Clinical experience with (18)F-fluorodeoxyglucose positron emission tomography and (123)I-metaiodobenzylguanine scintigraphy in pediatric neuroblastoma: complementary roles in follow-up of patients

Diagnostic Value of Seven Different Imaging Modalities for Patients with Neuroblastic Tumors: A Network Meta-Analysis

Objective

We performed a systematic review and network meta-analysis (NMA) to compare the diagnostic value of seven different imaging modalities for the detection of neuroblastic tumors in diverse clinical settings.

Methods

PubMed, Embase, Medline, and the Cochrane Library were searched to identify eligible studies from inception to Sep 29, 2020. Quality assessment of included studies was appraised with Quality Assessment of Diagnostic Accuracy Studies. Firstly, direct pairwise meta-analysis was conducted to calculate the pooled estimates of odds ratio (OR) and 95% confidence interval (CI) of the sensitivity, specificity, NPV, PPV, and DR. Next, NMA using Bayesian methods was performed. The superiority index was assessed to quantify the rank probability of a diagnostic test. The studies performed SPECT/CT or SPECT were analyzed separately from the ones only performed planar imaging.

Results

A total of 1135 patients from 32 studies, including 7 different imaging modalities, were eligible for this NMA. In the pairwise meta-analysis, ¹⁸F-FDOPA PET/CT had a relatively high value of all the outcomes (sensitivity: 10.195 [5.332–19.493]; specificity: 17.906 [5.950–53.884]; NPV: 16.819 [7.033–40.218]; PPV: 11.154 [4.216–29.512]; and DR 5.616 [3.609–8.739]). In the NMA, ¹⁸F-FDOPA PET/CT exhibited relatively high sensitivity in all subgroups (all data: 0.94 [0.87–0.98]; primary tumor: 0.89 [0.53–1]; bone/bone marrow metastases: 0.96 [0.83–1]; and primary tumor and metastases (P + M): 0.92 [0.80–0.97]), the highest specificity in the subgroup of P + M (0.85 [0.61–0.97]), and achieved the highest superiority index in the subgroups of all data (8.57 [1–15]) and P + M (7.25 [1–13]).

Conclusion

¹⁸F-FDOPA PET/CT exhibited the best diagnostic performance in the comprehensive detection of primary tumor and metastases for neuroblastic tumors, followed by ⁶⁸Ga-somatostatin analogs, ¹²³I-meta-iodobenzylguanidine (MIBG), ¹⁸F-FDG, and ¹³¹I-MIBG tomographic imaging.

Diagnostic Performance of 18F-FDG PET(CT) in Bone-Bone Marrow Involvement in Pediatric Neuroblastoma: A Systemic Review and Meta-Analysis

Objective

We sought to perform a systemic review and meta-analysis of the diagnostic performance of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (computed tomography) (PET(CT)) in detection of bone and/or bone marrow involvement (BMI) in pediatric neuroblastoma (NB).

Materials and Methods

We searched electronic databases Pubmed and Embase to retrieve relevant references. We calculated pooled sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR−), diagnostic odds ratio (DOR), and the area under the curve (AUC). Moreover, a summary receiver operating characteristic (SROC) curve and likelihood ratio dot plot were plotted. Study-between statistical heterogeneity was evaluated via I-square index (I²). Subgroup analyses were used to explore heterogeneity.

Results

Seven studies including 127 patients were involved in this meta-analysis. The overall sensitivity and specificity were 0.87 (95% CI: 0.65–0.96) with heterogeneity I² = 88.1% (p < 0.001) and 0.96 (95% CI: 0.67–1.00) with heterogeneity I² = 77.8% (p < 0.001), respectively. The pooled LR+, LR−, and DOR were 21.3 (95% CI: 2.1–213.9), 0.14 (95% CI: 0.05–0.40), and 157 (95% CI: 16–1532), respectively. The area under the SROC curve was 0.97 (95% CI: 0.95–0.98).

Conclusions

Through a meta-analysis, this study suggested that ¹⁸F-FDG PET(CT) has a good overall diagnostic accuracy in the detection of bone/BMI in pediatric neuroblastoma.

Nuclear Medicine Imaging in Neuroblastoma: Current Status and New Developments

Neuroblastoma is the most common extracranial solid malignancy in children. At diagnosis, approximately 50% of patients present with metastatic disease. These patients are at high risk for refractory or recurrent disease, which conveys a very poor prognosis. During the past decades, nuclear medicine has been essential for the staging and response assessment of neuroblastoma. Currently, the standard nuclear imaging technique is meta-[¹²³I]iodobenzylguanidine ([¹²³I]mIBG) whole-body scintigraphy, usually combined with single-photon emission computed tomography with computed tomography (SPECT-CT). Nevertheless, 10% of neuroblastomas are mIBG non-avid and [¹²³I]mIBG imaging has relatively low spatial resolution, resulting in limited sensitivity for smaller lesions. More accurate methods to assess full disease extent are needed in order to optimize treatment strategies. Advances in nuclear medicine have led to the introduction of radiotracers compatible for positron emission tomography (PET) imaging in neuroblastoma, such as [¹²⁴I]mIBG, [¹⁸F]mFBG, [¹⁸F]FDG, [⁶⁸Ga]Ga-DOTA peptides, [¹⁸F]F-DOPA, and [¹¹C]mHED. PET has multiple advantages over SPECT, including a superior resolution and whole-body tomographic range. This article reviews the use, characteristics, diagnostic accuracy, advantages, and limitations of current and new tracers for nuclear medicine imaging in neuroblastoma.

Roles of PET/Computed Tomography in the Evaluation of Neuroblastoma

Neuroblastoma is one of the most common pediatric malignant tumors. Functional imaging plays an important role in the diagnosis, staging, and therapy response monitoring of neuroblastoma. Although metaiodobenzylguanidine scan with single-photon emission computed tomography/computed tomography remains the mainstay in functional imaging of the neuroblastomas, PET/CT has begun to show increased utility in this clinical setting.

The Diagnostic Accuracy of PET(CT) in Patients With Neuroblastoma: A Meta-Analysis and Systematic Review

OBJECTIVE

The objective of this study was to evaluate the overall diagnostic value of PET(CT) in patients with neuroblastoma (NB) based on qualified studies.

METHODS

PubMed, Cochrane, and Embase database were searched by the index words to identify the qualified studies, and relevant literature sources were also searched. The latest research was performed in April 2019. Heterogeneity of the included studies was tested, which was used to select proper effect model to calculate pooled weighted sensitivity, specificity, and diagnostic odds ratio (DOR). Summary receiver operating characteristic (SROC) analyses were also performed.

RESULTS

Eleven studies with 580 patients were involved in the meta-analysis to explore the diagnostic accuracy of PET(CT) for NB. PET(CT) has high diagnostic accuracy of NB: the global sensitivity was 91% (95% confidence interval [CI], 86%-94%), the global specificity was 78% (95% CI, 66%-86%), the global positive likelihood ratio was 4.07 (95% CI, 2.54-6.50), the global negative likelihood ratio was 0.12 (95% CI, 0.08-0.18), the global DOR was 27.43 (95% CI, 14.45-52.07), and the area under the SROC was high (area under the curve, 0.93; 95% CI, 0.90-0.95). Besides this, PET(CT) has high diagnostic accuracy of primary NB: the global sensitivity was 86% (95% CI, 73%-93%), the global specificity was 82% (95% CI, 57%-94%), the global positive likelihood ratio was 4.90 (95% CI, 1.63-14.72), the global negative likelihood ratio was 0.17 (95% CI, 0.07-0.40), the global DOR was 25.427 (95% CI, 3.988-162.098), and the area under the SROC was high (area under the curve, 0.91; 95% CI, 0.88-0.93). However, there has no significant accuracy of PET(CT) in NB with bone marrow.

CONCLUSIONS

This study provides a systematic review and meta-analysis of diagnostic accuracy studies of PET(CT) for NB. The results indicated that PET(CT) is a highly accurate diagnostic tool for NB.

Comparison of diagnosing and staging accuracy of PET (CT) and MIBG on patients with neuroblastoma: Systemic review and meta-analysis

To perform a systemic review and meta-analysis of the diagnostic accuracy of PET (CT) and metaiodobenzylguanidine (MIBG) for diagnosing neuroblastoma (NB), electronic databases were searched as well as relevant references and conference proceedings. The diagnostic accuracy of MIBG and PET (CT) was calculated for NB, primary NB, and relapse/metastasis of NB based on their sensitivity, specificity, and area under the summary receiver operating characteristic curve (AUSROC) in terms of per-lesion and per-patient data. A total of 40 eligible studies comprising 1134 patients with 939 NB lesions were considered for the meta-analysis. For the staging of NB, the per-lesion AUSROC value of MIBG was lower than that of PET (CT) [0.8064±0.0414 vs. 0.9366±0.0166 (P<0.05)]. The per-patient AUSROC value of MIBG and PET (CT) for the diagnosis of NB was 0.8771±0.0230 and 0.6851±0.2111, respectively. The summary sensitivity for MIBG and PET (CT) was 0.79 and 0.89, respectively. The summary specificity for MIBG and PET (CT) was 0.84 and 0.71, respectively. PET (CT) showed higher per-lesion accuracy than MIBG and might be the preferred modality for the staging of NB. On the other hand, MIBG has a comparable diagnosing performance with PET (CT) in per-patient analysis but shows a better specificity.

Risk Stratification of Pediatric Patients With Neuroblastoma Using Volumetric Parameters of 18F-FDG and 18F-DOPA PET/CT

PURPOSE

This study determined the prognostic value of volumetric parameters derived from pretreatment F-FDG and F-DOPA PET/CT of neuroblastoma and their correlation with clinical and histopathologic features.

PATIENTS AND METHODS

A total of 25 children with neuroblastoma underwent pretreatment F-FDG and F-DOPA PET/CT within 4 weeks. The SUVmax of primary tumors on F-FDG and F-DOPA PET were recorded as SUVFDG and SUVDOPA, respectively. For volumetric parameters of primary tumors, 40% of SUVmax was used to generate volume of interest. If the 40% of SUVmax was below 2.5, an SUV threshold of 2.5 was used instead. Metabolic tumor volume (MTV), total lesion glycolysis (TLG), dopaminergic tumor volume (DTV), and total lesion F-DOPA activity (TLDA) were recorded as F-FDG and F-DOPA volumetric parameters. All indices were compared between groups distinguished by survival status and clinical features, including bone marrow involvement, lymph node metastasis, amplification of the MYCN oncogene, invasive features on anatomic images, and risk categories. The Kaplan-Meier method and log-rank test were used to compare the survival curves between groups.

RESULTS

The median follow-up period was 28.2 months. Nonsurvivors (20%) tended to have lower SUVDOPA, DTV, and TLDA (P ≤ 0.05), and higher SUVFDG, MTV, and TLG (all P < 0.05). Lower F-DOPA uptake is associated with bone marrow and lymph node metastases (all P < 0.05). Higher F-FDG uptake is associated with MYCN amplification (all P < 0.05) and anatomic invasive features of tumors such as vascular encasement or adjacent organ invasion (TLG, P = 0.05). Only volumetric indices (DTV, TLDA, MTV, and TLG) significantly differed among risk groups (all P < 0.05).

CONCLUSIONS

Pretherapeutic F-DOPA and F-FDG PET provided complementary information, and both can be served for risk stratification. Volumetric indices of F-DOPA and F-FDG PET correlate more highly with risk grouping.