Data for this Review were identified by searches of Medline and PubMed and by review of the reference lists of relevant articles. Search terms used were “breast cancer”, “PET/CT”, “FDG”, “PET”, “whole-body MRI”, “SPECT/CT”, and “SPECT”. Articles without abstracts in English were excluded. For the section of this Review devoted to recent advances in imaging, data published between January, 2004, and January, 2008, were included.
ReviewImaging bone metastases in breast cancer: techniques and recommendations for diagnosis
Introduction
Bone is the most common site of distant metastases from breast cancer. Osseous metastases develop in 8% of patients with breast cancer and 69% of patients with advanced disease.1 To increase the likelihood of detecting bone metastases in a timely and cost-effective manner, the most effective imaging studies must be ordered at the initial work-up. In a previous review,2 we outlined the clinical application of imaging techniques for the detection and management of bone metastases in breast cancer, including skeletal scintigraphy, plain-film radiography, CT, MRI, PET, and single-photon-emission CT (SPECT). Three techniques have progressed substantially over the past 5 years: dual-modality PET with integrated CT, dual-modality SPECT with integrated CT, and whole-body MRI (figure 1). In this Review, we discuss these innovations and recommend imaging strategies for the detection of bone metastases in both emergent and non-emergent situations.
Section snippets
PET–CT
PET is a nuclear medicine technique that produces high-resolution tomographic images through the detection of high-energy photon pairs emitted during positron decay of a radioisotope. Fluorodeoxyglucose PET is a functional rather than anatomic imaging method that detects cellular metabolism of a glucose analogue. Many radiopharmaceuticals are available that can be imaged with PET, but fluorodeoxyglucose is commonly used in oncology because of the high glucose uptake by many tumours.
A patient's
SPECT and SPECT–CT
SPECT imaging of the skeleton uses Tc-99m methylene diphosphonate, the same radionuclide used in conventional skeletal scintigraphy, but images are acquired in a cross-sectional rather than a planar fashion. Whereas planar imaging is limited by superimposition of structures, SPECT can show axial slices through the body, providing better localisation of abnormal radionuclide uptake. In this way, SPECT can improve sentinel-node identification when used with lymphoscintigraphy.29, 30
Compared with
Whole-body MRI
Whole-body MRI detects more bone metastases than does skeletal scintigraphy,35, 36, 37, 38, 39, 40, 41, 42, 43 and might replace scintigraphy for first detection of these lesions. In addition to detecting metastases from breast cancer,36, 38, 39, 40, 44 whole-body MRI is used to find bone lesions in Langerhans cell histiocytosis45, 46 and multiple myeloma,47 and metastases from lung cancer,48, 49 colon cancer,50 and prostate cancer.51, 52
Whole-body MRI uses fast pulse sequences over multiple
General guidelines
Our recommendations regarding the use of imaging modalities for detection of osseous metastases are outlined in figure 2. In reviewing the literature, we found substantial variations in estimates of the sensitivity and specificity of each imaging technique—largely because reference standards differed between studies.
The first choice for screening should be skeletal scintigraphy; however, because this method shows only bone metabolism, another imaging study might be needed for an accurate
Conclusion
A range of imaging techniques is available for assessment of osseous metastases in patients with breast cancer. Skeletal scintigraphy is highly sensitive in the detection of osseous metastases, allows excellent overall assessment of the skeleton, and is suggested as the first imaging study in asymptomatic patients. Radiography is less sensitive but more specific than skeletal scintigraphy and is recommended to further investigate abnormal radionuclide uptake. Radiography can also be used to
Search strategy and selection criteria
References (68)
- et al.
Effect of (18)F-FDG PET–CT imaging in patients with clinical stage II and III breast cancer
Int J Radiat Oncol Biol Phys
(2008) - et al.
Impact of the introduction of integrated PET–CT into the preoperative staging pathway of patients with potentially operable oesophageal carcinoma
Clin Radiol
(2008) - et al.
Clinical implications of F-18 FDG PET–CT for differentiated thyroid cancer in patients with negative diagnostic iodine 123 scan and elevated thyroglobulin
Eur J Radiol
(2009) - et al.
Comprehensive imaging of tumor recurrence in breast cancer patients using whole-body MRI at 1.5 and 3 T compared to FDG-PET–CT
Eur J Radiol
(2008) - et al.
Early diagnosis of occult hip fractures MRI versus CT scan
Injury
(2005) - et al.
The clinical course of bone metastases from breast cancer
Br J Cancer
(1987) - et al.
Bone imaging in metastatic breast cancer
J Clin Oncol
(2004) - et al.
Effective doses in radiology and diagnostic nuclear medicine: a catalog
Radiology
(2008) - et al.
Preoperative staging of large primary breast cancer with [18F]fluorodeoxyglucose positron emission tomography/computed tomography compared with conventional imaging procedures
J Clin Oncol
(2008) - et al.
Additional value of integrated PET–CT in the detection and characterization of lung metastases: correlation with CT alone and PET alone
Eur Radiol
(2007)
Staging of non-small-cell lung cancer with integrated positron-emission tomography and computed tomography
N Engl J Med
Detection of interval distant metastases: clinical utility of integrated CT-PET imaging in patients with esophageal carcinoma after neoadjuvant therapy
Cancer
Whole body positron emission tomography/computed tomography (PET–CT) tumour staging with integrated PET–CT colonography: technical feasibility and first experiences in patients with colorectal cancer
Gut
Whole-body PET–CT-colonography: a possible new concept for colorectal cancer staging
Abdom Imaging
Comparison of 18F-FDG PET and bone scintigraphy in detection of bone metastases of thyroid cancer
J Nucl Med
Identification of distant metastases with positron-emission tomography-computed tomography in patients with previously untreated head and neck cancer
Laryngoscope
Impact of [18F]-2-fluorodeoxyglucose-positron emission tomography/computed tomography on previously untreated head and neck cancer patients
Laryngoscope
Detection of occult bone metastases from head and neck squamous cell carcinoma: impact of positron emission tomography computed tomography with fluorodeoxyglucose F 18
Arch Otolaryngol Head Neck Surg
Detection of metastases in patients with cutaneous melanoma using FDG-PET–CT
J Int Med Res
2-Deoxy-2-[F-18]fluoro-D-glucose positron emission tomography/computed tomography in the management of melanoma
Mol Imaging Biol
Diagnostic performance of whole body dual modality 18F-FDG PET–CT imaging for N- and M-staging of malignant melanoma: experience with 250 consecutive patients
J Clin Oncol
Role of whole-body [18F] fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET–CT) and conventional techniques in the staging of patients with Hodgkin and aggressive non Hodgkin lymphoma
Radiol Med
Centers for Medicare and Medicaid services
Meta-analysis: comparison of F-18 fluorodeoxyglucose-positron emission tomography and bone scintigraphy in the detection of bone metastases in patients with breast cancer
Clin Nucl Med
Detection of bone metastases in breast cancer by 18FDG PET: differing metabolic activity in osteoblastic and osteolytic lesions
J Clin Oncol
Comparing whole body (18)F-2-deoxyglucose positron emission tomography and technetium-99m methylene diphosphonate bone scan to detect bone metastases in patients with breast cancer
J Cancer Res Clin Oncol
Whole body PET for the evaluation of bony metastases in patients with breast cancer: comparison with 99Tcm-MDP bone scintigraphy
Nucl Med Commun
Comparison and discrepancy of 18F-2-deoxyglucose positron emission tomography and Tc-99m MDP bone scan to detect bone metastases
Anticancer Res
Comparison of FDG PET and SPECT for detection of bone metastases in breast cancer
Am J Roentgenol
American Society of Clinical Oncology treatment of unresectable non-small-cell lung cancer guideline: update 2003
J Clin Oncol
The additional value of SPECT–CT in lymphatic mapping in breast cancer and melanoma
J Nucl Med
Improved sentinel node identification by SPECT–CT in overweight patients with breast cancer
J Nucl Med
Comparison of bone single-photon emission tomography and planar imaging in the detection of vertebral metastases in patients with back pain
Eur J Nucl Med
The benefit of SPECT when added to planar scintigraphy in patients with bone metastases in the spine
Clin Nucl Med
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