.main topic.

The journal of Nuclear medicine Volume 41 no 5 is a table relateThe journal of Nuclear medicine Volume 41 no 5 is a table related d summary of the FDG PET Literature. It serves as a useful tool fsummary of the FDG PET Literature. It serves as a useful tool for the or the measurement of the management effect as a result of PET imaging measurement of the management effect as a result of PET imaging and is available for your scrutiny.and is available for your scrutiny.

More recently the Radiological clinics of North America Volume 4More recently the Radiological clinics of North America Volume 42 2 No 6 & 7 November 2004 and January 2005 is dedicated to PET No 6 & 7 November 2004 and January 2005 is dedicated to PET imaging. imaging.

-- It emphasizes that PET is a revolution in medical imagingIt emphasizes that PET is a revolution in medical imaging-- It discusses instrumentationIt discusses instrumentation-- It explores the potential of the development of other It explores the potential of the development of other

IsotopesIsotopes-- It discusses the usefulness of PET in the management of It discusses the usefulness of PET in the management of

patient’s with:patient’s with:

** Hodgkins and NonHodgkins and Non--Hodgkins lymphomaHodgkins lymphoma** Thyroid head and neck and cancerThyroid head and neck and cancer** Breast cancerBreast cancer** GI tumorsGI tumors** Urological malignanciesUrological malignancies** Gynaecological malignanciesGynaecological malignancies

QUOTE FROM THE ARTICLE ON THE QUOTE FROM THE ARTICLE ON THE IMAGING OF LYMPHOMA’SIMAGING OF LYMPHOMA’S

PET and CT must be considered as given complimentary staging PET and CT must be considered as given complimentary staging information. FDG PET also has high diagnostic accuracy for restinformation. FDG PET also has high diagnostic accuracy for restaging aging

lymphoma after initial treatment.lymphoma after initial treatment.

FDG PET has shown high accuracy in the early prediction of respoFDG PET has shown high accuracy in the early prediction of response to nse to chemotherapy and in the evaluation of residual masses after chemchemotherapy and in the evaluation of residual masses after chemo or o or

radiation therapy.radiation therapy.

PET is established and reimbursed in the rest of the world.PET is established and reimbursed in the rest of the world.There are a number of articles relating to the cost effectivenesThere are a number of articles relating to the cost effectiveness of PETs of PETThe timing is ideal for the introduction of PET into the countryThe timing is ideal for the introduction of PET into the country becausebecause** new developments in the Isotope industrynew developments in the Isotope industry** the strong randthe strong randIt must be emphasized that the introduction is a transparent proIt must be emphasized that the introduction is a transparent processcessThere is also drive from academic groups for the introduction ofThere is also drive from academic groups for the introduction of PETPETPET certainly has applications in paediatric oncology (possiblyPET certainly has applications in paediatric oncology (possibly aids aids research)research)Clinical trials now depend on PET as part of their research baseClinical trials now depend on PET as part of their research base

COST EFFECTIVENESSCOST EFFECTIVENESS

Difficult to accurately quantifyDifficult to accurately quantify

Many references in literatureMany references in literature

Different models usedDifferent models used

List of relevant articlesList of relevant articles

Some of applications of PET that have been subject to cost effecSome of applications of PET that have been subject to cost effectiveness analysis tiveness analysis are shown in the next slide.are shown in the next slide.

TARGET POPULATIONTARGET POPULATION EVALUATIONEVALUATION METHODMETHOD REFERENCEREFERENCE

Coronary artery diseaseCoronary artery disease Decision Analysis ModelDecision Analysis Model Garber (19)Garber (19)Patterson (20)Patterson (20)MaddahiMaddahi

Solitary Pulmonary NoduleSolitary Pulmonary Nodule Decision Analysis ModelDecision Analysis Model Gambhir (21)Gambhir (21)Decision Analysis ModelDecision Analysis Model GouldGouldDecision Analysis ModelDecision Analysis Model Dietlein (17)Dietlein (17)

Staging NSCLCStaging NSCLC Decision Analysis ModelDecision Analysis Model Gambhir (22)Gambhir (22)Decision Analysis Model Decision Analysis Model Dietlein (23)Dietlein (23)Decision Analysis Model Decision Analysis Model Scott (24)Scott (24)

ReRe--staging colorectal cancerstaging colorectal cancer Decision Analysis Model Decision Analysis Model Park Sanders (18)Park Sanders (18)

Lymphoma stagingLymphoma staging Retrospective costingRetrospective costing Hoh (25)Hoh (25)Klose (26)Klose (26)

Multiple tumorsMultiple tumors Retrospective costingRetrospective costing Valk (28)Valk (28)

DementiaDementia -- Small (29)Small (29)

SOLITARY PULMONARY NODULESOLITARY PULMONARY NODULEFDG PET is cost effective when preFDG PET is cost effective when pre--test probability and CT results are discordant, test probability and CT results are discordant, the risk of surgical complication is high, the diagnostic yield the risk of surgical complication is high, the diagnostic yield of needle biopsy is low or of needle biopsy is low or the utility of time spent in observation is lowthe utility of time spent in observation is low

STAGING OF NSCLCSTAGING OF NSCLC** Cost effective in staging all patients and NSCLC.Cost effective in staging all patients and NSCLC.

** Most cost effective in staging patients with normal sized lymphnMost cost effective in staging patients with normal sized lymphnodes on CT odes on CT examinationexamination

STAGING OF RECURRENT STAGING OF RECURRENT COLOCOLO--RECTAL CANCERRECTAL CANCER

CT and PET is cost effective for the evaluation of resectabilityCT and PET is cost effective for the evaluation of resectabilityUp to 30% of patients referred for elective metastectomy have otUp to 30% of patients referred for elective metastectomy have other metastatic her metastatic lesions.lesions.

STAGING OF LYMPHOMASTAGING OF LYMPHOMA•• Cost effective in Hodgkin’s and NonCost effective in Hodgkin’s and Non--Hodgkin’s lymphomaHodgkin’s lymphoma

•• Cost per correct stage was assessed comparing CT to whole body FCost per correct stage was assessed comparing CT to whole body FDG PET DG PET –– 81% vs 100 %81% vs 100 %

•• Very accurate for measuring response to therapyVery accurate for measuring response to therapy

COST SAVINGSCOST SAVINGSAn example taken from the 10An example taken from the 10thth Annual Institute of Annual Institute of

clinical PET conference Boston MA.clinical PET conference Boston MA.

Regarding coloRegarding colo--rectal cancer, the clinical questions became:rectal cancer, the clinical questions became:

•• Can FDG PET more accurately stage the patient with potentially rCan FDG PET more accurately stage the patient with potentially resectable colon esectable colon rectal cancer?rectal cancer?

•• Can FDG PET be decreasing a number of unnecessary procedures incCan FDG PET be decreasing a number of unnecessary procedures including surgery luding surgery be more cost effective in the clinical setting?be more cost effective in the clinical setting?

Surgical procedures were avoided by demonstration of nonSurgical procedures were avoided by demonstration of non--resectable resectable tumour in 25 patient’s and calculated on the basis of PET reimbutumour in 25 patient’s and calculated on the basis of PET reimbursement at rsement at $1800, the net savings amounted to a total of $3760 per patient.$1800, the net savings amounted to a total of $3760 per patient. The The conclusion was that whole body metabolic PET imaging is more accconclusion was that whole body metabolic PET imaging is more accurate urate than CT alone for the demonstration of recurrent colothan CT alone for the demonstration of recurrent colo--rectal cancer and is a rectal cancer and is a cost effective means of differentiating resectable from noncost effective means of differentiating resectable from non--resectable resectable disease. The findings were similar to other trials done regardidisease. The findings were similar to other trials done regarding colong colo--rectal rectal cancer.cancer.

SUMMARYSUMMARYMc Master university currently assessing economics of PET scanneMc Master university currently assessing economics of PET scanners (2 rs (2 clinical trials)clinical trials)

Institute of clinical PET have also coInstitute of clinical PET have also co--ordinated a number of trials many of ordinated a number of trials many of which are currently under waywhich are currently under way

Available literature does support the cost effectiveness of CT/PAvailable literature does support the cost effectiveness of CT/PET if ET if appropriately usedappropriately used

Therefore it is proposed that the modality be strictly protocol Therefore it is proposed that the modality be strictly protocol driven to driven to ensure adequate controlensure adequate control

PROPOSED PROTOCOLSPROPOSED PROTOCOLSModality in SA should be strictly protocol drivenModality in SA should be strictly protocol drivenWill serve to prevent excessive use of modalityWill serve to prevent excessive use of modalityProtocols drawn up usingProtocols drawn up using

(i)(i) Local knowledge Local knowledge -- RadiologistsRadiologists-- Nuclear PhysicianNuclear Physician-- OncologistsOncologists

(ii)(ii) US Medicare protocolsUS Medicare protocols(iii)(iii) UK NHS GuidelinesUK NHS Guidelines

Covered Indications for PET Scans in South Africa and Covered Indications for PET Scans in South Africa and Limitations/Requirements Limitations/Requirements

for Usage for Usage (SAPUA protocol task group)(SAPUA protocol task group)

For all uses of PET relating to malignancies the following condiFor all uses of PET relating to malignancies the following conditions apply: tions apply:

A. DiagnosisA. Diagnosis

PET is covered only in clinical situations in which: (1) the PETPET is covered only in clinical situations in which: (1) the PET results may assist in results may assist in avoiding an invasive diagnostic procedure, or in which (2) the Pavoiding an invasive diagnostic procedure, or in which (2) the PET results may assist in ET results may assist in determining the optimal anatomical location to perform an invasidetermining the optimal anatomical location to perform an invasive diagnostic ve diagnostic procedure. In general, for most solid tumors, a tissue diagnosisprocedure. In general, for most solid tumors, a tissue diagnosis is made prior to the is made prior to the performance of PET scanning. PET scans following a tissue diagnoperformance of PET scanning. PET scans following a tissue diagnosis are generally sis are generally performed for staging rather than diagnosis. performed for staging rather than diagnosis. PET is not covered as a screening test (i.e., testing patients wPET is not covered as a screening test (i.e., testing patients without specific signs and ithout specific signs and symptoms of disease). symptoms of disease).

B. StagingB. Staging

PET is covered for staging in clinical situations in which: (1)(PET is covered for staging in clinical situations in which: (1)(a) the stage of the cancer a) the stage of the cancer remains in doubt after completion of a standard diagnostic workuremains in doubt after completion of a standard diagnostic workup, including p, including conventional imaging (computed tomography (CT), magnetic resonanconventional imaging (computed tomography (CT), magnetic resonance imaging (MRI), ce imaging (MRI), or ultrasound), or (1)(b) it could potentially replace one or moor ultrasound), or (1)(b) it could potentially replace one or more conventional imaging re conventional imaging studies when it is expected that conventional study information studies when it is expected that conventional study information is insufficient for the is insufficient for the clinical management of the patient, and 2) clinical management oclinical management of the patient, and 2) clinical management of the patient would f the patient would differ depending on the stage of the cancer identified. differ depending on the stage of the cancer identified.

C. RestagingC. Restaging

PET is covered for restaging: (1) after completion of treatment PET is covered for restaging: (1) after completion of treatment for the for the purpose of detecting residual disease, (2) for detecting suspectpurpose of detecting residual disease, (2) for detecting suspected ed recurrence or metastasis, (3) to determine the extent of a knownrecurrence or metastasis, (3) to determine the extent of a knownrecurrence, or (4) if it could potentially replace one or more crecurrence, or (4) if it could potentially replace one or more conventional onventional imaging studies when it is expected that conventional study infoimaging studies when it is expected that conventional study information is rmation is insufficient for the clinical management of the patient. Restagiinsufficient for the clinical management of the patient. Restaging applies to ng applies to testing after a course of treatment is completed, and is coveredtesting after a course of treatment is completed, and is covered subject to subject to the conditions above. the conditions above.

D. MonitoringD. Monitoring

This refers to use of PET to monitor tumor response to treatmentThis refers to use of PET to monitor tumor response to treatment during the during the planned course of therapy (i.e., when a change in therapy is antplanned course of therapy (i.e., when a change in therapy is anticipated). icipated). Clinical records documenting the medical necessity of the study Clinical records documenting the medical necessity of the study must be must be available at the provider of the PET study or the referring physavailable at the provider of the PET study or the referring physician.ician.

A POSITRON EMISSION TOMOGRAPHY DONE WITH A POSITRON EMISSION TOMOGRAPHY DONE WITH COINCIDENCE GAMMA CAMERAS.COINCIDENCE GAMMA CAMERAS.

Technical specificationsTechnical specifications

These coincidence systems must have all the following features:These coincidence systems must have all the following features:-- Crystal at least 5/8Crystal at least 5/8--inch thick;inch thick;-- Techniques to minimize or correct for scatter and/or randoms; aTechniques to minimize or correct for scatter and/or randoms; andnd-- Digital detectors and iterative reconstruction.Digital detectors and iterative reconstruction.Scans performed with gamma camera PET systems with crystals thinScans performed with gamma camera PET systems with crystals thinner than 5/8” should not be ner than 5/8” should not be covered. In addition, scans performed with systems with crystalscovered. In addition, scans performed with systems with crystals greater than or equal to 5/8” in greater than or equal to 5/8” in thickness, but that do not meet the other listed design charactethickness, but that do not meet the other listed design characteristics should not be covered.ristics should not be covered.

IndicationsIndications

• Characterization of single pulmonary nodules.( Requires diagn• Characterization of single pulmonary nodules.( Requires diagnostic evidence of primary tumor prior ostic evidence of primary tumor prior to PET. Tumour must be between 1to PET. Tumour must be between 1-- 4cm. Not covered if prior negative PET within 90 days.4cm. Not covered if prior negative PET within 90 days.• Initial staging of lung cancer (non small cell)• Initial staging of lung cancer (non small cell)• Determining location of colo• Determining location of colo--rectal tumors if rising CEA level suggests recurrence( once per rectal tumors if rising CEA level suggests recurrence( once per year)year)• Staging or restaging of lymphoma only when used as alternative• Staging or restaging of lymphoma only when used as alternative to gallium scan (up to four times to gallium scan (up to four times per year)per year)• Evaluating recurrence of melanoma prior to surgery (once per y• Evaluating recurrence of melanoma prior to surgery (once per year)ear)

INDICATIONSINDICATIONS

ABSOLUTE INDICATIONSABSOLUTE INDICATIONS

-- subject to the completion of the appropriate requisition form asubject to the completion of the appropriate requisition form and then tond then tonormal prenormal pre--authorisationauthorisation

RELATIVE INDICTIONSRELATIVE INDICTIONS

-- subject to peer reviewsubject to peer review

FUTURE INDICATIONSFUTURE INDICATIONS

-- subject to evidence development subject to evidence development –– not for 2006not for 2006

B)B) INDICATIONS FOR PET/CT AND DEDICATED PET INDICATIONS FOR PET/CT AND DEDICATED PET SYSTEMS (FULL AND PARTIAL RING)SYSTEMS (FULL AND PARTIAL RING)

1)1) ABSOLUTE INDICATIONSABSOLUTE INDICATIONS

INDICATIONS FOR 2005/2006INDICATIONS FOR 2005/2006 FREQUENCY OFFREQUENCY OFSCANSCAN

ONCOLOGY APPLICATIONSONCOLOGY APPLICATIONS

PAROTIDPAROTID Identification of metastatic disease in theIdentification of metastatic disease in the 1 / year1 / yearneck from a diagnosed malignancyneck from a diagnosed malignancy

MALIGNANCIES OF THEMALIGNANCIES OF THEOROPHARYNXOROPHARYNX Diagnosis, initial staging, restagingDiagnosis, initial staging, restaging up to 4 / yearup to 4 / year

LARYNXLARYNX Diagnosis, initial staging, restagingDiagnosis, initial staging, restaging up to 2 / yearup to 2 / year

THYROIDTHYROID 1) Assessment of patients with elevated 1) Assessment of patients with elevated up to 2 / hearup to 2 / hearthyroglobulin (or suspected false negativethyroglobulin (or suspected false negativevalue) and negative iodine scans for recurrent value) and negative iodine scans for recurrent disease. Applicable only in patients who diddisease. Applicable only in patients who didhave a thyroidectomy and / or Ihave a thyroidectomy and / or I--131 treatment131 treatment2) Assessment of tumour recurrence in medullary 2) Assessment of tumour recurrence in medullary up to 2 / yearup to 2 / yearcarcinoma of the thyroidcarcinoma of the thyroid

LUNGLUNG 1) Differentiation of benign versus malignant lesions1) Differentiation of benign versus malignant lesions not more thannot more thanwhere anatomical imaging or biopsy are inconclusivewhere anatomical imaging or biopsy are inconclusive every 90 daysevery 90 daysor there is a relative contraindication to biopsy. Theor there is a relative contraindication to biopsy. Thelesion must be between 1 lesion must be between 1 –– 4 cm in size.4 cm in size.2) Pre2) Pre--operative staging of non small cell primary lung operative staging of non small cell primary lung 1 / year1 / year3) Assessment of recurrent disease in previously treated3) Assessment of recurrent disease in previously treated up to 4 / yearup to 4 / yeartumours where anatomical imaging is unhelpful.tumours where anatomical imaging is unhelpful.4) Assessment of response to treatment4) Assessment of response to treatment

OESOPHAGUSOESOPHAGUS 1) Staging of primary cancer1) Staging of primary cancer up to 4 / yearup to 4 / year2) Assessment of disease recurrence in previously treated 2) Assessment of disease recurrence in previously treated cancerscancers3) Assessment of neo3) Assessment of neo--adjuvant chemotherapyadjuvant chemotherapy

BREAST CANCERBREAST CANCER 1) Assessment of the extent of disseminated disease1) Assessment of the extent of disseminated disease up to 4 / yearup to 4 / year2) Assessment of multi2) Assessment of multi--focal diseasefocal disease3) Suspected local recurrence3) Suspected local recurrence4) Assessment of chemotherapy response4) Assessment of chemotherapy response

COLON AND RECTUMCOLON AND RECTUM Diagnosis, initial staging and restagingDiagnosis, initial staging and restaging up to 4 / yearup to 4 / yearIntervals not less than Intervals not less than 12 months with no rising12 months with no risingCEA levels.CEA levels.

LYMPHOMALYMPHOMA 1) Staging of Hodgkins lymphoma1) Staging of Hodgkins lymphoma up to 4 / yearup to 4 / year2) Staging of non2) Staging of non--Hodgkins lymphomaHodgkins lymphoma3) Assessment of residual masses for active disease3) Assessment of residual masses for active disease4) Identification of disease sites when there is suspicion of 4) Identification of disease sites when there is suspicion of relapse from clinical assessment.relapse from clinical assessment.5) Response to chemotherapy5) Response to chemotherapy

6) Assessment of remission from lymphoma6) Assessment of remission from lymphoma every 12 monthsevery 12 months

MELANOMAMELANOMA Initial staging and restaging (not for evaluating regional nodesInitial staging and restaging (not for evaluating regional nodes))

2)2) RELATIVE INDICATIONSRELATIVE INDICATIONS

ONCOLOGYONCOLOGY

Liver Liver –– secondary lesionsecondary lesion 1) Equivocal diagnostic imaging (CT, MRI, Ultrasound)1) Equivocal diagnostic imaging (CT, MRI, Ultrasound) 1 / year1 / year2) Exclude other metastatic disease prior to metastectomy2) Exclude other metastatic disease prior to metastectomy 1 / year1 / year

Renal and adrenalRenal and adrenal Assessment of possible adrenal metastasesAssessment of possible adrenal metastases 1 / year1 / year

TesticleTesticle 1) Assessment of recurrent disease from seminomas and1) Assessment of recurrent disease from seminomas and 1 / year1 / yearteratomasteratomas2) Assessment of residual masses2) Assessment of residual masses

OvaryOvary Initial staging (in stage 1A disease where adjuvant therapyInitial staging (in stage 1A disease where adjuvant therapyis not contemplated) and restagingis not contemplated) and restaging up to 4 / yearup to 4 / year

UTERUS UTERUS –– CERVIXCERVIX difficult situations to define the extent of disease difficult situations to define the extent of disease up to 4 / yearup to 4 / yearwith accompanying image registration (staging and restaging)with accompanying image registration (staging and restaging)

METASTASES FROM UNKNOWN PRIMARYMETASTASES FROM UNKNOWN PRIMARY Determining the site of an unknown primary when thisDetermining the site of an unknown primary when thisinfluences managementinfluences management up to 1 / yearup to 1 / year

NEUROPSYCHIATRY APPLICATIONSNEUROPSYCHIATRY APPLICATIONS 1) Pre1) Pre--surgical evaluation of epilepsy.surgical evaluation of epilepsy.2) Early diagnosis of dementia, especially younger patients2) Early diagnosis of dementia, especially younger patients( particularly Alzheimer’s disease) when MR of CT is either nor( particularly Alzheimer’s disease) when MR of CT is either normal, mal, marginally abnormal or equivocally abnormal. marginally abnormal or equivocally abnormal. up to 1 / yearup to 1 / year

MICELLANEOUS APPLICATIONSMICELLANEOUS APPLICATIONS

FEVER OF UNKNOWN ORIGINFEVER OF UNKNOWN ORIGIN Identifying source of the fever of unknown origin when conventioIdentifying source of the fever of unknown origin when conventional diagnosticnal diagnosticworkout remains unequivocal.workout remains unequivocal.

3)3) FUTURE INDICATIONS SUBJECT TO FUTURE INDICATIONS SUBJECT TO EVIDENCE DEVELOPMENTEVIDENCE DEVELOPMENT

ONCOLOGY APPLICATIONSONCOLOGY APPLICATIONS

BRAIN AND SPINAL CORDBRAIN AND SPINAL CORD 1) Suspected tumour recurrence when anatomical imaging is 1) Suspected tumour recurrence when anatomical imaging is difficult or equivocal and management will be affected. difficult or equivocal and management will be affected. Often a combination of methionine and FDG PET scans will Often a combination of methionine and FDG PET scans will need to be performed.need to be performed.

2) Benign versus malignant lesions, where there is 2) Benign versus malignant lesions, where there is uncertainty on anatomical imaging and a relative contraindicatiouncertainty on anatomical imaging and a relative contraindication to biopsy.n to biopsy.

3) Investigation of the extent of tumour within the brain or sp3) Investigation of the extent of tumour within the brain or spinal cord.inal cord.4) Secondary tumours in the brain4) Secondary tumours in the brain5) Assess tumour response to therapy.5) Assess tumour response to therapy.

PARATHYROID PARATHYROID Localisation of parathyroid adenomas with methionine when Localisation of parathyroid adenomas with methionine when other investigations are negative other investigations are negative

PANCREAS PANCREAS 1) Staging a known primary.1) Staging a known primary.2) Differentiation of chronic pancreatitis from pancreatic carc2) Differentiation of chronic pancreatitis from pancreatic carcinoma.inoma.3) Assessment of pancreatic masses to determine benign or 3) Assessment of pancreatic masses to determine benign or malignant status.malignant status.

MUSCULOSKELETAL TUMOURSMUSCULOSKELETAL TUMOURS 1) Soft tissue primary mass assessment to distinguish high grad1) Soft tissue primary mass assessment to distinguish high gradeemalignancy from low or benign diseasemalignancy from low or benign disease2) Staging of primary soft tissue malignancy to assess non2) Staging of primary soft tissue malignancy to assess non--skeletal metastasesskeletal metastases3) Assessment of recurrent abnormalities in operative sites3) Assessment of recurrent abnormalities in operative sites4) Assessment of osteogenic sarcomas for metastatic disease4) Assessment of osteogenic sarcomas for metastatic disease5) Follow up to detect recurrence or metastases5) Follow up to detect recurrence or metastases

HEARTHEART Diagnosis or coronary artery disease or assessment of Diagnosis or coronary artery disease or assessment of known coronary stenosis where other investigations known coronary stenosis where other investigations (spect, etc.) are unhelpful(spect, etc.) are unhelpful

DISEASE ASSESSMENT IN HIV AND OTHERDISEASE ASSESSMENT IN HIV AND OTHERIMMUNOSUPPRESSED PATIENTSIMMUNOSUPPRESSED PATIENTS 1) Identifying sites to biopsy in patients with pyrexia.1) Identifying sites to biopsy in patients with pyrexia.

2) Differentiating benign from malignant cerebral pathology2) Differentiating benign from malignant cerebral pathology3) Routine assessment of weight loss where malignancy is suspec3) Routine assessment of weight loss where malignancy is suspected.ted.

ASSESSMENT OF BONE INFECTIONASSESSMENT OF BONE INFECTION Assessment of spinal infection or problematic cases of infectionAssessment of spinal infection or problematic cases of infection..

ASSESSMENT OF BONE METASTASESASSESSMENT OF BONE METASTASES When bone scan or other imaging is equivocal.When bone scan or other imaging is equivocal.

ASSESSMENT OF TUMOUR RECURRENCE INASSESSMENT OF TUMOUR RECURRENCE INTHE PITUITARYTHE PITUITARY Identifying recurrent functional pituitary tumours when anatomicIdentifying recurrent functional pituitary tumours when anatomical imaging has not al imaging has not

been successful.been successful.

REQUISITION FOR WHOLE BODY REQUISITION FOR WHOLE BODY PETPET

Esophageal, Head /Neck, or Colorectal cancer, Melanoma and LymphEsophageal, Head /Neck, or Colorectal cancer, Melanoma and LymphomaomaDate: --____ /____ /____Date: --____ /____ /____

Patient name:____________________________________Patient name:____________________________________

Medical aid:_____________________________________Medical aid:_____________________________________

Medical aid number:_______________________________Medical aid number:_______________________________

Practice number:__________________________________Practice number:__________________________________

ICDICD--10 Code(s): ________________10 Code(s): ________________

Reason for Exam: ___________________________________________Reason for Exam: ___________________________________________

Has patient had recent CT? ___ YesHas patient had recent CT? ___ Yes ___ No___ No

Has patient had recent biopsy? ___ YesHas patient had recent biopsy? ___ Yes ___ No___ No

Instructions: Please check below to indicate the type of PET scaInstructions: Please check below to indicate the type of PET scan ordered and answer the questions included in each category. n ordered and answer the questions included in each category.

If your patient does not meet payor medical necessity guidelinesIf your patient does not meet payor medical necessity guidelines, there is a high probability that they will have to pay for thi, there is a high probability that they will have to pay for this s exam. exam.

Please fax this requisition, with recent CT or biopsy/pathology Please fax this requisition, with recent CT or biopsy/pathology reports toreports to ______.______.

TYPE OF CANCER:TYPE OF CANCER:___ Esophageal, ___ Head and Neck, ___ Colorectal, ___ L___ Esophageal, ___ Head and Neck, ___ Colorectal, ___ Lymphoma, ___ Melanoma.ymphoma, ___ Melanoma.________

DIAGNOSIS:DIAGNOSIS: (Covered only if YES is answered to 2. or 3.)(Covered only if YES is answered to 2. or 3.)

1. If tissue diagnosis of malignancy has been made, you must use1. If tissue diagnosis of malignancy has been made, you must use “Initial Staging” category.“Initial Staging” category.2. Will this PET assist in avoiding an invasive exam? __ Yes 2. Will this PET assist in avoiding an invasive exam? __ Yes __ No__ No3. Will PET assist in determining optimal anatomical site for an3. Will PET assist in determining optimal anatomical site for an invasive procedure? invasive procedure? ___ Yes ___ No___ Yes ___ No

INITIAL STAGING (Covered only if YES is answered to 2. OR 3. ANDINITIAL STAGING (Covered only if YES is answered to 2. OR 3. AND 4.) 4.) (Not covered for evaluation of regional lymph nodes for melanoma(Not covered for evaluation of regional lymph nodes for melanoma.):.):

1. Date of tissue diagnosis: ____________1. Date of tissue diagnosis: ____________2. Does the stage of the cancer remain in doubt after completion2. Does the stage of the cancer remain in doubt after completion of a standard diagnostic workof a standard diagnostic work--up? up? ___ Yes___ No___ Yes___ No3. Will PET replace conventional imaging studies that are expect3. Will PET replace conventional imaging studies that are expected to be insufficient for clinical ed to be insufficient for clinical management? ___ Yes___ Nomanagement? ___ Yes___ No4. Will clinical management of the patient differ depending on s4. Will clinical management of the patient differ depending on stage identified? ___ Yes ___ Notage identified? ___ Yes ___ No

RESTAGING (Covered only if YES is answered to 1. OR 2.):RESTAGING (Covered only if YES is answered to 1. OR 2.):

1. Is this PET being performed after the completion of treatment1. Is this PET being performed after the completion of treatment for detection of residual or suspected recurrent for detection of residual or suspected recurrent disease or to determine the extent of a known recurrence? disease or to determine the extent of a known recurrence? ___ Yes ____ No___ Yes ____ No2. Will PET replace conventional imaging studies that are expect2. Will PET replace conventional imaging studies that are expected to be insufficient for clinical management? ed to be insufficient for clinical management? ___ Yes ___ No___ Yes ___ No

Date: ______________Date: ______________

Physician Signature: ________________________________________Physician Signature: ________________________________________Physician Name Printed: __________________________________ Physician Name Printed: __________________________________ Physician Phone: _____________________Physician Phone: _____________________

REQUESITION FOR WHOLE BODY REQUESITION FOR WHOLE BODY PET PET –– LUNGLUNG

Date: --____ /____ /____Date: --____ /____ /____





ICDICD--10 Code(s): ________________10 Code(s): ________________

Reason for Exam: ______________________________________________Reason for Exam: ______________________________________________* Note: ICD* Note: ICD--9 code 162.9 is not specific enough to meet medical necessity 9 code 162.9 is not specific enough to meet medical necessity –– please indicate please indicate specific nodule sitespecific nodule siteHas patient had recent CT? ___ YesHas patient had recent CT? ___ Yes ___ No___ NoHas patient had recent biopsy? ___ YesHas patient had recent biopsy? ___ Yes ___ No___ No

Instructions: Please check below to indicate the type of PET scaInstructions: Please check below to indicate the type of PET scan ordered and answer the n ordered and answer the questions included in each category. If your patient does not mequestions included in each category. If your patient does not meet the medical necessity et the medical necessity guidelines, there is a high probability that your patient have guidelines, there is a high probability that your patient have to pay for this examto pay for this exam... Please . Please fax this requisition, with CT or biopsy/pathology reports to____fax this requisition, with CT or biopsy/pathology reports to___________________._______________.

Single Pulmonary Nodule (covered only if YES is answered to 3. Single Pulmonary Nodule (covered only if YES is answered to 3. and 4.):and 4.):1. If a tissue diagnosis of malignancy has been made, use the “L1. If a tissue diagnosis of malignancy has been made, use the “Lung Cancer ung Cancer –– Initial Staging” category.Initial Staging” category.2. If > 4 cm, use the “Lung Cancer2. If > 4 cm, use the “Lung Cancer--Diagnosis” category.Diagnosis” category.3. Is nodule less than 4 cm in diameter?3. Is nodule less than 4 cm in diameter? ___ Yes___ Yes ___ No___ No ___ Unknown___ Unknown4. Is nodule indeterminate by chest x4. Is nodule indeterminate by chest x--ray or CT criteria? ___ray or CT criteria? ___ YesYes ___ No___ No

Lung Cancer (nonLung Cancer (non--small cell only) for:small cell only) for:

DIAGNOSIS (covered only if YES is answered to 2. or 3.):DIAGNOSIS (covered only if YES is answered to 2. or 3.):

1. If tissue diagnosis of malignancy has been made, you must use1. If tissue diagnosis of malignancy has been made, you must use “Initial Staging” category.“Initial Staging” category.2. Will this PET assist in avoiding an invasive exam? __ Yes 2. Will this PET assist in avoiding an invasive exam? __ Yes __ No__ No3. Will PET assist in determining optimal anatomical site for in3. Will PET assist in determining optimal anatomical site for invasive procedure? ___ Yes ___ No vasive procedure? ___ Yes ___ No

INITIAL STAGING (covered only if YES is answered to 2. OR 3. ANINITIAL STAGING (covered only if YES is answered to 2. OR 3. AND 4.):D 4.):

1. Date of tissue diagnosis: ____________1. Date of tissue diagnosis: ____________ Finding: ___ NSCLC ___ OtherFinding: ___ NSCLC ___ Other2. Does the stage of the cancer remain in doubt after completion2. Does the stage of the cancer remain in doubt after completion of a standard diagnostic workof a standard diagnostic work--up?up?___ Yes___ Yes ___ No___ No

3. Will PET replace conventional imaging studies that are expect3. Will PET replace conventional imaging studies that are expected to be insufficient for clinical management? ed to be insufficient for clinical management? ___ Yes___ No___ Yes___ No4. Will clinical management of the patient differ depending on s4. Will clinical management of the patient differ depending on stage identified? ___ Yes ___ Notage identified? ___ Yes ___ No

RESTAGING (covered only if YES is answered to 1. or 2.):RESTAGING (covered only if YES is answered to 1. or 2.):

1. Is this PET being performed after the completion of treatment1. Is this PET being performed after the completion of treatment for detection of residual or suspected recurrent for detection of residual or suspected recurrent disease or to determine the extent of a known recurrence?disease or to determine the extent of a known recurrence? ___ Yes ___ Yes ___ No___ No2. Will PET replace conventional imaging studies that are expect2. Will PET replace conventional imaging studies that are expected to be insufficient for clinical management?ed to be insufficient for clinical management?___ Yes ___ Yes ___ No___ No

Date: ______________Date: ______________

Physician Signature: ________________________________________Physician Signature: ________________________________________

REQUISITION FORREQUISITION FORWHOLE BODY PET WHOLE BODY PET

–– Breast CancerBreast CancerDate: --____ /____ /____Date: --____ /____ /____





ICD 10Code(s): __________________ICD 10Code(s): __________________

Reason for Exam: ______________________________________________Reason for Exam: ______________________________________________



Instructions: Please check below to indicate the type of PET scaInstructions: Please check below to indicate the type of PET scan ordered and answer the questions n ordered and answer the questions included in each category. If your patient does not meet payor mincluded in each category. If your patient does not meet payor medical necessity guidelines, there is a edical necessity guidelines, there is a high probability that they will have to pay for this exam . Pleahigh probability that they will have to pay for this exam . Please fax this requisition, with recent CT or se fax this requisition, with recent CT or biopsy/pathology reports to ___________________biopsy/pathology reports to ___________________

BREAST CANCER (covered only if YES is answered to 2., 3., or 4.BREAST CANCER (covered only if YES is answered to 2., 3., or 4.))(not covered for initial diagnosis or for evaluation of regional(not covered for initial diagnosis or for evaluation of regional lymph nodes)lymph nodes)

1. Tissue diagnosis: ___ Yes1. Tissue diagnosis: ___ Yes ___ No___ No Date ________________ Date ________________

2. Is PET performed for staging patients with distant metastases2. Is PET performed for staging patients with distant metastases? ___ Yes? ___ Yes ___ No ___ No

3. Is PET performed for restaging patients with locoregional rec3. Is PET performed for restaging patients with locoregional recurrence or metastases? ___ Yesurrence or metastases? ___ Yes ___ No___ No

4. Is PET performed to monitor the results of treatment and is a4. Is PET performed to monitor the results of treatment and is a change in therapy contemplated based change in therapy contemplated based on PET results? ____ Yes _____ Noon PET results? ____ Yes _____ No

Date: ______________Date: ______________


Physician Name Printed: __________________________________ Physician Name Printed: __________________________________

Physician Phone: _____________________Physician Phone: _____________________

REQUISITION FORREQUISITION FORWHOLE BODY PET WHOLE BODY PET –– Thyroid CancerThyroid Cancer

Date: --____ /____ /____Date: --____ /____ /____



Medical aid number:______________________________Medical aid number:______________________________

Practice number:_________________________________Practice number:_________________________________

ICDICD--10 Code(s): _________________10 Code(s): _________________

Reason for Exam: _____________________________________________Reason for Exam: _____________________________________________



Instructions: Please check below to indicate the type of PET scaInstructions: Please check below to indicate the type of PET scan ordered and answer the questions n ordered and answer the questions included in each category. If your patient does not meet payor mincluded in each category. If your patient does not meet payor medical necessity guidelines, there is a edical necessity guidelines, there is a high probability that they will have to pay for this exam. Pleashigh probability that they will have to pay for this exam. Please fax this requisition, with recent CT or e fax this requisition, with recent CT or biopsy/pathology reports to _______________________biopsy/pathology reports to _______________________

Thyroid Cancer(covered only for assessment of patients with recuThyroid Cancer(covered only for assessment of patients with recurrent or residual thyroid cancers of rrent or residual thyroid cancers of follicular origin with elevated thyroglobulin(or suspected falsefollicular origin with elevated thyroglobulin(or suspected false negative value) and negative iodine negative value) and negative iodine scans for recurrent disease. Applicable only in patients who didscans for recurrent disease. Applicable only in patients who did have a thyroidectomy and/or Ihave a thyroidectomy and/or I--131 131 treatment: if YES is answered to 1., 2., 3., 4., and 5.)treatment: if YES is answered to 1., 2., 3., 4., and 5.)

(Medullary and anaplastic cancers are not typically covered)(Medullary and anaplastic cancers are not typically covered)

1. Tissue diagnosis: follicular origin1. Tissue diagnosis: follicular origin ___ Yes___ Yes ___ No___ No Date ___________ Date ___________

2. Thyroidectomy: 2. Thyroidectomy: ___ Yes___ Yes ___ No ___ No Date ___________ Date ___________

3. Radioiodine therapy: 3. Radioiodine therapy: ___ Yes___ Yes ___ No___ No Date ____________Date ____________

4. Thyroglobulin levels > ________: 4. Thyroglobulin levels > ________: ___ Yes___ Yes ___ No___ No Date____________Date____________

5. Negative I5. Negative I--131 whole body scan: 131 whole body scan: ___ Yes___ Yes ___ No___ No Date ____________Date ____________

6. Thyrogen administration: 6. Thyrogen administration: ___ Yes___ Yes ___ No___ No

7. Hormonal withdrawal: 7. Hormonal withdrawal: ___ Yes___ Yes ___ No___ No Date Last Dose ____________Date Last Dose ____________

Date: ______________Date: ______________




REQUISITION FOR Cardiac PETREQUISITION FOR Cardiac PETDate: --____ /____ /____Date: --____ /____ /____





ICDICD--10Code(s): ________________10Code(s): ________________

Reason for Exam: __________________________________________Reason for Exam: __________________________________________

Has patient had any of the following procedures recently (check Has patient had any of the following procedures recently (check all that apply):all that apply):

___ ___ CT of the chest or heart?CT of the chest or heart?______ MRI of the chest?MRI of the chest?______ PET cardiac imaging?PET cardiac imaging?______ Nuclear medicine cardiac SPECT imaging? If yes, ___ RestNuclear medicine cardiac SPECT imaging? If yes, ___ Resting OR ___ Stressing OR ___ Stress______ Coronary angiography? Coronary angiography? ______ Stress echocardiogram?Stress echocardiogram?______ Electrocardiogram? If yes, ___ Resting OR ___ StrElectrocardiogram? If yes, ___ Resting OR ___ Stress ?ess ?______ Coronary artery bypass graft (CABG)? Coronary artery bypass graft (CABG)? Date: _______________Date: _____________________ Percutaneous Coronary Intervention (PCI)? Percutaneous Coronary Intervention (PCI)? Date: _________________Date: _________________

Instructions: Please check below to indicate the type of PET scaInstructions: Please check below to indicate the type of PET scan ordered and answer the questions included in each category. n ordered and answer the questions included in each category. If your patient does not meet payor medical necessity guidelinesIf your patient does not meet payor medical necessity guidelines, there is a high probability that they will have to pay for thi, there is a high probability that they will have to pay for this s exam). Please fax this requisition, with recent nuclear cardioloexam). Please fax this requisition, with recent nuclear cardiology and coronary angiogram reports to _______________________gy and coronary angiogram reports to _______________________

PET is covered if YES is answered to 1. or 2.PET is covered if YES is answered to 1. or 2.

Myocardial Viability with FDGMyocardial Viability with FDG

Resting myocardial perfusion with 13NResting myocardial perfusion with 13N--ammoniaammonia

Is the PET scan performed in place of, but not in addition to a Is the PET scan performed in place of, but not in addition to a SPECT scan? SPECT scan? ___ Yes ____ No___ Yes ____ NoIs the PET scan performed following a SPECT scan found to be incIs the PET scan performed following a SPECT scan found to be inconclusive and is PET considered necessary in order to determine onclusive and is PET considered necessary in order to determine how how to treat the patient? to treat the patient? ____ Yes ____ No____ Yes ____ No

Pharmacological Stress myocardial perfusion with 13NPharmacological Stress myocardial perfusion with 13N--ammoniaammonia

Is the PET scan performed in place of, but not in addition to a Is the PET scan performed in place of, but not in addition to a SPECT scan? SPECT scan? ___ Yes ____ No___ Yes ____ NoIs the PET scan performed following a SPECT scan found to be incIs the PET scan performed following a SPECT scan found to be inconclusive and is PET considered necessary in order to determine onclusive and is PET considered necessary in order to determine how how to treat the patient? to treat the patient? ____ Yes ____ No____ Yes ____ No

Date: ______________Date: ______________




MC 3894 5/1/04MC 3894 5/1/04

CODES AND FEES CODES AND FEES 00950 PET scan local -00951 PET/CT local 7,01900952 PET/CT local with contrast 7,20200955 PET scan whole body -00956 PET/CT scan whole body without contrast 8,97800957 PET/CT scan whole body with contrast 9,161

REGIONAL 10970 PET scan of the brain -10971 PET/CT scan of the brain uncontrasted 6,83410972 PET/CT of the brain contrasted 7,03610980 PET perfusion scan of the brain -10981 PET/CT perfusion scan of the brain 7,87221960 PET scan of the thyroid -22940 PET scan of the parathyroid -29960 PET scan of the soft tissue of the neck -29961 PET/CT scan of the soft tissue of the neck uncontrasted 6,92729962 PET/CT scan of the soft tissue of the neck contrasted 7,12830980 PET scan of the chest -30981 PET/CT scan of the chest uncontrasted 6,92730982 PET/CT scan of the chest contrasted 7,12830983 PET/CT scan of the chest pre and post contrast 8,93334900 PET scan of the breast/mamma -33980 PET scan of the heart -33981 PET/CT scan of the heart? 7,45943961 PET scan of the testis -40950 PET scan of the abdomen and pelvis -40951 PET/CT scan of the abdomen and pelvis uncontrasted 8,23040952 PET/CT scan of the abdomen and pelvis contrasted 8,43240953 PET/CT scan of the abdomen and pelvis pre and post contrast 9,847

REFERENCESREFERENCES1. ONCOLOGY1. ONCOLOGY

** GENERALGENERALWeinstein MC, Stason WB, Foundations of costWeinstein MC, Stason WB, Foundations of cost--effectiveness for health and medial practices. New England Joureffectiveness for health and medial practices. New England Journal of Medicine nal of Medicine 1977;296:7161977;296:716--21.21.

** LUNGLUNGDietlein M, Weber K, Gandjour A et al. Cost effectiveness of FDDietlein M, Weber K, Gandjour A et al. Cost effectiveness of FDG PET for the management of solitary pulmonary nodules; a G PET for the management of solitary pulmonary nodules; a decision decision analysis based on cost reimbursement in Germany. Eur J Nucl Medanalysis based on cost reimbursement in Germany. Eur J Nucl Med 2000;27: 14412000;27: 1441--1456.1456.

Dietlein M, Weber K, Gandjour A et al. Cost effectiveness of FDietlein M, Weber K, Gandjour A et al. Cost effectiveness of FDG PET for the management of potentially operable nonDG PET for the management of potentially operable non--small small cell lung cell lung cancer: priority for a PETcancer: priority for a PET--based strategy after nodalbased strategy after nodal--negative CT results. Eür J Nucl Med 2000;27:1598negative CT results. Eür J Nucl Med 2000;27:1598--16091609

Gambhir SS, Hoh CK, Phelps ME et al. Decision tree sensitivity Gambhir SS, Hoh CK, Phelps ME et al. Decision tree sensitivity analysis for cost effectiveness of FDG PET in the staging and analysis for cost effectiveness of FDG PET in the staging and management of nonmanagement of non--small cell lung carcinoma. J Nucl Med 1996;37:1428small cell lung carcinoma. J Nucl Med 1996;37:1428--1436.1436.

Gambhir SS, Shepherd JE, Shah BD et al. Analyticla decision modGambhir SS, Shepherd JE, Shah BD et al. Analyticla decision model for the cost effective management of solitary pulmonary el for the cost effective management of solitary pulmonary nodules. J nodules. J Clin Oncol 1998;16:2113Clin Oncol 1998;16:2113--21252125

Dietlein M, Weber K, Gandjour A et al. Cost effectiveness of FDDietlein M, Weber K, Gandjour A et al. Cost effectiveness of FDG PET for the management of solitar pulmonary nodules: a decisiG PET for the management of solitar pulmonary nodules: a decision on analysis based on cost reimbursement in Germany. Eur J Nucl Meanalysis based on cost reimbursement in Germany. Eur J Nucl Med 2000;27:1441d 2000;27:1441--1456.1456.

Dietlein M, Weber K, Gandjour A et al. Cost effectiveness of poDietlein M, Weber K, Gandjour A et al. Cost effectiveness of potentially operable nontentially operable non--small cell lung cancer: priority for a PETsmall cell lung cancer: priority for a PET--based based strategy after nodalstrategy after nodal--negative CT results. Eur J Nucl Med 2000;27:1598negative CT results. Eur J Nucl Med 2000;27:1598--16091609

** COLOCOLO--RECTALRECTALHuebner RH, Park KC, Shepherd JE et al. A metaHuebner RH, Park KC, Shepherd JE et al. A meta--analysis of the literature for whole body FDG PET detection of ranalysis of the literature for whole body FDG PET detection of recurrent colorectal ecurrent colorectal cancer. J Nucl Med 2000;41;1177cancer. J Nucl Med 2000;41;1177--1189.1189.

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Adams S, Baum RP, Stuckensen T et al. Prospective comparison ofAdams S, Baum RP, Stuckensen T et al. Prospective comparison of 18F18F--FDG PET with conventional imaging modalities (CT, MRI, US) in FDG PET with conventional imaging modalities (CT, MRI, US) in lymph node staging of head and neck cancer. Eur J Nucl Med 1998lymph node staging of head and neck cancer. Eur J Nucl Med 1998;25:1255;25:1255--12601260

** LYMPHOMALYMPHOMAKlose T, Leidl R, Buchmann, I, Brambs HJ, Reske SN. Primary staKlose T, Leidl R, Buchmann, I, Brambs HJ, Reske SN. Primary staging of lymphomas: costging of lymphomas: cost--effectiveness of FDGeffectiveness of FDG--PET versus computed PET versus computed tomography. European Journal of Nuclear Medicine 2000;27(10):14tomography. European Journal of Nuclear Medicine 2000;27(10):145757--6464

Hob CK, Glaspy J, Rosen P, Dahlbom M, Lee SJ, Kunkel L et al. WHob CK, Glaspy J, Rosen P, Dahlbom M, Lee SJ, Kunkel L et al. Wholehole--body FDGbody FDG--PET imaging for staging of Hodgkin’s disease and PET imaging for staging of Hodgkin’s disease and lymphoma. Journal of Nuclear Medicine 1997;38(3):343lymphoma. Journal of Nuclear Medicine 1997;38(3):343--8.8.

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