Comparison of whole-body FDG-PET to bone scan for detection of bone metastases in patients with a new diagnosis of lung cancer

Does clinical T1N0 GGN really require checking for distant metastasis during initial staging for lung cancer?

BACKGROUND

Accurate clinical staging is crucial for selection of optimal oncological treatment strategies in non-small cell lung cancer (NSCLC). Although brain MRI, bone scintigraphy and whole-body PET/CT play important roles in detecting distant metastases, there is a lack of evidence regarding the indication for metastatic staging in early NSCLCs, especially ground-grass nodules (GGNs). Our aim was to determine whether checking for distant metastasis is required in cases of clinical T1N0 GGN.

METHODS

This was a retrospective study of initial staging using imaging tests in patients who had undergone complete surgical R0 resection for clinical T1N0 Stage IA NSCLC.

RESULTS

A total of 273 patients with cT1N0 GGNs (n = 183) or cT1N0 solid tumors (STs, n = 90) were deemed eligible. No cases of distant metastasis were detected on initial routine imaging evaluations. Among all cT1N0M0 cases, there were 191 incidental findings on various modalities (128 in the GGN). Most frequently detected on brain MRI was cerebral leukoaraiosis, which was found in 98/273 (35.9%) patients, while cerebral infarction was detected in 12/273 (4.4%) patients. Treatable neoplasms, including brain meningioma and thyroid, gastric, renal and colon cancers were also detected on PET/CT (and/or MRI). Among those, 19 patients were diagnosed with a treatable disease, including other-site cancers curable with surgery.

CONCLUSIONS

Extensive staging (MRI, scintigraphy, PET/CT etc.) for distant metastasis is not required for patients diagnosed with clinical T1N0 GGNs, though various imaging modalities revealed the presence of adventitious diseases with the potential to increase surgical risks, lead to separate management, and worsen patient outcomes, especially in elderly patients. If clinically feasible, it could be considered to complement staging with whole-body procedures including PET/CT.

Diagnostic Accuracy of PET with Different Radiotracers versus Bone Scintigraphy for Detecting Bone Metastases of Breast Cancer: A Systematic Review and a Meta-Analysis

Due to the importance of correct and timely diagnosis of bone metastases in advanced breast cancer (BrC), we performed a meta-analysis evaluating the diagnostic accuracy of [18F]FDG, or Na[18F]F PET, PET(/CT), and (/MRI) versus [99mTc]Tc-diphosphonates bone scintigraphy (BS). The PubMed, Embase, Scopus, and Scholar electronic databases were searched. The results of the selected studies were analyzed using pooled sensitivity and specificity, diagnostic odds ratio (DOR), positive-negative likelihood ratio (LR+-LR-), and summary receiver-operating characteristic (SROC) curves. Eleven studies including 753 BrC patients were included in the meta-analysis. The patient-based pooled values of sensitivity, specificity, and area under the SROC curve (AUC) for BS (with 95% confidence interval values) were 90% (86-93), 91% (87-94), and 0.93, respectively. These indices for [18F]FDG PET(/CT) were 92% (88-95), 99% (96-100), and 0.99, respectively, and for Na[18F]F PET(/CT) were 96% (90-99), 81% (72-88), and 0.99, respectively. BS has good diagnostic performance in detecting BrC bone metastases. However, due to the higher and balanced sensitivity and specificity of [18F]FDG PET(/CT) compared to BS and Na[18F]F PET(/CT), and its advantage in evaluating extra-skeletal lesions, [18F]FDG PET(/CT) should be the preferred multimodal imaging method for evaluating bone metastases of BrC, if available.

Multimodal Imaging-Based Potential Visualization of the Tumor Microenvironment in Bone Metastasis

Bone metastasis (BM) is the most common malignant bone tumor and a significant cause of morbidity and mortality for patients with cancer. Compared to other metastatic organs, bone has unique characteristics in terms of the tumor microenvironment (TME). Precise assessments of the TME in BM could be an important step for developing an optimized management plan for patient care. Imaging approaches for BM have several advantages, such as biopsy not being required, multiple site evaluation, and serial assessment in the same sites. Owing to the developments of new imaging tracers or imaging modalities, bone TME could be visualized using multimodal imaging techniques. In this review, we describe the BM pathophysiology, diagnostic principles of major imaging modalities, and clinically available imaging modalities to visualize the TME in BM. We also discuss how the interactions between various factors affecting the TME could be visualized using multimodal imaging techniques.

Management guidelines for stage III non-small cell lung cancer

Management of stage III non- small cell lung cancer (NSCLC) is very challenging due to being a group of widely heterogeneous diseases that require multidisciplinary approaches with timely and coordinated care. The standards of care had significant changes over the last couple of years because of the introduction of consolidation therapy with checkpoint inhibitor following concurrent chemo-radiotherapy and the evolving new role of tyrosine kinase inhibitors in the adjuvant setting. The manuscript presents evidence-based recommendations for the workup, staging, treatment and follow up of the various subtypes of stage III NSCLC. The guidelines were developed by experts in various fields of thoracic oncology and guidelines development. The guidelines consider the sequence of interventions and the role of each discipline in the management of the disease taking into account the recent development and included required resources to help physicians provide better care.

ACR Appropriateness Criteria® Noninvasive Clinical Staging of Primary Lung Cancer

Lung cancer is the leading cause of cancer-related deaths in both men and women. The major risk factor for lung cancer is personal tobacco smoking, particularly for small-cell lung cancer (SCLC) and squamous cell lung cancers, but other significant risk factors include exposure to secondhand smoke, environmental radon, occupational exposures, and air pollution. Education and socioeconomic status affect both incidence and outcomes. Non-small-cell lung cancer (NSCLC), including adenocarcinoma, squamous cell carcinoma, and large cell carcinoma, comprises about 85% of lung cancers. SCLC accounts for approximately 13% to 15% of cases. Prognosis is directly related to stage at presentation. NSCLC is staged using the eighth edition of the tumor-node-metastasis (TNM) criteria of the American Joint Committee on Cancer. For SCLC the eighth edition of TNM staging is recommended to be used in conjunction with the modified Veterans Administration Lung Study Group classification system distinguishing limited stage from extensive stage SCLC. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Utility of FDG PET/CT for Preoperative Staging of Non-Small Cell Lung Cancers Manifesting as Subsolid Nodules With a Solid Portion of 3 cm or Smaller

OBJECTIVE. The objective of our study was to investigate the utility of FDG PET/CT for the preoperative staging of subsolid non-small cell lung cancers (NSCLCs) with a solid portion size of 3 cm or smaller. MATERIALS AND METHODS. We retrospectively enrolled 855 patients with pathologically proven NSCLCs manifesting as subsolid nodules with a solid portion of 3 cm or smaller on CT. We then compared the diagnostic performances of FDG PET/CT and chest CT for detecting lymph node (LN), intrathoracic, or distant metastases in patients who underwent preoperative chest CT and FDG PET/CT. After propensity score matching, we compared the diagnostic performance of FDG PET/CT in the group who underwent both chest CT and FDG PET/CT with that of chest CT in patients who did not undergo FDG PET/CT. RESULTS. There were LN metastases in 25 of 765 patients (3.3%) who underwent surgical LN dissection or biopsy and intrathoracic or distant metastasis in two of 855 patients (0.2%). For LN staging, FDG PET/CT showed a sensitivity of 44.0%, specificity of 81.5%, positive predictive value of 9.6%, negative predictive value of 97.0%, and accuracy of 79.9%, which were lower than those of chest CT for accuracy (p < 0.0001). FDG PET/CT could not accurately detect any intrathoracic or distant metastasis. After propensity score matching, the diagnostic accuracy for LN staging of FDG PET/CT in the group who underwent both CT and FDG PET/CT was lower than that of chest CT in the group who did not undergo FDG PET/CT (p = 0.002), and the diagnostic accuracy for intrathoracic and distant metastases was not different (p > 0.999). CONCLUSION. FDG PET/CT has limited utility in preoperatively detecting LN or distant metastasis in patients with subsolid NSCLCs with a solid portion size of 3 cm or smaller.

Role of 18F-FDG PET/CT in establishing new clinical and therapeutic modalities in lung cancer. A short review

Lung cancer is a fairly common malignancy. An early diagnosis and a reliable staging and re-staging with the aim to detect both local and distant relapse are of utmost importance in planning the therapeutic management. The imaging diagnostic work-up of patients with lung cancer usually includes conventional imaging (chest X-ray, contrast-enhanced CT, bone scan) and more recently ¹⁸F-FDG PET/CT. Great advances in the management of lung cancer are based on the information provided by ¹⁸F-FDG PET/CT, as it supplies both metabolic and anatomic information (better localisation). There is vast evidence in the literature demonstrating its utility in (a) characterising benign versus malignant solitary nodules, (b) staging and re-staging lung cancer, (c) guiding the type of therapy, (d) monitoring treatment response and (e) predicting outcome. In particular, given its specificity in differentiating ¹⁸F-FDG-avid relapse from post-surgical changes or post-radiation fibrosis (which do not take up ¹⁸F-FDG), PET/CT can detect recurrent disease after initial treatment and (being a whole-body technique) has demonstrated high accuracy in the detection of distant metastases or secondary tumours. In conclusion, ¹⁸F-FDG PET/CT can be considered a highly accurate and reliable method for staging and re-staging lung cancer, and is highly effective in guiding personalised therapies.

Metastatic Seeding Attacks Bone Marrow, Not Bone: Rectifying Ongoing Misconceptions

Conventional modalities, such as bone scintigraphy, are commonly used to assess osseous abnormalities in skeletal metastasis. Fluorine-18 (¹⁸F)-sodium fluoride (NaF) PET similarly portrays osteoblastic activity but with improved spatial and contrast resolution and more accurate anatomic localization. However, these modalities rely on indirect evidence for tumor activity. PET imaging with ¹⁸F-fluorodeoxyglucose (FDG) and tumor-specific tracers may have an increased role by directly portraying the metabolic activity of cancer cells, which are often seeded in bone marrow and cause osseous disease after initial latency. This article describes the utility and limitations of these modalities in assessing skeletal metastases.

PET/CT features discriminate risk of metastasis among single-bone FDG lesions detected in newly diagnosed non-small-cell lung cancer patients

OBJECTIVES

We investigated the capacity of fluorodeoxyglucose (FDG) PET/CT features for stratifying probability of metastasis for single-bone FDG lesions in non-small-cell lung cancer (NSCLC).

METHODS

Subjects were 118 newly diagnosed NSCLC patients with a solitary bone FDG lesion and no evidence of other distant metastasis based on PET/CT, brain MRI, and contrast-enhanced chest CT. Bone lesion SUV_max and CT findings, primary tumor SUV_max, clinical T stage, and N stage were analyzed.

RESULTS

The bone lesions were determined by biopsy, characteristic MRI findings and clinical follow-up to be metastatic in 33 (28.0%) and benign in 85 cases (72.0%). A cutoff bone SUV_max of 4.3 showed good diagnostic performance (81.8% sensitivity, 84.7% specificity, and 83.9% accuracy), but there was considerable overlap. Bone lesion PET/CT features of SUV_max ≤ 2, osteosclerotic rim or fracture correctly diagnosed 20/20 benign, while SUV_max > 10, soft-tissue mass or bone destruction correctly diagnosed 18/18 metastatic cases. In the remaining 80 cases, bone features of SUV_max > 4.3 and osteolytic change, and lung tumor features of SUV_max > 6.4, ≥ T2 stage (n = 70), and ≥ N1 stage (n = 43) favored metastasis. The presence of one or less of these features correctly diagnosed 38/38 benign, while the presence of four or more features correctly diagnosed 5/5 metastatic cases. The 37 cases with two or three features had either benign (n = 27) or metastatic bone disease (n = 10).

CONCLUSION

Combining bone lesion and lung tumor PET/CT features can help stratify risk of bone metastasis in these patients.

KEY POINTS

• In NSCLC with a single-bone FDG lesion, lesion SUV_maxis useful for differential diagnosis. • CT features of the single-bone FDG lesions provide additional diagnostic value. • High NSCLC SUV_max, greater T stage, and FDG positive nodes also favor metastasis.

Diagnostic Value of Technetium-99m Bone Scintigraphy in the Detection of Cervical Spine Metastases in Oncological Patients

MINI: Bone scan remains the modality of choice for the screening of bone metastases. This study demonstrated the diagnostic value of bone scan in detecting bone metastases limited to the cervical spine in oncological patients remains uncertain due to the moderately high false-negative diagnostic rate.

STUDY DESIGN

A retrospective cohort, radiographic study.

OBJECTIVE

To assess the diagnostic accuracy of bone scintigraphy (BS) for the detection of cervical spine metastases in oncological patients.

SUMMARY OF BACKGROUND DATA

BS remains the modality of choice for the screening of bone metastases, because of its feasibility in whole-body scanning and its widespread availability at low cost. Current practice guidelines for patients with malignant diseases recommend BS imaging as the primary screening method for detecting both axial and appendicular skeletal metastases.

METHODS

Of 481 patients, 242 were diagnosed with cervical spinal metastases from a primary cancer. The BS findings of these patients, evaluated by nuclear medicine physicians, were assessed with respect to their usefulness for detecting cervical spine metastases. Magnetic resonance imaging findings, evaluated by radiologists, were used as the reference standards. The diagnostic value of BS was compared between subgroups according to the order in which the diagnostic procedures (magnetic resonance imaging and BS) were completed, the presence of pathological fractures, the location of the primary malignancy, and the number of cervical metastases.

RESULTS

The sensitivity of BS in the detection of cervical spine metastases was 59.1%, with a 40.9% rate of false-negative diagnoses; the specificity was 94.6%, with a 5.4% rate of false-positive diagnoses. The sensitivity tended to be higher in the presence of pathological fractures (72.1% in cases with a fracture vs. 3% in cases without a fracture) and a greater number of lesions (r = 0.921). Neither the order in which the diagnostic examinations were performed nor the location of the primary cancer, except for those in the stomach and liver, appeared to affect the diagnostic accuracy of BS.

CONCLUSION

Considering the moderately high false-negative diagnostic rate obtained in the present study, BS alone cannot accurately diagnose metastases in the cervical spine in oncological patients.

LEVEL OF EVIDENCE

3.

Incidence and predictors of Bone Metastases (BM) and Skeletal-Related Events (SREs) in Small Cell Lung Cancer (SCLC): A Swiss patient cohort

Objectives: Bone metastases (BM) and skeletal-related events (SREs) are frequent complications in patients with lung cancer. Whereas in non-small-cell lung cancer (NSCLC) incidence, prognostic impact, and risk factors are well established, there is only little knowledge in patients with small cell lung cancer (SCLC). We retrospectively evaluated the incidence of BM, SRE and their treatment in a SCLC patient cohort treated at our hospital. We further assessed the role of Lactate Dehydrogenase (LDH), a possible predictor of BM development in SCLC patients.

Materials and Methods: We retrospectively analyzed patients with the diagnosis of SCLC for BM, SRE, overall treatment patterns, outcome and established prognostic parameters by record review. The prognostic role of LDH was tested using univariate longitudinal regression analysis.

Results: We identified 92 consecutive patients with SCLC diagnosed between 2000 and 2010 at our institution. Overall, 36.9% presented with BM at first diagnosis. Median time to BM from first diagnosis was 14.8 months (range) in limited disease (LD) and 0.9 months (range) in extensive disease (ED). The overall incidence of SRE was 18.4%. Only 19.6% of patients with BM were initially treated with bisphosphonates.

Conclusions: Elevated LDH, as well as age ≥75 years were independent predictors for BM development in SCLC patients. Although SREs are relevant complications in SCLC, early antiresorptive treatment of BM to reduce the risk of SREs was rare. LDH served as a predictive factor for BM development in our SCLC cohort and therefore should be taken into account in future randomized controlled trials.

Therapeutic Potential of Denosumab in Patients With Lung Cancer: Beyond Prevention of Skeletal Complications

Approximately up to 40% of patients with lung cancer develop bone metastasis, with 22% to 59% of them experiencing skeletal-related events (SREs), which result in an important quality of life deterioration and economic burden. Denosumab, a fully human antibody that targets the receptor activator of nuclear factor-κB (RANK) ligand (RANKL), is indicated for prevention of SREs in patients with solid tumors and has demonstrated superiority in breast and prostate cancer, and in other solid tumors, in reducing the risk of first SRE by 17% versus zoledronic acid. In the subset of patients with non-small-cell lung carcinoma (NSCLC), denosumab has also shown a positive trend to SRE risk reduction. Denosumab might have direct or indirect antitumor effects. Cancer cells produce factors that stimulate increased bone resorption by osteoclasts, which in turn release tumor growth factors into the bone microenvironment, initiating a tumor/bone vicious cycle. An increasing body of evidence suggests RANK/RANKL signaling plays a role in this tumorigenesis. Both proteins are overexpressed in different tumor types including lung cancer cells. RANK/RANKL signaling activates nuclear factor-κB pathways related to lung carcinogenesis and increases intercellular adhesion molecule 1 expression and MEK/extracellular signal-regulated kinase phosphorylation, which in turn enhances tumor cell migration. In animal NSCLC models, denosumab delayed bone metastases and reduced skeletal tumor growth. In patients with lung cancer (post hoc analysis), denosumab prolonged overall survival by 1.2 months versus zoledronic acid (P = .01). This hypothesis-generating outcome warrants further investigation and 2 studies in lung cancer are ongoing to elucidate the therapeutic potential of denosumab beyond SRE prevention.

A Case of Massive Bone Metastases From Lung Cancer Detected Only by 18F-FDG PET/CT

A 74-year-old man was diagnosed with small cell lung carcinoma in the left upper lobe. (18)F-FDG PET/CT showed multifocal strong abnormal uptakes in the axial skeleton and those of the primary lung tumor. CT failed to demonstrate the bony abnormalities. A subsequent (99m)Tc-MDP bone scintigraphy was also almost negative. It is important to note that bone metastasis may be undetectable by both CT and bone scintigraphy even if it is massive.

Appropriateness of imaging for lung cancer staging in a national cohort

PURPOSE

Optimizing evidence-based care to improve quality is a critical priority in the United States. We sought to examine adherence to imaging guideline recommendations for staging in patients with locally advanced lung cancer in a national cohort.

METHODS

We identified 3,808 patients with stage IIB, IIIA, or IIIB lung cancer by using the national Department of Veterans Affairs (VA) Central Cancer Registry (2004-2007) and linked these patients to VA and Medicare databases to examine receipt of guideline-recommended imaging based on National Comprehensive Cancer Network and American College of Radiology Appropriateness Criteria. Our primary outcomes were receipt of guideline-recommended brain imaging and positron emission tomography (PET) imaging. We also examined rates of overuse defined as combined use of bone scintigraphy (BS) and PET, which current guidelines recommend against. All imaging was assessed during the period 180 days before and 180 days after diagnosis.

RESULTS

Nearly 75% of patients received recommended brain imaging, and 60% received recommended PET imaging. Overuse of BS and PET occurred in 25% of patients. More advanced clinical stage and later year of diagnosis were the only clinical or demographic factors associated with higher rates of guideline-recommended imaging after adjusting for covariates. We observed considerable regional variation in recommended PET imaging and overuse of combined BS and PET.

CONCLUSION

Receipt of guideline-recommended imaging is not universal. PET appears to be underused overall, whereas BS demonstrates continued overuse. Wide regional variation suggests that these findings could be the result of local practice patterns, which may be amenable to provider education efforts such as Choosing Wisely.

Modern diagnostic and therapeutic interventional radiology in lung cancer

Imaging has an important role in the multidisciplinary management of primary lung cancer. This article reviews the current state-of-the-art imaging modalities used for the evaluation, staging and post-treatment follow-up and surveillance of lung cancers, and image-guided percutaneous techniques for biopsy to confirm the diagnosis and for local therapy in non-surgical candidates.

Is there any significance of lung cancer histology to compare the diagnostic accuracies of (18)F-FDG-PET/CT and (99m)Tc-MDP BS for the detection of bone metastases in advanced NSCLC?

Aim of the study

Bone scintigraphy (BS) and fluorine-18 deoxyglucose positron emission tomography computed tomography (¹⁸F-FDG-PET/CT) are widely used for the detection of bone involvement. The optimal imaging modality for the detection of bone metastases in histological subgroups of non-small cell lung cancer (NSCLC) remains ambiguous. The aim of this study was to compare the efficacy of ¹⁸F-FDG-PET/C and 99mTc-methylene diphosphonate (^99mTc-MDP) BS in the detection of bone metastases of patients in NSCLC. Specifically, we compared the diagnostic accuracies of these imaging techniques evaluating bone metastasis in histological subgroups of NSCLC.

Material and methods

Fifty-three patients with advanced NSCLC, who had undergone both ¹⁸F-FDG-PET/CT and BS and were eventually diagnosed as having bone metastasis, were enrolled in this retrospective study.

Results

The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ¹⁸F-FDG-PET/CT and BS were 90.4%, 99.4%, 98.1%, 96.6%, 97.0% and 84.6%, 93.1%, 82.5%, 93.2, 90.8%, respectively. The κ statistics were calculated for ¹⁸F-FDG-PET/CT and BS. The κ-value was 0.67 between ¹⁸F-FDG-PET/CT and BS in all patients. On the other hand, the κ-value was 0.65 in adenocarcinoma, and 0.61 in squamous cell carcinoma between ¹⁸F-FDG-PET/CT and BS. The κ-values suggested excellent agreement between all patients and histological subgroups of NSCLC.

Conclusions

¹⁸F-FDG-PET/CT was more favorable than BS in the screening of metastatic bone lesions, but the trend did not reach statistical significance in all patients and histological subgroups of NSCLC. Our results need to be validated in prospective and larger study clinical trials to further clarify this topic.

Bone metastases: When and how lung cancer interacts with bone

Bone metastasis is a common and debilitating consequence of lung cancer: 30%-40% of patients with non-small cell lung cancer develop bone metastases during the course of their disease. Lung cancer cells find a favorable soil in the bone microenvironment due to factors released by the bone matrix, the immune system cells, and the same cancer cells. Many aspects of the cross-talk among lung tumor cells, the immune system, and bone cells are not clear, but this review aims to summarize the recent findings in this field, with particular attention to studies conducted to identify biomarkers for early detection of lung cancer bone metastases.

Prospective study on the incidence of bone metastasis (BM) and skeletal-related events (SREs) in patients (pts) with stage IIIB and IV lung cancer-CSP-HOR 13

BACKGROUND

Bone metastasis (BM) is a frequent complication in patients with advanced lung cancer and it causes skeletal-related events (SREs). Our study aim is to prospectively investigate the incidence of BM, incidence and types of SRE, and predictive factors of BM and SREs.

METHODS

Newly diagnosed, advanced non-small-cell lung cancer (NSCLC) or small-cell lung cancer (SCLC) patients were enrolled into the study. Patients were followed up every 4 weeks to monitor the development of SREs. Treatment for lung cancer was performed at the discretion of the investigator.

RESULTS

Two hundred seventy-four patients were enrolled in this study between April 2007 and December 2009 from 12 institutions. Patients included 77 cases of SCLC and 197 of NSCLC (stage IIIB/IV = 73/124). Median follow-up time was 13.8 months. The incidence of BM at initial diagnosis was 48% in stage IV NSCLC and 40% in extensive stage (ED)-SCLC. Forty-five percent of patients who developed BM had SREs consisting of pathologic fracture (4.7%), radiation to bone (15.3%), spinal cord compression (1.1%), and hypercalcemia (2.2%). Multivariate analysis revealed that factors predicting BM are stage IV, performance status 1 or greater and higher bone alkaline phosphatase in NSCLC patients, higher lactate dehydrogenase, and lower parathyroid hormone-related peptide in SCLC patients. Factors predicting SREs were stage IV, age 64 or younger, and lower albumin in NSCLC patients. Multivariate analysis of SRE was not performed for SCLC because of the small number of events.

CONCLUSION

Predictive factors should be taken into consideration in future randomized studies evaluating BM and SREs.

Impact of PET staging in limited-stage small-cell lung cancer

INTRODUCTION

Although positron emission tomography computed tomography (PET-CT) has been widely used for small-cell lung cancer (SCLC) staging, no study has examined the clinical impact of PET staging in limited-stage (LS) SCLC.

METHODS

We identified patients with LS-SCLC treated definitively with concurrent chemoradiation. Outcomes were assessed using the Kaplan-Meier approach, Cox regression, and competing risks method.

RESULTS

We treated 54 consecutive LS-SCLC patients with concurrent chemoradiation from January 2002 to August 2010. Forty underwent PET, 14 did not, and all underwent thoracoabdominopelvic CT and magnetic resonance imaging neuroimaging. Most patient characteristics were balanced between the comparison groups, including age, race, sex, bone scanning, median dosage, and performance status. More number of PET-staged patients presented with nodal metastases (p = 0.05). Median follow-up was similar for PET-staged and non-PET-staged patients (p = 0.59). Median overall survival from diagnosis in PET-staged patients was 32 versus 17 months in patients staged without PET (p = 0.03), and 3-year survival was 47% versus 19%. Median time-to-distant failure was 29 versus 12 months (p = 0.04); median time-to-local failure was not reached versus 16 months (p = 0.04). On multivariable analysis, PET staging (odds ratio [OR] = 0.24; p = 0.04), performance status (OR = 1.89; p = 0.05), and N-stage (OR = 4.94; p < 0.01) were associated with survival.

CONCLUSION

LS-SCLC patients staged with PET exhibited improved disease control and survival when compared with non-PET-staged LS-SCLC patients. Improved staging accuracy and better identification of intrathoracic disease may explain these findings, underscoring the value of PET-CT in these patients.

(18)F-FDG PET/CT for Diagnosis of Osteosclerotic and Osteolytic Vertebral Metastatic Lesions: Comparison with Bone Scintigraphy

Study Design

A retrospective study.

Purpose

The aims of this study were to investigate the diagnostic value of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in PET/computed tomography (CT) in the evaluation of spinal metastatic lesions.

Overview of Literature

Recent studies described limitations regarding how many lesions with abnormal ¹⁸F-FDG PET findings in the bone show corresponding morphologic abnormalities.

Methods

The subjects for this retrospective study were 227 patients with primary malignant tumors, who were suspected of having spinal metastases. They underwent combined whole-body ¹⁸F-FDG PET/CT scanning for evaluation of known neoplasms in the whole spine. ^99mTc-methylene diphosphonate bone scan was performed within 2 weeks following PET/CT examinations. The final diagnosis of spinal metastasis was established by histopathological examination regarding bone biopsy or magnetic resonance imaging (MRI) findings, and follow-up MRI, CT and ¹⁸F-FDG PET for extensively wide lesions with subsequent progression.

Results

From a total of 504 spinal lesions in 227 patients, 224 lesions showed discordant image findings. For 122 metastatic lesions with confirmed diagnosis, the sensitivity/specificity of bone scan and FDG PET were 84%/21% and 89%/76%, respectively. In 102 true-positive metastatic lesions, the bone scan depicted predominantly osteosclerotic changes in 36% and osteolytic changes in 19%. In 109 true-positive lesions of FDG PET, osteolytic changes were depicted predominantly in 38% while osteosclerotic changes were portrayed in 15%.

Conclusions

¹⁸F-FDG PET in PET/CT could be used as a substitute for bone scan in the evaluation of spinal metastasis, especially for patients with spinal osteolytic lesions on CT.

The role of 18F-fluoride PET-CT in the detection of bone metastases in patients with breast, lung and prostate carcinoma: a comparison with FDG PET/CT and 99mTc-MDP bone scan

OBJECTIVES

We aimed to compare the role of (18)F-fluoride PET/CT, FDG PET/CT and (99m)Tc-MDP bone scans in the detection of bone metastases in patients with lung, breast and prostate carcinoma.

METHODS

This was a prospective study including patients for staging (S) and restaging (R). Seventy-two patients (23S, 49R) with infiltrating ductal breast carcinoma, 49 patients (25S, 24R) with prostate adenocarcinoma and 30 patients (17S, 13R) with non-small-cell lung carcinoma (NSCLC), without known bone metastases but with high risk/clinical suspicion for the same, underwent a (99m)Tc-MDP bone scan, FDG PET/CT and (18)F-fluoride PET/CT within 2 weeks. All scans were reviewed by two experienced nuclear medicine physicians, and the findings were correlated with MRI/thin-slice CT/skeletal survey. Histological verification was done wherever feasible.

RESULTS

Sensitivity and negative predictive value (NPV) of (18)F-fluoride PET/CT was 100 % in all three malignancies, while that of FDG PET/CT was 79 % and 73 % in NSCLC, 73 % and 80 % in breast cancer and 72 and 65 % in prostate cancer. Specificity and positive predictive value (PPV) of FDG PET/CT were 100 % in NSCLC and prostate and 97 % and 96 % in breast cancer. As compared to the (99m)Tc-MDP bone scan, all parameters were superior for (18)F-fluoride PET/CT in prostate and breast cancer, but sensitivity and NPV were equal in NSCLC. The MDP bone scan had superior sensitivity and NPV compared to FDG PET/CT but had low specificity and PPV.

CONCLUSION

To rule out bone metastases in cases where there is a high index of suspicion, (18)F-fluoride PET/CT is the most reliable investigation. (18)F-fluoride PET/CT has the potential to replace the (99m)Tc-MDP bone scan for the detection of bone metastases.

Increasing Role of FDG-PET/CT in Detecting Bone Marrow Metastasis of Solid Tumors in Adults: An Analysis of Ten Patients

Background

We aimed to test the hypothesis that whether FDG-PET/CT which was ordered for various purposes can predict suspected or particularly unsuspected bone marrow metastasis (BMM) from the complete blood count and therefore can change the management of these patients.

Methods

In this retrospective study, the study sample consisted of 68 subsequent patients presented to our institution’s pathology department with bone marrow metastases of solid tumors. PET/CT was found to have been ordered in 10 out of 68 patients (6.8%) for various purposes. All patients gave informed consent about the PET/CT examinations and bone marrow biopsies.

Result

FDG-PET/CT was ordered in 10 out of 68 solid tumor patients with pathologically proven BMM. Of these 10 patients, 3 were female and 7 were male; mean age was 54.7 years. While FDG PET/CT showed bone and BMM in 4 of 10 patients (40%), the rest of the patients had BMM without bone involvement. Five patients (50%) who had probable bone marrow involvement on their FDG PET/CT scans had unsuspected complete blood counts with regard to BMM.

Conclusion

PET/CT has the ability to detect a substantial number of metabolically active tumor cells in the bone marrow in all of our patients which we proved by bone marrow biopsies. We think that this cohort of patients with solid tumors is hypothesis-generating with regard to detecting early bone marrow metastases by FDG PET/CT.

Role of FDG-PET scans in staging, response assessment, and follow-up care for non-small cell lung cancer

The integral role of positron-emission tomography (PET) using the glucose analog tracer fluorine-18 fluorodeoxyglucose (FDG) in the staging of non-small cell lung cancer (NSCLC) is well established. Evidence is emerging for the role of PET in response assessment to neoadjuvant therapy, combined-modality therapy, and early detection of recurrence. Here, we review the current literature on these aspects of PET in the management of NSCLC. FDG-PET, particularly integrated (18)F-FDG-PET/CT, scans have become a standard test in the staging of local tumor extent, mediastinal lymph node involvement, and distant metastatic disease in NSCLC. (18)F-FDG-PET sensitivity is generally superior to computed tomography (CT) scans alone. Local tumor extent and T stage can be more accurately determined with FDG-PET in certain cases, especially in areas of post-obstructive atelectasis or low CT density variation. FDG-PET sensitivity is decreased in tumors <1 cm, at least in part due to respiratory motion. False-negative results can occur in areas of low tumor burden, e.g., small lymph nodes or ground-glass opacities. (18)F-FDG-PET-CT nodal staging is more accurate than CT alone, as hilar and mediastinal involvement is often detected first on (18)F-FDG-PET scan when CT criteria for malignant involvement are not met. (18)F-FDG-PET scans have widely replaced bone scintography for assessing distant metastases, except for the brain, which still warrants dedicated brain imaging. (18)F-FDG uptake has also been shown to vary between histologies, with adenocarcinomas generally being less FDG avid than squamous cell carcinomas. (18)F-FDG-PET scans are useful to detect recurrences, but are currently not recommended for routine follow-up. Typically, patients are followed with chest CT scans every 3-6 months, using (18)F-FDG-PET to evaluate equivocal CT findings. As high (18)F-FDG uptake can occur in infectious, inflammatory, and other non-neoplastic conditions, (18)F-FDG-PET-positive findings require pathological confirmation in most cases. There is increased interest in the prognostic and predictive role of FDG-PET scans. Studies show that absence of metabolic response to neoadjuvant therapy correlates with poor pathologic response, and a favorable (18)F-FDG-PET response appears to be associated with improved survival. Further work is underway to identify subsets of patients that might benefit individualized management based on FDG-PET.

Bone matters in lung cancer

BACKGROUND

Bone metastases are a significant and undertreated clinical problem in patients with advanced lung cancer.

DESIGN

We reviewed the incidence of bone metastases and skeletal-related events (SREs) in patients with lung cancer and examined the burden on patients' lives and on health care systems. Available therapies to improve survival and lessen the impact of SREs on quality of life (QoL) were also investigated.

RESULTS

Bone metastases are common in lung cancer; however, owing to short survival times, data on the incidences of SREs are limited. As with other cancers, the costs associated with treating SREs in lung cancer are substantial. Bisphosphonates reduce the frequency of SREs and improve measures of pain and QoL in patients with lung cancer; however, nephrotoxicity is a common complication of therapy. Denosumab, a recently approved bone-targeted therapy, is superior to zoledronic acid in increasing the time to first on-study SRE in patients with solid tumours, including lung cancer. Additional roles of bone-targeted therapies beyond the prevention of SREs are under investigation.

CONCLUSIONS

With increasing awareness of the consequences of SREs, bone-targeted therapies may play a greater role in the management of patients with lung cancer, with the aim of delaying disease progression and preserving QoL.

High prevalence of osteoblastic bone reaction in computed tomography scans of an European Organisation for Research and Treatment of Cancer prospective randomised phase II trial in extensive stage small cell lung cancer

BACKGROUND

Osteoblastic bone reaction is an important phenomenon defined by an increase in apparent bone density of previously known bone metastasis or development of new osteoblastic lesions in the presence of response in other tumour sites. Osteoblastic bone reaction in lung cancer has only been described in a few reports and mostly in patients with pre-existing bone metastasis.

METHODS

In this report we present the data of an independent, blinded and preplanned radiological review of the occurrence of osteoblastic lesions in patients with extensive stage small cell lung cancer (SCLC). The computed tomography (CT) scans of the chest and upper abdomen of 71/88 patients who had an investigator reported complete response (CR), partial response (PR) or stable disease (SD) were retrospectively analysed for the development of osteoblastic lesions. Furthermore, baseline exams were reviewed for the presence and location of bone metastasis and local radiological reports were reviewed for any knowledge of bone metastasis.

RESULTS

There were 14 patients with osteoblastic bone lesions in the reviewed follow-up CT scans. Three patients had known bone metastases at baseline, and 11 patients had no history or findings of bone metastases on the baseline scan. During the course of the disease, 13 out of 14 patients developed new osteoblastic lesions, while all responded in other sites. The prevalence of osteoblastic bone reaction in our study was 19.7%.

CONCLUSION

In this study osteoblastic bone reaction was observed in a larger number of patients without previously documented bone metastases, indicating a high prevalence of occult bone metastases in SCLC. If bone metastases are not documented at diagnosis, then osteoblastic bone reaction may cause confusion in a responding patient.

The role of integrated 18F-FDG PET-CT as a staging tool for limited-stage small cell lung cancer: a retrospective study

BACKGROUND

The aim of this study was to evaluate whether positron emission tomography-computed tomography (PET-CT) could be used as part of the staging work-up in patients with limited-stage disease (LD) small cell lung cancer (SCLC).

PATIENTS AND METHODS

Between January 2002 and December 2007, a total of 73 patients with presumed LD on CT, who underwent a PET-CT scan, were included in this study.

RESULTS

Conventional work-up revealed distant metastases in 12 patients. Out of 61 patients diagnosed as LD SCLC, PET-CT found unexpected distant metastases in 15 (24.6%) patients (LD/extensive-stage disease (ED)) of whom 13 (21.3%) were upstaged as a consequence. In 10 (76.9%) of the 13 upstaged patients, treatment was changed. The median survival of LD/LD SCLC patients who underwent concurrent chemoradiotherapy and chemotherapy only was 21.9 and 17.5 months, respectively. The median survival of LD/ED and ED/ED SCLC patients who received chemotherapy only was 17.4 and 14.1 months, respectively. The median survival of LD/LD SCLC patients who received concurrent chemoradiotherapy was superior to that of LD/ ED and ED/ED patients who received chemotherapy only (p = 0.037 and 0.004, respectively).

CONCLUSION

The addition of PET-CT seems to allow more accurate staging and may thus protect a percentage of SCLC patients from potentially futile and toxic radiotherapy.

Meta-analysis: comparison of F-18 fluorodeoxyglucose-positron emission tomography and bone scintigraphy in the detection of bone metastasis in patients with lung cancer

RATIONALE AND OBJECTIVES

The aim of this review was to evaluate the diagnostic properties of (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) or PET/computed tomography (CT) and bone scintigraphy in the detection of osseous metastases in patients with lung cancer.

MATERIALS AND METHODS

MEDLINE was searched for relevant original articles published between January 1995 and August 2010. Inclusion criteria were as follows: FDG-PET or PET/CT and bone scintigraphy was carried out to detect bone metastases in patients with lung cancer, sufficient data were presented to construct a 2 × 2 contingency table, and histopathologic analysis and/or close clinical and imaging follow-up and/or radiographic confirmation by multiple imaging modalities was used as the reference standard. Two reviewers independently extracted data related to research design, sample size, imaging techniques, technical characteristics, reference standards, methods of imaging interpretation, and totals of true-positives, false-positives, true-negatives, and false-negatives. Stata was used to obtain per patient and per lesion pooled estimates of sensitivity, specificity, and positive and negative likelihood ratios, and areas under summary receiver-operating characteristic curves (AUCs) were calculated.

RESULTS

The pooled patient-based sensitivity of FDG-PET or PET/CT was 0.93 (95% confidence interval [CI], 0.88-0.96), specificity was 0.95 (95% CI, 0.91-0.98), and the AUC was 0.94. The pooled sensitivity of bone scans was 0.87 (95% CI, 0.79-0.93), specificity was 0.82 (95% CI, 0.62-0.92), and the AUC was 0.91. The pooled lesion-based sensitivity of FDG-PET or PET/CT was 0.93 (95% CI, 0.84-0.97), specificity was 0.91 (95% CI, 0.80-0.96), and the AUC was 0.97. The pooled sensitivity of bone scans was 0.92 (95% CI, 0.87-0.95), specificity was 0.57 (95% CI, 0.09-0.95), and the AUC was 0.92.

CONCLUSIONS

Although FDG-PET or PET/CT has higher sensitivity and specificity than bone scintigraphy, further research with a less biased design is needed to determine the most efficacious imaging modality for the detection of metastatic lung cancer.

Radionuclide imaging in the diagnosis and management of orthopaedic disease

Nuclear medicine imaging is often used in the diagnosis and management of several orthopaedic conditions. Bone scintigraphy measures gamma ray emission to detect the distribution of an injected radiolabeled tracer on multiple image projections. In general, this imaging modality has relatively high sensitivity but low specificity in the diagnosis of occult fractures, bone tumors, metabolic bone disease, and infection. Positron emission tomography measures tissue metabolism and perfusion by detecting short half-life positron ray emission of an injected radiopharmaceutical tracer. Historically, positron emission tomography has been used only to monitor bone metastasis and aid in the diagnosis of osteomyelitis; however, this technology has recently been applied to other orthopaedic conditions for which current imaging modalities are insufficient.

Diagnosis of bone metastases: a meta-analysis comparing ¹⁸FDG PET, CT, MRI and bone scintigraphy

OBJECTIVE

To perform a meta-analysis to compare (18)FDG PET, CT, MRI and bone scintigraphy (BS) for the diagnosis of bone metastases.

METHODS

Databases including MEDLINE and EMBASE were searched for relevant original articles published from January 1995 to January 2010. Software was used to obtain pooled estimates of sensitivity, specificity and summary receiver operating characteristic curves (SROC).

RESULTS

67 articles consisting of 145 studies fulfilled all inclusion criteria. On per-patient basis, the pooled sensitivity estimates for PET, CT, MRI and BS were 89.7%, 72.9%, 90.6% and 86.0% respectively. PET=MRI>BS>CT. ("="indicated no significant difference, P > 0.05; ">" indicated significantly higher, P < 0.05). The pooled specificity estimates for PET, CT, MRI and BS were 96.8%, 94.8%, 95.4% and 81.4% respectively. PET = CT = MRI>BS. On per-lesion basis, the pooled sensitivity estimates for PET, CT, MRI and BS were 86.9%, 77.1%, 90.4% and 75.1% respectively. PET = MRI>BS>CT. The pooled specificity estimates for PET, CT, MRI and BS were 97.0%, 83.2%, 96.0% and 93.6% respectively. PET>MRI>BS>CT.

CONCLUSION

PET and MRI were found to be comparable and both significantly more accurate than CT and BS for the diagnosis of bone metastases.

Evaluation of Bone Metastasis from Hepatocellular Carcinoma Using (18)F-FDG PET/CT and (99m)Tc-HDP Bone Scintigraphy: Characteristics of Soft Tissue Formation

PURPOSE

Bone metastasis from hepatocellular carcinoma (HCC) can present with soft tissue formation, resulting in oncologic emergency. Contrast-enhanced FDG PET/CT and bone scintigraphy were compared to evaluate characteristics of bone metastases with or without soft tissue formation from HCC.

METHODS

Of 4,151 patients with HCC, 263 patients had bone metastases. Eighty-five patients with bone metastasis from HCC underwent contrast-enhanced FDG PET/CT. Fifty-four of the enrolled subjects had recent (99m)Tc-HDP bone scintigraphy available for comparison. Metastatic bone lesions were identified with visual inspection on FDG PET/CT, and maximum standardized uptake value (SUVmax) was used for the quantitative analysis. Confirmation of bone metastasis was based on histopathology, combined imaging modalities, or serial follow-up studies.

RESULTS

Forty-seven patients (55%) presented with soft tissue formation, while the remaining 38 patients presented without soft tissue formation. Frequent sites of bone metastases from HCC were the spine (39%), pelvis (19%), and rib cage (14%). The soft-tissue-formation group had more frequent bone pain (77 vs. 37%, p < 0.0001), higher SUVmax (6.02 vs. 3.52, p < 0.007), and higher incidence of photon defect in bone scintigraphy (75 vs. 0%) compared to the non-soft-tissue-formation group. FDG PET/CT had higher detection rate for bone metastasis than bone scintigraphy both in lesion-based analysis (98 vs. 53%, p = 0.0015) and in patient-based analysis (100 vs. 80%, p < 0 .001).

CONCLUSIONS

Bone metastasis from HCC showed a high incidence of soft tissue formation requiring emergency treatment. Although the characteristic findings for soft tissue formation such as photon defect in bone scintigraphy are helpful in detection, overall detectability of bone metastasis is higher in FDG PET/CT. Contrast-enhanced PET/CT will be useful in finding and delineating soft-tissue-forming bone metastasis from HCC.

PET/CT imaging in different types of lung cancer: an overview

Lung cancer (LC) still represents one of the most common tumours in both women and men. PET/CT is a whole-body non-invasive imaging procedure that has been increasingly used for the assessment of LC patients. In particular, PET/CT added value to CT is mainly related to a more accurate staging of nodal and metastatic sites and to the evaluation of the response to therapy. Although the most common PET tracer for LC evaluation is 18F-FDG, new tracers have been proposed for the evaluation of lung neuroendocrine tumours (68Ga-DOTA-peptides, 18F-DOPA) and for the assessment of central nervous system metastasis (11C-methionine). This review focuses on the main clinical applications and accuracy of PET/CT for the detection of non-small cells lung cancer (NSCLC), broncho-alveolar carcinoma (BAC), small cells lung cancer (SCLC), lung neuroendocrine tumours (NET) and solitary pulmonary nodules (SPN).

A meta-analysis of ¹⁸FDG-PET-CT, ¹⁸FDG-PET, MRI and bone scintigraphy for diagnosis of bone metastases in patients with lung cancer

BACKGROUND AND PURPOSE

Lung cancer is the most common cause of cancer related death among both men and women worldwide. The skeleton is the most common site of cancer metastasis. Early detection is crucial for prognosis. To evaluate and compare the capability for bone metastasis assessment of [(18)F] fluoro-2-d-glucose positron emission tomography with computed tomography ((18)FDG-PET-CT), [(18)F] fluoro-2-d-glucose positron emission tomography ((18)FDG-PET), magnetic resonance imaging (MRI) and bone scintigraphy (BS) in lung cancer patients, a meta-analysis is preformed.

METHODS

We searched MEDLINE, OVID, EMBASE and the Cochrane Library for studies evaluating diagnosis validity of (18)FDG-PET-CT, (18)FDG-PET, MRI and BS between January 1990 and August 2010. Meta-analysis methods were used to pool sensitivity, specificity, diagnostic odd ratios (DORs) and to construct a summary receiver-operating characteristic curve (SROC).

RESULTS

A total of 17 articles (9 (18)FDG-PET-CT studies, 9 (18)FDG-PET studies, 6 MRI studies and 16 BS studies) that included 2940 patients who fulfilled all of the inclusion criteria were considered for inclusion in the analysis. The pooled sensitivity for the detection of bone metastasis in lung cancer using (18)FDG-PET-CT, (18)FDG-PET, MRI and BS were 0.92 (95% CI, 0.88-0.95), 0.87 (95% CI, 0.81-0.92), 0.77 (95% CI, 0.65-0.87) and 0.86 (95% CI, 0.82-0.89), respectively. The pooled specificity for the detection of bone metastasis from lung cancer using (18)FDG-PET-CT, (18)FDG-PET, MRI and BS were 0.98 (95% CI, 0.97-0.98), 0.94 (95% CI, 0.92-0.96), 0.92 (95% CI, 0.88-0.95), 0.88 (95% CI, 0.86-0.89), respectively. The pooled DORs estimates for (18)FDG-PET-CT 449.17 were significantly higher than for (18)FDG-PET (118.25, P<0.001), MRI (38.27, P<0.001) and BS (63.37, P<0.001). The pooled sensitivity of BS was not correlated with the prevalence of bone metastasis.

CONCLUSION

The results showed that both (18)FDG-PET-CT and (18)FDG-PET were better imaging methods for diagnosing bone metastasis from lung cancer than MRI and BS. (18)FDG-PET-CT has higher diagnostic value (sensitivity, specificity and DORs) for diagnosing bone metastasis from lung cancer than any other imaging methods.

Fluorine-18 deoxyglucose positron emission tomography, magnetic resonance imaging and bone scintigraphy for the diagnosis of bone metastases in patients with lung cancer: which one is the best?--a meta-analysis

AIMS

To carry out a meta-analysis to compare fluorine-18 deoxyglucose ((18)FDG) positron emission tomography (PET), magnetic resonance imaging (MRI) and bone scintigraphy imaging for the diagnosis of bone metastases in patients with lung cancer.

MATERIALS AND METHODS

MEDLINE, EMBASE, Scopus and other databases were searched for relevant original articles published between January 1995 and January 2010. Inclusion criteria were as follows: (18)FDG PET, MRI or (99m)Tc-MDP bone scintigraphy was carried out to detect bone metastases in patients with lung cancer; sufficient data were presented to construct a 2×2 contingency table; histopathological analysis and/or close clinical and imaging follow-up and/or radiographic confirmation by multiple imaging modalities were used as the reference standard. Two reviewers independently extracted data. META-DiSc was used to obtain pooled estimates of sensitivity, specificity, diagnostic odds ratio (DOR), summary receiver operating characteristic (SROC) curves and the *Q index.

RESULTS

In total, 14 articles that consisted of 34 studies fulfilled all inclusion criteria. On a per-patient basis, the pooled sensitivity estimates for PET, MRI and bone scintigraphy were 91.9, 80.0 and 91.8%, respectively. The sensitivity for PET and bone scintigraphy were significantly higher than for MRI (P<0.05). There was no significant difference between PET and bone scintigraphy (P>0.05). The pooled specificity estimates for PET, MRI and bone scintigraphy were 96.8, 90.6 and 68.8%, respectively. The specificity for PET was significantly higher than for MRI and bone scintigraphy (P<0.05), and the specificity for MRI was significantly higher than for bone scintigraphy (P<0.05). The pooled DOR estimates for PET, MRI and bone scintigraphy were 365.5, 53.8 and 34.4, respectively. The DOR for PET was significantly higher than for MRI and bone scintigraphy (P<0.05). There was no significant difference between MRI and bone scintigraphy (P>0.05). The SROC curve for PET showed better diagnostic accuracy than for MRI and bone scintigraphy. The SROC curve for MRI was better than for bone scintigraphy. The *Q index estimates for PET, MRI and bone scintigraphy were 0.933, 0.903 and 0.857, respectively. The *Q index for PET and MRI were significantly higher than for bone scintigraphy (P<0.05). There was no significant difference between PET and MRI (P>0.05). On a per-lesion basis, the pooled sensitivity estimates for PET, MRI and bone scintigraphy were 95.0, 83.8 and 71.5%, respectively. The sensitivity for PET was significantly higher than for MRI and bone scintigraphy (P<0.05), and the sensitivity for MRI was significantly higher than for bone scintigraphy (P<0.05). The pooled specificity estimates for PET, MRI and bone scintigraphy were 94.6, 96.3 and 91.0%, respectively. The specificity for MRI was significantly higher than for PET and bone scintigraphy (P<0.05), and the specificity for PET was significantly higher than for bone scintigraphy (P<0.05). The pooled DOR estimates for PET, MRI and bone scintigraphy were 431.9, 158.1 and 9.0, respectively. The DOR for PET was significantly higher than for MRI and bone scintigraphy (P<0.05) and the DOR for MRI was significantly higher than for bone scintigraphy (P<0.05). The SROC curve for PET and MRI showed better diagnostic accuracy than for bone scintigraphy. There was no significant difference between PET and MRI. The *Q index estimates for PET, MRI and bone scintigraphy were 0.953, 0.962 and 0.778, respectively. The *Q index for PET and MRI were significantly higher than for bone scintigraphy (P<0.05). There was no significant difference between PET and MRI (P>0.05).

CONCLUSION

(18)FDG PET was found to be the best modality to detect bone metastasis in patients with lung cancer, both on a per-patient basis and a per-lesion basis; MRI had the highest specificity on a per-lesion basis. For the subgroup analysis of (18)FDG PET, PET/computed tomography was shown to be better than PET and there were no significant differences between using (68)Ge and computed tomography for attenuation correction on a per-patient basis.

Staging of non-small cell lung cancer (NSCLC): a review

Lung cancer remains the most common cause of cancer-related mortality in Scotland, accounting for 28.9% of all cancer deaths in 2007. (1) Current guidelines recommend assessment of patient fitness and operability by a multi-disciplinary team when selecting management options. (2-6) Two of the most important prognostic markers are the stage of disease and ECOG performance status. The most commonly used cancer staging system is the tumour, node, metastasis (TNM) staging system, which is maintained by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC). In 1998, the International Association for the Study of Lung Cancer (IASLC) established The Lung Cancer Staging Project, collecting data on over 100,000 patients diagnosed with lung cancer between 1990-2000 worldwide, in order to revise the 6th edition TNM staging system for non-small cell lung cancer (NSCLC).(7) The 7th edition was published in late 2009. This review of staging in NSCLC, includes a summary of the different staging techniques currently available and the 7th edition TNM staging system for NSCLC.(8).

Radionuclide imaging of bone marrow disorders

Noninvasive imaging techniques have been used in the past for visualization the functional activity of the bone marrow compartment. Imaging with radiolabelled compounds may allow different bone marrow disorders to be distinguished. These imaging techniques, almost all of which use radionuclide-labelled tracers, such as ^99mTc-nanocolloid, ^99mTc-sulphur colloid, ¹¹¹In-chloride, and radiolabelled white blood cells, have been used in nuclear medicine for several decades. With these techniques three separate compartments can be recognized including the reticuloendothelial system, the erythroid compartment and the myeloid compartment. Recent developments in research and the clinical use of PET tracers have made possible the analysis of additional properties such as cellular metabolism and proliferative activity, using ¹⁸F-FDG and ¹⁸F-FLT. These tracers may lead to better quantification and targeting of different cell systems in the bone marrow. In this review the imaging of different bone marrow targets with radionuclides including PET tracers in various bone marrow diseases are discussed.