The role of whole-body FDG PET/CT, Tc 99m MDP bone scintigraphy, and serum alkaline phosphatase in detecting bone metastasis in patients with newly diagnosed lung cancer

Imaging in Lung Cancer Staging

Lung cancer remains one of the leading causes of mortality worldwide, as well as in the United States. Clinical staging, primarily with imaging, is integral to stratify patients into groups that determine treatment options and predict survival. The eighth edition of the tumor, node, metastasis (TNM-8) staging system proposed in 2016 by the International Association for the Study of Lung Cancer remains the current standard for lung cancer staging. The system is used for all subtypes of lung cancer, including non-small cell lung cancer, small cell lung cancer, and bronchopulmonary carcinoid tumors.

An acid-responsive DNA hydrogel-mediated cascaded enzymatic nucleic acid amplification system for the sensitive imaging of alkaline phosphatase in living cells

Alkaline phosphatase (ALP) is a class of hydrolase that catalyzes the dephosphorylation of phosphorylated species in biological tissues, playing an important role in many physiological and pathological processes. Sensitive imaging of ALP activity in living cells is contributory to the research on these processes. Herein, we propose an acid-responsive DNA hydrogel to deliver a cascaded enzymatic nucleic acid amplification system into cells for the sensitive imaging of intracellular ALP activity. The DNA hydrogel is formed by two kinds of Y-shaped DNA monomers and acid-responsive cytosine-rich linkers. The amplification system contained Bst DNA polymerase (Bst DP), Nt.BbvCI endonuclease, a Recognition Probe (RP, containing a DNAzyme sequence, a Nt.BbvCI recognition sequence, and a phosphate group at the 3'-end), and a Signal Probe (SP, containing a cleavage site for DNAzyme, Cy3 and BHQ2 at the two ends). The amplification system was trapped into the DNA hydrogel and taken up by cells, and the cytosine-rich linkers folded into a quadruplex i-motif in the acidic lysosomes, leading to the collapse of the hydrogel and releasing the amplification system. The phosphate groups on RPs were recognized and removed by the target ALP, triggering a polymerization-nicking cycle to produce large numbers of DNAzyme sequences, which then cleaved multiple SPs, restoring Cy3 fluorescence to indicate the ALP activity. This strategy achieved sensitive imaging of ALP in living HeLa, MCF-7, and NCM460 cells, and realized the sensitive detection of ALP in vitro with a detection limit of 2.0 × 10-5 U mL-1, providing a potential tool for the research of ALP-related physiological and pathological processes.

Potential biomarkers for the early detection of bone metastases

The clinical manifestations of bone metastases are diversified while many sites remain asymptomatic at early stage. As the early diagnosis method is not perfect and the early symptoms of tumor bone metastasis are not typical, bone metastasis is not easy to be detected. Therefore, the search for bone metastasis-related markers is effective for timely detection of tumor bone metastases and the development of drugs to inhibit bone metastases. As a result, bone metastases can only be diagnosed when symptoms are found, increasing the risk of developing skeletal-related event (SREs), which significantly impairs the patient's quality of life. Therefore, the early diagnosis of bone metastases is of great importance for the treatment and prognosis of cancer patients. Changes of bone metabolism indexes appear earlier in bone metastases, but the traditional biochemical indexes of bone metabolism lack of specificity and could be interfered by many factors, which limits their application in the study of bone metastases. Some new biomarkers of bone metastases have good diagnostic value, such as proteins, ncRNAs, circulating tumor cells (CTCs). Therefore, this study mainly reviewed the initial diagnostic biomarkers of bone metastases which were expected to provide references for the early detection of bone metastases.

Single-Molecule Biosensing of Alkaline Phosphatase in Cells and Serum Based on Dephosphorylation-Triggered Catalytic Assembly and Disassembly of the Fluorescent DNA Chain

Alkaline phosphatase (ALP) is a valuable biomarker and effective therapeutic target for the diagnosis and treatment of diverse human diseases, including bone disorder, cardiovascular disease, and cancers. The reported ALP assays often suffer from laborious procedures, costly reagents, inadequate sensitivity, and large sample consumption. Herein, we report a new single-molecule fluorescent biosensor for the simple and ultrasensitive detection of ALP. In this assay, the ALP-catalyzed dephosphorylation of detection probe can protect the detection probe against lambda exonuclease-mediated digestion, and the remaining detection probes can trigger ceaseless hybridization between two Cy5-labeled hairpin probes through toehold-mediated DNA strand displacement, generating a long fluorescent DNA chain, which can be subsequently separated from unhybridized hairpin probes and disassembled into dispersed Cy5 moieties upon NaOH treatment. The free Cy5 moieties indicate the presence of ALP and can be directly quantified via single-molecule counting. This biosensor enables efficient amplification and transduction of the target ALP signal through enzyme-free assembly and disassembly processes, significantly simplifying the experimental procedure and improving the assay accuracy. The proposed biosensor allows specific and ultrasensitive detection of ALP activity with a detection limit down to 2.61 × 10^-6 U mL^-1 and is suitable for ALP inhibition assay and kinetic analysis. Moreover, this biosensor can be applied for endogenous ALP detection in human cells and clinical human serum, holding the potential in the ALP biological function study and clinical diagnosis.

Multimodal Imaging-Based Potential Visualization of the Tumor Microenvironment in Bone Metastasis

Bone metastasis (BM) is the most common malignant bone tumor and a significant cause of morbidity and mortality for patients with cancer. Compared to other metastatic organs, bone has unique characteristics in terms of the tumor microenvironment (TME). Precise assessments of the TME in BM could be an important step for developing an optimized management plan for patient care. Imaging approaches for BM have several advantages, such as biopsy not being required, multiple site evaluation, and serial assessment in the same sites. Owing to the developments of new imaging tracers or imaging modalities, bone TME could be visualized using multimodal imaging techniques. In this review, we describe the BM pathophysiology, diagnostic principles of major imaging modalities, and clinically available imaging modalities to visualize the TME in BM. We also discuss how the interactions between various factors affecting the TME could be visualized using multimodal imaging techniques.

Alkaline phosphatase (alp) levels in multiple myeloma and solid cancers with bone lesions: Is there any difference?

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Plasma ALP could be used as a discriminating marker in presence of bone lesions in solid tumor or MM.

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Multiple Myeloma, ALP values were mainly in the range of normality than those observed in patients with solid cancers and bone lesions.

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Lower or normal values, should suggest further investigations such as urinary and serum electrophoresis.

Introduction

Bone involvement in Multiple Myeloma results from increased osteoclast formation and activity that occurs in proximity to myeloma cells. The role of Alkaline Phosphatse (ALP) in this process and the diagnostic significance of plasma levels in patients with MM are unclear.

Aim

To compare plasma ALP levels in patients with MM and solid cancers and metastatic lesions to the bone.

Results

In this observational retrospective study we enrolled 901 patients were enrolled: 440 patients (49%) with Multiple Myeloma, 461 (51%) with solid cancers. All 901 patients had bone lesions. Among patients with Multiple Myeloma, ALP values were mainly in the range of normality than those observed in patients with solid cancers and bone lesions. This difference is independent of stage, number and type of bone lesions.

Conclusion

This study suggests that plasma ALP has a different clinical significance in MM than in other neoplasms and could be used as a discriminating marker in presence of bone lesions. In particular, lower or normal values, should suggest further investigations such as urinary and serum electrophoresis, associated with bone marrow aspirate in case of the presence of a monoclonal component, in order to confirm or exclude a MM diagnosis.

Role of 18F-FDG PET/CT in establishing new clinical and therapeutic modalities in lung cancer. A short review

Lung cancer is a fairly common malignancy. An early diagnosis and a reliable staging and re-staging with the aim to detect both local and distant relapse are of utmost importance in planning the therapeutic management. The imaging diagnostic work-up of patients with lung cancer usually includes conventional imaging (chest X-ray, contrast-enhanced CT, bone scan) and more recently ¹⁸F-FDG PET/CT. Great advances in the management of lung cancer are based on the information provided by ¹⁸F-FDG PET/CT, as it supplies both metabolic and anatomic information (better localisation). There is vast evidence in the literature demonstrating its utility in (a) characterising benign versus malignant solitary nodules, (b) staging and re-staging lung cancer, (c) guiding the type of therapy, (d) monitoring treatment response and (e) predicting outcome. In particular, given its specificity in differentiating ¹⁸F-FDG-avid relapse from post-surgical changes or post-radiation fibrosis (which do not take up ¹⁸F-FDG), PET/CT can detect recurrent disease after initial treatment and (being a whole-body technique) has demonstrated high accuracy in the detection of distant metastases or secondary tumours. In conclusion, ¹⁸F-FDG PET/CT can be considered a highly accurate and reliable method for staging and re-staging lung cancer, and is highly effective in guiding personalised therapies.

Bone turnover markers and novel biomarkers in lung cancer bone metastases

CONTEXT

Lung cancer still remains the leading cause of cancer-related mortality worldwide. Bone is one of preferred metastatic sites for lung cancer cells. So far, both accurate diagnosis and effective treatment of lung cancer bone metastases are difficult.

OBJECTIVE

This review aimed to evaluate roles of bone turnover markers (BTMs), microRNAs (miRNAs), dickkopf1 (DKK1) and insulin like growth factor binding protein 3 (IGFBP-3) in lung cancer bone metastases.

METHODS

We searched articles about these four biomarkers in lung cancer bone metastases mainly in PubMed.

RESULT

The levels of bone specific alkaline phosphatase (BALP), cross-linked carboxy-terminal telopeptide of type-I collagen (ICTP) and N-terminal telopeptides of type-I collagen (NTX) were reported to be significantly increased in lung cancer patients with bone metastases. ALP, NTX and bone sialoprotein were thought to be associated with prognosis of lung cancer patients with bone metastases. MiRNA-335, miRNA-33a, miRNA-21, DKK1 and IGFBP-3 were revealed to be novel biomarkers in lung cancer bone metastases.

DISCUSSION AND CONCLUSION

Current researches have revealed that BTMs, miRNAs, DKK1 and IGFBP-3 may be useful in diagnosis, prognosis evaluation or treatment of lung cancer bone metastases. More studies about these biomarkers in lung cancer bone metastases are needed.

Bone metastases from lung cancer: A paradigm for multidisciplinary onco-rheumatology management

Bone is the third metastatic site after liver and lungs. Bone metastases occur in one out of three lung cancers and are usually of osteolytic aspect. Osteolytic bone metastases are responsible of long bone and vertebral fractures leading to restricted mobility, surgery and medullar compression that severely alter quality of life and that have a huge medico-economic impact. In the recent years, Bone Metastatic Multidisciplinary Tumour Board (BM²TB) have been developed to optimize bone metastases management for each patient in harmony with oncology program. In this review, we will go through all the different aspects of bone metastases management including diagnosis and evaluation (CT scan, Tc 99m-MDP bone scan, ¹⁸FDG-PET scan and biopsy for molecular diagnosis), systemic bone treatments (zoledronic acid and denosumab) and local treatments (interventional radiology and radiotherapy). Surgical strategies will be discussed elsewhere. Based on the last 2017-Lung Cancer South East French Guidelines, we present a practical decision tree to help the physicians for decision making in order to reach a personalized locomotor strategy for every patient.

Staging Lung Cancer: Metastasis

The updated eighth edition of the tumor, node, metastasis (TNM) classification for lung cancer includes revisions to T and M descriptors. In terms of the M descriptor, the classification of intrathoracic metastatic disease as M1a is unchanged from TNM-7. Extrathoracic metastatic disease, which was classified as M1b in TNM-7, is now subdivided into M1b (single metastasis, single organ) and M1c (multiple metastases in one or multiple organs) descriptors. In this article, the rationale for changes in the M descriptors, the utility of preoperative staging with PET/computed tomography, and the treatment options available for patients with oligometastatic disease are discussed.

Development and external validation of nomograms to predict the risk of skeletal metastasis at the time of diagnosis and skeletal metastasis-free survival in nasopharyngeal carcinoma

Background

The skeletal system is the most common site of distant metastasis in nasopharyngeal carcinoma (NPC); various prognostic factors have been reported for skeletal metastasis, though most studies have focused on a single factor. We aimed to establish nomograms to effectively predict skeletal metastasis at initial diagnosis (SMAD) and skeletal metastasis-free survival (SMFS) in NPC.

Methods

A total of 2685 patients with NPC who received bone scintigraphy (BS) and/or 18F–deoxyglucose positron emission tomography/computed tomography (18F–FDG PET/CT) and 2496 patients without skeletal metastasis were retrospectively assessed to develop individual nomograms for SMAD and SMFS. The models were validated externally using separate cohorts of 1329 and 1231 patients treated at two other institutions.

Results

Five independent prognostic factors were included in each nomogram. The SMAD nomogram had a significantly higher c-index than the TNM staging system (training cohort, P = 0.005; validation cohort, P < 0.001). The SMFS nomogram had significantly higher c-index values in the training and validation sets than the TNM staging system (P < 0.001 and P = 0.005, respectively). Three proposed risk stratification groups were created using the nomograms, and enabled significant discrimination of SMFS for each risk group.

Conclusion

The prognostic nomograms established in this study enable accurate stratification of distinct risk groups for skeletal metastasis, which may improve counseling and facilitate individualized management of patients with NPC.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3630-9) contains supplementary material, which is available to authorized users.

Comparison of 18FDG PET/PET-CT and bone scintigraphy for detecting bone metastases in patients with nasopharyngeal cancer: a meta-analysis

OBJECTIVE

We performed a meta-analysis to compare the diagnostic efficacy of ¹⁸FDG PET/PET-CT and bone scintigraphy (BS) for diagnosing bone metastatic cancers in nasopharyngeal cancer patients.

RESULTS

6 studies (1238 patients) fulfilled the inclusion criteria. The pooled sensitivities for ¹⁸FDG PET/PET-CT and BS were 0.81 (95% confidence interval [CI] = 0.70 to 0.98) and 0.39 (95% CI = 0.26 to 0.54), specificities were 0.99 (95% CI = 0.98 to 0.99) and 0.98 (95% CI = 0.96 to 0.99), and the areas under curve were 0.98 (95% CI = 0.97 to 0.99) and 0.84 (95% CI = 0.81 to 0.87).

MATERIALS AND METHODS

Several databases were searched for all available articles. We calculated the sensitivities, specificities, diagnostic odds ratios, likelihood ratios, and area under summary receiver operating characteristic curves for ¹⁸FDG PET/PET-CT and BS, respectively.

CONCLUSIONS

¹⁸FDG PET/PET-CT is superior to BS for diagnosing bone metastases in nasopharyngeal cancer patients.¹⁸FDG PET/PET-CT may enhance the diagnosis of bone metastases and provide more accurate information for the optimal management of nasopharyngeal cancer.

A meta-analysis survey of appropriate bone turnover markers in the detection of bone metastasis in lung cancer

BACKGROUND

A number of studies have investigated the clinical significance of bone turnover markers (BTMs) for the diagnosis of bone metastasis (BM) in lung cancer; however, they led to contradictory results. The aim of this meta-analysis was to investigate whether BTMs differ between lung cancer patients with and without BM.

METHODS

Articles were identified by searching Medline, Embase, Web of Science and Scopus. The studies that were identified were pooled and the weighted mean difference (WMD) and its corresponding 95% confidence interval (CI) were calculated. Subgroup analyses and publication bias detection were also conducted.

RESULTS

A final analysis of 1720 subjects (707 patients with BM and 1013 patients without BM) was performed from 16 cohort studies. From the pooled data in the meta-analysis, the total alkaline phosphatase (TALP) (104.35 U/l [95% CI 33.36-175.34]), bone-specific ALP (BALP) (13.24 μg/l [95% CI 8.50-17.98] or 6.84 U/l [95% CI 2.98-10.70]), C-terminal cross-linked telopeptide of type I collagen (ICTP) (5.07 μg/l [95% CI 3.58-6.56]) and N-terminal cross-linked telopeptide of type I collagen (NTX) (5.08 nM bone collagen equivalent/l [95% CI 2.82-7.33]) were significantly lower among BM patients than non-BM patients. Subgroup analyses detected that the serum level of tartrate-resistant acid phosphatase isoform 5b was significantly reduced in Caucasian patients with BM (-0.64 U/l [95% CI -1.02 to -0.25]), while increased in Asian patients with BM (2.69 U/l [95% CI 0.08-5.31]), compared to patients without BM.

CONCLUSIONS

The present meta-analysis suggested that serum measurement of TALP, BALP, ICTP and NTX might be helpful in detecting BM in lung cancer.

Multi-technique imaging of bone metastases: spotlight on PET-CT

There is growing evidence that molecular imaging of bone metastases with positron-emission tomography (PET) can improve diagnosis and treatment response assessment over current conventional standard imaging methods, although cost-effectiveness has not been assessed. In most cancer types, 2-[(18)F]-fluoro-2-deoxy-d-glucose ((18)F-FDG)-PET is an accurate method for detecting bone metastases. For example, in breast cancer, combined (18)F-FDG-PET and computed tomography (CT) is more sensitive at detecting bone metastases than (99m)technetium (Tc)-labelled diphosphonate planar bone scintigraphy (BS) and there is increasing evidence to support the use of serial (18)F-FDG-PET for the assessment of osseous response to treatment. Preliminary data suggest improved diagnostic accuracy of (18)F-FDG-PET-CT in a number of other malignancies including lung, thyroid, head and neck, gastro-oesophageal cancers, and osteosarcoma. As a bone-specific tracer, there is accumulating evidence to support the use of sodium (18)F-fluoride ((18)F-NaF) PET-CT in the diagnosis of skeletal metastases in breast and prostate cancer, although relatively little data are available to support its use for assessment of treatment response. In prostate cancer, (11)C-choline and (18)F-choline PET-CT have better specificities than (18)F-NaF-PET-CT, but equivalent sensitivities in the detection of bone metastases. We review the current literature for staging and response assessment of bone metastases in different cancers.

Diagnostic value of bone-specific alkaline phosphatase in lung carcinoma patients with bone metastases: a meta-analysis

Aim and Backgrounds: The accurate diagnosis of lung carcinoma patients with bone metastases is crucial for therapy and the prevention of complications. We performed a systematic review and meta-analysis to evaluate the diagnostic value of serum bone-specific alkaline phosphatase (BALP) in lung carcinoma patients with bone metastases.

METHODS

Such databases as PubMed, Embase, Cochrane Library, Web of Science, Ovid, BioMed Central, Biosis previews and four Chinese databases (Chinese Biomedical Literature Database-disc (CBM), Chinese National Knowledge Infrastructure (CNKI), Technology of Chongqing (VIP) and Wan Fang DATA) were retrieved on computer, and the relevant journals were also manually searched to collect the trials on BALP in diagnosis of lung carcinoma patients with bone metastases. The meta-analysis was conducted by using Meta-Disc 1.4 software.

RESULTS

A total of 8 studies were included, and there were 848 lung carcinoma patients diagnosed by gold standard, patients were divided into two groups: 419 cases with bone metastases and 429 cases without bone metastases. The meta-analysis showed that, the pooled sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) was 0.48 [95% CI (0.43 to 0.53)], 0.86 [95% CI (0.82 to 0.89)], 3.14 [95% CI (2.47 to 3.99)], 0.62 [95% CI (0.56 to 0.68)], 6.66 [95% CI (4.62 to 9.60)] respectively. And the AUC of SROC was 0.78, (Q*=0.72).

CONCLUSION

BALP has greater diagnostic value in detecting lung carcinoma patients with bone metastases. However, further large scale studies are required to confirm the predictive value.

A Case of Massive Bone Metastases From Lung Cancer Detected Only by 18F-FDG PET/CT

A 74-year-old man was diagnosed with small cell lung carcinoma in the left upper lobe. (18)F-FDG PET/CT showed multifocal strong abnormal uptakes in the axial skeleton and those of the primary lung tumor. CT failed to demonstrate the bony abnormalities. A subsequent (99m)Tc-MDP bone scintigraphy was also almost negative. It is important to note that bone metastasis may be undetectable by both CT and bone scintigraphy even if it is massive.

Staging of lung cancer

Primary lung cancer is the leading cause of cancer mortality in the world. Thorough clinical staging of patients with lung cancer is important, because therapeutic options and management are to a considerable degree dependent on stage at presentation. Radiologic imaging is an essential component of clinical staging, including chest radiography in some cases, computed tomography, MRI, and PET. Multiplanar imaging modalities allow assessment of features that are important for surgical, oncologic, and radiation therapy planning, including size of the primary tumor, location and relationship to normal anatomic structures in the thorax, and existence of nodal and/or metastatic disease.

Improved detection of bone metastases from lung cancer in the thoracic cage using 5- and 1-mm axial images versus a new CT software generating rib unfolding images: comparison with standard ¹⁸F-FDG-PET/CT

RATIONALE AND OBJECTIVES

To evaluate the performance of a dedicated computed tomography (CT) software called "bone reading" generating rib unfolded images for improved detection of rib metastases in patients with lung cancer in comparison to readings of 5- and 1-mm axial CT images and (18)F-Fluordeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT).

MATERIALS AND METHODS

Ninety consecutive patients who underwent (18)F-FDG-PET/CT and chest CT scanning between 2012 and 2014 at our institution were analyzed retrospectively. Chest CT scans with 5- and 1-mm slice thickness were interpreted blindly and separately focused on the detection of rib metastases (location, number, cortical vs. medullary, and osteoblastic vs. sclerotic). Subsequent image analysis of unfolded 1 mm-based CT rib images was performed. For all three data sets the reading time was registered. Finally, results were compared to those of FDG-PET. Validation was based on FDG-PET positivity for osteolytic and mixed osteolytic/osteoblastic focal rib lesions and follow-up for sclerotic PET-negative lesions.

RESULTS

A total of 47 metastatic rib lesions were found on FDG-PET/CT plus another 30 detected by CT bone reading and confirmed by follow-up CT. Twenty-nine lesions were osteolytic, 14 were mixed osteolytic/osteoblastic, and 34 were sclerotic. On a patient-based analysis, CT (5 mm), CT (1 mm), and CT (1-mm bone reading) yielded a sensitivity, specificity, and accuracy of 76.5/97.3/93, 81.3/97.3/94, and 88.2/95.9/92, respectively. On segment-based (unfolded rib) analysis, the sensitivity, specificity, and accuracy of the three evaluations were 47.7/95.7/67, 59.5/95.8/77, and 94.8/88.2/92, respectively. Reading time for 5 mm/1 mm axial images and unfolded images was 40.5/50.7/21.56 seconds, respectively.

CONCLUSIONS

The use of unfolded rib images in patients with lung cancer improves sensitivity and specificity of rib metastasis detection in comparison to 5- and 1-mm CT slice reading. Moreover, it may reduce the reading time.

A comparative study of 18F-fluorodeoxyglucose positron emission tomography/computed tomography and (99m)Tc-MDP whole-body bone scanning for imaging osteolytic bone metastases

Background

The objective of this study was to evaluate the feasibility and diagnostic value of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) and ^99mTc-methylenediphosphonate (MDP) whole-body bone scanning (BS) for the detection of osteolytic bone metastases.

Methods

Thirty-four patients with pathologically confirmed malignancies and suspected osteolytic bone metastases underwent ¹⁸F-FDG PET/CT and ^99mTc-MDP whole-body BS within 30 days. The sensitivity, specificity, and accuracy with respect to the diagnosis of osteolytic bone metastases and bone lesions were compared between the two imaging methods.

Results

The sensitivity, specificity, and accuracy of ¹⁸F-FDG PET/CT for the diagnosis of osteolytic bone metastases were 94.3% (95% confidence interval [CI], 91.6–96.2%), 83.3% (95% CI, 43.6–96.9%), and 94.2% (95% CI, 91.5–96.1%), respectively. It was found that ^99mTc-MDP whole-body BS could discriminate between patients with 50.2% (95% CI, 45.4–55.1%) sensitivity, 50.0% (95% CI, 18.8–81.2%) specificity, and 50.2% (95% CI, 45.5–55.1%) accuracy. ¹⁸F-FDG PET/CT achieved higher sensitivity, specificity, and accuracy in detecting osteolytic bone metastases than 99mTc-MDP whole-body BS (p<0.001).

Conclusions

F-FDG PET/CT has a higher diagnostic value than ^99mTc-MDP whole-body BS in the detection of osteolytic bone metastases, especially in the vertebra.

PET-based radiation therapy planning

In this review, we review the literature on the use of PET in radiation treatment planning, with an emphasis on describing our institutional methodology (where applicable). This discussion is intended to provide other radiation oncologists with methodological details on the use of PET imaging for treatment planning in radiation oncology, or other oncologists with an introduction to the use of PET in planning radiation therapy.

Cytotoxicity and enzyme inhibition studies of polyoxometalates and their chitosan nanoassemblies

Polyoxometalates (POMs) have become very significant in biomedical research for their structural diversity which renders them highly active against bacterial, viral and cancer diseases. In this study three different POMs were synthesized and nanoassemblies were made with chitosan (CTS), a natural biodegradable polymer with excellent drug carrier properties. The compounds were tested on two isoenzymes of alkaline phosphatases including tissue specific calf intestine alkaline phosphatase (CIAP) and tissue non-specific alkaline phosphatase (TNAP). Compound [TeW₆O₂₄]⁶⁻ (TeW₆) showed the highest activity (45.4 ± 11.3 nM) among tested compounds against TNAP. Similarly, chitosan-[TeW₆O₂₄]⁶⁻ (CTS-TeW₆) was proved to be a potent inhibitor of CIAP with K_i value of 22 ± 7 nM. A comparative study was made to evaluate their cytotoxic potential against HeLa cells. Among all tested compounds, Chitosan-[NaP₅W₃₀O₁₁₀]¹⁴⁻ (CTS-P₅W₃₀) has showed higher percent cytotoxicity (88 ± 10%) at 10 μM when compared with the standard anticancer drug vincristine (72 ± 7%). The study revealed that selected POMs proved excellent anticancer potential and were equally effective against alkaline phosphatase enzyme, an increased level of which may indicate cancer metastasis.

Is there any significance of lung cancer histology to compare the diagnostic accuracies of (18)F-FDG-PET/CT and (99m)Tc-MDP BS for the detection of bone metastases in advanced NSCLC?

Aim of the study

Bone scintigraphy (BS) and fluorine-18 deoxyglucose positron emission tomography computed tomography (¹⁸F-FDG-PET/CT) are widely used for the detection of bone involvement. The optimal imaging modality for the detection of bone metastases in histological subgroups of non-small cell lung cancer (NSCLC) remains ambiguous. The aim of this study was to compare the efficacy of ¹⁸F-FDG-PET/C and 99mTc-methylene diphosphonate (^99mTc-MDP) BS in the detection of bone metastases of patients in NSCLC. Specifically, we compared the diagnostic accuracies of these imaging techniques evaluating bone metastasis in histological subgroups of NSCLC.

Material and methods

Fifty-three patients with advanced NSCLC, who had undergone both ¹⁸F-FDG-PET/CT and BS and were eventually diagnosed as having bone metastasis, were enrolled in this retrospective study.

Results

The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ¹⁸F-FDG-PET/CT and BS were 90.4%, 99.4%, 98.1%, 96.6%, 97.0% and 84.6%, 93.1%, 82.5%, 93.2, 90.8%, respectively. The κ statistics were calculated for ¹⁸F-FDG-PET/CT and BS. The κ-value was 0.67 between ¹⁸F-FDG-PET/CT and BS in all patients. On the other hand, the κ-value was 0.65 in adenocarcinoma, and 0.61 in squamous cell carcinoma between ¹⁸F-FDG-PET/CT and BS. The κ-values suggested excellent agreement between all patients and histological subgroups of NSCLC.

Conclusions

¹⁸F-FDG-PET/CT was more favorable than BS in the screening of metastatic bone lesions, but the trend did not reach statistical significance in all patients and histological subgroups of NSCLC. Our results need to be validated in prospective and larger study clinical trials to further clarify this topic.

[Correlation of the levels of the bone turnover markers BAP and β-CTX with bone metastasis progress in lung cancer patients]

背景与目的

肺癌易发生骨转移，Ⅰ型胶原羧基端肽β特殊序列（β isomer of C-terminal telopeptide of type Ⅰ collagen, β-CTX）和骨源性碱性磷酸酶（bone-specific alkaline phosphates, BAP）在骨质代谢中是重要的生化标记物，本研究旨在探讨骨代谢生化指标和肺癌骨转移进展程度的相关性，有助于早期判断是否有肺癌骨转移的发生。

方法

天津市人民医院2009年7月-2012年7月共收治92例肺癌并发生骨转移患者，全部病例其原发灶均经细胞学检查证实，骨转移灶的数目及类型经ECT结合X线片、CT证实，采用ELISA方法检测血β-CTX、BAP的浓度水平。

结果

收集的92例肺癌伴骨转移的患者中，转移灶 < 3处为58例，≥3处为34例；溶骨型68例，成骨型9例，混合型15例。血β-CTX、BAP水平在不同的骨转移数目组间差异有统计学意义（P < 0.05），β-CTX在肺癌溶骨型骨转移患者中具有较高的敏感性。

结论

骨代谢生化指标β-CTX、BAP对肺癌骨转移具有辅助诊断意义，是判断转移进展程度的良好指标。

¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography for the evaluation of bone metastasis in patients with gastric cancer

BACKGROUND

The roles of positron emission tomography and bone scanning in identifying bone metastasis in gastric cancer are unclear.

AIM

We compared the usefulness of positron emission tomography-computed tomography and scanning in detecting bone metastasis in gastric cancer.

METHODS

Data from 1485 patients diagnosed with gastric cancer who had undergone positron emission tomography-computed tomography and scanning were reviewed. Of 170 enrolled patients who were suspected of bone metastasis in either positron emission tomography or scanning, 81.2% were confirmed to have bone metastasis.

RESULTS

The sensitivity, specificity, and accuracy were 93.5%, 25.0%, and 80.6%, respectively, for positron emission tomography and 93.5%, 37.5%, and 82.9%, respectively, for scanning. 87.7% of patients with bone metastasis showed positive findings on two modalities. 15.0% of solitary bone metastases were positive on positron emission tomography only. Positron emission tomography was superior to scanning for the detection of synchronous bone metastasis, but the two modalities were similar for the detection of metachronous bone metastasis. The concordance rate of response assessment after treatment between two modalities was moderate.

CONCLUSIONS

Positron emission tomography-computed tomography may be more effective for the diagnosis of bone metastasis in the initial staging workup. Conversely, bone scanning and positron emission tomography-computed tomography may be similarly effective for the detection of metachronous bone metastasis.

Role of FDG-PET scans in staging, response assessment, and follow-up care for non-small cell lung cancer

The integral role of positron-emission tomography (PET) using the glucose analog tracer fluorine-18 fluorodeoxyglucose (FDG) in the staging of non-small cell lung cancer (NSCLC) is well established. Evidence is emerging for the role of PET in response assessment to neoadjuvant therapy, combined-modality therapy, and early detection of recurrence. Here, we review the current literature on these aspects of PET in the management of NSCLC. FDG-PET, particularly integrated (18)F-FDG-PET/CT, scans have become a standard test in the staging of local tumor extent, mediastinal lymph node involvement, and distant metastatic disease in NSCLC. (18)F-FDG-PET sensitivity is generally superior to computed tomography (CT) scans alone. Local tumor extent and T stage can be more accurately determined with FDG-PET in certain cases, especially in areas of post-obstructive atelectasis or low CT density variation. FDG-PET sensitivity is decreased in tumors <1 cm, at least in part due to respiratory motion. False-negative results can occur in areas of low tumor burden, e.g., small lymph nodes or ground-glass opacities. (18)F-FDG-PET-CT nodal staging is more accurate than CT alone, as hilar and mediastinal involvement is often detected first on (18)F-FDG-PET scan when CT criteria for malignant involvement are not met. (18)F-FDG-PET scans have widely replaced bone scintography for assessing distant metastases, except for the brain, which still warrants dedicated brain imaging. (18)F-FDG uptake has also been shown to vary between histologies, with adenocarcinomas generally being less FDG avid than squamous cell carcinomas. (18)F-FDG-PET scans are useful to detect recurrences, but are currently not recommended for routine follow-up. Typically, patients are followed with chest CT scans every 3-6 months, using (18)F-FDG-PET to evaluate equivocal CT findings. As high (18)F-FDG uptake can occur in infectious, inflammatory, and other non-neoplastic conditions, (18)F-FDG-PET-positive findings require pathological confirmation in most cases. There is increased interest in the prognostic and predictive role of FDG-PET scans. Studies show that absence of metabolic response to neoadjuvant therapy correlates with poor pathologic response, and a favorable (18)F-FDG-PET response appears to be associated with improved survival. Further work is underway to identify subsets of patients that might benefit individualized management based on FDG-PET.

Prospective evaluation of (99m)Tc MDP scintigraphy, (18)F NaF PET/CT, and (18)F FDG PET/CT for detection of skeletal metastases

INTRODUCTION

Technetium (Tc) methylene diphosphonate (MDP) has been the standard method for bone scintigraphy for three decades. (18)F sodium fluoride ((18)F NaF) positron emission tomography (PET)/computed tomography (CT) has better resolution and is considered superior. The role of 2-deoxy-2-[(18)F]fluoro-D-glucose ((18)F FDG) PET/CT is proven in a variety of cancers, for which it has changed the practice of oncology. There are few prospective studies comparing these three methods of detection of skeletal metastases. Thus, we were prompted to initiate this prospective pilot trial.

METHODS

This is a prospective study (Sep 2007-Dec 2010) of 52 patients with proven malignancy referred for evaluation of skeletal metastases. There were 37 men and 15 women, 19-84 years old (average, 55.6 ± 15.9). Technetium-99m ((99m)Tc) MDP bone scintigraphy, (18)F NaF PET/CT, and (18)F FDG PET/CT were subsequently performed within 1 month.

RESULTS

Skeletal lesions were detected by (99m)Tc MDP bone scintigraphy in 22 of 52 patients, by (18)F NaF PET/CT in 24 of 52 patients, and by (18)F FDG PET/CT in 16 of 52 patients. The image quality and evaluation of extent of disease were superior by (18)F NaF PET/CT over (99m)Tc MDP scintigraphy in all 22 patients with skeletal lesions on both scans and over (18)F FDG PET/CT in 11 of 16 patients with skeletal metastases on (18)F FDG PET/CT. In two patients, (18)F NaF PET/CT showed skeletal metastases not seen on either of the other two scans. Extraskeletal lesions were identified by (18)F FDG PET/CT in 28 of 52 subjects.

CONCLUSION

Our prospective pilot-phase trial demonstrates superior image quality and evaluation of skeletal disease extent with (18)F NaF PET/CT over (99m)Tc MDP scintigraphy and (18)F FDG PET/CT. At the same time, (18)F FDG PET detects extraskeletal disease that can significantly change disease management. As such, a combination of (18)F FDG PET/CT and (18)F NaF PET/CT may be necessary for cancer detection. Additional evaluation with larger cohorts is required to confirm these preliminary findings.

Diagnostic value of fluorine 18 fluorodeoxyglucose positron emission tomography/computed tomography for the detection of metastases in non-small-cell lung cancer patients

In the recent years, fluorine 18 fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET)/computed tomography (CT) has emerged as a new modality for staging non-small-cell lung cancer (NSCLC) patients. The aim of this meta-analysis was to assess the diagnostic value of (18)F-FDG PET/CT in detecting metastatic lesions in NSCLC patients. Meta-analysis methods were used to pool sensitivity, specificity, positive and negative likehood ratios, diagnostic odd ratios and to construct a summary receiver-operating characteristic curve. Data from included studies were pooled to compare the diagnostic accuracy between PET/CT and PET or CT alone in nodal staging. Totally, 56 studies involving 8,699 patients met the inclusion criteria. The pooled sensitivities and specificities of (18)F-FDG PET/CT were 0.72 [95% confidence interval (CI): 0.65-0.78] and 0.91 (95% CI: 0.86-0.94) in determining mediastinal nodal staging; 0.71 (95% CI: 0.60-0.80) and 0.83 (95% CI: 0.77-0.88) in intrathoracic staging; 0.78 (95% CI: 0.64-0.87) and 0.90 (95% CI: 0.84-0.94) in intrathoracic staging on a per-node basis. For detecting extrathoracic metastases, the pooled sensitivities and specificities of (18)F-FDG PET/CT were 0.77 (95% CI: 0.47-0.93) and 0.95 (95% CI: 0.92-0.97) for all extrathoracic metastases; 0.91 (95% CI: 0.80-0.97) and 0.98 (95% CI: 0.94-0.99) for bone metastases. (18)F-FDG PET/CT is beneficial in detecting lymph node metastases and extrathoracic metastases although PET/CT showed low sensitivity in detecting brain metastases. (18)F-FDG PET/CT confers significantly higher sensitivity and specificity than contrast-enhanced CT (both p < 0.01) and higher sensitivity than (18)F-FDG PET in staging NSCLC (p < 0.05).

Imaging findings of solitary spinal bony lesions and the differential diagnosis of benign and malignant lesions

OBJECTIVE

The purpose of this study was to present the MRI and CT findings of solitary spinal bone lesions (SSBLs) with the aims of aiding the differential diagnoses of malignant tumors and benign lesions, and proposing a diagnostic strategy for obscure SSBLs.

METHODS

The authors retrospectively reviewed the imaging findings of 19 patients with an obscure SSBL on MRI at our hospital from January 1994 to April 2011. The 19 patients were divided to benign groups and malignant groups according to final diagnosis. MRI and CT findings were evaluated and the results of additional work-up studies were conducted to achieve a differential diagnosis.

RESULTS

At final diagnoses, 10 (52.6%) of the 19 SSBLs were malignant tumors and 9 (47.4%) were benign lesions. The malignant tumors included 6 metastatic cancers, 3 multiple myelomas, and 1 chordoma, and the benign lesions included 4 osteomyelitis, 2 hemangiomas, 2 nonspecific chronic inflammations, and 1 giant cell tumor. No MRI characteristics examined was found to be significantly different in the benign and malignant groups. Reactive sclerotic change was observed by CT in 1 (10.0%) of the 10 malignant lesions and in 7 (77.8%) of the 9 benign lesions (p=0.005).

CONCLUSION

Approximately half of the obscure SSBLs were malignant tumors. CT and MRI findings in combination may aid the differential diagnosis of obscure SSBLs. In particular, sclerotic change on CT images was an important finding implying benign lesion. Finally, we suggest a possible diagnostic strategy for obscure SSBLs on MRI.

Experimental model of heterotopic ossification in Wistar rats

Heterotopic ossification (HO) is a metaplastic biological process in which there is newly formed bone in soft tissues adjacent to large joints, resulting in joint mobility deficit. In order to determine which treatment techniques are more appropriate for such condition, experimental models of induced heterotopic bone formation have been proposed using heterologous demineralized bone matrix implants and bone morphogenetic protein and other tissues. The objective of the present experimental study was to identify a reliable protocol to induce HO in Wistar rats, based on autologous bone marrow (BM) implantation, comparing 3 different BM volumes and based on literature evidence of this HO induction model in larger laboratory animals. Twelve male Wistar albino rats weighing 350/390 g were used. The animals were anesthetized for blood sampling before HO induction in order to quantify serum alkaline phosphatase (ALP). HO was induced by BM implantation in both quadriceps muscles of these animals, experimental group (EG). Thirty-five days after the induction, another blood sample was collected for ALP determination. The results showed a weight gain in the EG and no significant difference in ALP levels when comparing the periods before and after induction. Qualitative histological analysis confirmed the occurrence of heterotopic ossification in all 12 EG rats. In conclusion, the HO induction model was effective when 0.35 mL autologous BM was applied to the quadriceps of Wistar rats.

Meta-analysis: comparison of F-18 fluorodeoxyglucose-positron emission tomography and bone scintigraphy in the detection of bone metastasis in patients with lung cancer

RATIONALE AND OBJECTIVES

The aim of this review was to evaluate the diagnostic properties of (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) or PET/computed tomography (CT) and bone scintigraphy in the detection of osseous metastases in patients with lung cancer.

MATERIALS AND METHODS

MEDLINE was searched for relevant original articles published between January 1995 and August 2010. Inclusion criteria were as follows: FDG-PET or PET/CT and bone scintigraphy was carried out to detect bone metastases in patients with lung cancer, sufficient data were presented to construct a 2 × 2 contingency table, and histopathologic analysis and/or close clinical and imaging follow-up and/or radiographic confirmation by multiple imaging modalities was used as the reference standard. Two reviewers independently extracted data related to research design, sample size, imaging techniques, technical characteristics, reference standards, methods of imaging interpretation, and totals of true-positives, false-positives, true-negatives, and false-negatives. Stata was used to obtain per patient and per lesion pooled estimates of sensitivity, specificity, and positive and negative likelihood ratios, and areas under summary receiver-operating characteristic curves (AUCs) were calculated.

RESULTS

The pooled patient-based sensitivity of FDG-PET or PET/CT was 0.93 (95% confidence interval [CI], 0.88-0.96), specificity was 0.95 (95% CI, 0.91-0.98), and the AUC was 0.94. The pooled sensitivity of bone scans was 0.87 (95% CI, 0.79-0.93), specificity was 0.82 (95% CI, 0.62-0.92), and the AUC was 0.91. The pooled lesion-based sensitivity of FDG-PET or PET/CT was 0.93 (95% CI, 0.84-0.97), specificity was 0.91 (95% CI, 0.80-0.96), and the AUC was 0.97. The pooled sensitivity of bone scans was 0.92 (95% CI, 0.87-0.95), specificity was 0.57 (95% CI, 0.09-0.95), and the AUC was 0.92.

CONCLUSIONS

Although FDG-PET or PET/CT has higher sensitivity and specificity than bone scintigraphy, further research with a less biased design is needed to determine the most efficacious imaging modality for the detection of metastatic lung cancer.

To build a prognostic score model containing indispensible tumour markers for metastatic nasopharyngeal carcinoma in an epidemic area

BACKGROUND AND OBJECTIVE

The survival outcomes of patients with metastatic nasopharyngeal carcinoma (NPC) differ significantly between individuals. The aim of this study is to build a prognostic score model (PSM) incorporating circulating tumour markers for metastatic NPC in an epidemic area.

METHODS

Seven hundred and ninety-nine patients with disseminated NPC were analysed retrospectively. Univariate and multivariable analyses were conducted using the Cox proportion hazards model. Factors analysed included patients' characteristics (gender, age group, performance status), circulating tumour-marker characteristics (Epstein-Barr virus (EBV) DNA level, EBV VCA-IgA level, lactate dehydrogenase (LDH) level, alkaline phosphatase (ALP) level), basic laboratory characteristics (leucocyte count, haemoglobin level, albumin level), and disease characteristics (presence of metastasis at presentation, disease-free interval, number of metastatic sites, specific metastatic sites). The PSM was built according to numerical score derived from the regression coefficients of each independent prognostic variable. The prognostic score of each patient was calculated by totalling up the scores of each independent variable.

RESULTS

Independent prognostic factors included performance status, age, haemoglobin level, LDH level, ALP level and EBV DNA level. Three prognostic groups based on PSM were obtained: low risk (total score=0-4); intermediate risk (5-8); high risk (9-12). Median survivals of the three groups were 25.5, 15.1 and 7 months, respectively, (P<0.001).

CONCLUSION

Clinical and laboratory characteristics can help guide the prognostication of patients with metastatic NPC in epidemic areas.

Diagnosis of bone metastases: a meta-analysis comparing ¹⁸FDG PET, CT, MRI and bone scintigraphy

OBJECTIVE

To perform a meta-analysis to compare (18)FDG PET, CT, MRI and bone scintigraphy (BS) for the diagnosis of bone metastases.

METHODS

Databases including MEDLINE and EMBASE were searched for relevant original articles published from January 1995 to January 2010. Software was used to obtain pooled estimates of sensitivity, specificity and summary receiver operating characteristic curves (SROC).

RESULTS

67 articles consisting of 145 studies fulfilled all inclusion criteria. On per-patient basis, the pooled sensitivity estimates for PET, CT, MRI and BS were 89.7%, 72.9%, 90.6% and 86.0% respectively. PET=MRI>BS>CT. ("="indicated no significant difference, P > 0.05; ">" indicated significantly higher, P < 0.05). The pooled specificity estimates for PET, CT, MRI and BS were 96.8%, 94.8%, 95.4% and 81.4% respectively. PET = CT = MRI>BS. On per-lesion basis, the pooled sensitivity estimates for PET, CT, MRI and BS were 86.9%, 77.1%, 90.4% and 75.1% respectively. PET = MRI>BS>CT. The pooled specificity estimates for PET, CT, MRI and BS were 97.0%, 83.2%, 96.0% and 93.6% respectively. PET>MRI>BS>CT.

CONCLUSION

PET and MRI were found to be comparable and both significantly more accurate than CT and BS for the diagnosis of bone metastases.

Comparison of 18F-FDG PET/CT with bone scintigraphy for detection of bone metastasis: a meta-analysis

BACKGROUND

The skeleton is one of the favorable sites for the metastasis of almost all human malignant neoplasms. An accurate diagnosis of bone metastasis is crucial for the patient's staging and management.

PURPOSE

To investigate and compare diagnostic performance of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) and bone scintigraphy (BS) for detection of bone metastasis in malignancies using meta-analysis.

MATERIAL AND METHODS

PubMed (Medline included) was searched for relevant articles. We assessed the methodological quality with Quality Assessment of Diagnosis Accuracy Studies (QUADAS) score tool, and used statistical software to obtain pooled estimates of sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver-operating characteristic (SROC) curve.

RESULTS

Six studies met inclusion criteria. For 18F-FDG PET/CT, the pooled sensitivity and specificity were 0.934 and 0.975, respectively. The pooled positive likelihood ratio (LR+), negative likelihood ratio (LR-) and diagnostic odds ratio (DOR) were 34.990, 0.068 and 559.02, respectively. The area under the SROC curve was 0.9854. For BS, the pooled sensitivity, specificity, LR + , LR- and DOR were 0.706 (0.642-0.764), 0.911 (0.896-0.926), 13.982 (2.419-80.817), 0.319 (0.143-0.712), and 60.420 (21.393-170.64), respectively. The area under the SROC curve was 0.9386.

CONCLUSION

The results indicate that 18F-FDG PET/CT do have both higher sensitivity and specificity than bone scintigraphy for detecting metastatic bone tumor. However, further research is needed to evaluate the diagnostic performance of 18F-FDG PET/CT and BS in each common malignancy.

Zoledronic acid combined with chemotherapy bring survival benefits to patients with bone metastases from nasopharyngeal carcinoma

PURPOSE

Bone is the most common site of metastases from nasopharyngeal carcinoma (NPC). Zoledronic acid (ZA) used to prevent skeletal-related events (SREs) of bone metastases has shown anti-tumor effects; yet, no report has been found on the survival benefit of ZA in NPC. This study aimed to evaluate whether ZA can bring survival benefits to patients with bone metastases from NPC.

METHODS

A total of 307 patients with of NPC who had bone metastases were analyzed retrospectively. The differences of survival between patients treated with chemotherapy combined with ZA and those with chemotherapy alone were evaluated by the log-rank test. The Cox multivariate analyses of clinical features and different treatment methods of the 307 patients were conducted.

RESULTS

The prevalence of SREs in the combined approach group was lower than that with chemotherapy alone (34% vs. 48%, X (2) = 7.003, P = 0.008). The combined approach group had better progression-free survival (PFS) (11.5 vs. 5.5 months, P < 0.001) and overall survival (OS) (23.5 vs. 17.5 months, P < 0.001) than chemotherapy alone group. Cox multivariate analysis identified the following independent prognostic factors: ZA treatment, bone metastatic sites, baseline serum alkaline phosphatase (ALP) level, SREs and cycles of chemotherapy.

CONCLUSIONS

ZA treatment combined with chemotherapy could reduce SREs and improve PFS and OS for NPC patients with bone metastases.

Prognostic significance of bone markers in patients with lung cancer metastatic to the skeleton: a review of published data

The presence of bone metastases significantly affects clinical outcome and quality of life parameters in patients with lung cancer. In this review, we aimed to evaluate the predictive value of markers of bone turnover in skeletal morbidity and clinical parameters, including disease-free survival (DFS) and overall survival (OS), in patients with lung cancer metastatic to the skeleton who were receiving bisphosphonate treatment. A comprehensive overview of all articles published from 1995 to date in 3 medical databases (PubMed, Scopus, and Cochrane) was performed using the keywords bone markers and lung cancer. Most bone formation markers (including bone alkaline phosphatase [bALP], osteocalcin [OC], and osteoprotegerin [OPG]), most bone absorption markers (including urinary calcium, osteopontin [OPN], receptor activator of nuclear factor κ-B ligand [RANKL], tartrate-resistant acid phosphatase isoform-5b [TRACP 5b]), and the metabolites of type I collagen had elevated concentrations in patients with lung cancer and bone metastases compared with patients without skeletal involvement. Two large studies showed that urinary N-terminal telopeptide (NTX) levels are a valid diagnostic method for early detection of bone metastases and a more consistent prognosticator than bALP. Treatment with zoledronic acid reduces NTX, TRACP-5b, RANKL, and OPG levels. Furthermore posttherapeutic reduction of urinary NTX levels seems to correlate with lower risk of skeletal-related events (SREs). Levels of markers of bone remodeling reflect the presence of bone metastases and may contribute to early detection of occult skeletal disease or monitor the effect of bisphosphonate treatment. However their ability to predict SREs, as well as DFS and OS, remains debatable.

Evaluation of Response to Therapy in a Patient with Lung Cancer: Correlation of Sclerotic Bone Lesions with F 18 FDG PET/CT and Bone Scintigraphy

A 64-year-old male patient with small cell lung cancer underwent Fluorine-18 fluorodeoxyglucose (F 18 FDG) positron emission tomography (PET)/CT scan which revealed multiple F 18 FDG uptake in the spine, both humeri, ribs, pelvis and proximal long bones. There was no obvious lytic or sclerotic bone destruction accompanying these lesions on CT component of the study. After the patient received six courses of chemotherapy a repeat F 18 FDG-PET/CT was performed for evaluation of therapy response. The PET/CT showed the presence of multiple sclerotic lesions on CT without FDG uptake, corresponding to the bone lesions on the previous PET/CT scan. A concomitant Tc 99m Methylene diphosphonate (Tc 99m MDP) bone scintigraphy (BS) revealed no pathologically increased Tc 99m MDP uptake in the skeletal system. The FDG avid lesions in the skeletal system, which were not sclerotic initially, were transformed into FDG non-avid sclerotic lesions after chemotherapy. This was attributed to the direct effect of previous successful therapy for bone metastases, leading to the transformation of metabolically active disease, into blastic metabolically inactive metastases. In conclusion, a F 18 FDG negative bone lesion, which is sclerotic on CT, may represent post-treatment osteoblastic change rather than active tumor and BS might play a role in the discrimination of these two situations.

CONFLICT OF INTEREST

None declared.

PET/CT imaging in different types of lung cancer: an overview

Lung cancer (LC) still represents one of the most common tumours in both women and men. PET/CT is a whole-body non-invasive imaging procedure that has been increasingly used for the assessment of LC patients. In particular, PET/CT added value to CT is mainly related to a more accurate staging of nodal and metastatic sites and to the evaluation of the response to therapy. Although the most common PET tracer for LC evaluation is 18F-FDG, new tracers have been proposed for the evaluation of lung neuroendocrine tumours (68Ga-DOTA-peptides, 18F-DOPA) and for the assessment of central nervous system metastasis (11C-methionine). This review focuses on the main clinical applications and accuracy of PET/CT for the detection of non-small cells lung cancer (NSCLC), broncho-alveolar carcinoma (BAC), small cells lung cancer (SCLC), lung neuroendocrine tumours (NET) and solitary pulmonary nodules (SPN).

A meta-analysis of ¹⁸FDG-PET-CT, ¹⁸FDG-PET, MRI and bone scintigraphy for diagnosis of bone metastases in patients with lung cancer

BACKGROUND AND PURPOSE

Lung cancer is the most common cause of cancer related death among both men and women worldwide. The skeleton is the most common site of cancer metastasis. Early detection is crucial for prognosis. To evaluate and compare the capability for bone metastasis assessment of [(18)F] fluoro-2-d-glucose positron emission tomography with computed tomography ((18)FDG-PET-CT), [(18)F] fluoro-2-d-glucose positron emission tomography ((18)FDG-PET), magnetic resonance imaging (MRI) and bone scintigraphy (BS) in lung cancer patients, a meta-analysis is preformed.

METHODS

We searched MEDLINE, OVID, EMBASE and the Cochrane Library for studies evaluating diagnosis validity of (18)FDG-PET-CT, (18)FDG-PET, MRI and BS between January 1990 and August 2010. Meta-analysis methods were used to pool sensitivity, specificity, diagnostic odd ratios (DORs) and to construct a summary receiver-operating characteristic curve (SROC).

RESULTS

A total of 17 articles (9 (18)FDG-PET-CT studies, 9 (18)FDG-PET studies, 6 MRI studies and 16 BS studies) that included 2940 patients who fulfilled all of the inclusion criteria were considered for inclusion in the analysis. The pooled sensitivity for the detection of bone metastasis in lung cancer using (18)FDG-PET-CT, (18)FDG-PET, MRI and BS were 0.92 (95% CI, 0.88-0.95), 0.87 (95% CI, 0.81-0.92), 0.77 (95% CI, 0.65-0.87) and 0.86 (95% CI, 0.82-0.89), respectively. The pooled specificity for the detection of bone metastasis from lung cancer using (18)FDG-PET-CT, (18)FDG-PET, MRI and BS were 0.98 (95% CI, 0.97-0.98), 0.94 (95% CI, 0.92-0.96), 0.92 (95% CI, 0.88-0.95), 0.88 (95% CI, 0.86-0.89), respectively. The pooled DORs estimates for (18)FDG-PET-CT 449.17 were significantly higher than for (18)FDG-PET (118.25, P<0.001), MRI (38.27, P<0.001) and BS (63.37, P<0.001). The pooled sensitivity of BS was not correlated with the prevalence of bone metastasis.

CONCLUSION

The results showed that both (18)FDG-PET-CT and (18)FDG-PET were better imaging methods for diagnosing bone metastasis from lung cancer than MRI and BS. (18)FDG-PET-CT has higher diagnostic value (sensitivity, specificity and DORs) for diagnosing bone metastasis from lung cancer than any other imaging methods.

Oral and maxillofacial desmoid-type fibromatoses in an eastern Chinese population: a report of 20 cases

OBJECTIVE

Primary desmoid-type fibromatoses arising from the oral and maxillofacial region are uncommon and hold the character of local invasion and regional recurrence. The purpose of this study was to analyze the clinicoepidemiologic characteristics of this rare disease in an eastern Chinese population.

STUDY DESIGN

Epidemiological and clinicopathological data on 20 patients were reviewed from the hospital records and analyzed accordingly.

RESULTS

Twelve males and 8 females with a ratio of 3:2 were involved. The mandible was the most common site of presentation. Suspected malignant change was found in 6 cases and an extremely high recurrence rate was also found in up to 53%. Abnormally high blood levels of alkaline phosphatase were found in 65% of patients, which had a close relation with tumor malignant change.

CONCLUSION

Chinese people are more susceptible to desmoid-type fibromatoses and are at an extremely high risk of regional malignant change. Elevated serum alkaline phosphatase levels may be taken as an indicator for malignant transformation.

Fluorine-18 deoxyglucose positron emission tomography, magnetic resonance imaging and bone scintigraphy for the diagnosis of bone metastases in patients with lung cancer: which one is the best?--a meta-analysis

AIMS

To carry out a meta-analysis to compare fluorine-18 deoxyglucose ((18)FDG) positron emission tomography (PET), magnetic resonance imaging (MRI) and bone scintigraphy imaging for the diagnosis of bone metastases in patients with lung cancer.

MATERIALS AND METHODS

MEDLINE, EMBASE, Scopus and other databases were searched for relevant original articles published between January 1995 and January 2010. Inclusion criteria were as follows: (18)FDG PET, MRI or (99m)Tc-MDP bone scintigraphy was carried out to detect bone metastases in patients with lung cancer; sufficient data were presented to construct a 2×2 contingency table; histopathological analysis and/or close clinical and imaging follow-up and/or radiographic confirmation by multiple imaging modalities were used as the reference standard. Two reviewers independently extracted data. META-DiSc was used to obtain pooled estimates of sensitivity, specificity, diagnostic odds ratio (DOR), summary receiver operating characteristic (SROC) curves and the *Q index.

RESULTS

In total, 14 articles that consisted of 34 studies fulfilled all inclusion criteria. On a per-patient basis, the pooled sensitivity estimates for PET, MRI and bone scintigraphy were 91.9, 80.0 and 91.8%, respectively. The sensitivity for PET and bone scintigraphy were significantly higher than for MRI (P<0.05). There was no significant difference between PET and bone scintigraphy (P>0.05). The pooled specificity estimates for PET, MRI and bone scintigraphy were 96.8, 90.6 and 68.8%, respectively. The specificity for PET was significantly higher than for MRI and bone scintigraphy (P<0.05), and the specificity for MRI was significantly higher than for bone scintigraphy (P<0.05). The pooled DOR estimates for PET, MRI and bone scintigraphy were 365.5, 53.8 and 34.4, respectively. The DOR for PET was significantly higher than for MRI and bone scintigraphy (P<0.05). There was no significant difference between MRI and bone scintigraphy (P>0.05). The SROC curve for PET showed better diagnostic accuracy than for MRI and bone scintigraphy. The SROC curve for MRI was better than for bone scintigraphy. The *Q index estimates for PET, MRI and bone scintigraphy were 0.933, 0.903 and 0.857, respectively. The *Q index for PET and MRI were significantly higher than for bone scintigraphy (P<0.05). There was no significant difference between PET and MRI (P>0.05). On a per-lesion basis, the pooled sensitivity estimates for PET, MRI and bone scintigraphy were 95.0, 83.8 and 71.5%, respectively. The sensitivity for PET was significantly higher than for MRI and bone scintigraphy (P<0.05), and the sensitivity for MRI was significantly higher than for bone scintigraphy (P<0.05). The pooled specificity estimates for PET, MRI and bone scintigraphy were 94.6, 96.3 and 91.0%, respectively. The specificity for MRI was significantly higher than for PET and bone scintigraphy (P<0.05), and the specificity for PET was significantly higher than for bone scintigraphy (P<0.05). The pooled DOR estimates for PET, MRI and bone scintigraphy were 431.9, 158.1 and 9.0, respectively. The DOR for PET was significantly higher than for MRI and bone scintigraphy (P<0.05) and the DOR for MRI was significantly higher than for bone scintigraphy (P<0.05). The SROC curve for PET and MRI showed better diagnostic accuracy than for bone scintigraphy. There was no significant difference between PET and MRI. The *Q index estimates for PET, MRI and bone scintigraphy were 0.953, 0.962 and 0.778, respectively. The *Q index for PET and MRI were significantly higher than for bone scintigraphy (P<0.05). There was no significant difference between PET and MRI (P>0.05).

CONCLUSION

(18)FDG PET was found to be the best modality to detect bone metastasis in patients with lung cancer, both on a per-patient basis and a per-lesion basis; MRI had the highest specificity on a per-lesion basis. For the subgroup analysis of (18)FDG PET, PET/computed tomography was shown to be better than PET and there were no significant differences between using (68)Ge and computed tomography for attenuation correction on a per-patient basis.

FDG PET for the Detection of Bone Metastases: Sensitivity, Specificity and Comparison with Other Imaging Modalities

A literature review was performed of studies reporting sensitivity and specificity of [18F]fluorodeoxyglucose (FDG) PET from January 1, 2000 to January 1, 2010. PET was found to have higher sensitivity for the detection of osseous metastases when compared to CT, skeletal scintigraphy, whole body MRI and combined conventional imaging modalities. A potential exception is when comparing PET with bone scan in the setting of blastic metastases. PET may be a better indicator of active bony metastases. The efficacy of PET can be increased with fused anatomic imaging.