Download GA-DOTA-TATE(NETSPOT)_Eligibility_Form

68Ga-DOTA-TATE
(NetSpot) PET/CT
Order Form/Patient History
Indiana University School of Medicine
Patient Name: _____________________________________
Gender:
M
F
Patient I.D. ____________________
Date of Birth: ________________________
Referring Physician: _________________________________________________________________
Specify the indication for a 68Ga-DOTA-TATE (NetSpot) PET/CT scan in this patient:*
☐ NEN patient, who is a potential candidate for multi-visceral organ transplant (MVOT), to determine extent
of disease
☐ Patient with biopsy-proven NEN or NESSTR, where there is clinical need to determine extent of disease
or location of unknown primary
☐ Patient with strong clinical suspicion of NEN or NESSTR, but no tumor location is known
☐ Patient with NEN or NESSTR who has had disease-specific treatment, and where there is clinical need to
establish interim response to therapy or evaluate for disease recurrence
* Intended for Neuroendocrine Neoplasia (NEN) or other neoplasms expressing somatostatin receptors (NESSTR), such as
astrocytomas and meningiomas in the brain; adrenal medullary tumors (pheochromocytoma, neuroblastoma, ganglioneuroma),
medullary thyroid cancer, renal cell cancer, pituitary adenomas, paragangliomas, and patients with primary tumor-induced
osteomalacia. 68Ga-DOTA-TATE specifically targets SSTR2. If the tumor is expected to primarily express SSTR3, SSTR4, or
SSTR5, 68Ga-DOTA-NOC may be more appropriate. 68Ga-DOTA-NOC may also be more appropriate, if the patient is being
followed longitudinally and has a prior 68Ga-DOTA-NOC scan.
Have we performed a prior PET/CT study on this patient using Expanded Access
Is a contrast-enhanced CT scan indicated, independent of the
68Ga-DOTA-TATE
68Ga-DOTA-NOC?
study?
☐Y
☐Y
☐N
☐N
Is patient receiving Octreotide, Lanreotide, or other somatostatin-receptor-binding drug, therapeutically? ☐ Y ☐ N
If yes, Drug: __________________________________
Dose: ________________________
Date of last administration: _____________________________
Date of next planned administration: ______________________
Scan date should be coordinated to occur just prior to the next planned dose.
Other relevant medical history: ___________________________________________________________
____________________________________________________________________________________
Referring Physician’s Clinical Objectives for this Diagnostic Study:_______________________________
____________________________________________________________________________________
NOTE 1: NetSpot (68Ga-DOTA-TATE) is an FDA-approved radiopharmaceutical for PET evaluation of patients with
neuroendocrine tumors. PET/CT scan. But, it may be necessary to obtain pre-authorization from the patient’s insurance to
cover this imaging procedure.
Ordering Physician: _____________________________
12/29/2016
Date: ______________