Jpn J Radiol (2013) 31:262–269 DOI 10.1007/s11604-013-0179-7
ORIGINAL ARTICLE
The role of 18F-fluoride PET-CT in the detection of bone metastases in patients with breast, lung and prostate carcinoma: a comparison with FDG PET/CT and 99mTc-MDP bone scan Nishikant Avinash Damle • Chandrasekhar Bal G. P. Bandopadhyaya • Lalit Kumar • Praveen Kumar • Arun Malhotra • Sneh Lata
•
Received: 1 October 2012 / Accepted: 6 January 2013 / Published online: 2 February 2013 Ó Japan Radiological Society 2013
Abstract Objectives We aimed to compare the role of 18F-fluoride PET/CT, FDG PET/CT and 99mTc-MDP bone scans in the detection of bone metastases in patients with lung, breast and prostate carcinoma. Methods This was a prospective study including patients for staging (S) and restaging (R). Seventy-two patients (23S, 49R) with infiltrating ductal breast carcinoma, 49 patients (25S, 24R) with prostate adenocarcinoma and 30 patients (17S, 13R) with non-small-cell lung carcinoma (NSCLC), without known bone metastases but with high risk/clinical suspicion for the same, underwent a 99mTcMDP bone scan, FDG PET/CT and 18F-fluoride PET/CT within 2 weeks. All scans were reviewed by two experienced nuclear medicine physicians, and the findings were correlated with MRI/thin-slice CT/skeletal survey. Histological verification was done wherever feasible. Results Sensitivity and negative predictive value (NPV) of 18F-fluoride PET/CT was 100 % in all three malignancies, while that of FDG PET/CT was 79 % and 73 % in NSCLC, 73 % and 80 % in breast cancer and 72 and 65 % in prostate cancer. Specificity and positive predictive value (PPV) of FDG PET/CT were 100 % in NSCLC and prostate and 97 % and 96 % in breast cancer. As compared to the 99mTc-MDP bone scan, all parameters were superior for 18 F-fluoride PET/CT in prostate and breast cancer, but N. A. Damle (&) C. Bal G. P. Bandopadhyaya P. Kumar A. Malhotra S. Lata Department of Nuclear Medicine, All India Institute of Medical Sciences, Room no. 59 A, New Delhi 110029, India e-mail:
[email protected] L. Kumar Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
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sensitivity and NPV were equal in NSCLC. The MDP bone scan had superior sensitivity and NPV compared to FDG PET/CT but had low specificity and PPV. Conclusion To rule out bone metastases in cases where there is a high index of suspicion, 18F-fluoride PET/CT is the most reliable investigation. 18F-fluoride PET/CT has the potential to replace the 99mTc-MDP bone scan for the detection of bone metastases. Keywords metastases
Fluoride FDG PET/CT MDP Bone
Introduction Bone is a very common site of metastases for various malignancies including prostate, breast, lung, kidney and thyroid. Of these, prostate, breast, lung, kidney and thyroid cancers account for about 80 % of cases [1]. Non-smallcell lung cancer (NSCLC) without distant metastases is potentially curable, while that with bone metastases is not. In lung cancer, bone metastases are present in approximately 20–30 % of patients at the initial diagnosis and in 35–66 % at autopsy [2–4]. Carcinoma of the breast is also commonly associated with metastatic bone disease. Although the frequency of bone metastases is 1–2 % at the time of primary diagnosis [5, 6], bone metastases are found in up to one-third of all patients with recurrent disease [7]. Bone is also the most common site of metastases from prostate cancer, and the likelihood of detecting bone involvement correlates with the Gleason score and PSA levels [8, 9]. In all three of these malignancies, patient management changes significantly with bone involvement. Thus, accurate staging of the skeleton is crucial in all patients. It is important to note that these malignancies
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have been known to manifest morphologically differing types of metastases. Prostate cancer shows almost exclusively osteosclerotic lesions, whereas NSCLC and breast cancer have a higher proportion of lytic and lytic-sclerotic lesions. 18 F-fluoride PET/CT has shown promise as a good modality for early and accurate detection of bone metastases. We aimed to evaluate the role of 18F-fluoride PETCT in the detection of bone metastases in patients with NSCLC, prostate adenocarcinoma and breast carcinoma with the intent to compare it with FDG PET-CT and 99mTcMDP bone scans (planar and SPECT).
Methods This was a prospective study including patients for staging (S) as well as restaging (R), with no previously known bone metastases, but with high risk/clinical suspicion for the same. The study was conducted at the Department of Nuclear Medicine of our institution over 2 years. It was ethically approved by the institutional ethics committee, and written informed consent was obtained from each patient. We studied 72 patients (23S, 49R) with pathologically proven infiltrating ductal breast carcinoma, 49 (25S, 24R) patients with prostate adenocarcinoma and 30 (17S, 13R) patients with NSCLC who were at high risk for bone metastases based on the T or N stage or other organ metastases at presentation and those in whom metastases were clinically suspected. For breast and lung cancer, patients with T3 and T4 tumors and/or node-positive patients were included, while for prostate cancer, patients with T3/T4 tumors and those with high Gleason scores (8/ 9/10) were included (AJCC TNM staging, 7th edition). Uncontrolled diabetics and patients who had undergone surgery in the past 4 weeks and/or chemotherapy or radiotherapy in the past 8 weeks were excluded from the study. We chose these three malignancies for two reasons: first, they show lesions of a different nature in the bone; second, they account for the majority of bone metastases. All patients included in the study underwent a 99mTc-MDP bone scan followed by FDG PET/CT scan and 18F-fluoride PET/CT within 2 weeks of each other. The two PET/CT studies were done randomly, and neither was necessarily done first. The 99mTc-MDP bone scan was done by injecting 740–925 MBq (20–25 mCi) of 99mTc-MDP intravenously, and imaging was done after 3–4 h. Planar images were acquired on a dual-head gamma camera with a high-resolution parallel hole collimator, with SPECT being done where necessary. FDG-PET/CT was performed using a Biograph-Duo LSO PET/CT scanner. For FDG PET/CT, patients fasted for at least 6 h, and a blood glucose level \160 mg/dl was ensured. Immediately prior to scan
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acquisition, patients were asked to void urine. Scanning was initiated 45 min after intravenous administration of 370–555 MBq (10–15 mCi) of FDG. 18F-fluoride PET/CT imaging was performed on a different day 45–60 min after intravenous administration of 370 MBq (10 mCi) of 18Fsodium fluoride. Patients were encouraged to drink adequate water post-injection. Immediately prior to PET/CT acquisition, all patients were asked to void. PET/CT images were reconstructed by the iterative method (2 iterations and 8 subsets) using the OSEM algorithm. Scan interpretation Images of all three scans were reviewed independently by two nuclear medicine physicians with 15 years’ scan reporting experience each, including 5 years in PET/CT, who were blinded to the results of the other scans while interpreting one scan. Scans were reported by both physicians at different time points without the patient identity being revealed. All scans were reported on the workstation computer with a DICOM viewer, and no hardcopy interpretation was done. No particular sequence was followed, and any scan was reported first for a patient. Where there was a difference in opinion, a consensus meeting was held to arrive at the final decision. Any abnormal foci of tracer uptake seen on the PET scans were correlated with the corresponding lesions on CT, and the lesions were characterized as sclerotic, lytic or mixed. However, a lesion was counted only on the basis of uptake and was only characterized on CT. This was done to ensure that findings were not biased against the MDP bone scan as it had no CT correlation. Results of the three scans were compared with MRI/thin-slice CECT/skeletal radiograph findings, and metastases were reported only if corroborated by these or if there was an unequivocal metastatic pattern on the nuclear scan. Histological verification was done wherever possible. Statistical analysis The sensitivity, specificity, accuracy, PPV and NPV of the MDP bone scan, fluoride PET/CT and FDG PET/CT for the detection of bone metastases in all three malignancies (lung, breast and prostate cancer) were calculated with confidence intervals and compared using the McNemar test. A p value \0.05 was considered statistically significant.
Results Lung cancer A total of 30 lung cancer patients were evaluated (17S, 13R). Mean age of the patients was 55 years with a range
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of 30–73 years. There were 25 males and 5 females. Histologically, there were 17 well-differentiated adenocarcinomas and 10 poorly differentiated adenocarcinomas, other than 3 squamous cell carcinomas (SCC). Bone metastases were confirmed to be present in 19 patients and absent in 11 patients. HPE was available in 5 patients, while other imaging was relied upon in 25 patients. In lung cancer patients, 18F-fluoride PET/CT and 99mTcMDP bone scans both showed equal and high sensitivity and NPV of 100 %, while for FDG PET/CT it was 79 and 73 %, respectively (Table 1). Thus, 18F-fluoride and MDP performed equally well in ruling out metastases. However, the specificity and PPV of FDG PET/CT were highest, and there were no false positives. Specificity and PPV of 18Ffluoride PET/CT and 99mTc-MDP bone scans were however significantly lower than for FDG PET/CT (p \ 0.05). But the accuracy of all three modalities was almost similar. A highly significant difference was noted between FDG and fluoride (p \ 0.05) and between FDG and MDP (p \ 0.05), but not between MDP and fluoride when the gold standard was positive as well as negative in all three malignancies. 18 F-fluoride PET/CT and 99mTc-MDP bone scan correctly upstaged four patients (13 %) as compared to FDG PET/CT, while 18F-fluoride PET/CT correctly downstaged one patient as compared to the 99mTc-MDP bone scan (3 %). However, five patients on 99mTc-MDP bone scan and four patients on 18F-fluoride PET/CT proved to be false positive compared to FDG PET/CT.
of 30–77 years. There were 71 females and 1 male. Histologically all had infiltrating ductal carcinoma. Bone metastases were confirmed to be present in 34 patients and absent in 38 patients. HPE was available in 14 patients and other imaging in 58 patients. In breast cancer patients 18F-fluoride PET/CT showed the highest sensitivity and NPV of 100 %, followed by 99m Tc-MDP bone scans (91, 88 %) (Table 2). FDG PET/ CT had moderate figures of 73 and 65 %, respectively. Thus, the best suited modality to rule out bone metastases when suspected seems to be 18F-fluoride PET/CT (Figs. 1, 2, 3). However, the specificity and PPV of FDG PET/CT was highest at 97.3 and 96 %, respectively. Corresponding values for 18F-fluoride PET/CT were 71 and 75 %, whereas those for the 99mTc-MDP bone scan were even lower. Thus, among the three modalities that we compared, FDG PET/ CT appeared most suited for confirming the malignant nature of a lesion. Nine additional patients were correctly detected to have metastases on 18F-fluoride PET/CT compared to FDG PET/ CT (Fig. 1a–c). Thus, correct upstaging occurred in 12.5 % of patients compared to FDG PET/CT. Compared to the 99m Tc-MDP bone scan, three patients were correctly upstaged, while five were correctly downstaged. Thus, management changed in 11 % of patients. However, 13 patients on MDP bone scan and 10 patients on 18F-fluoride PET/CT proved to be false positive compared to FDG PET/ CT.
Breast cancer
Prostate cancer
A total of 72 breast cancer patients were evaluated (23S, 49R). Mean age of the patients was 52 years with a range
A total of 49 prostate cancer patients were evaluated (25S, 24R). Mean age of the patients was 65 years with a range
Table 1 Lung cancer Sensitivity
Specificity
PPV
NPV
Accuracy
18
78.9 % (CI = 53.9–93 %)
100 % (CI = 67.9–100 %)
100 % (CI = 74.7–100 %)
73.3 % (CI = 44.8–91.1 %)
86.7 % (CI = 76.9–96.4 %)
18
100 % (CI = 79.1–100 %)
63.6 % (CI = 31.6–81.6 %)
83.6 % (CI = 60.5–94.3 %)
100 % CI = 56.1–100 %)
86.7 % (CI = 76.9–93.4 %)
99m
100 % (CI = 79.1–100 %)
54 % (CI = 24.6–81.9 %)
79.2 % (CI = 57.3–92.1 %)
100 % (CI = 51.7–100 %)
83.3 % (CI = 72.8–93.8 %)
Sensitivity
Specificity
PPV
NPV
Accuracy
18
73.5 % (CI = 55.3–86.5 %)
97.4 % (CI = 84.6–99.9 %)
96.2 % (CI = 78.4–99.8 %)
80.4 % (CI = 65.6–90.1 %)
86.1 % (CI = 78.1–94.1 %)
18
100 % (CI = 87.4–100 %)
71.1 % (CI = 53.9–84 %)
75.6 % (CI = 60.1–86.6 %)
100 % (CI = 84.5–100 %)
84.7 % (CI = 76.3–93.2 %)
99m
91.2 % (CI = 75.2–97.7 %)
63.2 % (CI = 46–77.7 %)
68.9 % (CI = 53.2–81.4 %)
88.9 % (CI = 69.7–97.1 %)
76.4 % (CI = 66.6–86.3 %)
F-FDG PET/CT
F-fluoride PET/ CT Tc-MDP bone scan
Table 2 Breast cancer
F-FDG PET/CT
F-fluoride PET/ CT Tc-MDP bone scan
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of 50–84 years. All had an adenocarcinoma. Findings were correlated with PSA levels. Bone metastases were confirmed to be present in 32 patients and absent in 17 patients. In our study we found that in prostate cancer the sensitivity and negative predictive value (NPV) were highest for 18F-fluoride PET/CT, followed by 99mTc-MDP bone scans followed by FDG PET/CT (Table 3). Specificity and
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positive predictive value (PPV) were highest for FDG PET/ CT. Accuracy of 18F-fluoride was highest at 90 %. 18Ffluoride PET/CT correctly upstaged nine patients compared to FDG PET/CT (18 %). Compared to 99mTc-MDP, one patient was correctly upstaged, and five were correctly downstaged by 18F-fluoride PET/CT. Thus, patient management changed in 12 % of patients. A detailed analysis of the number of lesions seen and their nature is shown in Tables 4 and 5. The number of lesions was not counted for prostate cancer as they were innumerable, and it was impractical to count them. Our data show that 18F-fluoride PET/CT detects the maximum number of lesions, followed by 99mTc-MDP bone scan followed by FDG PET/CT. The number of lytic lesions with uptake seen on 18F-fluoride PET/CT and FDG PET/ CT was almost equal in patients with lung and breast cancer considered together.
Discussion
Fig. 1 In a known case of breast cancer, 18F-fluoride PET/CT fused (a) and MIP image (b) showing intense uptake in the subtrochanteric and subcapital region of the right femur. The lesion was due to a pathological fracture that was confirmed on histopathology. A lesion in the sternum was completely sclerotic with good fluoride uptake and minimal MDP uptake but no FDG uptake. Another focus of increased uptake is in the mandible, probably secondary to dental caries
Metastases are more common than primary bone tumors. They usually occur because of hematogenous spread, but local invasion from adjacent soft tissue lesions is also known. Lesions in the bone may be osteolytic, osteoblastic or both. The objectives of various imaging modalities are to identify early bone involvement and complications, such as fracture or cord compression; to indicate the site for biopsy if histological diagnosis is necessary; and lastly to assess response to therapy [10–13]. Detection of metastases
Fig. 2 18F-FDG PET/CT showing unremarkable uptake in the PET (a), CT (b) and PET/CT fused (c) images in the subtrochanteric and subcapital regions that is evident in Fig. 1 of the same patient
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Fig. 3 Anterior (a) and posterior (b) 99mTc-MDP bone scan wholebody views showing no obvious metastatic lesion
can be by either direct visualization of the tumor or the bone’s response to the malignant process. Usually, purely osteolytic lesions are detected well by plain radiography, but may not be appreciated until about 30 % demineralization has occurred [10, 11, 13]. CT scans detect cortical and trabecular bone destruction, but sensitivity in the detection of early bone involvement is low as it often starts from the marrow [14]. Also, cortical destruction is difficult to detect in the presence of osteoporosis or degenerative changes [15]. MRI is optimal for detection of marrow involvement but not for cortical bone [15–17]. The 99mTcMDP bone scan is the commonly used modality for detection of bone metastases. It detects osteoblastic activity, is very sensitive and can detect 5–10 % change in normal to abnormal blastic response [10, 18]. However, it is less sensitive for purely lytic lesions. MDP is not tumor specific; uptake is increased in benign conditions as well. Addition of SPECT makes the test marginally more
sensitive, but specificity is seen to increase by 25–30 % [19]. Also it allows anatomic localization to some extent. But the drawback of SPECT is that it can be done only for a limited area. A previous study reported the sensitivity, specificity, positive and negative predictive value of bone SPECT imaging to be 91, 93, 73 and 98 %, respectively [20]. PET scanners offer the advantage of superior image resolution than the 99mTc-MDP bone scan done with a gamma camera and can acquire whole-body images much faster than MRI. FDG PET can detect both soft tissue and skeletal metastases and localizes directly to the tumor [21, 22]. Various clinical studies have found FDG PET to be superior to 99mTc-MDP bone scans in the detection of bone involvement in various malignant diseases [23]. Although reported as appropriate for all types of bone metastases, more data suggest that the sensitivity is higher in lytic than sclerotic or mixed lesions. Renewed interest in the fluoride ion as a bone tracer has been recently seen because of its application with PET technology. We studied a total of 151 patients, but the number of patients with each malignancy was less, particularly for NSCLC. Our prostate adenocarcinoma results are in agreement with those of Even-Sapir et al. [24], who compared the detection of bone metastases by 99mTc-MDP planar bone scintigraphy (BS), SPECT, 18F-fluoride PET and 18F-fluoride PET/CT in patients with high-risk prostate cancer. They concluded that 18F-fluoride PET/CT is a highly sensitive and specific modality for the detection of bone metastases in patients with high-risk prostate cancer, more specific than 18F-fluoride PET alone, and more sensitive and specific than planar and SPECT BS. They hypothesized that the added value of 18F-fluoride PET/CT may beneficially impact the clinical management of patients with high-risk prostate cancer [24]. de Jong et al. [25] found 18F-fluoride PET equally accurate in the detection of metastases as bone scans, but superior in details. Shreve et al. [26], in a comparison of FDG PET and 99mTc-MDP bone scans, concluded that the former can help identify osseous and soft tissue metastases of prostate cancer with a high PPV but is less sensitive. We too found the sensitivity as well as specificity of 18F-fluoride PET/CT to be higher than that of 99mTc-MDP bone scans.
Table 3 Prostate cancer Sensitivity
Specificity
PPV
NPV
Accuracy
18
71.9 % (CI = 53–85.6 %)
100 % (CI = 77.1–100 %)
100 % (CI = 82.2–100 %)
65.4 % (CI = 44.4–82.1 %)
81.6 % (CI = 70.7–92.5 %)
18
100 % (CI = 86.7–100 %) 96.9 % (CI = 82–99.8 %)
70.6 % (CI = 44–88.6 %) 41.2 % (CI = 19.4–66.5 %)
86.5 % (CI = 70.4–94.9 %) 75.6 % (CI = 59.4–87.1 %)
100 % (CI = 69.9–100 %) 87.5 % (CI = 46.7–99.3 %)
89.8 % (CI = 80.3–97.7 %) 77.5 % (CI = 65.8–89.2 %)
F-FDG PET/CT
F-fluoride PET/ CT 99m Tc-MDP bone scan
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Table 4 Breast cancer lesion analysis 18
18
FFDG
99m TcMDP
Ffluoride
Total no. of positive patients
26/72
45/72
45/72
Total no. of lesions
140
416
247
Sclerotic
110
392
234
Lytic
14
11
5
Mixed
16
13
8
Total no. of TP patients
25/26
34/45
31/45
Total no. of lesions
135
376
210
Sclerotic
105
352
197
Lytic
14
11
5
Mixed
16
13
8
Table 5 Total number of lesions
Total number of positive patients Total number of lesions
18
F-FDG PET/CT
18
F-fluoride PET/CT
99m Tc-MDP bone scan
15/30
23/30
24/30
124
188
102
Sclerotic
90
163
83
Lytic Mixed
17 17
12 13
8 11
Total number of true positives
15/30
19/30
19/30
Total number of lesions in true positives
124
177
89
Sclerotic
90
153
70
Lytic
17
12
8
Mixed
17
12
11
To the best of our knowledge, a study reporting the change in clinical management in prostate cancer patients with 18F-fluoride PET/CT and comparing the three modalities like we did has not yet been published. In NSCLC, FDG PET was initially shown to be more accurate than conventional staging modalities including MDP bone scans [27, 28]. A study by Lardinois et al. [29] concluded that integrated PET-CT improves the diagnostic accuracy of the staging of NSCLC over PET and CT alone. While Bury et al. [30] found that the sensitivity for detecting osseous involvement was similar for both FDGPET and 99mTc-MDP, but that PET yielded better specificity, Cheran et al. [31] suggested that since the advent of FDG PET, MDP bone scans can be eliminated from the staging evaluation at presentation. We feel that this can be done only if 18F-fluoride PET/CT is added to the FDG PET/CT as then none of the lesions will be missed. Our findings suggest that some patients may be negative on FDG PET/CT but positive on 18F-fluoride PET/CT or MDP
bone scans. Hence, the latter cannot be eliminated from the staging protocol. Schirrmeister et al. prospectively evaluated 53 patients with NSCLC comparing 18F-fluoride PET with 99mTc-MDP bone scans and SPECT. They concluded that 18F-fluoride PET is the most accurate whole-body imaging modality for screening for bone metastases. Also, routinely performing 99mTc-MDP bone scans with SPECT imaging is practicable, cost-effective and improves the accuracy of BS [32]. In a study by Even-Sapir et al. [33], 18 F-fluoride PET/CT was found to have a sensitivity of 99 % and specificity of 97 % when analyzed on a lesion basis, while it was 100 and 88 % on a patient based analysis. Almost all studies agree that FDG PET is able to detect osteolytic lesions better than 99mTc-MDP bone scans. But the latter is superior for osteoblastic metastases and shows more lesions [22, 34, 35]. Our data show that 18F-fluoride PET/CT detects a maximum number of lesions, followed by the 99mTc-MDP bone scan followed by FDG PET/CT. The number of lytic lesions with uptake seen on 18F-fluoride PET/CT and FDG PET/CT was almost equal in patients with lung and breast cancer considered together. Surveillance of metastatic spread to the skeleton in breast cancer patients based on FDG PET alone may not be possible [36]. In a study by Schirrmeister et al. in 34 breast cancer patients comparing 18F-fluoride PET and MDP bone scans, it was seen that 18F-PET detected 100 % of known metastases and two times the number of lesions compared to planar MDP bone scans. Also 97 % of lesions were correctly stratified as benign or malignant, and it correctly identified the extent of metastasis. 18F-fluoride PET influenced clinical management in 17.6 % of patients, which is slightly higher than in our data [37]. Withofs et al. [38] recently studied 24 patients with breast cancer and 10 patients with prostate cancer and concluded that 18F-fluoride PET/CT is significantly more accurate than 99mTc-MDP bone scans for detecting bone metastases from breast and prostate cancer. Ozulker et al. studied 70 patients with a variety of neoplastic diseases who had undergone both FDG-PET/CT and 99mTc-MDP bone scans and were eventually diagnosed as having metastatic bone disease. They used histopathological findings or clinical follow-up for 11 months as the gold standard. They found a sensitivity of 97.1 % for FDG PET/CT and 85.7 % for 99mTc-MDP bone scans [39]. Our results are in agreement with those of Kruger et al. [40], who also concluded that FDG PET/CT is superior to 99m Tc-MDP bone scans and 18F-fluoride PET/CT in the detection of lytic lesions. Yen et al. [41] showed that 18Ffluoride using the PET-CT system has significantly better sensitivity and specificity than conventional 99mTc-MDP bone scans in detecting metastatic HCC bone lesions that are predominantly osteolytic. A prospective pilot-phase trial by Iagaru et al. demonstrated superior image quality
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and evaluation of skeletal disease extent with 18F-NaF PET/CT over 99mTc-MDP scintigraphy and 18F-FDG PET/ CT. At the same time, because FDG PET detects extraskeletal disease that can significantly change disease management as well, the authors hypothesized that a combination of 18F-FDG PET/CT and 18F-fluoride PET/CT may be necessary for cancer detection [42]. Our data show that the total number of lesions seen on FDG PET/CT was less than that on 18F-fluoride PET/CT and 99mTc-MDP bone scans. However, the number of lytic lesions with uptake was more. The maximum number of sclerotic lesions with uptake was seen on fluoride PET/CT followed by the MDP bone scan and least on FDG PET/ CT. Apart from the pharmacokinetic superiority, 18F-fluoride has some other advantages vis-a`-vis MDP bone scans. It is easily obtained as a byproduct at centers where the facility of in-house 18F-FDG production is available. A limitation of our study in the current era of hybrid imaging could be the lack of CT correlation in the form of SPECT/CT with the MDP bone scan. With the advent of SPECT/CT, many of the false positives detected on 99mTcMDP bone scans may become true negatives. Another possible limitation is the lack of long-term follow-up. We conclude that 18F-fluoride PET/CT may be the only investigation necessary for staging the bone in prostate cancer. In lung cancer both 18F-fluoride and MDP perform equally well to rule out bone metastases. 18F-fluoride was also best in ruling out bone metastases in breast cancer patients. Thus, in view of the superior parameters for 18Ffluoride PET/CT compared to 99mTc-MDP bone scans, its potential to change management correctly, although in few patients, and its ease of use in an appropriate institution, 18 F-fluoride PET/CT has the potential to replace 99mTcMDP bone scans in the staging of the above three malignancies. Conflict of interest of interest.
The authors declare that they have no conflict
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