F-18 NaF PET for Detection of Bone Metastases in Lung Cancer: Accuracy, Cost-Effectiveness, and Impact on Patient Management

Abstract

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.

Prospective Study Evaluating Na18F PET/CT in Predicting Clinical Outcomes and Survival in Advanced Prostate Cancer

“…The ability of Na 18 F PET/CT to detect skeletal metastases has been evaluated in various types of cancer, including prostate cancer, and a series of studies has reported improved sensitivity and specificity compared with 99m Tc-BS (7)(8)(9)(10)(11)(12)(13). In 2011, the Food and Drug Administration approved a new-drug application for Na 18 F PET/CT from the National Cancer Institute; however, its routine clinical use is not yet defined.…”

Skeletal metastases: what is the future role for nuclear medicine?

“…These findings suggest that the differences between bone scintigraphy and 18 F-fluoride PET were mainly technical rather than due to mechanistic differences in the tracers. The same group took this analysis further in a group of 103 patients with lung cancer and on this occasion showed a statistically significant increase in the area under the ROC curve with 18 F-fluoride PET compared to SPECT and planar scintigraphy but it was noted that this was at higher incremental costs [14].…”

“…These generally showed an improved diagnostic accuracy for the PET method, particularly when compared to planar scintigraphy alone [11][12][13][14] In a study of 34 patients with breast cancer, 18 F-fluoride PET detected 64 metastases in 17 patients compared to planar bone scintigraphy, which only detected 29 metastases in 11 patients. 18 F-fluoride PET led to a change in management in 12% of patients overall [11].…”

“…However, it has been shown that not only bone-specific PET imaging with 18 F-fluoride [14] but tumour specific imaging with 18 FDG, are more accurate than bone scintigraphy in patients with lung cancer [29,30]. As potentially curable NSCLC is now almost routinely staged with 18 FDG PET/CT, the obvious question is whether bone-specific imaging, with SPECT, 18 F-fluoride PET or hybrid methods with CT, are required at all.…”

The isotope bone scan: we can do better

“…Where available, specificity (and to a lesser extent sensitivity) has been greatly improved with the use of single photon emission computed tomography (SPECT)/CT [1][2][3], but can be further significantly improved with the use of 18 F-fluoride positron emission tomography (PET)/CT [4][5][6]. Further, 18 F-fluoride can on occasion identify early metastatic lesions at a time when the bone scan is normal [7][8][9][10]. Nevertheless, 18 F-fluoride is rarely used routinely for bone imaging due to the limited availability of PET, cost and competition for time on the PET scanner.…”