A collaboration of multidisciplinary experts on the functional evaluation of lung cancer patients has been facilitated by the European Respiratory Society (ERS) and the European Society of Thoracic Surgery (ESTS), in order to draw up recommendations and provide clinicians with clear, up-to-date guidelines on fitness for surgery and chemo-radiotherapy.The subject was divided into different topics, which were then assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature review being performed. The draft reports written by the experts on each topic were reviewed, discussed and voted on by the entire expert panel. The evidence supporting each recommendation was summarised, and graded as described by the Scottish Intercollegiate Guidelines Network Grading Review Group. Clinical practice guidelines were generated and finalised in a functional algorithm for risk stratification of the lung resection candidates, emphasising cardiological evaluation, forced expiratory volume in 1 s, systematic carbon monoxide lung diffusion capacity and exercise testing.Contrary to lung resection, for which the scientific evidences are more robust, we were unable to recommend any specific test, cut-off value, or algorithm before chemo-radiotherapy due to the lack of data. We recommend that lung cancer patients should be managed in specialised settings by multidisciplinary teams.

BACKGROUND. The aim was to assess the relevant distribution of the novel PET tracer 68Ga‐DOTATATE in neuroendocrine tumors (NETs) with combined positron emission tomography / computed tomography (PET/CT) and compare its performance with that of 18F‐FDG PET/CT. METHODS. The imaging findings with 68Ga‐DOTATATE and 18F‐FDG on 38 consecutive patients with a diagnosis of primary or recurrent NET were compared and correlated with tumor grade on histology based on ki67 and mitotic index. RESULTS. The sensitivity of 68Ga‐DOTATATE PET/CT was 82% (31 of 38) and that of 18F‐FDG PET/CT was 66% (25 of 38). The sensitivity of combined 68Ga‐DOTATATE and 18F‐FDG PET/CT was 92% (35 of 38). There was greater uptake of 68Ga‐DOTATATE than 18F‐FDG in low‐grade NET (median SUV 29 vs 2.9, P < .001). In high‐grade NET there was higher uptake of 18F‐FDG over 68Ga‐DOTATATE (median SUV 11.7 vs 4.4, P = .03). There was a significant correlation with predominant tumor uptake of 68Ga‐DOTATATE or 18F‐FDG and tumor grade on histology (P < .0001). CONCLUSIONS. 68Ga‐DOTATATE PET/CT is a useful novel imaging modality for NETs and is superior to 18F‐FDG for imaging well‐differentiated NET. Functional imaging with both 68Ga‐DOTATATE and 18F‐FDG has potential for a more comprehensive tumor assessment in intermediate‐ and high‐grade tumors. Cancer 2008. ©2008 American Cancer Society.

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Purpose: We prospectively examined the role of tumor textural heterogeneity on positron emission tomography/computed tomography (PET/CT) in predicting survival compared with other clinical and imaging parameters in patients with non-small cell lung cancer (NSCLC).Experimental Design: The feasibility study consisted of 56 assessed consecutive patients with NSCLC (32 males, 24 females; mean age 67 AE 9.7 years) who underwent combined fluorodeoxyglucose (FDG) PET/ CT. The validation study population consisted of 66 prospectively recruited consecutive consenting patients with NSCLC (37 males, 29 females; mean age, 67.5 AE 7.8 years) who successfully underwent combined FDG PET/CT-dynamic contrast-enhanced (DCE) CT. Images were used to derive tumoral PET/CT textural heterogeneity, DCE CT permeability, and FDG uptake (SUV max ). The mean follow-up periods were 22.6 AE 13.3 months and 28.5AE 13.2 months for the feasibility and validation studies, respectively. Optimum threshold was determined for clinical stage and each of the above biomarkers (where available) from the feasibility study population. Kaplan-Meier analysis was used to assess the ability of the biomarkers to predict survival in the validation study. Cox regression determined survival factor independence.Results: Univariate analysis revealed that tumor CT-derived heterogeneity (P < 0.001), PET-derived heterogeneity (P ¼ 0.003), CT-derived permeability (P ¼ 0.002), and stage (P < 0Á001) were all significant survival predictors. The thresholds used in this study were derived from a previously conducted feasibility study. Tumor SUV max did not predict survival. Using multivariable analysis, tumor CT textural heterogeneity (P ¼ 0.021), stage (P ¼ 0.001), and permeability (P < 0.001) were independent survival predictors. These predictors were independent of patient treatment.Conclusions: Tumor stage and CT-derived textural heterogeneity were the best predictors of survival in NSCLC. The use of CT-derived textural heterogeneity should assist the management of many patients with NSCLC.

Our purpose was to compare the performance of 68 4,7,N9,N$,N%-tetraacetic acid-D-Phe 1 , Tyr 3 -octreotate (DOTATATE), a novel selective somatostatin receptor 2 PET ligand, and 18 F-FDG in the detection of pulmonary neuroendocrine tumors using PET/CT, with correlation of uptake and tumor grade on histology. Methods: The imaging findings of the first 18 consecutive patients (8 men and 10 women) with pulmonary neuroendocrine tumors (11 typical carcinoids, 2 atypical carcinoids, 1 large cell neuroendocrine tumor, 1 small cell neuroendocrine carcinoma, 1 non-small cell lung cancer with neuroendocrine differentiation, and 2 cases of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia) who underwent 68 Ga-DOTATATE and 18 F-FDG PET/CT were reviewed. In all cases, the diagnosis was established on histology. Results: Of 18 patients, 15 had primary tumors (median size, 2.7 cm; range, 0.5-8 cm) and 3 had recurrent tumors. All typical carcinoids showed high uptake of 68 Ga-DOTATATE (maximum standardized uptake value [SUV max ] $ 8.2), but 4 of 11 showed negative or minimal 18 F-FDG uptake (SUV max 5 1.7-2.9). All tumors of higher grade showed high uptake of 18 F-FDG (SUV max $ 11.7), but 3 of 5 showed only minimal accumulation of 68 Ga-DOTATATE (SUV max 5 2.2-2.8). Neither case of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia showed uptake of 68 Ga-DOTATATE or 18 F-FDG. Typical carcinoids showed significantly higher uptake of 68 Ga-DOTATATE and significantly less uptake of 18 F-FDG than did tumors of higher grade (P 5 0.002 and 0.005). There was no instance of falsepositive uptake of 68 Ga-DOTATATE, but there were 3 sites of 18 F-FDG uptake secondary to inflammation. 68 Ga-DOTATATE was superior to 18 F-FDG in discriminating endobronchial tumor from distal collapsed lung (P 5 0.02). Conclusion: Typical bronchial carcinoids showed higher and more selective uptake of 68 Ga-DOTATATE than of 18 F-FDG. Atypical carcinoids and higher grades had less 68 Ga-DOTATATE avidity but were 18 F-FDG-avid.