Home > DARE Reviews > Diagnosis of bone metastases: a...

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Diagnosis of bone metastases: a meta-analysis comparing 18FDG PET, CT, MRI and bone scintigraphy

HL Yang, T Liu, XM Wang, Y Xu, and SM Deng.

Review published: 2011.

Link to full article: [Journal publisher]

CRD summary

The review concluded that 18fluorodeoxyglucose positron emission tomography and magnetic resonance imaging had similar accuracy for the diagnosis of bone metastases; both were significantly more accurate than computed tomography or bone scintigraphy. These conclusions should be interpreted cautiously as they were based on both indirect comparisons between studies that assessed one imaging modality and studies that compared more multiple modalities.

Authors' objectives

To compare 18fluoro-deoxyglucose positron emission tomography (18FDG-PET), computed tomography (CT), magnetic resonance imaging (MRI) and bone scintigraphy for the diagnosis of bone metastases.

Searching

MEDLINE, EMBASE, Scopus, Science Direct, SpringerLink, Web of Knowledge, EBSCO and the Cochrane Database of Systematic Reviews were searched from January 1995 to January 2010 without language restrictions. Search terms were reported and included methodological terms for test accuracy studies. The bibliographies of retrieved articles were screened for additional studies.

Study selection

Studies that assessed the accuracy of 18FDG PET (including 18FDG PET and PET/CT), CT, MRI or technetium-99m methylene-diphosphonate (99mTc-MDP) bone scintigraphy for the detection of bone metastases were eligible for inclusion. Studies were required to use histopathological analysis and/or close clinical and imaging follow-up and/or radiographic confirmation by multiple imaging techniques as the reference standard to confirm diagnosis. Studies had to report sufficient data for the calculation of number of true positive, false negative, false positive and true negative test results (per patient or per lesion).

Studies were excluded if they reported the results of different imaging modalities in combination, and separate accuracy data could not be extracted for each imaging modality.

Study participants ranged from ten to 91 years of age. The year of publication ranged from 1997 to 2010 and the country of publication varied widely (majority Europe or Asia). Most included studies used both histopathological analysis and clinical and imaging follow-up as the reference standard. Primary tumour sites were in many different locations (fully reported in the paper).

Two reviewers independently assessed studies for inclusion.

Assessment of study quality

The methodological quality of included studies was assessed using the 14-item QUADAS tool.

Two reviewers independently assessed study quality and any disagreements were resolved by consultation with a third reviewer.

Data extraction

Two reviewers independently extracted data on the numbers of true positive, false negative, false positive and true negative test results for each study and imaging modality. Any disagreements were resolved by consultation with a third reviewer. The z test was used to determine whether there was a statistically significant difference in test performance between the imaging modalities.

The review included a large number of studies and study level results were not reported.

Methods of synthesis

Pooled estimates of sensitivity, specificity and diagnostic odds ratio (DOR), with 95% confidence intervals (CIs) were calculated, for each imaging modality, using the DerSimonian Laird random-effects model. Summary receiver operating characteristic (SROC) curves were estimated using the Moses and Littenberg model.

Meta-regression analysis was used to asses potential sources of between study heterogeneity; variables assessed were year of publication, sample size, type of reference stand, type of primary tumour, authors’ country and the 14 QUADAS items.

Subgroup analyses were performed to assess the effect on accuracy of different techniques within the same imaging modality. For PET, subgroup analyses were conducted for type of system (PET vs PET/CT) and type of analysis (qualitative analysis vs both qualitative and quantitative analysis). For MRI, subgroup analyses were conducted for axial vs whole body, un-enhanced vs contrast-enhanced and using diffusion weighted imaging sequences vs not using diffusion weighted imaging sequences. For bone scintigraphy, subgroup analyses were conducted for using single-photon emission computed tomography (SPECT) vs not using SPECT. There were insufficient data for any subgroup analyses of CT. Publication bias was assessed by considering whether the size of studies was associated with diagnostic accuracy.

Results of the review

Sixty-seven studies, reporting 145 data sets were included in the review. The most commonly failed QUADAS criteria were assessment of all participants with the same reference standard, adequate description of the reference standard, and interpretation of the reference standard without knowledge of the index test results.

18 FDG-PET and PET/CT: The pooled, per patient, estimate of sensitivity was 89.7% (95% CI 87.4 to 91.6%) and the corresponding pooled estimate of specificity was 96.8% (95% CI 96.2 to 97.3%); 26 studies, 4,367 participants. The pooled, per lesion, estimate of sensitivity was 86.9% (95% CI 85.3 to 88.3%) and the corresponding pooled estimate of specificity was 97.0% (95% CI 96.5 to 97.5%); 18 studies, 6,779 lesions.

CT Scan: The pooled, per patient, estimate of sensitivity was 72.9% (95% CI 66.6 to 78.6%) and the corresponding pooled estimate of specificity was 94.8% (95% CI 92.4 to 96.6%); seven studies, 723 participants. The pooled, per lesion, estimate of sensitivity was 77.1% (95% CI 72.9 to 81.0%) and the corresponding pooled estimate of specificity was 83.2% (95% CI 79.7 to 86.2%); three studies, 983 lesions.

MRI Scan: The pooled, per patient, estimate of sensitivity was 90.6% (95% CI 86.7 to 93.7%) and the corresponding pooled estimate of specificity was 95.4% (95% CI 93.6 to 96.8%); 15 studies, 1,032 participants. The pooled, per lesion, estimate of sensitivity was 90.4% (95% CI 87.2 to 93.0%) and the corresponding pooled estimate of specificity was 96.0% (95% CI 95.2 to 96.8%); seven studies, 2,874 lesions.

Bone scintigraphy: The pooled, per patient, estimate of sensitivity was 86.0% (95% CI 84.0 to 87.8%) and the corresponding pooled estimate of specificity was 81.4% (95% CI 80.0 to 82.8%); 48 studies, n=4,638 participants. The pooled, per lesion, estimate of sensitivity was 75.1% (95% CI 72.9 to 77.2%) and the corresponding pooled estimate of specificity was 93.6% (95% CI 92.8 to 94.2%); 21 studies, n=6,083 lesions.

The pooled, per patient and per lesion, estimates of sensitivity were similar for 18FDG-PET and MRI and both were significantly higher than those for CT and bone scintigraphy. The pooled, per patient, estimates of specificity were similar for 18FDG-PET, CT and MRI; all were higher than bone scintigraphy. For pooled per lesion estimates, the specificity of CT was lower than that of bone scintigraphy.

Subgroup analyses indicated that PET/CT was more sensitive than PET, axial MRI was more sensitive than whole body MRI, and bone scintigraphy using SPECT was more specific than without SPECT. Full results of subgroup analyses and meta-regression were reported in the article.

Authors' conclusions

18FDG-PET and MRI had similar accuracy for the diagnosis of bone metastases and both were significantly more accurate than CT and bone scintigraphy.

CRD commentary

The article reported a clearly stated research objective and defined appropriate inclusion criteria. Several sources were searched for relevant studies, but the inclusion of methodological terms for test accuracy studies may have reduced the sensitivity of searches and could have resulted in relevant studies being omitted. Measures to minimise error and/or bias were applied throughout the review process. The methodological quality of included studies was assessed and the results of quality assessment were reported and were incorporated in the analyses. The statistical methods used in the synthesis were broadly suitable, but more advanced methods were available which may have been more appropriate, with more reliable results. Comparisons between imaging techniques were derived from a mixture of direct and indirect sources; data were not reported separately for studies which assessed more than one imaging modality in the same patients. Therefore, the authors' conclusions about the comparative accuracy of imaging modalities should be interpreted cautiously.

Implications of the review for practice and research

Practice: The authors stated that, because it was non-invasive and low cost, bone scintigraphy could be used to help distinguish patients with diffuse disease who were not eligible for curative treatment from patients with no bone metastases or a limited number of bone metastases. The patients in the latter group should undergo MR imaging or 18FDG PET.

Research: The authors stated that further, better designed studies were needed to compare the effectiveness of different imaging techniques for the detection of bone metastases from different types of primary tumour.

Funding

Not stated.

Bibliographic details

Yang HL, Liu T, Wang XM, Xu Y, Deng SM. Diagnosis of bone metastases: a meta-analysis comparing 18FDG PET, CT, MRI and bone scintigraphy. European Radiology 2011; 21(12): 2604-2617. [PubMed: 21887484]

Indexing Status

Subject indexing assigned by NLM

MeSH

Adolescent; Adult; Aged; Aged, 80 and over; Bone Neoplasms /diagnosis /radiography /radionuclide imaging /secondary; Child; Early Detection of Cancer; Female; Fluorodeoxyglucose F18 /diagnostic use; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Positron-Emission Tomography; Radiopharmaceuticals /diagnostic use; Sensitivity and Specificity; Tomography, X-Ray Computed; Young Adult

AccessionNumber

12012000294

Database entry date

06/07/2012

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 21887484