Whole-Body SPECT/CT versus Planar Bone Scan with Targeted SPECT/CT for Metastatic Workup

Olivier Rager, René Nkoulou, Nadia Exquis, Valentina Garibotto, Claire Tabouret-Viaud, Habib Zaidi, Gaël Amzalag, Stephanie Anne Lee-Felker, Thomas Zilli, Osman Ratib, Olivier Rager, René Nkoulou, Nadia Exquis, Valentina Garibotto, Claire Tabouret-Viaud, Habib Zaidi, Gaël Amzalag, Stephanie Anne Lee-Felker, Thomas Zilli, Osman Ratib

Abstract

Purpose: The use of SPECT/CT in bone scans has been widespread in recent years, but there are no specific guidelines concerning the optimal acquisition protocol. Two strategies have been proposed: targeted SPECT/CT for equivocal lesions detected on planar images or systematic whole-body SPECT/CT. Our aim was to compare the diagnostic accuracy of the two approaches.

Methods: 212 consecutive patients with a history of cancer were referred for bone scans to detect bone metastases. Two experienced readers randomly evaluated for each patient either planar images with one-field SPECT/CT targeted on equivocal focal uptakes (targeted SPECT/CT) or a whole-body (two-field) SPECT/CT acquisition from the base of the skull to the proximal femurs (whole-body SPECT/CT). The exams were categorized as "nonmetastatic," "equivocal," or "metastatic" on both protocols. The presence or absence of any extra-axial skeletal lesions was also assessed. The sensitivity and specificity of both strategies were measured using the results of subsequent imaging follow-up as the reference standard.

Results: Whole-body SPECT/CT had a significantly higher sensitivity than targeted SPECT/CT to detect bone metastases (p = 0.0297) and to detect extra-axial metastases (p = 0.0266). There was no significant difference in specificity among the two approaches.

Conclusion: Whole-body SPECT/CT is the optimal modality of choice for metastatic workup, including detection of extra-axial lesions, with improved sensitivity and similar specificity compared to targeted SPECT/CT.

Figures

Figure 1
Figure 1
Metastatic workup for prostate cancer. Based on planar scintigraphy (a), a targeted SPECT/CT was acquired of the thorax. MIP of the SPECT (b) shows two areas of focal uptake corresponding to fractures on axial SPECT/CT (c) in the anterior third (c, up) and fourth ribs (c, down). The patient was classified as “not metastatic.”
Figure 2
Figure 2
Whole-body SPECT/CT of the same patient as in Figure 1. Not only did the MIP-SPECT (a) show the 2 rib fractures seen in Figure 1, but also it showed an area of focal uptake in the superior pubic ramus. SPECT/CT fusion (b) shows focal uptake within the medullary bone without any correlative abnormality on the CT (c), and the patient was classified as “metastatic.”
Figure 3
Figure 3
Prostate cancer patient with a history of carcinoma of the larynx. Markedly increased uptake relative to soft tissue, with absence of the urinary tract activity, consistent with Super Bone Scan on planar scintigraphy (a). MIP-SPECT (b) shows heterogeneous radiotracer uptake. Sagittal SPECT/CT (c) revealed diffuse metastases based on multiple areas of focal uptake and corresponding areas of sclerosis. The tracheotomy, in relationship with the treatment of the carcinoma of the larynx, is also visible on the images.
Figure 4
Figure 4
Breast cancer patient. Planar scintigraphy (a) showed artifactual uptake in a subclavian catheter, focal uptake at the 8th rib costochondral junction considered as a fracture, and heterogeneity of the thoracic spine without any focal uptake. MIP-SPECT (b) shows 3 additional areas of focal uptake: in L5-S1 corresponding to degenerative changes on the sagittal SPECT/CT (c), in the vertebral body of T9 (c), and in the right scapula (d) without lesion seen on CT, classified as “metastatic.”

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