FDG PET/CT versus Bone Marrow Biopsy for Diagnosis of Bone Marrow Involvement in Non-Hodgkin Lymphoma: A Systematic Review

Abstract

The management of non-Hodgkin lymphoma (NHL) patients requires the identification of bone marrow involvement (BMI) using a bone marrow biopsy (BMB), as recommended by international guidelines. Multiple studies have shown that [18F]FDG positron emission tomography, combined with computed tomography (PET/CT), may provide important information and may detect BMI, but there is still an ongoing debate as to whether it is sensitive enough for NHL patients in order to replace or be used as a complimentary method to BMB. The objective of this article is to systematically review published studies on the performance of [18F]FDG PET/CT in detecting BMI compared to the BMB for NHL patients. A population, intervention, comparison, and outcome (PICO) search in PubMed and Scopus databases (until 1 November 2021) was performed. A total of 41 studies, comprising 6147 NHL patients, were found to be eligible and were included in the analysis conducted in this systematic review. The sensitivity and specificity for identifying BMI in NHL patients were 73% and 90% for [18F]FDG PET/CT and 56% and 100% for BMB. For aggressive NHL, the sensitivity and specificity to assess the BMI for the [18F]FDG PET/CT was 77% and 94%, while for the BMB it was 58% and 100%. However, sensitivity and specificity to assess the BMI for indolent NHL for the [18F]FDG PET/CT was 59% and 85%, while for the BMB it was superior, and equal to 94% and 100%. With regard to NHL, a [18F]FDG PET/CT scan can only replace BMB if it is found to be positive and if patients can be categorized as having advanced staged NHL with high certainty. [18F]FDG PET/CT might recover tumors missed by BMB, and is recommended for use as a complimentary method, even in indolent histologic subtypes of NHL.

The Diagnostic Accuracy of Bone Marrow Biopsy Versus PET/CT Scan in Identifying Bone Marrow Involvement in Diffuse Large B Cell Lymphoma Patients at a Cancer Hospital

“…In a study conducted by Teagle et al [12], it was concluded that FDG PET/CT has 100% sensitivity and specificity for detecting bone marrow involvement in DLBCL, keeping bone marrow biopsy as the reference standard. In a recent systematic review by Almaimani et al [10], including 41 studies, the total number of patients with DLBCL was 2336; among the included studies with patients' data of DLBCL for PET/CT, the sensitivity, specificity, PPV, and NPV were 77.40%, 91.65%, 63.60%, and 97.00%, respectively, and the sensitivity of BMB in finding out BMI was 47.00%, specificity was 100%, PPV was 100%, and NPV was 80.00%. In another recent study conducted by Xiao-Xue and coworkers [18], it was found that the sensitivity, specificity, and accuracy of PET/CT to detect BMI in aggressive B cell lymphoma (DLBCL and Burkitt lymphoma) were 80.0%, 90.0%, and 88.1%, respectively.…”

“…One of the most common methods used for the detection of BMI by the underlying lymphoma is bone marrow biopsy (BMB) [10]. Although BMB is considered a gold standard and a safe procedure for the evaluation of BMI, it has certain limitations and risks [11,12].…”

“…Although BMB is considered a gold standard and a safe procedure for the evaluation of BMI, it has certain limitations and risks [11,12]. It is an invasive and painful procedure and might not yield adequate material for pathologists to interpret [10]. It may also miss patchy or focal bone marrow lymphoma outside the iliac crest area [10,12].…”

“…It is an invasive and painful procedure and might not yield adequate material for pathologists to interpret [10]. It may also miss patchy or focal bone marrow lymphoma outside the iliac crest area [10,12]. Unfavorable outcomes such as bleeding, infection, allergy, and failure of procedure have also been reported in around 0.12% of patients [11].…”

A comprehensive review of the role of bone marrow biopsy and PET-CT in the evaluation of bone marrow involvement in adults newly diagnosed with DLBCL

“…Non-Hodgkin lymphoma (NHL) constitutes approximately 4% of annual cancer diagnoses. It ranks as the sixth most common cause of cancer and accounts for almost 6% of malignancy-related mortality in Europe and the United States ( 1 – 3 ). Within the spectrum of NHL, diffuse large B cell lymphoma (DLBCL) emerges as the most prevalent subtype, accounting for 30 – 40% of aggressive NHL cases in adults worldwide ( 3 – 7 ).…”