Observational Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Radiol. Feb 28, 2016; 8(2): 200-209
Published online Feb 28, 2016. doi: 10.4329/wjr.v8.i2.200
Comparisons between glucose analogue 2-deoxy-2-(18F)fluoro-D-glucose and 18F-sodium fluoride positron emission tomography/computed tomography in breast cancer patients with bone lesions
Selene Capitanio, Francesca Bongioanni, Arnoldo Piccardo, Claudio Campus, Roberta Gonella, Lucia Tixi, Mehrdad Naseri, Michele Pennone, Vania Altrinetti, Ambra Buschiazzo, Irene Bossert, Francesco Fiz, Andrea Bruno, Andrea DeCensi, Gianmario Sambuceti, Silvia Morbelli
Selene Capitanio, Andrea Bruno, Department of Nuclear Medicine, A.O. Papa Giovanni XXIII, 24127 Bergamo, Italy
Francesca Bongioanni, Michele Pennone, Ambra Buschiazzo, Irene Bossert, Francesco Fiz, Gianmario Sambuceti, Silvia Morbelli, Nuclear Medicine, IRCCS AOU San Martino-IST, Department of Health Sciences, University of Genoa, 16132 Genoa, Italy
Arnoldo Piccardo, Mehrdad Naseri, Vania Altrinetti, Department of Nuclear Medicine, E.O. Ospedali Galliera, 16128 Genoa, Italy
Andrea DeCensi, Department of Medical Oncology, E.O. Ospedali Galliera, 16128 Genoa, Italy
Claudio Campus, Istituto Italiano di Tecnologia, 16163 Genoa, Italy
Roberta Gonella, Lucia Tixi, Dipartimento di Terapie Oncologiche Integrate, Clinica di Medicina Interna a indirizzo oncologico, 16132 Genoa, Italy
Author contributions: Capitanio S performed the literature search and drafted the manuscript; Bongioanni F, Naseri M, Pennone M, Altrinetti V, Buschiazzo A, Bossert I and Fiz F collected the data and took care of patients during diagnostic exams; Campus C performed the statistical analysis; Gonella R, Tixi L and DeCensi A took care of patients during follow-up; Piccardo A, Bruno A, DeCensi A, Sambuceti G, and Morbelli S made critical revisions to the manuscript relating to important intellectual content; Morbelli S designed the study and gave final approval for the version of the article to be published; all authors read and approved the final manuscript.
Institutional review board statement: The Internal Review Board (Comitato Etico Regionale della Liguria) evaluated and approved this retrospective study.
Informed consent statement: All study participants, or their legal guardians, provided informed written consent prior to study enrollment. We did not report any details that might disclose the identity of the subjects under study.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Silvia Morbelli, Full Staff Nuclear Medicine Physician, Nuclear Medicine, IRCCS AOU San Martino-IST, Department of Health Sciences, University of Genoa, L.go R. Benzi 10, 16132 Genova, Italy. silviadaniela.morbelli@hsanmartino.it
Telephone: +39-010-5552025 Fax: +39-010-5556911
Received: May 28, 2015
Peer-review started: May 31, 2015
First decision: September 18, 2015
Revised: October 23, 2015
Accepted: December 9, 2015
Article in press: December 11, 2015
Published online: February 28, 2016

AIM: To compare 2-deoxy-2-(18F)fluoro-D-glucose(18F-FDG) and 18F-sodium (18F-NaF) positron emission tomography/computed tomography (PET/CT) accuracy in breast cancer patients with clinically/radiologically suspected or known bone metastases.

METHODS: A total of 45 consecutive patients with breast cancer and the presence or clinical/biochemical or radiological suspicion of bone metastatic disease underwent 18F-FDG and 18F-fluoride PET/CT. Imaging results were compared with histopathology when available, or clinical and radiological follow-up of at least 1 year. For each technique we calculated: Sensitivity (Se), specificity (Sp), overall accuracy, positive and negative predictive values, error rate, and Youden’s index. McNemar’s χ2 test was used to test the difference in sensitivity and specificity between the two diagnostic methods. All analyses were computed on a patient basis, and then on a lesion basis, with consideration ofthe density of independent lesions on the co-registered CT (sclerotic, lytic, mixed, no-lesions) and the divergent site of disease (skull, spine, ribs, extremities, pelvis). The impact of adding 18F-NaF PET/CT to the work-up of patients was also measured in terms of change in their management due to 18F-NaF PET/CT findings.

RESULTS: The two imaging methods of 18F-FDG and 18F-fluoride PET/CT were significantly different at the patient-based analysis: Accuracy was 86.7% and 84.4%, respectively (McNemar’s χ2 = 6.23, df = 1, P = 0.01). Overall, 244 bone lesions were detected in our analysis. The overall accuracy of the two methods was significantly different at lesion-based analysis (McNemar’s χ2 = 93.4, df = 1, P < 0.0001). In the lesion density-based and site-based analysis, 18F-FDG PET/CT provided more accurate results in the detection of CT-negative metastasis (P < 0.002) and vertebral localizations (P < 0.002); 18F-NaF PET/CT was more accurate in detecting sclerotic (P < 0.005) and rib lesions (P < 0.04). 18F-NaF PET/CT led to a change of management in 3 of the 45 patients (6.6%) by revealing findings that were not detected at 18F-FDG PET/CT.

CONCLUSION: 18F-FDG PET/CT is a reliable imaging tool in the detection of bone metastasis in most cases, with a diagnostic accuracy that is slightly, but significantly, superior to that of 18F-NaF PET/CT in the general population of breast cancer patients. However, the extremely high sensitivity of 18F-fluoride PET/CT can exploit its diagnostic potential in specific clinical settings (i.e., small CT-evident sclerotic lesions, high clinical suspicious of relapse, and negative 18F-FDG PET and conventional imaging).

Keywords: 18F-sodium positron emission tomography/computed tomography, Breast cancer, Bone lesion, 2-deoxy-2-(18F)fluoro-D-glucose

Core tip:18F-fluorodeoxyglucose (18F-FDG) and 18F-sodium positron (18F-NaF) positron emission tomography/computed tomography (PET/CT) is undoubtedly an accurate and validated imaging tool in the general population of breast cancer patients for the detection of bone metastasis in most cases. However, thanks to its extremely high sensitivity, 18F-NaF PET/CT could have an adjunctive value in selected patients, significantly impacting their management (i.e., small CT-evident sclerotic lesions, high clinical suspicious of relapse, and negative 18F-FDG PET and conventional imaging). This sensitivity might be particularly relevant for patients who are candidates for surgery or radiotherapy.