As bone metastases might be present in lung cancer despite a normal bone scan, we examined various alternatives prospectively. Positron emission tomography using F-18 sodium fluoride (PET) and single photon emission tomography (SPECT) were more sensitive than a planar bone scan. PET was more accurate with a shorter examination time than SPECT but had higher incremental costs. Introduction:Previous studies have shown that vertebral bone metastases not seen on planar bone scans may be present on F-18 fluoride positron emission tomography (PET) scan or single photon emission computed tomography (SPECT). The purpose of this study was to measure the accuracy, clinical value and cost-effectiveness of tomographic bone imaging. Materials and Methods: A total of 103 patients with initial diagnosis of lung cancer was prospectively examined with planar bone scintigraphy (BS), SPECT of the vertebral column and PET using F-18 sodium fluoride (F-18 PET). Receiver operating characteristic (ROC) curve analysis was used for determination of the diagnostic accuracy. A decision-analysis model and the national charge schedule of the German Hospital Association were used for determination of the cost-effectiveness. Results: Thirteen of 33 patients with bone metastases were false negative on BS, 4 on SPECT, and 2 on F-18 PET. The area under the ROC curve was 0.771 for BS, 0.875 for SPECT, and 0.989 for F-18 PET (p Ͻ 0.05). As a result of SPECT and F-18 PET imaging, clinical management was changed in 8 (7.8%) and 10 (9.7%) patients. Compared with BS, the costs per additional correctly diagnosed patient were 1272 Euro with SPECT and 2861 Euro with F-18 PET. The threshold for the costs of F-18 PET being more cost-effective than SPECT was 345 EUR. Conclusion: Routine performance of tomographic bone imaging improves the therapeutic strategy because of detection of otherwise missed metastases. F-18 PET is more effective than SPECT but is associated with higher incremental costs.
The leading European and American professional societies recommend that bone scans (BS) should be performed in the staging of lung cancer only in those patients with bone pain. This prospective study investigated the sensitivity of conventional skeletal scintigraphy in detecting osseous metastases in patients with lung cancer and addressed the potential consequences of failure to use this method in the work-up of asymptomatic patients. Subsequent to initial diagnosis of non-small cell lung cancer, 100 patients were examined and questioned regarding skeletal complaints. Two specialists in internal medicine decided whether they would recommend a bone scan on the basis of the clinical evaluation. Skeletal scintigraphy was then performed blinded to the findings of history and physical examination. The combined results of magnetic resonance imaging (MRI) of the vertebral column, positron emission tomography (PET) of skeletal bone and the subsequent clinical course served as the gold standard for the identification of osseous metastases. Bone scintigraphy showed an 87% sensitivity in the detection of bone metastases. Failure to perform skeletal scintigraphy in asymptomatic patients reduced the sensitivity of the method, depending on the interpretation of the symptoms, to 19-39%. Without the findings of skeletal scintigraphy and the gold standard methods, 14-22% of patients would have undergone unnecessary surgery or neoadjuvant therapy. On this basis it is concluded that bone scans should not be omitted in asymptomatic patients.
Based on the hypotheses that most skeletal metastases in lung cancer are clinically symptomatic, that the incidence of bony metastases in early stages is low, and that bone scintigraphy has a sensitivity of nearly 100%, leading professional societies recommend diagnostic skeletal imaging depending on clinical symptoms. No study has assessed the significance of skeletal symptoms as a criterion for skeletal imaging in patients with lung cancer since 1991.3 But in the intervening period gamma camera technology has been considerably refined and more sensitive methods such as magnetic resonance imaging have become available for skeletal imaging.We redetermine the role of symptoms and serum concentrations in detecting bony metastases in lung cancer and reassess the accuracy of bone scans for screening. Participants, methods, and resultsFrom September 1999 to September 2001 we recruited 153 consecutive patients at University Hospital Ulm. We included patients based on cytological or histological evidence of lung cancer returned no more than 10 days before entry into the study. Of these, 121 (79%; 88 men and 33 women; median age 66, range 40-83 years) agreed to participate. Exclusion criteria were a history of malignant disease, pregnancy, and age less than 18 years. All patients gave written informed consent. Diagnosis was non-small cell lung cancer in 84 patients and small cell lung cancer in 37 patients. We questioned and examined all patients about skeletal complaints. Physical examination included percussion, compression, flexion, extension, and rotation of the vertebral column and extremities and evaluations of patients' neurological status. We also measured serum calcium and alkaline phosphatase concentrations. New skeletal symptoms within the previous six months were judged as suspicious for bony metastases.We did bone scans blinded to the history and findings of the physical examination. The combined results of magnetic resonance imaging of the vertebral column and patients' subsequent clinical course were the ideal for identification of bony metastases.We found skeletal metastases in 40 patients (33%). Incidence was nearly identical at 33% (28) in patients with non-small cell lung cancer and 32% (12) in those with small cell lung cancer. These patients had normal serum alkaline phosphatase and calcium concentrations. Three quarters (91) of patients had symptoms. In only 19% (23) of patients with symptoms did the location of metastases correspond to the symptoms. Routine bone scans correctly identified skeletal metastases in 29 patients (sensitivity 73%; 95% confidence interval 56% to 85%). Bone scans were correctly negative in 80 of 81 patients (specificity 99%; 93% to 100%). If bone scans were done in only the 91 patients reporting skeletal complaints, the sensitivity would have been reduced to 53%. A further restriction of the method to those 23 patients with suspicious complaints would have resulted in a further reduction in sensitivity to 20% (8 patients). CommentOnly a small proportion of bone metastases ...
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