Use and perceived utility of [¹⁸F]FDG PET/CT in neuroendocrine neoplasms: A consensus report from the European Neuroendocrine Tumor Society (ENETS) Advisory Board Meeting 2022

Abstract

Somatostatin receptor (SST) PET/CT is the gold standard for well‐differentiated neuroendocrine tumours (NET) imaging. Higher grades of neuroendocrine neoplasms (NEN) show preferential [18F]FDG (FDG) uptake, and even low‐grade NET may de‐differentiate over time. FDG PET/CT's prognostic role is widely accepted; however, its impact on clinical decision‐making remains controversial and its use varies widely. A questionnaire‐based survey on FDG PET/CT use and perceived decision‐making utility in NEN was submitted to the ENETS Advisory Board Meeting attendees (November 2022, response rate = 70%). In 3/15 statements, agreement was higher than 75%: (i) FDG was considered useful in NET, irrespective of grade, in case of mis‐matched lesions (detectable on diagnostic CT but negative/faintly positive on SST PET/CT), especially if PRRT is contemplated (80%); (ii) in NET G3 if curative surgery is considered (82%); and (iii) in NEC prior to surgery with curative intent (98%). FDG use in NET G3, even in the presence of matched lesions, as a baseline for response assessment was favoured by 74%. Four statements obtained more than 60% consensus: (i) FDG use in NET G3 if locoregional therapy is considered (65%); (ii) in neuroendocrine carcinoma before initiating active therapy as a baseline for response assessment (61%); (iii) biopsy to re‐assess tumour grade prior to a change in therapeutic management (68%) upon detection of FDG‐positivity on the background of a prior G1‐2 NET; (iv) 67% were in favour to reconsider PRRT to treat residual SST‐positive lesions after achieving complete remission on FDG of the SST‐negative disease component. Multidisciplinary opinion broadly supports the use of FDG PET/CT for characterisation of disease biology and to guide treatment selection across a range of indications, despite the lack of full consensus in many situations. This may reflect existing clinical access due to lack of reimbursement or experience with this investigation, which should be addressed by further research.

Theranostics in Neuroendocrine Tumors

“…However, its complementary role is increasingly recognized in G3 and high G2 tumors (Ki-67 >10%) in scenarios where it can help guide treatment through the identification of potential hypermetabolic lesions lacking SSTR expression. 23,24 This is especially the case in patients exhibiting rapid or accelerating progression. A recent consensus from the European Neuroendocrine Tumor Society advisory board reports high agreement on the utility of FDG PET, irrespective of tumor grade, to evaluate tumors visible on anatomic imaging but negative or faintly positive on DOTATATE PET especially if PRRT is considered, as well as in G3 NET and NEC particularly if surgery with curative intent is considered.…”

“…A recent consensus from the European Neuroendocrine Tumor Society advisory board reports high agreement on the utility of FDG PET, irrespective of tumor grade, to evaluate tumors visible on anatomic imaging but negative or faintly positive on DOTATATE PET especially if PRRT is considered, as well as in G3 NET and NEC particularly if surgery with curative intent is considered. 24 New FDG-positive lesions on a background of G1/G2 NET may justify a biopsy to assess for potential change in tumor grade.…”