Breast Cancer: Role of SPECT and PET in Imaging Bone Metastases

https://doi.org/10.1053/j.semnuclmed.2009.05.002Get rights and content

Breast cancer is the most common cause of bone metastases in women. Imaging studies are useful to identify bone involvement and associated complications, for follow-up of disease spread and for the assessment of response to therapy. Bone scintigraphy with 99mtechnetium-labeled diphosphonates is most widely used, due to its availability, high sensitivity, and low cost, despite the relatively low specificity. The addition of single-photon emission computed tomography and recently single-photon emission computed tomography/computed tomography improves the diagnostic accuracy of this modality. Serial follow-up scans can demonstrate disease progression, but this method is less accurate in determining response to treatment. Positron emission tomography (PET), a tomographic modality with improved resolution shows improved sensitivity and specificity. 18F-fluorodeoxyglucose (FDG)-PET is the most common clinically used procedure. FDG is taken up by the tumor cells and has therefore the advantage of demonstrating the presence of disease in both bone and soft tissues. FDG-PET is highly sensitive mainly in diagnosis of early metastatic disease, which may still be confined to the bone marrow, as well as for the detection of lytic bone metastases and can be also reliably used to monitor response to therapy. For the detection of sclerotic lesions, however, imaging with a bone-seeking tracer such as 18F-fluoride, may have a complementary role. As a nonspecific skeletal imaging tracer, 18F-fluoride has great potential, being more sensitive than bone scintigraphy and when PET/computed tomography is performed it is highly accurate for detection of both lytic and sclerotic lesions and to distinguish benign from malignant skeletal findings.

Section snippets

Bone Scintigraphy

Bone scintigraphy (BS), commonly performed with 99mtechnetium-methylene diphosphonate (99mTc-MDP) is a widely used procedure, provides a whole-body skeletal survey at a relatively low cost and is the standard initial imaging modality for assessment of bone metastases.5, 7, 8, 9 The uptake of 99mTc-MDP on the bone surface reflects increased vascularity and increased osteoblastic activity. Osteolytic lesions also demonstrated secondary bone formation, and therefore even osteolytic metastases can

Bone SPECT and SPECT/CT

The addition of single-photon emission computed tomography (SPECT) improves the diagnostic accuracy of BS.6 SPECT enables accurate localization of tracer activity, especially in complex skeletal structures, such as spine, skull, and pelvis, and therefore can improve diagnostic specificity.20 For example, early metastatic spread to the vertebral column is usually confined to the posterior part of the vertebral body and the pedicle, adjacent to the venous network. Therefore, accurate localization

Detection of Bone Metastases With 18F-Fluoride and FDG and Comparison With BS

Positron emission tomography (PET) images have higher resolution as well as higher sensitivity and specificity compared with BS with or without SPECT.31 In addition, PET/CT enables fusion of metabolic function and morphology in a single acquisition, also assisting in a clear differentiation between malignant and benign lesions.32

18F-labeled sodium fluoride is a nonspecific PET tracer used for assessment of bone metastases.12, 16 18F-fluoride diffuses through capillaries into the extracellular

Conclusion

FDG-PET/CT may be less sensitive than BS and 18F-fluoride PET/CT for the detection of bone metastases in patients with breast cancer, mainly in predominantly sclerotic lesions, with better performance indexes in osteolytic sites. However, compared with studies performed with 99mTc-MDP and 18F-fluoride, FDG-PET/CT is associated with a higher specificity for the assessment of bone lesions and, in addition, enables also accurate evaluation of the primary tumor, as well as soft-tissue metastases in

References (45)

  • R.E. Coleman et al.

    The clinical course of bone metastases from breast cancer

    Br J Cancer

    (1987)
  • G.J. Cook et al.

    Detection of bone metastases in breast cancer by 18FDG PET: Differing metabolic activity in osteoblastic and osteolytic lesions

    J Clin Oncol

    (1998)
  • T. Hamaoka et al.

    Bone imaging in metastatic breast cancer

    J Clin Oncol

    (2005)
  • E. Even-Sapir

    Imaging of malignant bone involvement by morphologic, scintigraphic and hybrid modalities

    J Nucl Med

    (2005)
  • P. Shie et al.

    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

    (2007)
  • J.A. Frank et al.

    Detection of malignant bone tumors: MR imaging vs scintigraphy

    Am J Roentgenol

    (1990)
  • E. Gosfield et al.

    Comparison of radionuclide bone scans and magnetic resonance imaging in detecting spinal metastases

    J Nucl Med

    (1993)
  • R.E. Coleman et al.

    Reappraisal of the baseline bone scan in breast cancer

    J Nucl Med

    (1988)
  • K.A. Yeh et al.

    Routine bone scanning in patients with T1 and T2 breast cancer: A waste of money

    Ann Surg Oncol

    (1995)
  • L. Maffioli et al.

    Breast cancer: Diagnostic and therapeutic options

    Eur J Nucl Med Mol Imaging

    (2004)
  • W. Langster et al.

    The role of fluorodeoxyglucose, 18F-dihydroxyphenylalanine, 18F-choline and 18F-fluoride in bone imaging with emphasis on prostate and breast

    Semin Nucl Med

    (2006)
  • R.E. Coleman et al.

    Bone scan flare predicts successful systemic therapy for bone metastases

    J Nucl Med

    (1988)
  • Cited by (68)

    • Recent developments in peptide-based SPECT radiopharmaceuticals for breast tumor targeting

      2019, Life Sciences
      Citation Excerpt :

      With respect to the ability of SPECT imaging in many patients, may be need to correlation with high-quality anatomic images, CT, or MRI. Therefor it's better that Hybrid SPECT/CT devices equipped with multislice CT scanners were used [10]. It has been demonstrated various types of receptor such as, HER2 [11], EGFR [12], hepatocyte growth factor receptor (HGFR; also known as c-MET), type I insulin-like growth factor receptor (IGFIR) and estrogen receptor (ER) [13] that are overexpressed on breast cancer cells that regulate important biological processes, including cell proliferation, differentiation, metabolism, and survival with different signaling pathways.

    • Multi-technique imaging of bone metastases: Spotlight on PET-CT

      2016, Clinical Radiology
      Citation Excerpt :

      A human monoclonal antibody to RANKL, denosumab, is currently being used in the treatment of cancer-related bone disease. SPECT identifies bone lesions more sensitively compared to planar BS and improves characterisation of equivocal lesions.22 This is clinically relevant as certain sites, particularly the spine, tend to be affected by degenerative disease and it is vital to differentiate these benign lesions from skeletal metastases.

    • Detection of bone metastases in breast cancer patients in the PET/CT era: Do we still need the bone scan?

      2016, Revista Espanola de Medicina Nuclear e Imagen Molecular
      Citation Excerpt :

      Bone metastases affect 8% of all patients with breast cancer, but can reach an incidence of 30–85% in patients with advanced disease.1–3 Tumor cells spread hematogenously, starting as intramedullary lesions, found in more than 90% of the cases in the red marrow.4 The lesions can be osteolytic, osteoblastic (sclerotic) or mixed.

    View all citing articles on Scopus
    View full text