Elsevier

The Lancet Oncology

Volume 10, Issue 6, June 2009, Pages 606-614
The Lancet Oncology

Review
Imaging bone metastases in breast cancer: techniques and recommendations for diagnosis

https://doi.org/10.1016/S1470-2045(09)70088-9Get rights and content

Summary

Bone is the most common site of distant metastases from breast carcinoma. The presence of bone metastases affects a patient's prognosis, quality of life, and the planning of their treatment. We discuss recent innovations in bone imaging and present algorithms, based on the strengths and weaknesses of each technique, to facilitate the most successful and cost-effective choice of imaging studies for the detection of osseous metastases. Skeletal scintigraphy (bone scan) is very sensitive in the detection of osseous metastases and is recommended as the first imaging study in patients who are asymptomatic. Radiographs are recommended for the assessment of abnormal radionuclide uptake or the risk of pathological fracture and as initial imaging studies in patients with bone pain. MRI or PET–CT can be considered for cases of abnormal radionuclide uptake that are not addressed by radiography. Osseous metastases can lead to emergent situations, such as spinal-cord compression or impending fracture of a weight-bearing bone, and imaging guidelines are essential for early detection and initiation of appropriate therapy. The imaging method used in non-emergent situations, such as assessment of the ribs, sternum, pelvis, hips, and joints, should be guided by the strengths and limitations of each technique.

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

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.

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