FDG-PET/CT-guided biopsy of bone metastases sets a new course in patient management after extensive imaging and multiple futile biopsies

Clinical application of real-time PET/CT guided targeted retroperitoneal masses biopsy in diagnosing malignant tumors

OBJECTIVE

To explore the feasibility, safety, and clinical application value based on the fusion image of 18 F-FDG PET/CT, for guiding retroperitoneal puncture biopsy technology and to determine the diagnosis of retroperitoneal masses in diagnosing malignant tumors.

METHODS

From March 2019 to January 2023, 42 patients underwent 18 F-FDG PET/CT imaging and were found to have retroperitoneal lesions that required definite diagnosis; 22 were male, 20 were female, and the average age was(59.17 ± 13.23) years. According to the fused 18 F-FDG PET/CT tomographic image, the target point with the highest metabolic activity, the safest, and expected maximum sample size was selected. CT scans were acquired with the same machine and fused with 18 F-FDG PET, guiding the puncture biopsy needle to approach the expected target zone, enabling timely delivery of pathological and immunohistochemical examination of the biopsy. Success rate, total examination time, biopsy operation time, complications, CT radiation dose, pathological, and immunohistochemical results were recorded.

RESULTS

All 42 patients were sampled successfully with the successful rate being 100%. The site of sampling of 42 patients accurately targeted the highest metabolic activity, the safest, and the expected maximum sample size. All 42 patients received clear diagnosis (25 cases of malignant tumors and cases of 17 benign tissues). 15 cases of patients had a change in clinical diagnosis, accounting for 35.7% of all patients, and affecting subsequent treatment plans. The average total examination time for patients was (41.3 ± 7.3) minutes, and the biopsy operation time was (29.1 ± 8.7) minutes. The effective radiation dose generated by the entire examination generated by CT guidance was (2.0 ± 0.5) mSv; no severe complications occurred in the patients.

CONCLUSION

Real-time-guided retroperitoneal puncture biopsy based on 18 F-FDG PET/CT fusion image is safe, accurate, and feasible, and can provide patients of retroperitoneal mass with clear pathological diagnosis and immunohistochemical evaluation.

A case series on the role of 18F-FDG PET/CT-guided biopsy of osseous metastases

Purpose

This case series explores the utility of positron emission tomography (PET)/computed tomography (CT) guidance for biopsy of ¹⁸F-fludeoxyglucose (FDG)-avid osseous lesions that are inconspicuous on CT.

Methods

PET/CT-guided core biopsies were performed in four patients with suspected malignancies given ¹⁸F-FDG-avid osseous lesions that were inconspicuous on CT alone. The final diagnosis for each patient was determined by histopathological and molecular testing.

Results

PET/CT-guided biopsy yielded accurate sampling via core needle biopsy (CNB) with histopathological confirmation of osseous metastases of the primary malignancy as opposed to a secondary malignancy in three patients and ruled-out metastatic spread in the fourth.

Conclusion

PET/CT-guided biopsy of hypermetabolic osseous lesions that are inconspicuous on CT alone is an effective and safe diagnostic tool in patients with suspected malignancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41824-021-00095-1.

PET/CT-guided versus CT-guided percutaneous core biopsies in the diagnosis of bone tumors and tumor-like lesions: which is the better choice?

OBJECTIVE

The present study aimed to evaluate the diagnostic performance and safety of PET/CT-guided percutaneous core bone biopsy and to compare the PET/CT-guided method to conventional CT-guided percutaneous core biopsies to diagnose Chinese patients with bone tumors and tumor-like lesions.

METHODS

Data for 97 patients with bone tumors and tumor-like lesions diagnosed by percutaneous core bone biopsy from February 2013 to November 2018 were retrospectively analyzed. The study included 42 cases in the PET/CT group and 55 cases in the CT alone group. The diagnostic performance, cost and complications associated with the intervention were compared between the two groups. All patients were eventually confirmed to have bone tumors and tumor-like lesions according to surgical pathology findings.

RESULTS

There were no significant differences in patient characteristics (P > 0.05). For the patients in the PET/CT group, the overall diagnostic yield of the initial biopsies and the diagnostic accuracy derived from the surgically proven cases were both 97.62%, which was significantly higher than the values in the CT group during the same period (P < 0.05). No major biopsy-related complications (e.g., serious bleeding or tumor dissemination) occurred before, during, or after the intervention. Therefore, no significant difference was observed between the two groups with regard to the complication rate (P > 0.05).

CONCLUSION

Compared with CT-guided percutaneous bone biopsy, PET/CT-guided percutaneous bone biopsy is an effective and safe alternative with high diagnostic performance in the evaluation of hypermetabolic bone lesions to diagnose bone tumors and tumor-like lesions.

Gummatous Syphilis Mimicking Malignant Bone Tumor on FDG PET/CT

A 47-year-old woman suffered worsening pain in the waist and numbness in the right thigh for 1 month. MRI was performed to determine the cause, which detected an osteolytic lesion in the T12 vertebral body, suggestive of possible bone metastasis. FDG PET/CT scan was undertaken to detect the primary tumor, which only showed the same isolated lesion in the T12 without any other abnormal hypermetabolic lesion. The pathology following vertebrectomy revealed granulomatous infection. The diagnosis of osseous syphilis was eventually made following a subsequent positive Treponema pallidum serological test.

PET-CT gamma probe-guided lymph node biopsy: a new diagnostic surgical approach

PURPOSE

The higher sensitivity of new diagnostic tools makes it easier to detect relapse in asymptomatic stages when classic procedures of lymph node biopsies are difficult to perform. The aim of this article is to describe the combination of gamma probe and 18F-FDG positron emission tomography-computed tomography (PET-CT) images in combination with sentinel lymph node biopsy technique for detection of nonpalpable lymph nodes.

METHODS

After a dose of 18F-FDG was administered and PET-CT images that showed the location of suspected pathologic lymph nodes were obtained, transcutaneous localization of the lymph nodes with the highest captation of the tracer was done. The gamma probe was programmed to detect the radioactive signal from the F18, instead of the Tc99m that is usual in the sentinel node biopsy technique. Once the hottest point was detected, a short incision was made on this area, and suspicious nodes with the highest uptake registered by the gamma probe were localized and removed. After the surgical removal from the operating field, the surgical pieces stood positive to the gamma probe. Lymph node involvement, and subsequent relapse, was diagnosed before their clinical manifestation.

CONCLUSIONS

This methodology confirms new horizons for the surgical approach of lymph node biopsies in patients with previous tumors with 18F-FDG avidity and suspicion of relapse.

PET Molecular Imaging-Directed Biopsy: A Review

OBJECTIVE

The purpose of this review is to summarize the applications of PET molecular imaging-directed biopsy of a variety of organs in the management of various diseases with a focus on cancers.

CONCLUSION

PET can yield metabolic information at the cellular and molecular levels, and PET-directed biopsy is playing an increasing role in the diagnosis and staging of diseases.

Feasibility of a multimodal (18)F-FDG-directed lymph node surgical excisional biopsy approach for appropriate diagnostic tissue sampling in patients with suspected lymphoma

Background

¹⁸F-FDG PET/CT imaging is widely utilized in the clinical evaluation of patients with suspected or documented lymphoma. The aim was to describe our cumulative experience with a multimodal ¹⁸F-FDG-directed lymph node surgical excisional biopsy approach in patients with suspected lymphoma.

Methods

Thirteen patients (mean age 51 (±16;22–76) years), with suspected new or suspected recurrent lymphoma suggested by ¹⁸F-FDG-avid lesions seen on prior diagnostic whole-body PET/CT imaging, were injected IV with ¹⁸F-FDG prior to undergoing same-day diagnostic lymph node surgical excisional biopsy in the operating room. Various ¹⁸F-FDG detection strategies were used on the day of surgery, including, (1) same-day pre-resection patient PET/CT; (2) intraoperative gamma probe assessment; (3) clinical scanner specimen PET/CT imaging of whole surgically excised tissue specimens; (4) specimen gamma well counts; and/or (5) same-day post-resection patient PET/CT.

Results

Same-day ¹⁸F-FDG injection dose was 14.8 (±2.4;12.5-20.6) millicuries or 548 (±89;463–762) megabecquerels. Sites of ¹⁸F-FDG-avid lesions were 4 inguinal, 3 cervical, 3 abdominal/retroperitoneal, 2 axillary, and 1 gluteal region subcutaneous tissue. Same-day pre-resection patient PET/CT was performed on 6 patients. Intraoperative gamma probe assessment was performed on 13 patients. Clinical scanner PET/CT imaging of whole surgically excised tissue specimens was performed in 10 cases. Specimen gamma well counts were performed in 6 cases. Same-day post-resection patient PET/CT imaging was performed on 8 patients. Time from ¹⁸F-FDG injection to same-day pre-resection patient PET/CT, intraoperative gamma probe assessment, and same-day post-resection patient PET/CT were 76 (±8;64–84), 240 (±63;168–304), and 487 (±104;331–599) minutes, respectively. Time from ¹⁸F-FDG injection to clinical scanner PET/CT of whole surgically excised tissue specimens was 363 (±60;272–446) minutes. Time from ¹⁸F-FDG injection to specimen gamma well counts was 591 (±96;420–689) minutes. Intraoperative gamma probe assessment successfully identified ¹⁸F-FDG-avid lesions in 12/13 patients. Histopathologic evaluation confirmed lymphoma in 12/13 patients and benign disease in 1/13 patients.

Conclusions

A multimodal approach to ¹⁸F-FDG-directed lymph node surgical excisional biopsy for suspected lymphoma is technically feasible for guiding appropriate diagnostic tissue sampling of lymph nodes seen as ¹⁸F-FDG-avid lesions on diagnostic ¹⁸F-FDG PET/CT imaging.

Computed tomography-guided percutaneous biopsy of bone lesions: rate of diagnostic success and complications

OBJECTIVE

To determine the rates of diagnostic success and complications of computed tomography (CT)-guided percutaneous biopsy of bone lesions suspected for malignancy.

MATERIALS AND METHODS

Retrospective study including 186 cases of CT-guided percutaneous biopsies of bone lesions in the period from January, 2010 to December, 2012. All the specimens were obtained with 8-10 gauge needles. The following data were collected: demographics, previous history of malignancy, data related to the lesion, to the procedure, and to histological results.

RESULTS

Most patients were women (57%), and the mean age was 53.0 ± 16.4 years. In 139 cases (74.6%), there was diagnostic suspicion of metastasis and the most common primary tumors were breast (32.1%) and prostate (11.8%). The bones most commonly involved were spine (36.0%), hip (32.8%) and long bones (18.3%). Complications occurred in only three cases (1.6%) including bone fracture, paresthesia with functional impairment, and needle breakage requiring surgical removal. The specimens collected from 183 lesions (98.4%) were considered appropriate for diagnosis. Malignant results were more frequently found in patients who had a suspected secondary lesion and history of known malignancy (p < 0.001), and in patients who underwent PET/CT-guided procedures (p = 0.011).

CONCLUSION

CT-guided percutaneous biopsy is a safe and effective procedure for the diagnosis of suspicious bone lesions.

Initial Experience of Utilizing Real-Time Intra-Procedural PET/CT Biopsy

OBJECTIVES

Nonreal-time Positron Emission Tomography/Computed Tomography (PET/CT) biopsies that use the image co-registration of a prior PET with an intra-procedural CT have been reported. The aim of this study was to report the initial experience of performing real-time intra-procedural PET/CT-guided biopsies.

MATERIALS AND METHODS

All patients (n = 4) had a prior PET/CT examination of the concerning lesion and no significant CT correlate. On the day of the biopsy, 5 mCi of 18F-fluorodeoxyglucose (FDG) or NaF18 was intravenously injected. After 60 min of biodistribution of the molecular probe, PET/CT images were obtained in a limited one bed position over the region of the concerning lesion to be biopsied.

RESULTS

One patient had a mesenteric mass and the other three had bone lesions, one located in the rib and two in the iliac bone. The pathology report revealed that two lesions (50%) were malignant and two lesions (50%) were benign. The results of the biopsy changed management in all cases. There was 0% complication rate.

CONCLUSIONS

No additional software or hardware is required to perform real-time intra-procedural PET/CT-guided biopsies. It can optimize the yield, especially in cases where there are no anatomical abnormalities. Real-time intra-procedural PET/CT biopsy may have benefits over conventional biopsy techniques in terms of accuracy.

18F-FDG PET/CT oncologic imaging at extended injection-to-scan acquisition time intervals derived from a single-institution 18F-FDG-directed surgery experience: feasibility and quantification of 18F-FDG accumulation within 18F-FDG-avid lesions and background tissues

Background

¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) is a well-established imaging modality for a wide variety of solid malignancies. Currently, only limited data exists regarding the utility of PET/CT imaging at very extended injection-to-scan acquisition times. The current retrospective data analysis assessed the feasibility and quantification of diagnostic ¹⁸F-FDG PET/CT oncologic imaging at extended injection-to-scan acquisition time intervals.

Methods

¹⁸F-FDG-avid lesions (not surgically manipulated or altered during ¹⁸F-FDG-directed surgery, and visualized both on preoperative and postoperative ¹⁸F-FDG PET/CT imaging) and corresponding background tissues were assessed for ¹⁸F-FDG accumulation on same-day preoperative and postoperative ¹⁸F-FDG PET/CT imaging. Multiple patient variables and ¹⁸F-FDG-avid lesion variables were examined.

Results

For the 32 ¹⁸F-FDG-avid lesions making up the final ¹⁸F-FDG-avid lesion data set (from among 7 patients), the mean injection-to-scan times of the preoperative and postoperative ¹⁸F-FDG PET/CT scans were 73 (±3, 70-78) and 530 (±79, 413-739) minutes, respectively (P < 0.001). The preoperative and postoperative mean ¹⁸F-FDG-avid lesion SUV_max values were 7.7 (±4.0, 3.6-19.5) and 11.3 (±6.0, 4.1-29.2), respectively (P < 0.001). The preoperative and postoperative mean background SUV_max values were 2.3 (±0.6, 1.0-3.2) and 2.1 (±0.6, 1.0-3.3), respectively (P = 0.017). The preoperative and postoperative mean lesion-to-background SUV_max ratios were 3.7 (±2.3, 1.5-9.8) and 5.8 (±3.6, 1.6-16.2), respectively, (P < 0.001).

Conclusions

¹⁸F-FDG PET/CT oncologic imaging can be successfully performed at extended injection-to-scan acquisition time intervals of up to approximately 5 half-lives for ¹⁸F-FDG while maintaining good/adequate diagnostic image quality. The resultant increase in the ¹⁸F-FDG-avid lesion SUV_max values, decreased background SUV_max values, and increased lesion-to-background SUV_max ratios seen from preoperative to postoperative ¹⁸F-FDG PET/CT imaging have great potential for allowing for the integrated, real-time use of ¹⁸F-FDG PET/CT imaging in conjunction with ¹⁸F-FDG-directed interventional radiology biopsy and ablation procedures and ¹⁸F-FDG-directed surgical procedures, as well as have far-reaching impact on potentially re-shaping future thinking regarding the “most optimal” injection-to-scan acquisition time interval for all routine diagnostic ¹⁸F-FDG PET/CT oncologic imaging.

Feasibility of image-guided transthoracic core-needle biopsy in the BATTLE lung trial

BACKGROUND

As therapy for non-small-cell lung cancer (NSCLC) patients becomes more personalized, additional tissue in the form of core-needle biopsies (CNBs) for biomarker analysis is increasingly required for determining appropriate treatment and for enrollment into clinical trials. We report our experience with small-caliber percutaneous transthoracic (PT) CNBs for the evaluation of multiple molecular biomarkers in BATTLE (biomarker-integrated approaches of targeted therapy for lung cancer elimination), a personalized, targeted therapy NSCLC clinical trial.

METHODS

The medical records of patients who underwent PTCNB for consideration of enrollment in BATTLE were reviewed for diagnostic yield of 11 predetermined molecular markers and procedural complications. Univariate and multivariate analyses of factors related to patient and lesion characteristics were performed to determine possible influences on diagnostic yield.

RESULTS

One hundred and seventy PTCNBs were performed using 20-gauge biopsy needles in 151 NSCLC patients screened for the trial. The biopsy specimens of 82.9% of the patients were found to have adequate tumor tissue for analysis of the required biomarkers. On multivariate analysis, metastatic lesions were 5.4 times more likely to yield diagnostic tissue as compared with primary tumors (p = 0.0079). Pneumothorax and chest tube insertion rates were 15.3% and 9.4%, respectively.

CONCLUSIONS

Image-guided 20-gauge PTCNB is safe and provides adequate tissue for analysis of multiple biomarkers in the majority of patients being considered for enrollment into a personalized, targeted therapy NSCLC clinical trial. Metastatic lesions are more likely to yield diagnostic tissue as compared with primary tumors.