Ebner et al.

European Radiology (2025) 35:1894–1902

https://doi.org/10.1007/s00330-024-11094-8

INVITED REVIEW Open Access

ESR Essentials: staging and restaging with

FDG-PET/CT in oncology—practice
recommendations by the European Society for
Hybrid, Molecular and Translational Imaging
Ricarda Ebner1* , Gabriel T. Sheikh2, Matthias Brendel2, Jens Ricke1 and Clemens C. Cyran1

Abstract
Positron emission tomography (PET) stands as the paramount clinical molecular imaging modality, especially in
oncology. Unlike conventional anatomical-morphological imaging methods such as computed tomography (CT) and
magnetic resonance imaging (MRI), PET provides detailed visualizations of internal activity at the molecular and cellular
levels.
18-fluorine-fluorodeoxyglucose ([18F]FDG)-PET combined with contrast-enhanced CT (ceCT) significantly improves the
detection of various cancers. Appropriate patient selection is crucial, and physicians should carefully assess the
appropriateness of [18F]FDG-PET/CT based on specific clinical criteria and evidence. Due to its high diagnostic
accuracy, [18F]FDG-PET/CT is indispensable for evaluating the extent of disease, staging, and restaging known
malignancies, and assessing the response to therapy. PET/CT imaging offers significant advantages in patient
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management, particularly by identifying occult metastases that might otherwise go undetected. This can help prevent
unnecessary surgeries, allowing many patients to be redirected to systemic chemotherapy instead. However, it is
important to note that the gold standard for surgical planning remains CT and/or MRI, depending on the body region.
These imaging modalities, with or without associated angiography, provide superior contrast and spatial resolution,
essential for detailed surgical preparation and planning.
[18F]FDG-PET/CT has a central role in the precise and early diagnosis of cancer, contributing significantly to
personalized treatment plans. However, it has limitations, including non-tumor-specific uptake and the potential to
inaccurately capture the metabolic activity of certain tumor types due to low uptake in some well-differentiated tumor
cell lines. Therefore, it should be utilized in clinical scenarios where it offers crucial diagnostic insights not readily
available with other imaging modalities.

This article belongs to the ESR Essentials series guest edited by Marc Dewey
(Berlin/Germany).
*Correspondence:
Ricarda Ebner
[email protected]
1
Department of Radiology, LMU University Hospital, LMU Munich, Munich,
Germany
2
Department of Nuclear Medicine, LMU University Hospital, LMU Munich,
Munich, Germany

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Ebner et al. European Radiology (2025) 35:1894–1902 1895

Key Points
●
Use [18F]FDG-PET/CT selectively based on clinical appropriateness criteria and existing evidence to optimize resource
utilization and minimize patient exposure.
●
Employ [18F]FDG-PET/CT in treatment planning and monitoring, particularly for assessing chemotherapy or radiotherapy
response in FDG-avid lymphoma and solid tumors.
●
When available, [18F]FDG-PET/CT can be integrated with other diagnostic tools, such as MRI, to enhance overall diagnostic
accuracy.
Keywords Positron-emission tomography computed tomography, Fluorodeoxyglucose F18, Molecular imaging,
Radiopharmaceuticals, Clinical decision-making

Key recommendations Fluorodeoxyglucose (FDG) is the most common radio-

pharmaceutical for cancer imaging. Positron emission
●
Proper selection of patients: Before deciding whether tomography with 18-fluorine [18F]FDG combined with
or not to perform a [18F]FDG-PET/CT, carefully computed tomography ([18F]FDG-PET/CT) has become
evaluate its appropriateness for the corresponding an established imaging method for detecting various
indication based on specific clinical criteria and cancers. The half-life of [18F], a radioisotope of fluorine
existing evidence. [18F]FDG-PET/CT should be that emits positrons, is 110 min, making it feasible to scan
selectively used in cases where it offers superior patients at sites distant from the cyclotron where [18F]
diagnostic accuracy compared to conventional FDG is produced.
imaging in terms of sensitivity, specificity, and [18F]FDG-PET has a high sensitivity for the detection of
impact on clinical management (level of evidence: tumors but is not tumor-specific. Increased utilization of
moderate). glucose is characteristic of most cancers, primarily due to
●
Use in treatment planning and monitoring: leverage the overexpression of membrane glucose transporters
the capabilities of [18F]FDG-PET/CT in treatment (GLUT 1) and elevated expression and activity of glyco-
planning and response monitoring. It has lytic enzymes, such as hexokinase, compared to non-
demonstrated significant utility in assessing responses malignant cells [2].
to treatments such as chemotherapy, immunotherapy, In this review, we focus on the most prevalent and
or radiotherapy. Additionally, [18F]FDG-PET/CT can clinically significant tumors, including lung cancer, lym-
detect non-responding tumors at an early stage, phoma, head and neck cancer, breast cancer, and color-
allowing timely modification of treatment approaches ectal cancer. While [18F]FDG-PET/CT can be used to
(level of evidence: high). assess a wide range of tumor types, we specifically high-
●
Integration with other Diagnostic Tools: When light these cancers due to their high incidence and con-
available, [18F]FDG-PET/CT can be complemented siderable impact.
with other diagnostic modalities to enhance diagnostic
accuracy. Additionally, combination with other Indications for [18F]FDG-PET/CT
imaging modalities like MRI complements PET/CT, Evaluating the extent of disease in staging of the known
e.g., providing detailed evaluation of liver metastases malignancy is essential for determining the appropriate
(level of evidence: high). treatment plan and predicting prognosis. PET imaging is
also key to the early detection of (recurrent) tumors in the
Introduction presence of elevated tumor markers, even when there is
Positron emission tomography (PET) is the most impor- no clinical or morphological evidence of disease, allowing
tant molecular imaging modality, particularly in the field for timely intervention. In addition, imaging is helpful in
of oncology. PET differs from conventional anatomical- the search for an unknown primary when metastatic
morphological imaging techniques, such as computed disease is the first clinical presentation or when patients
tomography (CT) and magnetic resonance imaging present with paraneoplastic symptoms, guiding further
(MRI), in that it provides detailed visualizations of the diagnostic and therapeutic steps. Conventional imaging
body’s internal activities at the molecular and cellular techniques provide valuable information to distinguish
levels [1]. However, this advantage comes with a com- between benign and malignant lesions, but in approxi-
promise, as molecular imaging usually demonstrates mately one-third of patients, therapeutic management is
lower spatial resolution compared to CT or MRI. significantly altered by [18F]FDG-PET/CT. Due to
Ebner et al. European Radiology (2025) 35:1894–1902 1896

significantly higher diagnostic accuracy in the detection of the importance of structured reporting for referring
metastatic lesions, PET/CT usually leads to the detection clinicians, ensuring they receive clear and actionable
of additional metastasis and consequent upstaging [3]. information for patient management [5]. For most cancer-
Furthermore, [18F]FDG-PET/CT can play a crucial role related scans, covering the area from the base of the
in evaluating disease response to chemotherapy, immu- skull to mid-thigh is sufficient. However, for patients
notherapy, or radiotherapy. Precise imaging with PET/CT with a high likelihood of metastases in the lower
helps to identify optimal sites for biopsy, contributing to limbs, a full-body scan might be necessary. Figure 1
an accurate pathological diagnosis. It also assists in illustrates the clinical indications of [18F]FDG-PET/CT in
planning surgical procedures, allowing for optimized oncology.
tumor removal [2].
In addition to the acquisition of PET data, a sequential Lung cancer
CT scan is usually performed within the same examina- [18F]FDG-PET/CT plays a crucial role in lung cancer
tion. Low-dose CT is primarily used for attenuation cor- management, including both small cell lung cancer (SCLC)
rection, while a diagnostic CT scan involves the use of CT and non-small cell lung cancer (NSCLC). While solitary
with or without intravenous contrast agents (contrast- pulmonary nodules are often initially detected through
enhanced CT: ceCT) and helps with the anatomical plain chest radiographs or CT scans, conventional imaging
correlation of PET findings [4]. This diagnostic hybrid alone may not definitively determine malignancy due to
imaging approach leverages the combined strengths of non-specific anatomical findings. However, [18F]FDG-
complementary morphological and functional imaging PET/CT is sensitive to increased glucose metabolism
techniques. The inclusion of functional information associated with cancer before specific structural changes
about tumor physiology is essential for a comprehensive indicate malignancy. For the characterization of solitary
assessment of treatment response. While the Response pulmonary nodules, [18F]FDG-PET/CT demonstrated high
Evaluation Criteria in Solid Tumors (RECIST) criteria sensitivity (96%), accuracy (92%) and low specificity [6].
primarily focus on anatomical changes, PET Response Due to the low spatial and contrast resolution of PET,
Evaluation Criteria in Solid Tumors (PERCIST) criteria primarily resulting from its signal-to-noise ratio and the
integrate metabolic activity data from [18F]FDG-PET/CT, need for a substantial number of hypermetabolic cells to
providing a comprehensive view of tumor response. detect a signal above the background, subcentimeter
This combined approach not only enhances the evaluation nodules (< 8–10 mm) can result in false negatives on [18F]
of therapeutic effectiveness, especially in cases where FDG-PET. However, solid pulmonary nodules larger than 8
anatomical changes are minimal but also underscores to 10 mm without [18F]FDG uptake are likely benign [7].

•Determining the stage of various cancers, including lung cancer,lymphoma,

Diagnosis and staging head and neck tumor, breast cancer, and colorectal cancer.

Treatment response
assessment

•Idenficaon of recurrence in previously treated cancer paents,

Detecon of recurrence especially when other imaging techniques are inconclusive or negave, in
the presence of elevated tumor markers.

Search for unknown •In metastac disease, where the original tumor is unknown or the paent
presents with paraneoplasc symptoms, FDG-PET/CT can be used to
primary tumor idenfy the primary tumor.

•Selecon of the tumor region that is most likely to provide diagnosc

Guiding biopsy informaon for a biopsy.

Differenaon of benign •Inflammatory and infecous diseases, autoimmune diseases, vascular

from malignant lesions diseases.

Fig. 1 Clinical indications of [18F]FDG-PET/CT in oncology

Ebner et al. European Radiology (2025) 35:1894–1902 1897

Fig. 2 [18F]FDG-PET/CT (a and b) with pulmonary mass in the right upper lobe, suggestive of lung cancer. The pulmonary mass exhibited intense FDG
uptake (bottom row f–h, green arrow). Several mediastinal lymph nodes were identified as pathologic on the CT scan (c). However, FDG-PET/ceCT
revealed only medium FDG uptake in these lymph nodes (top row d and e, yellow arrow). A bronchoscopy was recommended for further evaluation,
which confirmed no lymph node metastases in the mediastinum

False positives may arise from conditions such as inflam- recurrence. [18F]FDG-PET/CT is recommended in
mation or infection. evidence-based guidelines for the initial staging of FDG-
Evidence-based guidelines, for example, the National avid lymphomas, such as Hodgkin’s lymphoma, diffuse
Comprehensive Cancer Network (NCCN), recommend large B-cell lymphoma (DLBCL), and follicular lym-
[18F]FDG-PET/CT for initial staging at diagnosis of phoma. [18F]FDG-PET/CT is more accurate than CT in
NSCLC, and for restaging after induction therapy or when staging aggressive lymphomas with significantly higher
recurrence is suspected. This recommendation is based sensitivity and specificity, especially in assessing lym-
on its higher sensitivity and specificity compared to con- phoma viability and in the detection of extranodal disease.
ventional CT, particularly in staging mediastinal lymph Guidelines state that [18F]FDG-PET/CT is useful for
nodes and excluding distant metastases. Accurate staging detecting histologic transformation from follicular lym-
determines whether patients will undergo surgery or, in phoma to DLBCL, as transformed lymphomas often show
cases where surgery is not an option, will benefit from higher FDG uptake values [10].
neoadjuvant chemotherapy, radiotherapy alone, or a The initial staging and treatment response of lymphoma
combination of chemotherapy and radiotherapy. can be objectively assessed using the Deauville five-point
The guidelines also advise its use in accurate radiation scale. The scoring system assigns a numerical value to
therapy planning for both NSCLC and SCLC when limited FDG uptake in lymph nodes or other sites of disease.
stage is suspected or when it is necessary to clarify the stage. It provides a standardized approach for interpreting
However, the guidelines do not support the routine use of [18F]FDG-PET/CT images, allowing for consistent
[18F]FDG-PET/CT for follow-up or surveillance in NSCLC assessment of treatment response across different centers
or SCLC, despite its superiority in differentiating benign and over time. However, it is essential to consider clinical
conditions such as atelectasis, consolidation, and radiation context and other imaging findings besides the Deauville
fibrosis from neoplasms, compared to conventional CT. score to ensure accurate interpretation and appropriate
Although [18F]FDG-PET/CT can be effective in these cases, clinical decision-making [11].
it requires histopathologic confirmation of recurrence, as Following the early evaluation of chemotherapy
post-radiation changes can remain FDG-avid for up to 2 response, typically after two or three cycles, decisions
years [8, 9]. For detailed visualization, Fig. 2 displays regarding treatment escalation or de-escalation can be
[18F]FDG-PET/ceCT imaging of a pulmonary mass in the made based on the results of [18F]FDG-PET/CT [12].
right upper lobe, indicative of lung cancer. Additionally, PET scans are valuable at the end of che-
motherapy for assessing residual masses on CT by
Lymphoma determining their metabolic activity and guiding decisions
In the diagnosis and treatment of hematologic malig- on the necessity of further treatment.
nancies, [18F]FDG-PET/CT is essential for initial staging, The German Hodgkin Study Group Hodgkin disease (HD)
assessing therapeutic responses, and detecting potential 15 and HD18 studies significantly impacted lymphoma
Ebner et al. European Radiology (2025) 35:1894–1902 1898

a
Baseline [18F]FDG-PET/CT before

b c
decision for CAR T-cell therapy

d e f
therapy before actual CAR T-cell
[18F]FDG-PET/CT aer bridging

therapy

g h i
[18F]FDG-PET/CT 1 months aer
CAR T-cell therapy

Fig. 3 Following initial chemotherapy and first response, the patient with NHL demonstrated disease progression on subsequent follow-up evaluation
(a–c). Consequently, an indication for chimeric antigen receptor (CAR) T-cell therapy was established. Prior to the infusion of CAR T cells, the patient was
commenced on R-CHOEP as bridging therapy. Despite this regimen, there was a further progression of the disease, evidenced by increasing nodal
involvement and new extranodal manifestations (liver, d–f). One month post-CAR T-cell therapy, imaging revealed only minimal residual nodal disease,
and both functional and morphological regression of the hepatic lesions (g–i)

treatment protocols by using PET scans to guide therapy BEACOPP, while those with PET-positive residual man-
adjustments. The HD15 study reduced the chemotherapy ifestations continue with six cycles and may require
regimen in patients with advanced-stage Hodgkin’s lymphoma radiation therapy [14].
from eight to six cycles for better efficacy and reduced toxicity. Chimeric antigen receptor (CAR T)-cell therapy repre-
It also determined that patients with PET-negative residual sents an innovative advancement in the treatment of
lymphomas post-chemotherapy had a prognosis as favorable hematologic malignancies, using the patient’s own
as those with a complete response. Only patients with PET- immune system to effectively target cancer cells. Acute
positive residuals were advised to undergo localized 30 Gray lymphocytic leukemia, non-Hodgkin lymphoma (NHL)
radiation [13]. and multiple myeloma are particularly difficult to manage,
The HD18 study tested further reduction of che- especially when they relapse after initial treatments. CAR
motherapy cycles for patients in patients with advanced- T-cell therapy offers a substantial overall response rate of
stage Hodgkin’s lymphoma responding well early on. up to 80%, achieving long-lasting remissions or potential
Results showed that patients who were PET-negative after cures in 40 to 50% of cases.
two cycles of escalated BEACOPP could safely reduce [18F]FDG-PET/CT imaging plays a crucial role in the
their treatment to four cycles without losing tumor con- evaluation and management of patients undergoing CAR
trol, with overall survival improving significantly. Hence, T-cell therapy. Two [18F]FDG-PET/CT scans should be
for advanced stages, patients with a negative PET after performed before CAR T-cell infusion: one at the time of
two cycles now receive only four cycles of escalated the decision to proceed with CAR T-cell therapy,
Ebner et al. European Radiology (2025) 35:1894–1902 1899

providing a new baseline study, identifying patients who symptoms of possible metastases, stage IV disease,
would benefit most, and deciding on aggressive bridging inflammatory breast cancer, more than four positive
treatments. Another PET/CT study should be conducted axillary nodes at surgery, and workup before preoperative
after the completion of bridging therapy, which may systemic therapy [21]. Routine systemic staging is not
include treatments such as steroids, systemic therapy, or recommended for early breast cancer in the absence of
radiotherapy, administered between T-cell harvesting and symptoms. [18F]FDG-PET/CT can be considered for sta-
CAR T-cell infusion. High metabolic activity in the dis- ging of recently diagnosed stage III and, in some cases,
ease at baseline is linked to shorter overall survival, higher stage IIB breast cancer. Due to its limited sensitivity in
tumor burdens associated with early relapse and lower detecting early axillary lymph node disease and micro
burdens with longer survival and progression-free peri- metastases, [18F]FDG-PET/CT cannot replace sentinel
ods. Post-therapy [18F]FDG-PET/CT scans at 1 and lymph node biopsy (SLNB) for staging. Precise staging,
3 months post-infusion assess treatment response, non- particularly in the axillary lymph nodes, is crucial for
response and treatment failure, classified as early or late assessing patient prognosis and selecting appropriate
depending on whether it occurs within or after 90 days (multimodality) treatment strategy. SLNB remains the
post-treatment [15, 16]. Figure 3 illustrates the disease reference standard for lymph node staging. However, in
progression and therapeutic responses in a patient with 25% of breast cancer patients who underwent [18F]FDG-
NHL following initial chemotherapy, highlighting the PET/CT, significant changes in staging were observed,
effectiveness of subsequent CAR T-cell therapy. and 18% experienced changes in treatment [22]. Figure 4
illustrates the diagnostic imaging sequence for a young
Head and neck tumors patient with dense breast tissue, where mammography did
[18F]FDG-PET/CT is recommended for various clinical not reveal any suspicious lesions, but subsequent ultra-
applications in head and neck cancer, including staging, sonography and FDG-PET/CT identified and character-
identifying lymph node and distant metastases, and ized a single lesion in the right breast.
detecting unknown primary tumors. It offers high sensi- The common sites of distant metastasis in breast cancer
tivity and specificity, both over 90% [17]. Furthermore, are bone, lung, liver, and brain with a sensitivity of 96%
hybrid imaging aids in detecting recurrent head and neck and a specificity of 95% for the detection of distant
tumors, especially when postradiogenic or postoperative metastasis by [18F]FDG-PET/CT [23]. [18F]FDG-PET/CT
changes complicate interpretation in morphological CT has demonstrated superior diagnostic accuracy in the
and MRI. [18F]FDG-PET/CT is superior to CT and MRI detection of frequently CT-occult bone metastasis,
in differentiating tumor recurrence from postradiogenic achieving a sensitivity of 93% and a specificity of 99%,
or postoperative inflammation or defects. Other guide- compared to bone scintigraphy [24].
lines recommend restaging with [18F]FDG-PET/CT [18F]FDG-PET/CT is not a standard procedure for the
3 months after surgery, with additional imaging only if routine follow-up of patients with breast cancer but is
symptoms arise or if results from conventional imaging highly recommended in asymptomatic patients with rising
are inconclusive. In advanced head and neck tumors that tumor markers (cancer antigen [CA 15-3], carcinoem-
cannot be treated surgically, [18F]FDG-PET/CT should be bryonic antigen, or CA 125), especially if the results of
considered 3–6 months after systemic treatment to assess conventional images are inconclusive [25].
residual disease. Earlier scans, which might yield false-
positive results, should be avoided [18]. Colorectal cancer
Over 75% of colorectal cancer (CRC) patients present with
Breast cancer the disease limited to the bowel or regional pericolic or
[18F]FDG-PET/CT is not routinely used for the early mesenteric lymph nodes at the initial diagnosis. Typically,
diagnosis of breast cancer, since it has low sensitivity for treatment in the early stages involves surgical removal with
local lesions below 5 mm (< 50%) and demonstrates only curative intent. A subset of patients (Union for Interna-
moderate diagnostic accuracy in axillary staging, but it tional Cancer Control: UICC stage III) receive adjuvant
can be very useful in detecting distant metastases [19]. chemotherapy. The spread to locoregional lymph nodes
The initial staging process in suspected breast cancer serves as an important prognostic factor. Five-year survival
should involve mammography, the reference standard for rates of 80% in UICC stage II and 45–50% in UICC stage III.
detecting primary breast tumors, and, where indicated, Accurate preoperative staging is crucial for assessing
MRI of the breast, as well as ultrasonography of the breast prognosis and establishing an appropriate, potentially
and axilla [20]. According to the NCCN guidelines, curative therapy regimen [26].
staging with body CT, bone scintigraphy, and optional Imaging techniques such as endoscopic ultrasound and
[18F]FDG-PET/CT is recommended for signs or MRI are preferred for locoregional staging. The current
Ebner et al. European Radiology (2025) 35:1894–1902 1900

Fig. 4 Due to the dense breast tissue (a), no suspicious lesions were detected on mammography. Ultrasonography of the right breast measured a
1.5 cm lesion (b). Given the patient’s young age (aged 30) and clinical suspicion of metastases, FDG-PET/CT was performed (c–e). FDG-avid lesion in the
right lower outer quadrant (d) was not clearly identified on CT (c). The right axillary lymph nodes were not enlarged and showed no suspicious FDG
uptake. The maximum intensity projection also shows a singular lesion in the right breast (e). No additional lesions suspicious for metastases were
detected

standard for staging and monitoring recurrence in CRC PET, as lesions smaller than 5 mm cannot usually be clearly
patients generally relies on conventional imaging techni- detected. The supplementary information provided by [18F]
ques, such as contrast-enhanced CT of the chest, abdo- FDG-PET/CT may not influence treatment decisions in
men, and pelvis. However, CT generally has a high false- early colorectal cancer, so its application is generally
negative rate for extrahepatic intra-abdominal lesions, reserved for certain conditions where its detailed diagnostic
such as paraaortic lymph nodes, and a high false-positive insight offers clear advantages, such as assessing the spread
rate for pulmonary lesions. [18F]FDG-PET/CT provides of metastases or response to treatment [27].
additional functional information on tumor glucose
metabolism, leading to higher diagnostic accuracy for Conclusion
initial staging, detection of nodal and extranodal [18F]FDG-PET/CT demonstrates a well-documented
metastases, therapy monitoring, and assessment of higher diagnostic accuracy for staging of most malignant
recurrence [27]. tumors, however indications for [18F]FDG-PET/CT need
According to evidence-based guidelines for CRC, CT is to be carefully selected depending on the clinical risk
considered the imaging first-choice procedure. However, profile to fully maximize its added value.
the guidelines also recommend that in cases where liver- Despite its strengths, [18F]FDG-PET/CT is not without
directed treatment or surgery is being considered, MRI of limitations. Its spatial resolution is about several milli-
the liver with intravenous contrast, using either standard meters, and it may not accurately capture the metabolic
or hepatobiliary agents, is preferred over CT and [18F] activity of certain tumor types. Furthermore, benign
FDG-PET/CT, to assess the exact number and distribu- conditions involving inflammation or infections can also
tion of metastases for local treatment planning [28]. MRI exhibit increased FDG uptake, necessitating cautious
is considered a cost-effective strategy for detecting liver interpretation of results.
metastases suitable for hepatic resection, making it the The future of PET/CT involves technological advances
preferred imaging modality in diagnostic workup [29]. aimed at reducing the radiation dose and improving
The role of [18F]FDG-PET/CT in the staging of CRC is resolution. The PET/MR system offers high soft tissue
limited by several factors. The ability to detect small or contrast with no additional ionizing radiation from the
early-stage tumors is impaired by the limited resolution of MR component, making it particularly suitable for
Ebner et al. European Radiology (2025) 35:1894–1902 1901

pediatric and nononcologic patients. However, PET/MR cells, with the anatomical detail provided by CT, offering
has longer examination times, lower throughput, and its therapeutic guidance for cancer diagnosis, staging, and
clinical use is currently limited, though ongoing research monitoring of treatment response. Despite its extensive
aims to expand its applications, including combinations utility, PET faces limitations such as comparably low spatial
with functional MRI techniques [30]. resolution in relation to CT or MRI, and the non-specific
Current innovations in cancer imaging with PET/CT uptake of [18F]FDG that may lead to false-positive results in
are focusing on the transition from the widely used [18F] inflammatory or infectious conditions. Moreover, while
FDG tracer to innovative, cancer- and receptor-specific PET/CT is instrumental in certain clinical scenarios, its
tracers. [68Ga] and [18F]–labeled fibroblast activation high cost and limited availability restrict its use as a routine
protein inhibitor (FAPI) PET serves as an advanced first-line imaging tool, especially for early-stage cancer.
imaging technique that targets cancer-associated fibro- Therefore, PET/CT is often reserved for specific indica-
blasts within tumor stroma, which are known for their tions where its detailed metabolic information can sig-
high expression of FAP. Furthermore, FAPI can be uti- nificantly influence clinical decisions.
lized in rheumatological disorders for enhanced precision
and disease management. FAPI stands out due to its rapid Patient summary
accumulation in tumors and minimal background inter- PET/CT imaging is an advanced diagnostic tool that
ference, leading to superior imaging quality in some combines the detailed anatomical depiction of CT with
malignancies. This radiotracer is particularly effective in the metabolic and functional information provided by
detecting small primary or metastatic lesions in areas like PET. This establishes PET/CT as an invaluable resource
the brain, liver, pancreas, and gastrointestinal tract that in the detection and management of cancer.
show high physiological [18F]FDG accumulation. Thus, Utilized not only for identifying the presence of cancer,
FAPI PET imaging may also have the potential to depict PET/CT scans are helpful in monitoring the effectiveness of
several common benign disease processes that are asso- ongoing treatments and in detecting the recurrence of disease
ciated with widespread morbidity [31]. after therapy. This innovative technology plays a crucial role in
Beyond that, prostate-specific membrane antigen devising personalized treatment plans, ensuring that each
PET/CT is particularly effective in the detection and patient receives the most effective and targeted therapy
staging of prostate cancer, while somatostatin receptor- available, thereby enhancing the chance of successful out-
PET/CT is highly effective for imaging neuroendocrine comes and improved quality of life.
tumors, offering high sensitivity and specificity. Its clinical
utility has been well-documented, making it a standard for Abbreviations
prostate cancer and neuroendocrine tumor imaging BEACOPP Cancer drug combination of Bleomycin, Etoposide, Adriamycin,
Cyclophosphamide, Vincristine, Procarbazine, Prednisolone
[32, 33]. [18F]-fluoroestradiol (FES) is another notable CA Cancer antigen
radiotracer, primarily used in breast cancer imaging. FES CAR T Chimeric antigen receptor
is utilized in clinical settings for patients with estrogen ceCT Contrast-enhanced computed tomography
CRC Colorectal cancer
receptor (ER)-positive recurrent or metastatic breast CT Computed tomography
cancer and as an adjunct to biopsy. It binds to ER, DLBCL Diffuse large B-cell lymphoma
allowing for a comprehensive in vivo assessment of ER F Fluorine
FAPI Fibroblast activation protein inhibitor
expression throughout the body [34]. FDG Fluorodeoxyglucose
These recent developments represent a significant FES Fluoroestradiol
advancement in molecular medicine and imaging, offering HD Hodgkin disease
MRI Magnetic resonance imaging
enhanced disease detection compared to conventional NCCN National Comprehensive Cancer Network
methods. This innovation is transforming patient care NHL Non-Hodgkin lymphoma
worldwide by improving the accuracy of staging and NSCLC Non-small cell lung cancer
PET Positron emission tomography
disease management in about one-third of cases. These R-CHOEP Cancer drug combination of Rituximab, Cyclophosphamide,
innovations promise to further refine diagnostic and Hydroxydaunorubicin, Vincristine, Prednisolone
therapeutic strategies, keeping hybrid imaging at the RECIST Response Evaluation Criteria In Solid Tumors
SCLC Small cell lung cancer
forefront of cancer treatment. SLNB Sentinel lymph node biopsy
UICC Union for International Cancer Control
Summary statement
PET with [18F]FDG, particularly when integrated with
ceCT is a highly valuable molecular imaging technique in Acknowledgements
This paper was endorsed by the Executive Council of the European Society of
oncology. This technology combines the functional insight Radiology (ESR) and the Executive Committee of the European Society for
of PET imaging, which highlights the metabolic activity of Hybrid, Molecular and Translational Imaging (ESHIMT) in September 2024.
Ebner et al. European Radiology (2025) 35:1894–1902 1902

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Hodgkin lymphoma. Blood 107:52–59
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Guarantor
trial by the German Hodgkin Study Group. Hemasphere 1:e5
The scientific guarantor of this publication is C.C.C.
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patients with advanced-stage Hodgkin’s lymphoma (HD18): final results
Conflict of interest of an open-label, international, randomised phase 3 trial by the German
The authors of this manuscript declare no relationships with any companies, Hodgkin Study Group. Lancet 390:2790–2802
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