title: F-18 NaF PET for detection of bone metastases in lung cancer: accuracy, cost-effectiveness, and impact on patient management.
abstract: As bone metastases might be present in lung cancer despite a normal bone scan, we examined various alternatives prospectively. Positron emission tomography using F-18 sodium fluoride (PET) and single photon emission tomography (SPECT) were more sensitive than a planar bone scan. PET was more accurate with a shorter examination time than SPECT but had higher incremental costs.
  
  
  BACKGROUND
  Previous studies have shown that vertebral bone metastases not seen on planar bone scans may be present on F-18 fluoride positron emission tomography (PET) scan or single photon emission computed tomography (SPECT). The purpose of this study was to measure the accuracy, clinical value and cost-effectiveness of tomographic bone imaging.
  
  
  METHODS
  A total of 103 patients with initial diagnosis of lung cancer was prospectively examined with planar bone scintigraphy (BS), SPECT of the vertebral column and PET using F-18 sodium fluoride (F-18 PET). Receiver operating characteristic (ROC) curve analysis was used for determination of the diagnostic accuracy. A decision-analysis model and the national charge schedule of the German Hospital Association were used for determination of the cost-effectiveness.
  
  
  RESULTS
  Thirteen of 33 patients with bone metastases were false negative on BS, 4 on SPECT, and 2 on F-18 PET. The area under the ROC curve was 0.771 for BS, 0.875 for SPECT, and 0.989 for F-18 PET (p < 0.05). As a result of SPECT and F-18 PET imaging, clinical management was changed in 8 (7.8%) and 10 (9.7%) patients. Compared with BS, the costs per additional correctly diagnosed patient were 1272 Euro with SPECT and 2861 Euro with F-18 PET. The threshold for the costs of F-18 PET being more cost-effective than SPECT was 345 EUR.
  
  
  CONCLUSIONS
  Routine performance of tomographic bone imaging improves the therapeutic strategy because of detection of otherwise missed metastases. F-18 PET is more effective than SPECT but is associated with higher incremental costs.
authors.affiliation: Department of Internal Medicine II, University of Ulm, Ulm, Germany. martin.hetzel@medizin.uni-ulm.de
authors.forename: Martin
authors.initials: M
authors.lastname: Hetzel
authors.forename: Coskun
authors.initials: C
authors.lastname: Arslandemir
authors.forename: Hans-Helmut
authors.initials: HH
authors.lastname: König
authors.forename: Andreas K
authors.initials: AK
authors.lastname: Buck
authors.forename: Karin
authors.initials: K
authors.lastname: Nüssle
authors.forename: Gerhard
authors.initials: G
authors.lastname: Glatting
authors.forename: Andreas
authors.initials: A
authors.lastname: Gabelmann
authors.forename: Jürgen
authors.initials: J
authors.lastname: Hetzel
authors.forename: Vinzenz
authors.initials: V
authors.lastname: Hombach
authors.forename: Holger
authors.initials: H
authors.lastname: Schirrmeister
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001859:Bone Neoplasms / Q000000981:diagnostic imaging* / Q000556:secondary*; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005260:Female; D005462:Fluorine Radioisotopes / Q000191:economics; D005858:Germany; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis / Q000000981:diagnostic imaging; D019275:Radiopharmaceuticals; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012969:Sodium Fluoride; D014055:Tomography, Emission-Computed / Q000191:economics / Q000379:methods; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics / Q000379:methods*
chemical_list: D005462:Fluorine Radioisotopes; D019275:Radiopharmaceuticals; D012969:Sodium Fluoride