Update to the RANO working group and EANO recommendations for the clinical use of PET imaging in gliomas

This Policy Review provides recommendations for the use of PET imaging in patients with gliomas and represents a joint effort of the Response Assessment in Neuro-Oncology (RANO) working group for PET and the European Association for Neuro-Oncology. The initial guideline was published in 2016, and summarised the previously established clinical benefit of PET with radiolabelled glucose and amino acid tracers in patients with gliomas. Since then, numerous additional studies have been published on this topic, focusing on differential diagnosis, prediction of molecular information, and prognostication. Further studies evaluated PET for biopsy guidance and delineation of glioma extent for local therapy planning, including resection and radiotherapy. In patients undergoing treatment, PET was studied for the assessment of response to local and systemic treatments and PET-based standardised response criteria (PET RANO 1.0) were proposed. In this Policy Review, the updated recommendations are based on evidence generated from studies that validated PET findings by histomolecular findings or clinical course. This guideline further underscores the previously reported clinical value of PET imaging and the superiority of amino acid PET over glucose PET, providing a framework for the use of PET in the management of patients with gliomas. The guideline also underscores the scarcity of class 1 evidence showing that incorporating PET imaging into clinical workflows improves patient outcomes, highlighting priority areas for future clinical studies designed to address this gap.