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Bang JI, Lee WW, Cho SG, Choi M, Song YS. The Diagnostic Accuracy of SPECT Imaging in Patients With Suspected Pulmonary Embolism: Systematic Review and Network Meta-analysis. Clin Nucl Med 2024; 49:637-643. [PMID: 38831512 DOI: 10.1097/rlu.0000000000005167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND This meta-analysis and systematic review assessed the diagnostic accuracy of lung SPECT compared with lung planar imaging in patients with suspected acute pulmonary embolism (PE) or chronic thromboembolic pulmonary hypertension. PATIENTS AND METHODS A search of Medline, Embase, and Cochrane databases identified suitable articles published before October 2023. Meta-analyses were performed to determine the diagnostic accuracy of SPECT imaging modalities, including perfusion (Q) SPECT, ventilation (V)/Q SPECT, Q SPECT/CT, and V/Q SPECT/CT. Network meta-analyses were performed to compare the diagnostic accuracy of SPECT and planar imaging in paired-design studies. RESULTS Twenty-four articles (total n = 6576) were included in the analysis. For suspected acute PE, the respective sensitivity and specificity of SPECT imaging modalities were as follows: Q SPECT, 0.93 (95% confidence interval [CI], 0.87-0.99; I2 = 49%) and 0.72 (95% CI, 0.54-0.95; I2 = 94%); V/Q SPECT, 0.96 (95% CI, 0.94-0.98; I2 = 51%) and 0.95 (95% CI, 0.92-0.98; I2 = 80%); Q SPECT/CT, 0.93 (95% CI, 0.87-0.98; I2 = 66%) and 0.82 (95% CI, 0.70-0.96; I2 = 87%); and V/Q SPECT/CT, 0.97 (95% CI, 0.93-1.00; I2 = 7%) and 0.98 (95% CI, 0.97-1.00; I2 = 31%). The relative sensitivity and specificity of SPECT compared with planar imaging were 1.17 (95% CI, 1.06-1.30; P < 0.001) and 1.14 (95% CI, 1.00-1.29; P = 0.05), respectively. For suspected chronic thromboembolic pulmonary hypertension, the pooled sensitivity and specificity of SPECT imaging were 0.97 (95% CI, 0.95-1.00; I2 = 0%) and 0.91 (95% CI, 0.87-0.94; I2 = 0%), respectively. CONCLUSIONS SPECT exhibited superior diagnostic performance for PE. V/Q SPECT/CT was the most accurate modality.
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Affiliation(s)
- Ji-In Bang
- From the Department of Nuclear Medicine, CHA Bundang Medical Center, CHA University, Pocheon
| | | | - Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju
| | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Yoo Sung Song
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam
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Le Roux PY, Le Pennec R, Salaun PY, Zuckier LS. Scintigraphic Diagnosis of Acute Pulmonary Embolism: From Basics to Best Practices. Semin Nucl Med 2023; 53:743-751. [PMID: 37142520 DOI: 10.1053/j.semnuclmed.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 05/06/2023]
Abstract
In this article the technique, interpretation, and diagnostic performance of scintigraphy for the diagnosis of acute pulmonary embolism (PE) are reviewed. Lung scintigraphy has stood the test of time as a reliable and validated examination for the determination of PE. Ventilation/perfusion (V/Q) lung scintigraphy assesses the functional consequences of the clot on its downstream vascular bed in conjunction with the underlying ventilatory status of the affected lung region, in contrast to CT pulmonary angiography (CTPA), which visualizes presence of the clot within affected vessels. Most-commonly used ventilation radiopharmaceuticals are Technetium-99m labeled aerosols (such as 99mTechnetium-DTPA), or ultrafine particle suspensions (99mTc-Technegas) which reach the distal lung in proportion to regional distribution of ventilation. Perfusion images are obtained after intravenous administration 99mTc-labeled macro-aggregated albumin particles which lodge in the distal pulmonary capillaries. Both planar and tomographic methods of imaging, each favored in different geographical regions, will be described. Guidelines for interpretation of scintigraphy have been issues by both the Society of Nuclear Medicine and Molecular Imaging, and by the European Association of Nuclear Medicine. Breast tissue is particularly radiosensitive during pregnancy due to its highly proliferative state and many guidelines recommend use of lung scintigraphy rather than CTPA in this population. Several maneuvers are available in order to further reduce radiation exposure including reducing radiopharmaceutical dosages or omitting ventilation altogether, functionally converting the study to a low-dose screening examination; if perfusion defects are present, further testing is necessary. Several groups have also performed perfusion-only studies during the COVID epidemic in order to reduce risk of respiratory contagion. In patients where perfusion defects are present, further testing is again necessary to avoid false-positive results. Improved availability of personal protective equipment, and reduced risk of serious infection, have rendered this maneuver moot in most practices. First introduced 60 years ago, subsequent advances in radiopharmaceutical development and imaging methods have positioned lung scintigraphy to continue to play an important clinical and research role in the diagnosis of acute PE.
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Affiliation(s)
- Pierre-Yves Le Roux
- Service de Médecine Nucléaire, CHU Brest, INSERM UMR 1304 (GETBO), Université de Bretagne Occidentale, Brest, France
| | - Romain Le Pennec
- Service de Médecine Nucléaire, CHU Brest, INSERM UMR 1304 (GETBO), Université de Bretagne Occidentale, Brest, France
| | - Pierre-Yves Salaun
- Service de Médecine Nucléaire, CHU Brest, INSERM UMR 1304 (GETBO), Université de Bretagne Occidentale, Brest, France
| | - Lionel S Zuckier
- Division of Nuclear Medicine, Department of Radiology, 1695A Eastchester Road, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY.
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Le Roux PY, Schafer WM, Blanc-Beguin F, Tulchinsky M. Ventilation Scintigraphy With Radiolabeled Carbon Nanoparticulate Aerosol (Technegas): State-of-the-Art Review and Diagnostic Applications to Pulmonary Embolism During COVID-19 Pandemic. Clin Nucl Med 2023; 48:8-17. [PMID: 36288606 PMCID: PMC9762616 DOI: 10.1097/rlu.0000000000004426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/01/2022] [Indexed: 12/14/2022]
Abstract
ABSTRACT Invented and first approved for clinical use in Australia 36 years ago, Technegas is the technology that enabled ventilation scintigraphy with 99m Tc-labeled carbon nanoparticles ( 99m Tc-CNP). The US Food and Drug Administration (FDA) has considered this technology for more than 30 years but only now is getting close to approving it. Meanwhile, more than 4.4 million patients benefited from this technology in 64 countries worldwide. The primary application of 99m Tc-CNP ventilation imaging is the diagnostic evaluation for suspicion of pulmonary embolism using ventilation-perfusion quotient (V/Q) imaging. Because of 99m Tc-CNP's long pulmonary residence, tomographic imaging emerged as the preferred V/Q methodology. The FDA-approved ventilation imaging agents are primarily suitable for planar imaging, which is less sensitive. After the FDA approval of Technegas, the US practice will likely shift to tomographic V/Q. The 99m Tc-CNP use is of particular interest in the COVID-19 pandemic because it offers an option of a dry radioaerosol that takes approximately only 3 to 5 tidal breaths, allowing the shortest exposure to and contact with possibly infected patients. Indeed, countries where 99m Tc-CNP was approved for clinical use continued using it throughout the COVID-19 pandemic without known negative viral transmission consequences. Conversely, the ventilation imaging was halted in most US facilities from the beginning of the pandemic. This review is intended to familiarize the US clinical nuclear medicine community with the basic science of 99m Tc-CNP ventilation imaging and its clinical applications, including common artifacts and interpretation criteria for tomographic V/Q imaging for pulmonary embolism.
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Affiliation(s)
- Pierre-Yves Le Roux
- From the INSERM (National Institute of Health and Medical Research) and Department of Nuclear Medicine, University Hospital of Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Wolfgang M. Schafer
- Nuclear Medicine Clinic, Maria Hilf Hospital Inc, Academic Teaching Hospital of RWTH Aachen University, Moenchengladbach, Germany
| | - Frédérique Blanc-Beguin
- From the INSERM (National Institute of Health and Medical Research) and Department of Nuclear Medicine, University Hospital of Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Mark Tulchinsky
- Section of Nuclear Medicine, Department of Radiology, Penn State University Hospital, Hershey, PA
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Le Pennec R, Tromeur C, Orione C, Robin P, Le Mao R, Gut-Gobert C, Le Gal G, Salaün PY, Le Roux PY. Quantification of the pulmonary vascular obstruction index on ventilation/perfusion lung scintigraphy: Comparison of a segmental visual scoring to the Meyer score. Front Med (Lausanne) 2022; 9:970808. [DOI: 10.3389/fmed.2022.970808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionQuantifying the pulmonary vascular obstruction index (PVOI) is essential for the management of patients with pulmonary embolism or chronic thromboembolic pulmonary hypertension (CTEPH). The reference method for quantifying the PVOI with planar lung ventilation/perfusion (V/Q) scintigraphy is the Meyer score, which was validated using pulmonary angiography as a reference standard. However, it is complex to use in daily practice. In contrast, a rapid and fast quantification method consists in estimating the PVOI based on the number of segmental perfusion defects. However, the accuracy of this method has never been evaluated. In this study, we aimed to compare PVOI quantification on planar V/Q scintigraphy assessed by a segmental visual scoring (SVS) to the Meyer score.Materials and methodsThe eligible study population consisted of consecutive patients who underwent planar V/Q scan for CTEPH screening. A central review was performed by three nuclear medicine physicians. PVOI was assessed by summing the number of segmental perfusion defects or equivalent (2 sub-segments = 1 segment = 5%) and by Meyer’s method. The two interpretations were performed 6 months apart. A Spearman rank correlation coefficient was calculated to evaluate correlation between the two measurement methods. An intra-class correlation (ICC) was calculated to assess agreement. A Bland et Altman plot analysis was used to evaluate agreement between the two measurements.ResultsA total of 226 V/Q scans were interpreted. Spearman rank correlation coefficient between SVS and Meyer was 0.963 (95%CI 0.952–0.971) for mismatched perfusion defects and 0.963 (95%CI 0.953–0.972) for perfusion defects regardless of ventilation. Intra-class correlation (ICC) for agreement was 0.978 (95%CI 0.972–0.983) for mismatched perfusion defects and 0.968 (95%CI 0.959–0.976) for perfusion defects regardless of ventilation. In Bland & Altmann analysis, the mean difference between the SVS method and the Meyer score was 0.42 and 0.61 for the mismatched or matched evaluation, respectively.ConclusionOur study shows a high correlation, and low differences in PVOI quantification when using a segmental visual scoring (SVS) as compared to the Meyer score. The SVS has the great advantage to be easy and rapid to apply in daily practice.
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Le Pennec R, Tromeur C, Orione C, Robin P, Le Mao R, De Moreuil C, Jevnikar M, Hoffman C, Savale L, Couturaud F, Sitbon O, Montani D, Jaïs X, Le Gal G, Salaün PY, Humbert M, Le Roux PY. Lung Ventilation/Perfusion Scintigraphy for the Screening of Chronic Thromboembolic Pulmonary Hypertension (CTEPH): Which Criteria to Use? Front Med (Lausanne) 2022; 9:851935. [PMID: 35321469 PMCID: PMC8936142 DOI: 10.3389/fmed.2022.851935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/31/2022] [Indexed: 12/03/2022] Open
Abstract
Objective The diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) is a major challenge as it is a curable cause of pulmonary hypertension (PH). Ventilation/Perfusion (V/Q) lung scintigraphy is the imaging modality of choice for the screening of CTEPH. However, there is no consensus on the criteria to use for interpretation. The aim of this study was to assess the accuracy of various interpretation criteria of planar V/Q scintigraphy for the screening of CTEPH in patients with PH. Methods The eligible study population consisted of consecutive patients with newly diagnosed PH in the Brest University Hospital, France. Final diagnosis (CTEPH or non-CTEPH) was established in a referential center on the management of PH, based on the ESC/ERS guidelines and a minimum follow-up of 3 years. A retrospective central review of planar V/Q scintigraphy was performed by three nuclear physicians blinded to clinical findings and to final diagnosis. The number, extent (sub-segmental or segmental) and type (matched or mismatched) of perfusion defects were reported. Sensitivity and specificity were evaluated for various criteria based on the number of mismatched perfusion defects and the number of perfusion defects (regardless of ventilation). Receiver operating characteristic (ROC) curves were generated and areas under the curve (AUC) were calculated for both. Results A total of 226 patients with newly diagnosed PH were analyzed. Fifty six (24.8%) were diagnosed with CTEPH while 170 patients (75.2%) were diagnosed with non-CTEPH. The optimal threshold was 2.5 segmental mismatched perfusion defects, providing a sensitivity of 100 % (95% CI 93.6–100%) and a specificity of 94.7% (95%CI 90.3–97.2%). Lower diagnostic cut-offs of mismatched perfusion defects provided similar sensitivity but lower specificity. Ninety five percent of patients with CTEPH had more than 4 segmental mismatched defects. An interpretation only based on perfusion provided similar sensitivity but a specificity of 81.8% (95%CI 75.3–86.9%). Conclusion Our study confirmed the high diagnostic performance of planar V/Q scintigraphy for the screening of CTEPH in patients with PH. The optimal diagnostic cut-off for interpretation was 2.5 segmental mismatched perfusion defects. An interpretation only based on perfusion defects provided similar sensitivity but lower specificity.
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Affiliation(s)
- Romain Le Pennec
- Service de médecine nucléaire, EA3878 (GETBO) IFR 148, CHRU de Brest, Université de Bretagne Occidentale, Brest, France
- *Correspondence: Romain Le Pennec
| | - Cécile Tromeur
- Département de Médecine Interne et Pneumologie, EA 3878 (GETBO), CHRU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Charles Orione
- Département de Médecine Interne et Pneumologie, EA 3878 (GETBO), CHRU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Philippe Robin
- Service de médecine nucléaire, EA3878 (GETBO) IFR 148, CHRU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Raphaël Le Mao
- Département de Médecine Interne et Pneumologie, EA 3878 (GETBO), CHRU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Claire De Moreuil
- Département de Médecine Interne et Pneumologie, EA 3878 (GETBO), CHRU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Mitja Jevnikar
- AP-HP, Service de Pneumologie, DHU Thorax Innovation, Hôpital Bicêtre, INSERM U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Université Paris-Sud, Paris, France
| | - Clément Hoffman
- Département de Médecine Interne et Pneumologie, EA 3878 (GETBO), CHRU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Laurent Savale
- AP-HP, Service de Pneumologie, DHU Thorax Innovation, Hôpital Bicêtre, INSERM U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Université Paris-Sud, Paris, France
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, EA 3878 (GETBO), CHRU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Olivier Sitbon
- AP-HP, Service de Pneumologie, DHU Thorax Innovation, Hôpital Bicêtre, INSERM U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Université Paris-Sud, Paris, France
| | - David Montani
- AP-HP, Service de Pneumologie, DHU Thorax Innovation, Hôpital Bicêtre, INSERM U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Université Paris-Sud, Paris, France
| | - Xavier Jaïs
- AP-HP, Service de Pneumologie, DHU Thorax Innovation, Hôpital Bicêtre, INSERM U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Université Paris-Sud, Paris, France
| | - Grégoire Le Gal
- Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, Brest, France
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Pierre Yves Salaün
- Service de médecine nucléaire, EA3878 (GETBO) IFR 148, CHRU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Marc Humbert
- AP-HP, Service de Pneumologie, DHU Thorax Innovation, Hôpital Bicêtre, INSERM U999, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Université Paris-Sud, Paris, France
| | - Pierre Yves Le Roux
- Service de médecine nucléaire, EA3878 (GETBO) IFR 148, CHRU de Brest, Université de Bretagne Occidentale, Brest, France
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Dissaux B, Le Floch PY, Le Pennec R, Tromeur C, Le Roux PY. Systemic Artery to Pulmonary Artery Shunt Mimicking Acute Pulmonary Embolism, Unmasked by a Multimodality Imaging Approach. Tomography 2022; 8:175-179. [PMID: 35076610 PMCID: PMC8788444 DOI: 10.3390/tomography8010014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022] Open
Abstract
In this report, we describe the functional imaging findings of systemic artery to pulmonary artery shunt in V/Q SPECT CT imaging. A 63-year-old man with small-cell lung cancer underwent CT pulmonary angiography (CTPA) for suspected acute pulmonary embolism (PE). The CTPA showed an isolated segmental filling defect in the right lower lobe, which was initially interpreted as positive for PE but was actually the consequence of a systemic artery to pulmonary artery shunt due to the recruitment of the bronchial arterial network by the adjacent tumor. A V/Q SPECT/CT scan was also performed, demonstrating a matched perfusion/ventilation defect in the right lower lobe.
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Affiliation(s)
- Brieg Dissaux
- Radiology Department, University Hospital of Brest, 29609 Brest, France;
- Correspondence: (B.D.); (P.-Y.L.R.)
| | | | - Romain Le Pennec
- Nuclear Medicine Department, University Hospital of Brest, 29609 Brest, France;
| | - Cécile Tromeur
- Pneumology Department, University Hospital of Brest, 29609 Brest, France;
| | - Pierre-Yves Le Roux
- Nuclear Medicine Department, University Hospital of Brest, 29609 Brest, France;
- Correspondence: (B.D.); (P.-Y.L.R.)
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Le Roux PY. Lung ventilation/perfusion SPECT/CT imaging of lung cancer. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Le Roux PY, Bonnefoy PB, Bahloul A, Denizot B, Barres B, Moreau-Triby C, Girma A, Pallardy A, Ceyrat Q, Sarda-Mantel L, Razzouk-Cadet M, Zsigmond R, Florent C, Karcher G, Salaun PY. Lung scintigraphy for pulmonary embolism diagnosis in COVID-19 patients: a multicenter study. J Nucl Med 2021; 63:1070-1074. [PMID: 34649944 PMCID: PMC9258571 DOI: 10.2967/jnumed.121.262955] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/29/2021] [Indexed: 11/16/2022] Open
Abstract
In patients with novel coronavirus disease 2019 (COVID-19) referred for lung scintigraphy for suspected pulmonary embolism (PE), there has been an ongoing debate within the nuclear medicine community as to whether and when the ventilation study should be performed. Indeed, while PE diagnosis typically relies on the recognition of ventilation/perfusion (V/P) mismatched defects, the ventilation procedure potentially increases the risk of contamination to the healthcare workers. The primary aim of this study was to assess the role of ventilation imaging when performing lung scintigraphy for suspected PE in COVID-19 patients. The secondary aim was to describe practices and imaging findings in this specific population. Methods: A national registry was created in collaboration with the French Society of Nuclear Medicine to collect lung scans performed in COVID-19 patients for suspected PE. Practices of departments were assessed regarding imaging protocols and aerosol precautions. A retrospective review of V/P SPECT/CT scans was then conducted. Two physicians blinded to clinical information reviewed each case by sequentially using P SPECT, P SPECT/CT and V/P SPECT/CT images. Scans were classified in one of the four following categories: patients for whom PE could reasonably be excluded based on 1) perfusion SPECT only, 2) P SPECT/CT, 3) V/P SPECT/CT; or 4) patients with mismatched defects suggestive of PE according to the EANM criteria. Results: Data from 12 French nuclear medicine departments were collected. Lung scans were performed between 03/2020 and 04/2021. Personal protective equipment and dedicated cleaning procedures were used in all departments. Out of the 145 V/Q SPECT/CT included in the central review, PE could be excluded using only P SPECT, P SPECT/CT and V/P SPECT/CT in 27 (19%), 55 (38%) and 45 (31%) patients, respectively. V/P SPECT/CT was positive for PE in 18 (12%) patients, including 12 (67%) with a low burden of PE (≤10%). Conclusion: In this population of COVID-19 patients assessed with lung scintigraphy, PE could be confidently excluded without ventilation in only 57% of patients. Ventilation imaging was required to confidently rule out PE in 31% of patients. Overall, the prevalence of PE was low (12%).
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Affiliation(s)
| | | | | | - Benoit Denizot
- Centre Hospitalier Alpes Léman, Service de Médecine Nucléaire
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Evbuomwan O, Engelbrecht G, Bergman MV, Mokwena S, Ayeni OA. Lung perfusion findings on perfusion SPECT/CT imaging in non-hospitalized de-isolated patients diagnosed with mild COVID-19 infection. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [PMCID: PMC8188766 DOI: 10.1186/s43055-021-00521-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Abstract
Background
The aim of this retrospective study is to assess the incidence and type of lung perfusion abnormalities in non-hospitalized patients diagnosed with mild COVID-19 infection after de-isolation. Data from 56 non-hospitalized patients diagnosed with COVID-19 infection referred to our nuclear medicine department from July–December 2020 for a perfusion only SPECT/CT study or a ventilation perfusion SPECT/CT study were collected. Images were assessed for the presence and type of perfusion defects. The CT component of the study was also assessed for the presence of mosaic attenuation and COVID pneumonia changes.
Results
Thirty-two (57.1%) cases had perfusion defects. There were 20 (35.7%) cases with defects in keeping with pulmonary embolism, 17 (30.4%) cases with defects associated with mosaic attenuation but not due to pulmonary embolism, and 6 (10.7%) of cases with defects due to pulmonary infiltrates from COVID pneumonia. A total of 24 (42.9%) cases had mosaic attenuation on CT, with 10 (17.9%) of them showing a pattern likely consistent with shunting on the perfusion images.
Conclusion
Lung perfusion abnormalities are a common finding in non-hospitalized COVID-19 patients with mild disease. They are usually either due to pulmonary embolism, parenchymal infiltrates, or other causes of mosaic attenuation related to, but not specific to the pathophysiology of COVID-19 infection. The value of VQ SPECT/CT imaging is also shown in this study, in detecting and differentiating the various types of perfusion abnormalities.
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Le Pennec R, Iravani A, Woon B, Dissaux B, Gest B, Le Floch PY, Salaün PY, Le Gal G, Hofman MS, Hicks RJ, Le Roux PY. Gallium-68 Ventilation/Perfusion PET-CT and CT Pulmonary Angiography for Pulmonary Embolism Diagnosis: An Interobserver Agreement Study. Front Med (Lausanne) 2021; 7:599901. [PMID: 33665194 PMCID: PMC7921798 DOI: 10.3389/fmed.2020.599901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/06/2020] [Indexed: 11/22/2022] Open
Abstract
Objectives:68Ga Ventilation/Perfusion V/Q PET-CT is a promising imaging tool for pulmonary embolism diagnosis. However, no study has verified whether the interpretation is reproducible between different observers. The aim of this study was to assess the interobserver agreement in the interpretation of V/Q PET-CT for the diagnosis of acute PE, and to compare it to the interobserver agreement of CTPA interpretation. Methods: Twenty-four cancer patients with suspected acute PE underwent V/Q PET-CT and CTPA within 24 h as part of a prospective pilot study evaluating V/Q PET-CT for the management of patients with suspected PE. V/Q PET-CT and CTPA scans were reassessed independently by four nuclear medicine physicians and four radiologists, respectively. Physicians had different levels of expertise in reading V/Q scintigraphy and CTPA. Interpretation was blinded to the initial interpretation and any clinical information or imaging test result. For each modality, results were reported on a binary fashion. V/Q PET/CT scans were read as positive if there was at least one segmental or two subsegmental mismatched perfusion defects. CTPA scans were interpreted as positive if there was a constant intraluminal filling defect. Interobserver agreement was assessed by calculating kappa (κ) coefficients. Results: Out of the 24 V/Q PET-CT scans, the diagnostic conclusion was concordantly negative in 22 patients and concordantly positive in one patient. The remaining scan was interpreted as positive by one reader and negative by three readers. Out of the 24 CTPA scans, the diagnostic conclusion was concordantly negative in 16 and concordantly positive in one. Out of the seven remaining scans, PE was reported by one reader in four cases, by two readers in two cases, by three readers in one case. Most of discordant results on CTPA were related to clots reported on subsegmental arteries. Mean kappa coefficient was 0.79 for V/Q PET-CT interpretation and 0.39 for CTPA interpretation. Conclusions: Interobserver agreement in the interpretation of V/Q PET-CT for PE diagnosis was substantial (kappa 0.79) in a population with a low prevalence of significant PE. Agreement was lower with CTPA, mainly as a result of discrepancies at the level of the subsegmental arteries.
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Affiliation(s)
- Romain Le Pennec
- Nuclear Medicine, Brest University Hospital, EA3878 (GETBO) IFR 148, Brest, France
| | - Amir Iravani
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Beverley Woon
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Brieg Dissaux
- Radiology, Brest University Hospital, EA3878 (GETBO) IFR 148, Brest, France
| | - Bibiche Gest
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | - Pierre-Yves Salaün
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Michael S Hofman
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Rodney J Hicks
- Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Pierre-Yves Le Roux
- Nuclear Medicine, Brest University Hospital, EA3878 (GETBO) IFR 148, Brest, France.,Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Le Roux PY, Le Gal G, Salaun PY. Lung scintigraphy for pulmonary embolism diagnosis during the COVID-19 pandemic: does the benefit-risk ratio really justify omitting the ventilation study? Eur J Nucl Med Mol Imaging 2020; 47:2499-2500. [PMID: 32700057 PMCID: PMC7375202 DOI: 10.1007/s00259-020-04964-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Pierre-Yves Le Roux
- Service de médecine nucléaire, CHRU de Brest, EA3878 (GETBO), Université de Brest, CHRU Morvan, Médecine nucléaire, 2 avenue Foch, 29609, Brest Cedex, France.
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Pierre-Yves Salaun
- Service de médecine nucléaire, CHRU de Brest, EA3878 (GETBO), Université de Brest, CHRU Morvan, Médecine nucléaire, 2 avenue Foch, 29609, Brest Cedex, France
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Abstract
Venous thromboembolism is a common disease which remains underdiagnosed because of nonspecific presentations which can range from asymptomatic incidental imaging findings to sudden death. Symptoms can overlap with comorbid cardiopulmonary disease, and risk factors that offer clues to the clinician are not always present. The diagnostic approach can vary depending on the specific clinical presentation, but ruling in the diagnosis nearly always depends on lung imaging. Overuse of diagnostic testing is another recognized problem; a cautious, evidence-based approach is required, although physician gestalt must be acknowledged. The following review offers an approach to the diagnosis of acute pulmonary embolism based on the assessment of symptoms, signs, risk factors, laboratory findings, and imaging studies.
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Affiliation(s)
- Ella Ishaaya
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
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Holstensson M, Smedby Ö, Poludniowski G, Sanchez-Crespo A, Savitcheva I, Öberg M, Grybäck P, Gabrielson S, Sandqvist P, Bartholdson E, Axelsson R. Comparison of acquisition protocols for ventilation/perfusion SPECT-a Monte Carlo study. Phys Med Biol 2019; 64:235018. [PMID: 31362272 DOI: 10.1088/1361-6560/ab36ee] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
One of the most commonly used imaging techniques for diagnosing pulmonary embolism (PE) is ventilation/perfusion (V/P) scintigraphy. The aim of this study was to evaluate the performance of the currently used imaging protocols for V/P single photon emission computed tomography (V/P SPECT) at two nuclear medicine department sites and to investigate the effect of altering important protocol parameters. The Monte Carlo technique was used to simulate 4D digital phantoms with perfusion defects. Six imaging protocols were included in the study and a total of 72 digital patients were simulated. Six dually trained radiologists/nuclear medicine physicians reviewed the images and reported all perfusion mismatch findings. The radiologists also visually graded the image quality. No statistically significant differences in diagnostic performance were found between the studied protocols, but visual grading analysis pointed out one protocol as significantly superior to four of the other protocols. Considering the study results, we have decided to harmonize our clinical protocols for imaging patients with suspected PE. The administered Technegas and macro aggregated albumin activities have been altered, a low energy all purpose collimator is used instead of a low energy high resolution collimator and the acquisition times have been lowered.
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Affiliation(s)
- Maria Holstensson
- Medical Radiation Physics and Nuclear Medicine, Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden. Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Functional Imaging and Technology, Karolinska Institutet, Stockholm, Sweden. Author to whom any corrrespondence should be addressed
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Bajc M, Schümichen C, Grüning T, Lindqvist A, Le Roux PY, Alatri A, Bauer RW, Dilic M, Neilly B, Verberne HJ, Delgado Bolton RC, Jonson B. EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond. Eur J Nucl Med Mol Imaging 2019; 46:2429-2451. [PMID: 31410539 PMCID: PMC6813289 DOI: 10.1007/s00259-019-04450-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/17/2019] [Indexed: 12/18/2022]
Abstract
These guidelines update the previous EANM 2009 guidelines on the diagnosis of pulmonary embolism (PE). Relevant new aspects are related to (a) quantification of PE and other ventilation/perfusion defects; (b) follow-up of patients with PE; (c) chronic PE; and (d) description of additional pulmonary physiological changes leading to diagnoses of left ventricular heart failure (HF), chronic obstructive pulmonary disease (COPD) and pneumonia. The diagnosis of PE should be reported when a mismatch of one segment or two subsegments is found. For ventilation, Technegas or krypton gas is preferred over diethylene triamine pentaacetic acid (DTPA) in patients with COPD. Tomographic imaging with V/PSPECT has higher sensitivity and specificity for PE compared with planar imaging. Absence of contraindications makes V/PSPECT an essential method for the diagnosis of PE. When V/PSPECT is combined with a low-dose CT, the specificity of the test can be further improved, especially in patients with other lung diseases. Pitfalls in V/PSPECT interpretation are discussed. In conclusion, V/PSPECT is strongly recommended as it accurately establishes the diagnosis of PE even in the presence of diseases like COPD, HF and pneumonia and has no contraindications.
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Affiliation(s)
- Marika Bajc
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden.
| | - Carl Schümichen
- University of Rostock, Formerly Clinic for Nuclear Medicine, Rostock, Germany
| | - Thomas Grüning
- Department of Nuclear Medicine, University Hospitals Plymouth, Plymouth, UK
| | - Ari Lindqvist
- Research Unit of Pulmonary Diseases, Clinical Research Institute, HUS Helsinki University Hospital, Helsinki, Finland
| | | | - Adriano Alatri
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Ralf W Bauer
- RNS Gemeinschaftspraxis, Wiesbaden, Germany
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt (Main), Frankfurt, Germany
| | - Mirza Dilic
- Clinic of Heart and Blood Vessel Disease, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Brian Neilly
- Department of Nuclear Medicine, Royal Infirmary, Glasgow, UK
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roberto C Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - Bjorn Jonson
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden
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Liu J, Larcos G. Radionuclide lung scans for suspected acute pulmonary embolism: Single photon emission computed tomography (SPECT) or hybrid SPECT/CT? J Med Imaging Radiat Oncol 2019; 63:731-736. [PMID: 31515905 DOI: 10.1111/1754-9485.12951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 07/29/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Hybrid single photon emission computed tomography (SPECT) with CT (SPECT/CT) may improve diagnostic accuracy in suspected acute pulmonary embolism, but further research is needed. We evaluated whether the use of attenuation correction and/or the depiction of lung pathology with hybrid SPECT/CT could significantly reduce potentially false-positive ventilation-perfusion (VQ) SPECT studies or obviate the need for a ventilation study. METHODS Two specialists (S1 and S2) reviewed prospectively acquired VQ SPECT/CT in 165 patients. Studies were reported using standard criteria and compared to VQ SPECT and Q SPECT/CT. RESULTS S1 and S2 recorded positive VQ SPECT in 54 (32.7%) and 42 (25.6%) cases, respectively. Hybrid SPECT/CT showed non-embolic pathology in 41 (S1) and 46 (S2) patients, but compared to VQ SPECT, neither hybrid SPECT/CT nor attenuation correction SPECT/CT had significantly fewer positive studies. Intra-observer agreement with VQ SPECT/CT was almost perfect (k = 0.91 for S1 and k = 0.95 for S2; P < 0.001), but not with Q SPECT/CT (k = 0.4 for S1 and k = 0.62 for S2; P < 0.001). Inter-observer agreement was moderate for VQ SPECT (k = 0.65) and VQ SPECT/CT (k = 0.63). CONCLUSION In our study, hybrid VQ SPECT/CT did not reduce the number of potentially false-positive VQ SPECT, nor did the CT obviate the need for a ventilation study. Thus, the routine use of hybrid SPECT/CT for suspected pulmonary embolism is not justified.
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Affiliation(s)
- Jui Liu
- Department of Nuclear Medicine and Ultrasound, Westmead Hospital, Sydney, New South Wales, Australia
| | - George Larcos
- Department of Nuclear Medicine and Ultrasound, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Le Roux PY, Iravani A, Callahan J, Burbury K, Eu P, Steinfort DP, Lau E, Woon B, Salaun PY, Hicks RJ, Hofman MS. Independent and incremental value of ventilation/perfusion PET/CT and CT pulmonary angiography for pulmonary embolism diagnosis: results of the PECAN pilot study. Eur J Nucl Med Mol Imaging 2019; 46:1596-1604. [PMID: 31044265 DOI: 10.1007/s00259-019-04338-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/15/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE This pilot study assessed the independent and incremental value of 68Ga-V/Q PET/CT as compared with CT pulmonary angiography (CTPA) for the management of cancer patients with suspected acute pulmonary embolism (PE). METHODS All 24 cancer patients with suspected acute PE prospectively recruited underwent both 68Ga-V/Q PET/CT and CTPA within 24 h. PET/CT was acquired after inhalation of Galligas prepared using a Technegas generator and administration of 68Ga-macroaggregated albumin. Initially, PET/CT and CTPA scans were read independently with the reader blinded to the results of the other imaging study. CTPA and PET/CT were then coregistered and reviewed by consensus between a radiologist and nuclear medicine physician. The therapeutic management was established by the managing physician based on all available data. RESULTS The diagnostic conclusion was concordantly negative in 18 patients (75%). Of the six discordant diagnoses on independent reading, combined interpretation of V/Q PET/CTPA enabled a consensus conclusion in two patients, excluding PE in one and confirming PE in the other, similar to the initial diagnostic conclusion of the V/Q PET/CT. Of the remaining four patients, three had a single subsegmental thrombus on CTPA but a negative V/Q PET/CT scan, and two of these did not receive long-term anticoagulation and did not have a venous thromboembolic event during a 3-year follow-up period. The third patient, along with a patient with a positive V/Q PET/CT scan but a negative CTPA scan, presented with acute complications preventing any conclusions with regard to the appropriateness of the V/Q PET/CT results in the management of PE. Overall, V/Q PET had an impact on management in four patients (17%). CONCLUSION In this pilot study, we demonstrated the feasibility and potential utility of V/Q PET/CT for the management of patients with suspected PE. V/Q PET/CT may be of particular relevance in patients with equivocal findings or isolated subsegmental findings on CTPA, adding further discriminatory information to allow important decision-making regarding the use or withholding of anticoagulation. Given the other advantages of V/Q PET/CT (reduced acquisition time, low radiation dose), and with the increasing availability of 68Ga generators, PET/CT is a potential replacement for V/Q SPECT/CT imaging.
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Affiliation(s)
- Pierre-Yves Le Roux
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia. .,Nuclear Medicine, Brest University Hospital, EA3878 (GETBO) IFR 148, Brest, France.
| | - Amir Iravani
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Jason Callahan
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Kate Burbury
- Department of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Peter Eu
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Daniel P Steinfort
- Respiratory Medicine, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
| | - Eddie Lau
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Beverly Woon
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Pierre-Yves Salaun
- Nuclear Medicine, Brest University Hospital, EA3878 (GETBO) IFR 148, Brest, France
| | - Rodney J Hicks
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Michael S Hofman
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
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Bajc M, Lindqvist A. Ventilation/Perfusion SPECT Imaging—Diagnosing Other Cardiopulmonary Diseases Beyond Pulmonary Embolism. Semin Nucl Med 2019; 49:4-10. [DOI: 10.1053/j.semnuclmed.2018.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Le Roux PY, Hicks RJ, Siva S, Hofman MS. PET/CT Lung Ventilation and Perfusion Scanning using Galligas and Gallium-68-MAA. Semin Nucl Med 2019; 49:71-81. [DOI: 10.1053/j.semnuclmed.2018.10.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Le Gal G, Le Roux PY. How to Assess Quality of Primary Research Studies in the Medical Literature? Semin Nucl Med 2018; 49:115-120. [PMID: 30819391 DOI: 10.1053/j.semnuclmed.2018.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Accuracy studies are the cornerstone of the evaluation of new diagnostic tests. In an accuracy study, patients with a clinical suspicion of disease undergo both the new tests that is being evaluated, and the reference test or "gold-standard" test for the disease. Patients are stratified according to the test result and to whether or not the diagnosis was confirmed by the reference test. Main accuracy indices include the sensitivity (proportion of patients who test positive among those who have the disease), specificity (proportion of patients who test negative among those without the disease), as well as the positive and negative predictive values (proportion of patients with the disease among those with a positive test, and of patients without the disease among those with a negative test, respectively). In appraising an accuracy study, the reader should check that the study design and analysis follow methodological standards. The study population should be representative of the population in which the test will be used in practice. The new test should be interpreted in a blinded and independent fashion from the reference standard to avoid expectation bias, and should not be used to establish the diagnosis (incorporation bias). The reproducibility should be verified. Interpretation criteria and technical aspects should be described with enough details to allow replication. Provided that these conditions are met, the next step is to decide whether the test may be used for patient care. The clinical setting in which the test will be used, and the corresponding pretest probability of disease, will determine how best can the test be used in practice.
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Affiliation(s)
- Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada.
| | - Pierre-Yves Le Roux
- Service de Médecine Nucléaire, Centre Hospitalier Régional et Universitaire, EA 3878 GETBO, Université de Brest, Brest, France
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Koukouraki SI, Hatzidakis AA, Mitrouska I, Stathaki MI, Perisinakis K. Does lung perfusion scintigraphy continue to have a role in the clinical management of patients suspected of pulmonary embolism in the CT pulmonary angiography era? Ann Nucl Med 2018; 32:709-714. [DOI: 10.1007/s12149-018-1295-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/30/2018] [Indexed: 11/24/2022]
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Le Roux PY, Robin P, Salaun PY. New developments and future challenges of nuclear medicine and molecular imaging for pulmonary embolism. Thromb Res 2017; 163:236-241. [PMID: 28673474 DOI: 10.1016/j.thromres.2017.06.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/20/2017] [Accepted: 06/25/2017] [Indexed: 11/29/2022]
Abstract
Although widely validated, current tests for pulmonary embolism (PE) diagnosis, i.e. computed tomography pulmonary angiography (CTPA) and V/Q planar scintigraphy, have some limitations. Drawbacks of CTPA include the radiation dose, some contra indications and a rising concern about a possible overdiagnosis/overtreatment of PE. On the other hand, V/Q planar scintigraphy has a high rate of non-diagnostic tests responsible for complex diagnostic algorithms. Since the PIOPED study, imaging equipment and radiopharmaceuticals have greatly evolved allowing the introduction of techniques that improve imaging of lung ventilation and perfusion. Single photon emission computed tomography (SPECT) and SPECT/CT techniques are already largely used in daily practice and have been described to have greater diagnostic performance and much fewer non-diagnostic tests as compared with planar scintigraphy. However, they have not yet been firmly validated in large scale prospective outcome studies. More recently, it has also been proposed to image pulmonary perfusion and ventilation using positron emission tomography (PET), which has an inherent technical superiority as compared to conventional scintigraphy and may provide new insight for pulmonary embolism. Regardless of modality, these new thoracic imaging modalities have to be integrated into diagnostic strategies. The other major challenge for venous thromboembolism diagnosis may be the potential additional value of molecular imaging allowing specific targeting of thrombi in order, for example, to differentiate venous thromboembolism from tumor or septic thrombus, or acute from residual disease. In this article, the new imaging procedures of lung ventilation perfusion imaging with SPECT, SPECT/CT and PET/CT are discussed. We also review the current status and future challenge of molecular imaging for the in vivo characterization of venous thromboembolism.
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Affiliation(s)
- Pierre-Yves Le Roux
- Université Européenne de Bretagne, Université de Brest, EA3878 (GETBO) IFR 148, CHRU de Brest, Service de Médecine Nucléaire, Brest, France.
| | - Philippe Robin
- Université Européenne de Bretagne, Université de Brest, EA3878 (GETBO) IFR 148, CHRU de Brest, Service de Médecine Nucléaire, Brest, France
| | - Pierre-Yves Salaun
- Université Européenne de Bretagne, Université de Brest, EA3878 (GETBO) IFR 148, CHRU de Brest, Service de Médecine Nucléaire, Brest, France
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Ibáñez-Bravo S, Banzo I, Quirce R, Martínez-Rodríguez I, Jiménez-Bonilla J, Martínez-Amador N, Parra J, González-Macías J, Carril J. Ventilation/Perfusion SPECT lung scintigraphy and computed tomography pulmonary angiography in patients with clinical suspicion of pulmonary embolism. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.remnie.2015.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Robert-Ebadi H, Le Gal G, Righini M. Evolving imaging techniques in diagnostic strategies of pulmonary embolism. Expert Rev Cardiovasc Ther 2016; 14:495-503. [DOI: 10.1586/14779072.2016.1134316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ibáñez-Bravo S, Banzo I, Quirce R, Martínez-Rodríguez I, Jiménez-Bonilla J, Martínez-Amador N, Parra JA, González-Macías J, Carril JM. Ventilation/Perfusion SPECT lung scintigraphy and computed tomography pulmonary angiography in patients with clinical suspicion of pulmonary embolism. Rev Esp Med Nucl Imagen Mol 2016; 35:215-20. [PMID: 26838481 DOI: 10.1016/j.remn.2015.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/18/2015] [Accepted: 12/23/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED The aim was to compare ventilation/perfusion SPECT lung scintigraphy (V/Q-SPECT) and computed tomography pulmonary angiography (CTPA) in patients with suspicion of pulmonary embolism (PE). MATERIAL AND METHODS This prospectively designed study included 53 patients with intermediate or high clinical probability of PE. A V/Q-SPECT and CTPA was performed on all patients. The V/Q-SPECT was interpreted according to the European Association of Nuclear Medicine and Molecular Imaging (EANMMI) guidelines. CTPA was reported as positive, negative, or indeterminate. RESULTS CTPA was positive in 22 cases, negative in 28, and indeterminate in 3. V/Q-SPECT was positive in 27 cases, negative in 24, and non-diagnostic in 2. In the 22 with positive CTPA, V/Q-SPECT was positive in 18, negative in 3, and non-diagnostic in 1. In the 28 with negative CTPA, V/Q-SPECT was positive in 8, negative in 19, and non-diagnostic in 1. In the 3 with indeterminate CTPA, V/Q-SPECT was positive in 1 and negative in 2. In the 2 non-diagnostic cases V/Q-SPECT, CTPA was positive in 1 and negative in one. In the 10 high clinical probabilities, CTPA and V/Q-SPECT were positive in 7, negative in 2, and in 1, CTPA was positive and V/Q-SPECT negative. In the 38 intermediate probability group, CTPA and V/Q-SPECT were positive in 11, negative in 17, with CTPA negative and V/Q-SPECT positive in 8, and in 2 CTPA was positive and V/Q-SPECT negative. The results show that V/Q-SPECT detected PE in 5 patients more than CTPA. CONCLUSION Our results show a 77% concordance of both techniques. Overall V/Q-SPECT detected PE in 18% more patients than CTPA in the intermediate group. Both techniques have a complementary role when a diagnosis cannot be made with one of them.
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Affiliation(s)
- S Ibáñez-Bravo
- Nuclear Medicine Department, University Hospital "Marqués de Valdecilla", Cantabria University, Molecular Imaging Group IDIVAL, Santander, Spain.
| | - I Banzo
- Nuclear Medicine Department, University Hospital "Marqués de Valdecilla", Cantabria University, Molecular Imaging Group IDIVAL, Santander, Spain
| | - R Quirce
- Nuclear Medicine Department, University Hospital "Marqués de Valdecilla", Cantabria University, Molecular Imaging Group IDIVAL, Santander, Spain
| | - I Martínez-Rodríguez
- Nuclear Medicine Department, University Hospital "Marqués de Valdecilla", Cantabria University, Molecular Imaging Group IDIVAL, Santander, Spain
| | - J Jiménez-Bonilla
- Nuclear Medicine Department, University Hospital "Marqués de Valdecilla", Cantabria University, Molecular Imaging Group IDIVAL, Santander, Spain
| | - N Martínez-Amador
- Nuclear Medicine Department, University Hospital "Marqués de Valdecilla", Cantabria University, Molecular Imaging Group IDIVAL, Santander, Spain
| | - J A Parra
- Radiology Department, University Hospital "Marqués de Valdecilla", Cantabria University, Santander, Spain
| | - J González-Macías
- Internal Medicine Department, University Hospital "Marqués de Valdecilla", Cantabria University, Santander, Spain
| | - J M Carril
- Nuclear Medicine Department, University Hospital "Marqués de Valdecilla", Cantabria University, Molecular Imaging Group IDIVAL, Santander, Spain
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Le Roux PY, Pelletier-Galarneau M, De Laroche R, Hofman MS, Zuckier LS, Roach P, Vuillez JP, Hicks RJ, Le Gal G, Salaun PY. Pulmonary Scintigraphy for the Diagnosis of Acute Pulmonary Embolism: A Survey of Current Practices in Australia, Canada, and France. J Nucl Med 2015; 56:1212-7. [PMID: 26135110 DOI: 10.2967/jnumed.115.157743] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 06/18/2015] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED There are currently no data published regarding the proportion of nuclear medicine centers using SPECT or SPECT/CT rather than planar ventilation/perfusion (V/Q) imaging in patients with suspected acute pulmonary embolism (PE). Furthermore, the reporting criteria used for interpretation of both planar and SPECT V/Q scans are variable and data are lacking regarding which criteria are commonly used in various centers. The aim of this study was to assess current practices regarding the performance and interpretation of lung scintigraphy across 3 different countries. METHODS A short online survey composed of simple multiple-choice questions was distributed to nuclear medicine departments in Australia, Canada, and France during the period April to December 2014. The survey covered image acquisition, interpretation criteria for SPECT and planar images, and use of pseudoplanar images and radiopharmaceuticals. Information was initially solicited by 2 sets of e-mails, which pointed to the survey internet link. Departments were subsequently contacted by telephone. A single response per department was consolidated. RESULTS Three hundred thirty-one responses were collected (Australia, 74; Canada, 48; and France, 209). Twenty-eight percent of centers indicated use of V/Q planar imaging alone whereas 72% of centers included some form of SPECT in their acquisition protocol for evaluation of PE, specifically V/Q SPECT in 36%, V/Q SPECT/CT in 29%, Q SPECT/CT in 2%, and both V/Q planar and SPECT in 5%, with a strong variability among countries. The most commonly used criteria for SPECT interpretation were the those of the European Association of Nuclear Medicine (60%). Criteria used for planar interpretation were heterogeneous (European Association of Nuclear Medicine criteria, 35%; Prospective Investigation of Pulmonary Embolism Diagnosis study, 29%; no standardized criteria, 21%). Sixty-three percent of departments used pseudoplanar images in addition to SPECT images. CONCLUSION In the 3 countries surveyed, SPECT has largely replaced planar imaging for evaluation of PE, with almost half of the SPECT studies incorporating a CT acquisition. Criteria used for interpretation are inconsistent, especially for planar imaging.
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Affiliation(s)
- Pierre-Yves Le Roux
- Université Européenne de Bretagne, Université de Brest, EA3878 (GETBO) IFR 148, CHRU de Brest, Service de Médecine Nucléaire, Brest, France Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Romain De Laroche
- Université Européenne de Bretagne, Université de Brest, EA3878 (GETBO) IFR 148, CHRU de Brest, Service de Médecine Nucléaire, Brest, France
| | - Michael S Hofman
- Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Paul Roach
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | | | - Rodney J Hicks
- Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Grégoire Le Gal
- The Ottawa Hospital, University of Ottawa, Ottawa, Canada Université Européenne de Bretagne, Université de Brest, INSERM CIC 05-02 IFR148, CHRU de Brest, Département de Médecine Interne et de Pneumologie, Brest, France
| | - Pierre-Yves Salaun
- Université Européenne de Bretagne, Université de Brest, EA3878 (GETBO) IFR 148, CHRU de Brest, Service de Médecine Nucléaire, Brest, France
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Value of ventilation/perfusion SPECT for diagnosis of pulmonary embolism: response to comments by Sinzinger et al. Eur J Nucl Med Mol Imaging 2015; 42:979-80. [DOI: 10.1007/s00259-015-3014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Safety of ventilation/perfusion single photon emission computed tomography for pulmonary embolism diagnosis. Eur J Nucl Med Mol Imaging 2014; 41:1957-64. [PMID: 24719158 DOI: 10.1007/s00259-014-2763-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 03/17/2014] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this management outcome study was to assess the safety of ventilation/perfusion single photon emission computed tomography (V/Q SPECT) for the diagnosis of pulmonary embolism (PE) using for interpretation the criteria proposed in the European Association of Nuclear Medicine (EANM) guidelines for V/Q scintigraphy. METHODS A total of 393 patients with clinically suspected PE referred to the Nuclear Medicine Department of Brest University Hospital from April 2011 to March 2013, with either a high clinical probability or a low or intermediate clinical probability but positive D-dimer, were retrospectively analysed. V/Q SPECT were interpreted by the attending nuclear medicine physician using a diagnostic cut-off of one segmental or two subsegmental mismatches. The final diagnostic conclusion was established by the physician responsible for patient care, based on clinical symptoms, laboratory test, V/Q SPECT and other imaging procedures performed. Patients in whom PE was deemed absent were not treated with anticoagulants and were followed up for 3 months. RESULTS Of the 393 patients, the prevalence of PE was 28 %. V/Q SPECT was positive for PE in 110 patients (28 %) and negative in 283 patients (72 %). Of the 110 patients with a positive V/Q SPECT, 78 (71 %) had at least one additional imaging test (computed tomography pulmonary angiography or ultrasound) and the diagnosis of PE was eventually excluded in one patient. Of the 283 patients with a negative V/Q SPECT, 74 (26 %) patients had another test. The diagnosis of PE was finally retained in one patient and excluded in 282 patients. The 3-month thromboembolic risk in the patients not treated with anticoagulants was 1/262: 0.38 % (95 % confidence interval 0.07-2.13). CONCLUSION A diagnostic management including V/Q SPECT interpreted with a diagnostic cut-off of "one segmental or two subsegmental mismatches" appears safe to exclude PE.
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Mortensen J, Gutte H. SPECT/CT and pulmonary embolism. Eur J Nucl Med Mol Imaging 2013; 41 Suppl 1:S81-90. [PMID: 24213621 PMCID: PMC4003400 DOI: 10.1007/s00259-013-2614-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/10/2013] [Indexed: 11/04/2022]
Abstract
Acute pulmonary embolism (PE) is diagnosed either by ventilation/perfusion (V/P) scintigraphy or pulmonary CT angiography (CTPA). In recent years both techniques have improved. Many nuclear medicine centres have adopted the single photon emission CT (SPECT) technique as opposed to the planar technique for diagnosing PE. SPECT has been shown to have fewer indeterminate results and a higher diagnostic value. The latest improvement is the combination of a low-dose CT scan with a V/P SPECT scan in a hybrid tomograph. In a study comparing CTPA, planar scintigraphy and SPECT alone, SPECT/CT had the best diagnostic accuracy for PE. In addition, recent developments in the CTPA technique have made it possible to image the pulmonary arteries of the lungs in one breath-hold. This development is based on the change from a single-detector to multidetector CT technology with an increase in volume coverage per rotation and faster rotation. Furthermore, the dual energy CT technique is a promising modality that can provide functional imaging in combination with anatomical information. Newer high-end CT scanners and SPECT systems are able to visualize smaller subsegmental emboli. However, consensus is lacking regarding the clinical impact and treatment. In the present review, SPECT and SPECT in combination with low-dose CT, CTPA and dual energy CT are discussed in the context of diagnosing PE.
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Affiliation(s)
- Jann Mortensen
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Copenhagen University Hospital, 2100, Copenhagen, Denmark,
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Perfusion SPECT in patients with suspected pulmonary embolism: how much sensitivity is needed to keep patients alive? Eur J Nucl Med Mol Imaging 2013; 40:1428-31. [PMID: 23748237 DOI: 10.1007/s00259-013-2470-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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