PET/PET-CT: Evidence for need-based planning in Germany and Austria – 2018 update

In October 2018, the Austrian HTA body, the Ludwig-Boltzmann Institue (LBI), published the update on the PET/PET-CT topic. The report was done together with the Berlin Technical University.

This HTA report intends to provide updated decision support for evidence-based PET/PET-CT planning in Germany and Austria. The authors have performed a systematic search of the literature on the websites such as MEDLINE, EMBASE, Pubmed and the Cochrane Library to identify evidence-based guidelines, systematic reviews/meta-analyses and other HTA reports. Furthermore, a manual search of clinical societies’ websites has been performed. Ten (10) HTA reports, 234 recommendations (both positive and negative) from 19 guidelines were included, together with data from twelve (12) systematic reviews/meta-analyses.

Oncological indications

A (relative) consensus exists, which agrees that there is sufficient evidence for sub-indications in 8 indications in favour of PET or PET-CT examinations:

• bronchial cancer (update: mainly pre-treatment, controversial in restaging and response control and in therapy monitoring)
• colon cancer
• malignant lymphoma
• malignant melanoma (update: controversies exist for diagnosis of recurrence)
• breast cancer (update: treatment response, for diagnosis of recurrence)
• head-neck tumours (in 2015 report: CUP, ThyroidCa; update: mainly for diagnosis of recurrence)
• myeloma and neuroendocrine tumours (added in this update)

There is also a (relative) consensus that there is not enough evidence in favour of PET examination in 8 indication areas (individual decisions possible):

• bladder cancer
• hepatic cancer
• cervical cancer
• gastric cancer
• ovarian and uterus cancer
• prostate cancer
• paraneoplastic neurological syndrome.

Due to the inconclusive evidence and recommendations made with reservations, the authors have identified further 8 indications for which they could not make a conclusion

• anal canal carcinoma
• brain (esp. glioma)
• testicular-, kidney- and penile-carcinoma
• esophagus cancer (except re-staging)
• pancreatic carcinomas
• bone and soft tissue tumours (+ GIST)

Neurological indications

The authors have identified evidence for two sub-indications: Alzheimer's dementia and epilepsy. A relative agreement is that there is not sufficient evidence in favour of a PET/PET-CT for either of these two sub-indications, though clinical societies could name specific cases of Alzheimer's dementia or other conditions that argue for or against the PET application. These also depend on their respective tracer (amyloid vs. FDG). However, these recommendations are based on a weak evidence base. Inconclusive evidence is identified for the evaluation of patients with epilepsy (only in some cases, in specialized epilepsy centres).

Inflammatory indications/infections

A relative consensus exists of sufficient evidence that is in favour or PET/PET-CT exists for infections of the vertebral column/ spondylodiscitis. The evidence is inconclusive for periprosthetic joint infection, osteomyelitis, sarcoidosis and fever of unclear origin.

Other

The authors state that no specific recommendations can be made with the existing evidence for PET-MRI to be superior to PET-CT in routine clinical practice. Regarding the planning of PET or PET-CT, this update was unable to identify new literature and developments. However, one Canadian report (CADTH 2018) provides continuous data on 6 imaging techniques (including also PET-CT) and can be used as a basis for research, policy and planning.

Conclusion

This 2018 update contains more details and specifications compared to the 2015 report. The overall recommendations for indications (and sub-indications), as well as the explicit non-recommendations, from the LBI 2015 report and this 2018 update can serve as needs-based and evidence-based decision support for PET/ PET-CT service provision in German and Austrian hospitals.

See the full report in German (with summary in English) here.

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