Can FDG-PET/CT replace blind bone marrow biopsy of the posterior iliac crest in Ewing sarcoma?

Background: FDG PET/CT and bone marrow biopsy (BMB) are considered standard procedures for the staging of patients with new, untreated FL. A key issue in FL is the early identification of patients who will fail early. We recently reported (Am J Hematology 2019) that the presence of ≥2 EN sites, spleen, bone or soft tissue involvement as detected by PET all predicted failure to achieve EFS24. In Hodgkin lymphoma and diffuse large B-cell NHL, PET has replaced the routine need for a staging BMB. However, there is no such evidence in FL. The goal of this study was to determine the value of FDG PET/CT in determining bone involvement in FL using BMB as the gold standard. Methods: Patients were identified using the Mayo Clinic Lymphoma Database. 548 patients with newly diagnosed FL grades 1-3A between years 2003-2016, available BMB results, and PET/CT imaging at diagnosis, were included in the analysis. The presence of bone and spleen involvement on PET/CT, SUVmax and SUVmean of the axial skeleton at L3, and BMB results were recorded and compared. Results: In all, 36% (197/548) of patients had a positive BMB, and 34% (189/548) had bone involvement detected on PET/CT. Compared to BMB, the sensitivity and specificity of PET/CT in detecting bone involvement as determined by BMB were 60% and 80%, respectively. We noted that 59 patients had focal bone involvement on PET/CT rather than a diffuse component, and found that 47% (28/59) of these patients had a negative BMB obtained in the posterior iliac crest. Excluding these patients, the sensitivity and specificity of PET/CT in detecting bone involvement were 53% and 88%, respectively (Table 1). With respect to the spleen, 29% (157/548) of patients had evidence of splenic FL involvement on PET/CT, and of these, 69% (109/157) also had a positive BMB. The sensitivity and specificity of spleen involvement on PET/CT in predicting bone involvement on BMB were 55% and 86%, respectively (Table 2). We recorded SUV data at L3 in the 439 patients who had either a diffuse pattern of bone involvement on PET/CT, or a PET/CT read as negative. We analyzed the positive and negative predictive values (PPV and NPV) of SUVmax and SUVmean at several cut-off points to determine whether axial bone SUV is reliable at determining patients with a positive or negative BMB. The NPV for an SUVmax of less than 2.0 was 96% (n=25 patients classified as negative). For SUVmean, the best cut-off point was at less than 1.4, where NPV was 100% (n=15 patients classified as negative). There was no logical cut-off point for a significant PPV > 95%. Conclusion: In newly diagnosed FL, the sensitivity and specificity of bone involvement on PET/CT are insufficient for PET/CT to routinely replace BMB. However, in patients where the need for BMB at staging is being debated, certain factors on PET/CT can help facilitate this decision. The detection of focal bone lesions, especially those that may be missed on posterior iliac crest BMB, can make BMB unnecessary. If both the spleen and bone appear involved on PET/CT, this confers a relatively high chance that BMB will be positive. If SUVmax at L3 is less than 2.0, or if SUVmean is less than 1.4, the BMB will likely be negative, with a NPV > 95%. This decision-making algorithm is outlined in Figure 1 and may serve as a useful guideline for clinical trials and routine practice. Disclosures No relevant conflicts of interest to declare.

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The Clinical Utility of FDG PET-CT in Evaluation of Bone Marrow Involvement by Diffuse Large B Cell Lymphoma

Blood ◽

10.1182/blood.v118.21.2661.2661 ◽

2011 ◽

Vol 118 (21) ◽

pp. 2661-2661

Author(s):

Hyo Jung Kim ◽

Boram Han ◽

Dok Hyun Yoon ◽

Ho Young Kim ◽

Shin Kim ◽

...

Keyword(s):

Bone Marrow ◽

Fdg Pet ◽

Iliac Crest ◽

Cell Lymphoma ◽

Medical Center ◽

B Cell Lymphoma ◽

Large B Cell Lymphoma ◽

Pet Ct ◽

Fdg Pet Ct ◽

Large B Cell

Abstract Abstract 2661 Background. In lymphoma, bone marrow (BM) involvement is a sign of extensive disease and BM biopsy is a standard method in the evaluation of BM infiltration by disease. Because of patchy BM involvement pattern by lymphoma, the reported rates of unilateral involvement in bilateral biopsies range from 10% to 50%. However BM biopsy is an invasive and painful procedure. The value of unilateral versus bilateral BM biopsy remains controversial. Fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) is a noninvasive imaging technique and currently it shows potential to detect BM involvement by lymphoma. Aims. We assess the abilities of FDG PET-CT to ascertain the presence of BM involvement in diffuse large B cell lymphoma (DLBCL) patients and to define the possibility that bilateral BM biopsies could be replaced by unilateral biopsy for DLBCL staging workup. Methods. We retrospectively reviewed medical records of histologically proven DLBCL patients from 2004 through 2010 at the Asan Medical Center and Hallym University Medical Center. All patients were examined by FDG PET-CT and bilateral BM biopsy at both posterior iliac crests for initial staging workup. Evaluation of PET studies was performed by board-certified nuclear medicine physicians of each institution. Quantitative analysis of FDG uptake was not performed. Data were expressed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for FDG PET-CT in evaluation of BM involvement by DLBCL, using BM biopsy as the reference standard. Two sets (right & left biopsy site) of pathologic and imaging data were analyzed separately. Results. Study population comprised 478 patients (median age 57, range 17–85 years; 269 male) with newly diagnosed DLBCL. Ann Arbor stage I, II, III and IV patients were 96, 120, 40 and 222, respectively. Overall, BM involvement by DLBCL that confirmed by bilateral BM biopsy occurred in 63 patients (13.2%, 15, 12, and 36 at right, left and both side biopsy, respectively). From the data of right side biopsy and FDG PET-CT images, comparison of the former and the later results revealed concordant positive findings in 22 cases (4.6%) and concordant negative findings in another 418 cases (87.4%). In 29 patients (6.1%) in whom FDG PET-CT returned findings of normal marrow, iliac crest BM biopsy revealed lymphomatous infiltration. On the other hand, in 9 patients (1.9%) in whom bilateral iliac crest BM biopsy had failed to reveal any abnormality, FDG PET-CT showed increased uptake. The calculated values for FDG PET-CT in evaluation of right BM infiltration were 43.1% (22/51) of sensitivity, 97.9% (418/427) of specificity, 71% (22/31) of PPV and 93.5% (418/447) of NPV. The values oriented from left BM biopsy and FDG PET-CT images were similar (sensitivity 41.7% (20/48), specificity 97.9% (421/430), PPV 69% (20/29), NPV 93.7% (421/449)). Conclusions. This study has the largest DLBCL cases among ever reported articles, and demonstrates not excellent sensitivity of FDG PET-CT against the results of BM biopsy for the detection of BM involvement in DLBCL patients. BM biopsy could not be completely replaced with FDG PET-CT. But it has relatively good PPV, FDG PET-CT will be a useful tool for image-guided biopsy for DLBCL staging. And in daily practice, clinicians could consider the possibility to do efficient unilateral BM biopsy for DLBCL patients who have increased posterior iliac crest FDG uptake, instead of bilateral biopsy. Disclosures: Kim: Novartis: Research Funding.

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The relationship between bone marrow involvement on 18F-FDG PET/CT and bone marrow biopsy in patients with multiple myeloma and other plasma cell neoplasms

South African Journal of Oncology ◽

10.4102/sajo.v6i0.197 ◽

2022 ◽

Vol 6 ◽

Author(s):

Kiflom S. Gebreslassie ◽

Fatima C. Bassa ◽

Zivanai C. Chapanduka ◽

James M. Warwick

Keyword(s):

Multiple Myeloma ◽

Bone Marrow ◽

Bone Marrow Biopsy ◽

Fdg Pet ◽

Bone Marrow Involvement ◽

Pet Ct ◽

Plasma Cell Neoplasms ◽

18F Fdg ◽

Fdg Pet Ct ◽

The Relationship

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Correlation of FDG-PET-CT with Bone Marrow Aspiration and Biopsy at the Initial Staging in Follicular Lymphoma: Can We Omit Bone Marrow Biopsy in Some?

Blood ◽

10.1182/blood.v124.21.4436.4436 ◽

2014 ◽

Vol 124 (21) ◽

pp. 4436-4436

Author(s):

Manju Sengar ◽

Hasmukh Jain ◽

Venkatesh Rangarajan ◽

Archi Agrawal ◽

Hari Menon ◽

...

Keyword(s):

Bone Marrow ◽

Follicular Lymphoma ◽

Bone Marrow Biopsy ◽

Predictive Value ◽

Fdg Pet ◽

Early Stage ◽

Bone Marrow Involvement ◽

Bone Marrow Uptake ◽

Pet Ct ◽

Fdg Pet Ct

Abstract Introduction: The role of FDG PET-CT in follicular lymphoma is limited to accurate assessment of disease extent in early stage patients and selection of biopsy site in cases of suspected high- grade transformation. Despite the known FDG avidity of follicular lymphoma, FDG PET-CT has not yet been included as part of standard staging procedures in these patients. FDG PET-CT has shown significant correlation with bone marrow biopsy in Hodgkin and diffuse large B-cell lymphomas. In this retrospective analysis we have assessed the correlation of PET-CT with that of bone marrow biopsy, the reference standard for assessment of bone marrow infiltration in follicular lymphoma. Methods: We retrospectively analyzed electronic medical records and database of patients with newly diagnosed follicular lymphoma registered at Tata Memorial Centre from July 2009 to Jun 2014, who underwent complete staging workup as per the current recommendations along with whole body 18FDG-PET/CT. The demographic features, performance status, stage, LDH, nodal sites, haemoglobin, follicular lymphoma international prognostic index (FLIPI), FDG PET-CT findings (bone marrow involvement, pattern of involvement- focal or diffuse, sites of marrow involvement, liver and spleen uptake, SUVmax of most FDG avid lesion) and bone marrow aspiration/biopsy (morphology, immunohistochemistry and immunophenotyping on aspirate, where available) findings were recorded. Focal uptake in marrow on baseline PET-CT was considered as marrow involvement if post therapy PET-CT showed resolution of these lesions. The sensitivity, specificity, negative and positive predictive value of PET-CT in detecting bone marrow infiltration was assessed taking bone marrow biopsy as gold standard. The factors responsible for discordant results were analyzed. Results: A total of 54 patients (males-38, females-16) were included in analysis with median age of 50 years, (range 22-73 years). At diagnosis 83% (45 patients) had stage III or IV disease and 57% patients had high-risk FLIPI score. Approximately 88% patients had good performance status (ECOG-<2). Bone marrow showed infiltration in approximately 60% (32 patients) on biopsy and immunophenotyping. PET-CT showed bone marrow involvement in 18 patients (focal-12, diffuse -6). In 4 patients with focal PET-CT positivity, bone marrow was uninvolved. However, post therapy these lesions showed resolution, thus confirming the presence of disease pretherapy. The sensitivity, specificity, positive and negative predictive value of PET/CT with respect to biopsy was 43.7%, 81.2%, 77.8% and 50% respectively. However, if we include the above mentioned 4 cases as true positives, then specificity and positive predictive value improves to 100% each. In addition, PET-CT could accurately predict absence of bone marrow involvement in stage I and stage II disease (100% concordance). The median SUVmax of most FDG avid lesion was 13.1 (5.25-34.93). However the SUVmax did not correlate with grade of lymphoma as the node biopsy was not done based on PET-CT results. Conclusion: This study shows that in patients with advanced stage follicular lymphoma bone marrow biopsy can be omitted if PET-CT shows focal or diffuse bone marrow uptake. Similarly, patients with early stage disease with no bone marrow uptake on PET-CT can be spared from bone marrow biopsy. Disclosures No relevant conflicts of interest to declare.

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