Every year, thousands of children are diagnosed with cancer. While survival has improved dramatically over the past few decades, many young patients still undergo lengthy investigations and intensive treatments. A recent review published in Seminars in Nuclear Medicine highlights how advances in nuclear medicine are helping doctors diagnose childhood cancers more accurately, monitor treatment more effectively and, increasingly, deliver highly targeted therapies that may improve outcomes while reducing unnecessary side effects.

Looking Beyond Conventional Imaging

Traditionally, imaging in childhood cancer has relied on techniques such as ultrasound, CT and MRI to identify where a tumour is located and how large it has become. While these remain essential tools, they mainly show the structure of a tumour. Nuclear medicine adds another layer of information by revealing how active a tumour is and how it behaves, helping doctors understand its biology rather than just its location. The review explains that this has become increasingly important because childhood cancers are remarkably diverse. Different cancers, and even tumours within the same cancer type, can behave very differently despite appearing similar on conventional imaging.

Using tiny amounts of specially designed radioactive tracers, nuclear medicine helps doctors understand how active a tumour is and whether it carries specific biological features that can guide treatment. These insights can improve diagnosis, refine disease staging and, in some cases, indicate how aggressive a tumour is likely to be. According to the review, advances in these tracers have significantly expanded the role of nuclear medicine in paediatric cancer care.

Different Childhood Cancers Need Different Approaches

A key message from the review is that nuclear medicine is not a one size fits all approach. Its role varies depending on the biology and behaviour of each childhood cancer.

Leukaemia is diagnosed mainly through bone marrow examination, though FDG PET CT could be useful in particular situations. It can detect disease sites in children with persistent and unspecified symptoms where routine testing has failed to produce results and also find diseases outside the bone marrow that may not be seen by CT, MRI, or ultrasound. The article is also useful in indicating treatment effects, finding residual disease, and recognizing relapse, especially when it is located away from the bone marrow.

Improving the Assessment of Brain Tumours

Brain tumours are the second most common childhood cancers after leukaemia. While MRI remains the primary imaging tool, the review notes that it can sometimes struggle to distinguish tumour types, assess tumour grade or tell the difference between recurrent disease and treatment related changes.

Here, nuclear medicine provides valuable additional information. Although FDG PET has limitations because healthy brain tissue naturally uses large amounts of glucose, newer amino acid based PET tracers, including Methionine, FET and DOPA, produce clearer tumour images because there is less background activity in normal brain tissue. According to the review, these tracers improve tumour detection, help define tumour margins before surgery, guide biopsy to the most biologically active areas and assist in distinguishing tumour recurrence from treatment related changes. The review also discusses several emerging tracers currently under investigation, including FLT, Choline, Copper 64 chloride and radioiodinated compounds.

Changing How Lymphomas Are Evaluated

Nuclear medicine has become an integral part of managing Hodgkin lymphoma and many Non Hodgkin lymphomas in children. The review describes FDG PET CT as the preferred imaging method for staging and treatment response because it shows whether lymph nodes contain active cancer, rather than simply whether they are enlarged. This allows doctors to identify additional sites of disease that may be missed on conventional imaging and improve treatment planning.

The review also highlights the growing role of PET based measurements, including metabolic tumour volume (MTV) and total lesion glycolysis (TLG), which help estimate how much active cancer is present and may predict how patients are likely to respond to treatment. By assessing tumour activity rather than relying only on changes in size, PET CT also provides a more accurate picture of whether treatment has successfully controlled the disease.

While nuclear medicine is improving diagnosis and treatment assessment across several childhood cancers, the review identifies neuroblastoma as one of the strongest examples of how the field is advancing towards theranostics.

Neuroblastoma: A Model for Theranostics

The review identifies neuroblastoma as one of the strongest examples of how nuclear medicine is advancing towards theranostics. As the most common extracranial solid tumour in children, neuroblastoma often presents with metastatic disease, making accurate staging essential.

MIBG imaging, a specialised scan widely used for neuroblastoma, remains the cornerstone of staging because most tumours naturally absorb the tracer. This enables doctors to detect both bone marrow and soft tissue metastases. Beyond diagnosis, validated scoring systems such as the Curie and SIOPEN scores help assess tumour burden, predict prognosis and identify children who may require alternative treatment strategies after induction chemotherapy.

For the small proportion of tumours with low or absent MIBG uptake, the review highlights the complementary role of FDG PET CT, which can detect additional disease, improve assessment of local and metastatic involvement and provide prognostic information, with higher FDG uptake associated with poorer survival.

From Diagnosis to Targeted Treatment

A major focus of the review is the growing role of theranostics, which combines molecular imaging and targeted radionuclide therapy using the same molecular target. In neuroblastoma, this approach is already being applied through 131I MIBG therapy, where the same tracer used for imaging delivers targeted radiation directly to tumour cells in children with disseminated disease.

The review also discusses the emerging role of Gallium 68 labelled DOTA peptides, which target somatostatin receptors expressed by many neuroblastomas. Although not yet part of guideline based practice, these tracers may improve lesion detection in selected patients and help identify children who may benefit from Peptide Receptor Radionuclide Therapy (PRRT), a treatment that delivers radiation directly to cancer cells using targeted molecules. Early paediatric studies cited in the review have demonstrated the feasibility of these therapies in children with relapsed or refractory neuroblastoma. Beyond current clinical applications, the review highlights several emerging PET tracers, including mFBG, DOPA and mHED, which are being investigated to further improve tumour detection and expand future theranostic opportunities.

Improving Care Across Other Childhood Tumours

The review highlights the expanding role of nuclear medicine across several other paediatric tumours. In soft tissue sarcomas, particularly rhabdomyosarcoma, FDG PET CT improves the detection of lymph node, bone and bone marrow metastases, supports treatment planning and provides an early assessment of chemotherapy response based on changes in tumour activity rather than tumour size. In osteosarcoma, PET CT offers greater sensitivity than conventional bone scintigraphy for detecting skeletal metastases, helps identify the most active areas for biopsy and plays an important role in monitoring treatment response. Similarly, in Ewing sarcoma, where conventional bone scans are less sensitive for detecting bone metastases, FDG PET CT provides more accurate staging, prognostic information and supports surveillance for disease recurrence.

Although many of these technologies are still evolving, the review suggests that Nuclear Medicine is steadily transforming childhood cancer care from a one-size-fits-all approach towards truly personalised medicine. As newer imaging agents and targeted radionuclide therapies become available, doctors may be able to diagnose cancers earlier, tailor treatments more precisely and improve outcomes while minimising unnecessary toxicity. For many children and their families, this represents not just scientific progress, but hope for a better future.

The future of childhood cancer care is no longer focused only on identifying where a tumour is located. Increasingly, it is about understanding its biology and selecting the right treatment for the right patient.

(By Dr. Swagat Dash, Associate Director & Head - Nuclear Medicine Sarvodaya Hospital, Sector-8, Faridabad)



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