The lung cancers: staging and response, CT, 18 F-FDG PET/CT, MRI, DWI - review and new perspectives

Sep 24, 2026

Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer deaths in both sexes combined. Recent advances have expanded diagnostic and treatment options for non-small-cell lung cancer (NSCLC), including routine use of 18F-FDG PET/CT for staging and response evaluation, along with minimally invasive procedures, targeted therapies, and molecular and immunotherapies. This review critically assesses CT and 18F-FDG PET/CT, summarizes TNM-8 and response criteria (RECIST 1.1, modified RECIST, metabolic and PERCIST 1.0), addresses immune responses and pseudoprogression, reviews solitary pulmonary nodules and lung screening systems, and evaluates emerging MRI roles and new PET-CT radiotracers.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages15

Reading Time38 min

AccessFree to download

Abstract

Introduction

Lung cancer diagnosis and staging

CT in screening and suspected disease

18F-FDG PET/CT for staging completion

TNM-8 and response evaluation criteria (RECIST, modified RECIST, PERCIST, iRECIST)

Metabolic response assessment and pseudoprogression in immunotherapy

Solitary pulmonary nodules: guidelines and risk models (Brock, Herder)

Lung screening systems (UK, Europe, North America)

Emerging roles for MRI and diffusion-weighted imaging

New PET-CT radiotracers and future directions with AI

BJR [https://doi.org/10.1259/bjr.20220339](https://doi.org/10.1259/bjr.20220339) |
Received:
24 March 2022
Accepted:
22 February 2023
Published online:
17 May 2023
© 2023 The Authors. Published by the British Institute of Radiology under the terms of the Creative Commons Attribution-NonCommercial 4.0 Unported License [http://creativecommons.org/l](http://creativecommons.org/l)icenses/by-nc/4 .0/, which permits unrestricted non-commercial reuse, provided the original author and source are credited.
Cite this article as:
Owens C, Hindocha S, Lee R, Millard T, Sharma B. The lung cancers: staging and response, CT, 18F-FDG PET/CT, MRI, DWI: review and new perspectives. Br J Radiol (2023) 10.1259/bjr.20220339. | | | --- | --- | | REVIEW ARTICLE
The lung cancers: staging and response, CT, 18 F-FDG PET/CT, MRI, DWI: review and new perspectives
1CARA OWENS, PhD FRCR MBBS BSc, 1,2SUMEET HINDOCHA, PhD MRCP, MBBS, BSc,
1,3,4,5RICHARD LEE, PhD, MRCP, MBBS, MA, 1THOMAS MILLARD, PhD FRCR, MBBS, BSc and
1,3BHUPINDER SHARMA, PhD FRCR, BM, BSc
1The Royal Marsden NHS Foundation Trust, Fulham Road, London, United Kingdom
2Artificial Intelligence for Healthcare Centre for Doctoral Training, Imperial College London, London, United Kingdom
3The Institute of Cancer Research, Sutton, United Kingdom
4National Heart and Lung Institute, Imperial College London, London, United Kingdom
5NIHR BRC at The Royal Marsden and the ICR, London, United Kingdom
Address correspondence to: Dr Cara Owens
E-mail: [c.owens22@imperial.ac.uk](c.owens22@imperial.ac.uk);[cara.owens@nhs.net](cara.owens@nhs.net) | | | ABSTRACT
Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer deaths in both sexes combined. Recent years have seen major advances in the diagnostic and treatment options for patients with non-small-cell lung cancer (NSCLC), including the routine use of 2-deoxy-2[18 F]-fluoro-D-glucose positron emission tomography/ computed tomography (18 F-FDG PET/CT) in staging and response evaluation, minimally invasive endoscopic biopsy, targeted radiotherapy, minimally invasive surgery, and molecular and immunotherapies.
In this review, the central roles of CT and 18 F-FDG PET/CT in staging and response in both NSCLC and malignant pleural mesothelioma (MPM) are critically assessed. The Tumour Node Metastases (TNM-8) staging systems for NSCLC and MPM are presented with critical appraisal of the strengths and pitfalls of imaging. Overviews of the Response Evaluation Criteria in Solid Tumours (RECIST 1.1) for NSCLC and the modified RECIST criteria for MPM are provided, together with discussion of the benefits and limitations of these anatomical-based tools. Metabolic response assessment (not evaluated by RECIST 1.1) will be explored. We introduce the Positron Emission Tomography Response Criteria in Solid Tumours (PERCIST 1.0) to include its advantages and challenges. The limitations of both anatomical and metabolic assessment criteria when applied to NSCLC treated with immunotherapy and the important concept of pseudoprogression are addressed with reference to immune RECIST (iRECIST) .
Separate consideration is given to the diagnosis and follow up of solitary pulmonary nodules with reference to the British Thoracic Society guidelines and Fleischner guidelines and use of the Brock (CT-based) and Herder (addition of 18 F-FDG PET/CT) models for assessing malignant potential. We discuss how these models inform decisions by the multidisciplinary team, including referral of suspicious nodules for non-surgical management in patients unsuitable for surgery. We briefly outline current lung screening systems being used in the UK, Europe and North America.
Emerging roles for MRI in lung cancer imaging are reviewed. The use of whole-body MRI in diagnosing and staging NSCLC is discussed with reference to the recent multicentre Streamline L trial. The potential use of diffusion-weighte

FAQs

What are the key imaging roles of CT and 18F-FDG PET/CT in lung cancer?

CT and 18F-FDG PET/CT have central roles in both staging and response assessment. The review critically evaluates their strengths, pitfalls, and how they support clinical decision-making.

Which staging and response assessment frameworks are covered?

The review presents the TNM-8 staging systems for NSCLC and malignant pleural mesothelioma and discusses response evaluation tools including RECIST 1.1, modified RECIST, metabolic assessment, and PERCIST 1.0, with consideration of immune RECIST (iRECIST).

How does the review address imaging response in patients treated with immunotherapy?

It discusses limitations of anatomical and metabolic criteria under immunotherapy and highlights the concept of pseudoprogression, using immune RECIST (iRECIST) to contextualize assessment challenges.

Sep 24, 2026

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