Clarity on imaging for childhood bone cancer
30 juni 2026
A large European group of physicians, led by researchers from the Princess Máxima Center, has developed the first European evidence-based guideline for the use of imaging in children and adults with bone tumors. The guideline harmonizes the use of imaging throughout the patient journey, from diagnosis to follow-up after treatment. It also highlights important knowledge gaps and identifies priorities for future research to further improve care.
Imaging techniques such as MRI, CT, and PET scans are essential in the treatment of children with osteosarcoma and Ewing sarcoma, two types of bone cancer. Physicians use these scans to detect tumors, determine the extent of disease, assess treatment response, and monitor patients after therapy has ended. However, the study found that surprisingly little strong scientific evidence exists to support many of these decisions.
Prof. Hans Merks is a pediatric oncologist and research group leader at the Princess Máxima Center. He specializes in imaging for bone and soft tissue sarcomas and led a study examining the scientific evidence underlying current imaging practices for children with cancer.
Merks explains: ‘For every type of childhood cancer, there are established recommendations regarding when scans should be performed, how often they should be used, and which imaging techniques are most appropriate. We wanted to know: are children really receiving the right scans at the right time? And what evidence are these decisions based on? We found that many routine choices are driven primarily by years of clinical experience, rather than by the strong scientific evidence one might expect. With this guideline, we bring together the current state of knowledge while also identifying the key questions that need to be addressed in the coming years.’
For children with bone cancer treated at the Princess Máxima Center, little will change. Current imaging practices already align closely with the new recommendations. The greatest benefit lies in greater international consistency. When hospitals use the same imaging techniques at the same points in care, outcomes can be compared more reliably. This will enable international studies to answer important questions about the best care for children with bone cancer more quickly. The guideline may also improve care for some patients by supporting more informed decisions about imaging, helping to ensure that children receive neither more nor fewer scans than necessary.
The study on imaging in children with bone cancer was funded by the EV@ Foundation (Ewing sarcoma Deserves Attention). The study results were published yesterday in the leading journal The Lancet Oncology.
Large-scale analysis
The guideline was developed by a large international group of 36 imaging experts in bone tumors from 12 countries, working together within the FOSTER and Euro Ewing Consortia. The group reviewed thousands of scientific publications as well as everyday clinical practice across hospitals. Of more than 2,000 studies initially identified, only 13 met the criteria for inclusion in the final analysis. Researchers combined these findings with expert experience from across Europe, resulting in concrete recommendations for imaging at diagnosis, during treatment monitoring, and in follow-up care. At the same time, the work highlighted important unresolved questions, including which imaging modality performs best in different clinical situations.
Building a foundation for the future of imaging
The new guideline provides a framework for further strengthening care. By adopting common protocols—whenever possible based on scientific evidence and otherwise on the consensus of European experts—physicians can improve current care while simultaneously contributing to research that will generate the evidence needed for tomorrow’s standards of care.
'If you want to define what standard care should be, you immediately discover where knowledge is still lacking,' says Merks. 'Those gaps become important questions for future research.'
The guideline also lays an important foundation for future studies. By harmonizing imaging practices, data from different hospitals can be combined more easily, enabling larger collaborative studies. This will be particularly valuable for research into imaging biomarkers that may predict whether a treatment is working. ‘If you want to combine data, you need to harmonize it,’ Merks explains. ‘Otherwise, it’s a classic case of garbage in, garbage out.’
This collaborative European approach creates a strong foundation for the step-by-step improvement of imaging in bone cancer care. The research that follows is expected to help determine more precisely which imaging strategies make the greatest difference for children with bone cancer.