Comparison of18FDG-PET with99mTc-HMDP scntigraphy for the detection of bone metastases in patients with breast cancer

OBJECTIVE: Bone is one of the most common sites of metastasis in breast cancer patients. Although bone scintigraphy is widely used to detect metastatic breast cancer, the usefulness of 18FDG-PET for detecting bone metastasis has not been clearly evaluated. The purpose of this study was to compare the diagnostic accuracy of 18FDG-PET with bone scintigraphy in detecting bone metastasis in breast cancer patients. METHODS: Forty-four women aged 35 to 81 years (mean, 56 years) with breast cancer were examined in this study. Both 18FDG-PET and bone scintigraphy were performed for each patient with 0-69 day intervals (mean, 11.5 days). The results of each image interpretation were compared retrospectively. Whole-body bones were classified into 9 anatomical regions. Metastases were confirmed at 45/187 regions in 14 patients by bone biopsy or clinical follow-up including other imaging techniques for a period of at least 6 months afterwards. RESULTS: On a region basis, the sensitivity, specificity, and accuracy of 18FDG-PET were 84%, 99% and 95%, respectively. Although these results were comparable to those of bone scintigraphy, the combination of 18FDG-PET and bone scintigraphy improved the sensitivity (98%) and accuracy (97%) of detection. False negative lesions of bone scintigraphy were mostly bone marrow metastases and those of 18FDG-PET were mostly osteoblastic metastases. 18FDG-PET was superior to bone scintigraphy in the detection of osteolytic lesions (92% vs. 73%), but inferior in the detection of osteoblastic lesions (74% vs. 95%). CONCLUSIONS: This study shows that 18FDG-PET tends to be superior to bone scintigraphy in the detection of osteolytic lesions, but inferior in the detection of osteoblastic lesions. 18FDG-PET should play a complementary role in detecting bone metastasis with bone scintigraphy.     

Diagnostic accuracy of bone metastases detection in cancer patients: Comparison between bone scintigraphy and whole-body FDG-PET

18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) has become widely available and an important oncological technique. To evaluate the influence of PET on detection of bone metastasis, we compared the diagnostic accuracy of PET and conventional bone scintigraphy (BS) in a variety of cancer patients. METHODS: Consecutive ninety-five patients with various cancers, who received both PET and BS within one month, were retrospectively analyzed. A whole-body PET (from face to upper thigh) and a standard whole body BS were performed and these images were interpreted by two experienced nuclear medicine physicians with and without patient information using monitor diagnosis. Each image interpretation was performed according to 8 separate areas (skull, vertebra, upper limbs, sternum and clavicles, scapula, ribs, pelvis, and lower limbs) using a 5-point-scale (0: definitely negative, 1: probably negative, 2: equivocal, 3: probably positive, 4: definitely positive for bone metastasis). RESULTS: Twenty-one of 95 patients (22.1%) with 43 of 760 areas (5.7%) of bone metastases were finally confirmed. In untreated patients, 12 of 14 bone metastasis positive patients were detected by PET, while 9 of 14 were detected by BS. Three cases showed true positive in PET and false negative in BS due to osteolytic type bone metastases. In untreated cases, PET with and without clinical information showed better sensitivity than BS in patient-based diagnosis. For the purpose of treatment effect evaluation, PET showed better results because of its ability in the evaluation of rapid response of tumor cells to chemotherapy. Out of 10 cases of multiple-area metastases, 9 cases included vertebrae. There was only one solitary lesion located outside of FOV of PET scan in the femur, but with clinical information that was no problem for PET diagnosis. CONCLUSION: Diagnostic accuracy of bone metastasis was comparable in PET and BS in the present study. In a usual clinical condition, limited FOV (from face to upper thigh) of PET scan may not be a major drawback in the detection of bone metastases because of the relatively low risk of solitary bone metastasis in skull bone and lower limbs.     

Strontium-89 for palliation of pain from bone metastases in patients with prostate and breast cancer

We have used strontium-89 chloride (⁸⁹Sr) for the palliative treatment of metastatic bone pain. Seventy-six patients (50 males with prostate carcinoma and 26 females with breast cancer) were treated with 148 MBq of ⁸⁹Sr. Sixteen patients were retreated, receiving two or three doses; the total number of injected doses was consequently 95. The Karnofsky performance status was assessed and pain and analgesia were scored on scales of 9 and 5 points, respectively. The efficacy of ⁸⁹Sr was evaluated at 3 months of treament. Three levels of response were considered: good – when there was an increase in the Karnofsky status and a decrease in the pain score (equal to or higher than 4) or analgesic score (equal to or higher than 1); partial – when there was an increase in the Karnofsky status and a decrease in the pain score (2 or 3 points) without significant changes in the analgesic score; no response – if no variation or deterioration in these parameters was observed. In prostate cancer patients, the response was good in 64% of cases and partial in 25%, and there was no response in the remaining 11%. In breast cancer patients, the response was good in 62% of cases and partial in 31%, and there was no response in the remaining 8%. Duration of the response ranged from 3 to 12 months (mean 6 months). In the patients who were retreated the effectiveness was as good as after the first dose of ⁸⁹Sr. A decrease in the initial leucocyte and platelet counts was observed after the 1st month of treatment, with a gradual partial to complete recovery within 6 months. It is concluded that ⁸⁹Sr is an effective agent in palliative therapy for metastatic bone pain in patients with prostate or breast carcinoma. If required, retreatment can be administered safely and with the same efficacy as is achieved by the first dose. Received 13 March and in revised form 6 June 1997     

The appearance of breast cancer metastases on dry bone: Implications for forensic anthropology

Breast carcinoma is a major cause of morbidity and mortality in women. The study of bone pathologies presents considerable potential in anthropology, paleopathology, forensic science and medicine. In this paper, we present and discuss metastatic lesions found in the skeletons of known individuals from the CAL Milano Cemetery Skeletal Collection, clinically diagnosed with breast cancer during life. Fourteen skeletons from a contemporary and identified collection were macroscopically studied and metastases were identified by comparison with clinical literature. As a result, bone metastases were observed in 43% of the study sample. They were located most commonly on the ribs (28.1%), pelvic girdle (19.8%), vertebrae (15.6%), skull (15.6%), scapulae (10.2%) as well as proximal segment of the femora (8.4%) and humeri (2.4%) respectively, favoring sites of high vascularization. The majority of the lesions were osteolytic, although osteoblastic and mixed metastases did occur. Osteolytic metastases appear as coalescent porosity or round to oval perforating lesions on bones with denticulated margins and pitted surrounding bone, whereas osteoblastic metastases thickened the existing trabecula (spongiosclerosis). Mixed metastases were perforating lytic lesions exposing the osteoblastic activity in the underlying trabecular bone. These results, consistent with the data from the literature, strengthen the diagnostic criteria for metastases and illustrate the aspect of bone metastases in breast carcinoma.     

Comparison of whole-body MRI with automatic moving table technique and bone scintigraphy for screening for bone metastases in patients with breast cancer

The aim of this study was presentation of a whole-body MRI technique with a moving table as a screening tool for bone metastases in patients with breast cancer. Twenty-two patients with breast carcinoma underwent both a planar whole-body bone scintigraphy and whole-body MRI at 1.5 T. The MRI images were acquired with a moving table at six different anatomical positions within a measurement time of 20 min. Coronal images were acquired using a short-tau inversion recovery sequence, accomplished by an axial T2-weighted turbo-spin-echo sequence through the head, and a T1-weighted opposed-phase sagittal 2D fast low-angle shot sequence covering the whole spine. The MRI findings indicating bone metastases were compared with findings from bone scintigraphy. Metastatic lesions were confirmed by follow-up examinations over 1 year. Twelve patients showed bone metastases. Whole-body MRI was superior to bone scintigraphy in predicting lesion origin with a sensitivity of 92% (bone scintigraphy 83%), a specificity of 90% (scintigraphy 80%) and an accuracy of 91% (scintigraphy 82%). The MRI showed additional findings such as metastases of the lung and liver. Whole-body MRI with moving table technique may be an effective method of total body screening for bone in selected patients with breast carcinoma and a high risk of distant metastases, although with the higher costs of MRI bone scintigraphy must still be considered as the first method for screening patients with breast cancer.     

Scintigraphic and radiographic patterns of skeletal metastases in breast cancer: value of sequential imaging in predicting outcome

Objective To determine whether temporal changes in scintigraphic and bone radiographic findings have prognostic significance in patients with skeletal metastases from breast cancer.Design Clinical information and films were retrospecitvely reviewed in 101 randomly selected patients with skeletal metastases. Images from sequential bone scans and bone radiographs were correlated with survival after detection of the metastases.Results Time to detection of skeletal metastases and the length of time for which patients were classified as radiologically stable after development of skeletal metastases correlated with survival (r=0.843; r=0.821, respectively). Failure to develop a radiographically and scintigraphically stable pattern after treatment was associated with significantly decreased survival compared with the rest of the patients (mean survival 2.1±1.3 years vs 4.3±2.3 years; p<0.001). Scintigraphic regression of metastases was associated with significant survival benefit and longer stabilization of disease compared to all other patterns (mean survival 5.0±2.7 years for regressive disease vs 3.7±1.9 years for stable disease and 2.2±1.3 years for progressive disease; p<0.001).Conclusions Sequential scintigraphic and radiographic imaging is useful in breast cancer patients not only for detection of metastases and monitoring of treatment effect, but also because these studies provide valuable prognostic information.     

FDG-PET in a case of multiple bone metastases of gastric cancer

F-18 2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) is useful for surveys to detect bone metastasis because of its greater specificity than bone scintigraphy. However, FDG-PET is also known to yield false-positive results in acute fractures and inflammatory lesions, and distinguishing between benign and malignant lesions is difficult, even when semiquantitative methods are used. We report a case of multiple bone metastases of gastric cancer. One of the bone lesions that was positive for FDG uptake was benign, suggesting that FDG-PET can yield false-positive results.     

骨扫描与肿瘤标志物联检在骨转移诊断中的应用进展

骨骼是晚期恶性肿瘤最常见的扩散转移部位之一.由骨转移引发的骨相关事件可以明显影响晚期肿瘤病人的生活质量和临床转归.骨扫描目前仍然是诊断骨转移的首选检查方法.尽管骨扫描具有高度的敏感性,但其特异性仍较低,如与不同癌症的相关肿瘤标志物联检,可明显提高骨扫描的诊断特异性,还可不同程度地提高其诊断的敏感性和准确性.就骨扫描与肿瘤标志物联检在骨转移诊断中的应用及其潜在的临床价值予以综述.     

Bone pain palliation with strontium-89 in breast cancer patients with bone metastases and refractory bone pain

Fifteen patients with breast cancer and skeletal metastases who had bone pain refractory to opioid analgesics and who were not eligible for or had not responded to local field radiotherapy, were treated with strontium-89. All patients had received previous treatment with chemotherapy and radiotherapy for bone metastases. Severity of bone pain, sleeping pattern, mobility and dependency on analgesics were evaluated before and 4, 8 and 12 weeks after⁸⁹Sr administration. Patients received 2 MBq/kg (118–148 MBq) of⁸⁹Sr by i.v. injection. Pain relief and a reduction in analgesic requirements were observed in 7 of the 15 (47%) patients, with a reduction in the severity score from 34% to 71%. Duration of the response varied from 3 to 7 months. A decrease in peripheral blood cell count was observed in 11 patients: a 15%–66% reduction in white cell count and a 14%–75% reduction in platelet count were detected at 12 weeks after treatment in these patients. We conclude that⁸⁹Sr is effective (47% response rate) for bone pain palliation in patients with bone metastases from breast cancer. Dependency on opioid analgesics may be reduced in patients with refractory bone pain.     

放射性核素骨显像在前列腺癌骨转移中的研究价值

目的:探讨放射性核素骨显像与血清前列腺特异性抗原(PSA)联合检测在前列腺癌骨转移诊断中的临床意义。方法:对130例前列腺癌患者的PSA检测结果及SPECT骨显像进行回顾性分析。结果:130例前列腺癌患者,骨显像诊断骨转移86例,阳性率为66.2%。在86例骨转移的患者中,发生脊椎转移77例,占77.9%,骨盆转移65例,占75.6%,肋骨转移42例,占48.8%,肩胛骨转移11例,占12.8%,胸骨转移7例,占8.1%,颅骨转移6例,占7%。脊椎和骨盆是前列腺癌骨转移主要涉及的部位。骨显像阳性组和骨显像阴性组PSA均值差异有显著性(P<0.01),PSA<20μg/L的前列腺癌患者发生骨转移的可能性小,PSA≥20μg/L的患者发生骨转移的可能性大。结论:PSA≥20μg/L的前列腺患者应行放射性核素骨显像检查。放射性核素全身骨显像与血清PSA浓度联合检测对于前列腺癌骨转移的临床诊断具有重要的指导意义。     

Whole-body MRI using a rolling table platform for the detection of bone metastases

The aim of this study was to compare the results of whole-body MRI using a recently developed rolling table platform with findings of nuclear scintigraphy in patients with bone metastases. Twenty-six patients with known or suspected bone metastases who had undergone radionuclide scintigraphy were examined by MRI. Patients were placed on a rolling table platform with integrated phased-array surface coils [BodySURF (system for unlimited field of view)] capable of pulling the patient through the isocenter of the magnet. Using a five-station approach three different image sets (T1-weighted gradient recalled echo, half-Fourier acquired single-shot turbo spin echo, and short tau inversion recovery) were collected in the coronal plane. In addition, the spine was imaged in the sagittal plane. The MRI findings were compared with the results obtained by scintigraphy. The whole-body MR examination lasting merely 40 min was feasible in all 26 patients. The MRI revealed excellent correlation with scintigraphy regarding metastatic lesions. A total of 60 regions with metastatic lesions were identified on bone scintigraphy. Fifty-three regions were detected on identical locations by MRI. The regions missed by MRI were located mainly in ribs and skull. The MRI could identify additional bone metastases in spine, pelvis, and femur. The MRI screening for bone metastases correlated well with bone scintigraphy. Use of the rolling table platform permits rapid imaging based on three different contrast mechanisms of the entire skeletal system.     

FDG-PET imaging in duodenal cancer

F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) imaging is a useful modality in the detection of various tumors, including colon cancer and gastric cancer. We evaluated a patient with duodenal cancer with multiple metastases including brain metastases using FDG-PET imaging. It revealed multiple tumor uptake in the brain, clavicular fossa, mediastinum, right adrenal gland and duodenum. These results suggest that FDG-PET imaging may be useful in detecting the primary and metastatic lesions of duodenal adenocarcinoma.     

The clinical utility of FDG-PET/CT in follow up and restaging of breast cancer patients

Background

Early diagnosis and accurate staging of loco-regional and distant recurrence after treatment of breast cancer is decisive for further therapeutic planning. Our aim was to evaluate the role of FDG-PET/CT in the follow up and restaging of breast cancer patients.

Methods

We retrospectively evaluated 34 female patients with a history of breast cancer. Patients were referred for a PET/CT scan because of suspected recurrence (n = 15), whole body staging in already confirmed cases of recurrence (n = 5), follow up and reassurance in asymptomatic patients (n = 7), follow up after local ablative therapy of liver metastases (n = 5), follow up after treatment of bone metastases (n = 2). PET-CT findings were compared with the findings obtained by other imaging modalities, histopathology, together with clinical and imaging follow up for at least 6 months.

Results

The PET/CT was considered pathological in 21/34 patients. Incorrect interpretations of PET/CT images occurred in 3 patients (8.8%). PET/CT showed an overall diagnostic accuracy of 91.2% with a sensitivity of 90.5% and a specificity of 92.3%. The PPV and NPV were 95% and 85.7%, respectively.

Conclusion

FDG-PET/CT may play a substantial role in the restaging and follow up of patients with breast cancer showing high sensitivity and specificity.     

Scintimammography with technetium-99m tetrofosmin in the diagnosis of breast cancer and lymph node metastases

The aim of the study was to evaluate the possible role of scintimammography (SMM) with technetium-99m tetrofosmin in breast cancer. Thirty-three patients with breast disease and ten normal controls were included in the study. Planar scintigraphic images in supine anterior, prone lateral and lateral views, with the patient lying in lateral recumbency, were acquired. A qualitative analysis evaluating both breasts and lymph nodes was performed. All breast lesions were verified after surgery and/or by fine-needle aspiration. In 8 of the 33 patients, mammography was inconclusive because of mastectomy or dense breasts. For mammography, a sensitivity of 95.6%, a specificity of 66.7% and an accuracy of 89.6% were obtained. At SMM, 26 out of 28 malignant lesions (average size 2.8 cm, range 0.4–12 cm), including two recurrences, were detected with a 92.8% sensitivity, a 100% specificity and a 95.1% accuracy. The smallest detectable carcinoma measured 0.6 cm. Two false-negative results on SMM were found in a 0.4-cm intraductal carcinoma and in the only mucinous papillary carcinoma in our series. With regard to lymph node analysis, 11 out of 12 axillary metastases (sensitivity=91.6%) were detected. A false-positive result, yielding a specificity of 92.3% was also obtained. A metastatic involvement of the internal mammary chain was observed. No uptake was seen in 11 benign mammary lesions or at the level of the breast and axilla when neoplastic involvement was absent. In conclusion, SMM with^99mTc-tetrofosmin is an effective technique for the evaluation of primary breast carcinomas, recurrences and lymph node metastases.     

Whole-body iodine-131 metaiodobenzylguanidine imaging for detection of bone metastases in patients with paraganglioma: comparison with bone scintigraphy

Iodine-131 metaiodobenzylguanidine (¹³¹I-MIBG) therapy is an effective treatment for patients with malignant paraganglioma for which surgical resection is not indicated. We performed high-dose ¹³¹I-MIBG therapy on two patients with malignant paraganglioma and multiple bone metastases. The bone metastases were diagnosed by magnetic resonance imaging (MRI). Metastatic bone lesions were evaluated by whole-body ¹³¹I-MIBG imaging and bone scintigraphy. Whole-body ¹³¹I-MIBG imaging showed extensive metastatic bone lesions, whereas conventional bone scintigraphy did not. There was a remarkable discrepancy between ¹³¹I-MIBG imaging and bone scintigraphy in the diagnosis of metastatic bone lesions of malignant paraganglioma in our two patients. High-dose ¹³¹I-MIBG imaging may detect early stages of bone metastases, compared with bone scintigraphy, in patients with malignant paraganglioma.     

The effect of repeated strontium-89 chloride therapy on bone pain palliation in patients with skeletal cancer metastases

One hundred and eighteen patients with painful skeletal metastases of malignant diseases (predominantly prostate, breast and lung cancer) were treated with 150 MBq of strontium-89 chloride (Metastron, Amersham, UK) intravenously. The results were evaluated according to a score considering pain relief, mobility, analgesic intake and general feeling. In only five patients (4.2%) was no improvement observed; mild improvement was noted in 48 (40.7%), and substantial or complete improvement in 56 (47.5%) and 9 (7.6%), respectively. The mean painless period after a single ⁸⁹SrCl dose was 3.3±2.28 months (in patients with prostate, lung, breast and other types of cancer it was 3.65±2.11, 3.29±1.27, 3.08±0.48 and 3.44±1.36 months, respectively). During a 3-year study, ⁸⁹SrCl treatment was successively repeated up to 5 times in some patients (total number of Metastron applications was 256) who benefited from the first Metastron administration and did not show signs of myelosuppression. Even after repeated treatment, relief was consistent and the duration of the period without pain increased (in particular in patients with breast cancer, in whom the period of relief was prolonged from 3.08±0.48 months after the first dose to 5.33±2.36 months after the fifth ⁸⁹SrCl administration). The increased painless period was not observed after repeated treatment in the patient group comprising miscellaneous types of cancer, and the degree of improvement was less apparent. During the course of successive ⁸⁹SrCl treatments, transient signs of myelosuppression indicated by a decrease in white cell and thrombocyte counts of at least 25% were observed 10 times after Metastron administration (twice in two patients), i.e. in 3.9% of all ⁸⁹SrCl administrations; these transient haematological changes of moderate grade were closely connected with Metastron administration. Palliative treatment of metastatic skeletal pain with ⁸⁹SrCl improves the quality of life in most patients suffering from prostate, lung and breast cancer and may be safely repeated with the same benefit and without significant myelosuppression. The beneficial effect of ⁸⁹SrCl treatment seems to be less pronounced in other types of cancer with painful skeletal metastases. Received 9 February and in revised form 20 May 1998     

Transarterial chemoembolisation (TACE) with gemcitabine: Phase II study in patients with liver metastases of breast cancer

Objective

Evaluation of the efficacy and tolerability of transarterial chemoembolization with gemcitabine in patients with inoperable liver metastases of breast cancer.

Materials and methods

Open-label, prospective non-randomized single-center study design; patients had previous chemotherapy including anthracyclines and/or taxanes in the metastatic setting, adequate bone marrow reserve, sufficient liver/renal function, no centralnervous system metastases, Karnovsky-performance-status >70%, and life expectancy >12 weeks. Forty-three patients were enrolled (median 58 years, range 48–71). A suspension of gemcitabine 1.200 mg/m², 2–10 ml/m² of Lipiodol, and 5 ml of a degradable starch microsphere (Embocept) suspension, were administered intra-arterially up to 3 times with a 4-weaks-interval. Dose-limiting toxicit is defined as grade 4 thrombocytopenia, neutropenia, or nonhematologic toxicity > grade 3. Tumor response was evaluated by magnetic resonance (MRI) and computed tomography (CT) imaging.

Results

All patients tolerated the treatment well; with no dose limiting toxicities. Imaging follow-up according to the RECIST-criteria (Response Evaluation Criteria in Solid Tumors) revealed a partial response in 3 patients, stable disease in 16 patients and progression in 22 patients. The progression free survival was 3.3 months.A significant correlation exists only with the factor vascularization: strongly vascularized tumors show a significantly lowered response. Patients with complete or partial response and the main fraction of the stable disease group showed in the MRI and angiography only a moderate vascularization.The resulting estimate of the total survival rate amounts to a median of 10.2 months.

Conclusion

Transarterial chemoembolization with gemcitabine is well tolerated and provides an alternative treatment method for patients with liver metastases of breast cancer.     

乳腺癌骨转移的影像学诊断进展

乳腺癌是“嗜骨性癌肿”,极易伴发骨转移,由骨转移引发的骨相关事件可明显影响晚期乳腺癌患者的生存质量及预后转归。因此,早期、准确诊断骨转移对乳腺癌的临床分期及治疗计划制定具有决定作用,对预后改善亦有重要意义。该文综述了乳腺癌骨转移影像学诊断的研究进展,为临床早期诊断骨转移提供影像学依据。     

Clinical and radiographic correlations in breast cancer patients with osseous metastases

Serial metastatic bone series on 12 patients with skeletal metastases from carcinoma of breast were studied. Changes in the clinical and radiographic parameters of the patients were correlated. Patients were all treated on a research protocol evaluating medical adrenalectomy with aminoglutethimide or surgical adrenalectomy. Seventeen clinical changes were noted in twelve patients. Sixteen of these observations demonstrated positive clinical correlations with concurrent skeletal radiographs. A lytic bone pattern correlated clinically with progressive tumor growth. A blastic bone pattern was present when objective clinical data indicated disease remission.