PET/CT-guided percutaneous biopsy of FDG-avid metastatic bone lesions in patients with advanced lung cancer: a safe and effective technique

Eur J Nucl Med Mol Imaging DOI 10.1007/s00259-016-3455-9 ORIGINAL ARTICLE PET/CT-guided percutaneous biopsy of FDG-avid metastatic bone lesions in patients with advanced lung cancer: a safe and effective technique Wei Guo 1 & Bing Hao 1 & Hao-jun Chen 1 & Long Zhao 1 & Zuo-ming Luo 1 & Hua Wu 1 & Long Sun 1 Received: 20 March 2016 / Accepted: 1 July 2016 # The Author(s) 2016. This article is published with open access at Springerlink.com Abstract Purpose 18F-FDG PET/CT should be performed before a diagnostic biopsy site is chosen in patients with a high clinical suspicion of aggressive, advanced tumour. The aim of this study was to evaluate the safety and efficacy of 18F-FDG PET/CT in guiding biopsy of bone metastases in patients with advanced lung cancer. Methods PET/CT-guided percutaneous core biopsies were performed in 51 consecutive patients with suspected lung cancer and 18F-FDG-avid bone lesions after whole-body 18FFDG PET/CT scans. Generally, one tissue sample was obtained from each patient. The final diagnoses were established on the basis of the histology results. The histopathological and molecular testing results were systematically evaluated. Results A total of 53 samples were obtained for histological examination or molecular testing as a second biopsy was required in two patients in whom the pathological diagnosis was unclear following the first biopsy. The pathological diagnosis and lung cancer classification were confirmed in 48 patients. The epidermal growth factor receptor mutation status was determined in 23 biopsies, and the mutation rate was 30.4 % (7/23). The anaplastic lymphoma kinase mutation status was determined in 19 biopsies, and the mutation rate was 31.6 % (6/19). Two of the 51 biopsies were positive for nonHodgkin’s lymphoma and one was positive for metastatic renal cell carcinoma. The first-time diagnostic success rate of * Long Sun Wei Guo 1 Department of Nuclear Medicine & Minnan PET Center, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, 55 Zhenhai Rd., Xiamen 361003, China biopsy was 96.1 % (49/51) and the overall diagnostic success rate and sensitivity were 100 %. All 51 patients were eventually confirmed as having stage IV disease. No serious complications were encountered and the average biopsy time was 30 min. Conclusion PET/CT-guided percutaneous biopsy of 18FFDG-avid bone metastases is an effective and safe method that yields a high diagnostic success rate in the evaluation of hypermetabolic bone lesions in patients with suspected advanced lung cancer. Keywords Lung cancer . FDG . PET/CT . Bone biopsy . EGFR . ALK Introduction Lung cancer is the primary cause of cancer-related mortality worldwide [1]. When the tumour is limited to the lung, with minimal regional lymph node spread, the most effective therapy is surgery. However, most patients present with locally advanced or metastatic disease and are ineligible for surgical resection. Besides surgical treatment, radiation and chemotherapy, molecularly targeted drugs have emerged as viable therapeutic options in patients with advanced and therefore inoperable cancer. Molecular targets include epidermal growth factor receptor (EGFR), tyrosine kinase inhibitors (TKIs; gefitinib and erlotinib) [2], and anaplastic lymphoma kinase (ALK) TKIs (crizotinib) [3]. Improved pretherapeutic staging, as part of a comprehensive approach to therapy, can limit unnecessary surgical interventions and provide greater benefit to patients. 18 F-FDG PET/CT has been used to evaluate the extent of disease in cancer patients and to provide more accurate staging [4]. According to the National Comprehensive Cancer Eur J Nucl Med Mol Imaging Network (NCCN) guidelines for non-small-cell lung cancer (NSCLC), 18F-FDG PET can play an important role in the evaluation and accurate staging of NSCLC. However, the guidelines also advocate that each positive PET scan finding for distant disease requires pathological or other radiological confirmation, with biopsy preferred to other methods. Since approximately 30 % to 65 % of patients with metastatic lung carcinoma will develop bone metastases [5], bone biopsy can aid in tumour staging of lung cancer patients with suspected bone metastases. Although the use of18F-FDG PET/CT-guided percutaneous biopsy has been reported in several types of malignant tumour [6, 7], its use for the biopsy of 18F-FDG-avid metastatic bone lesions has not been reported in patients with advanced lung cancer. The goal of the present study was to evaluate the safety and efficacy of 18F-FDG PET/CT guided biopsy of 18F-FDGavid metastatic bone lesions in patients with advanced lung cancer. The disease in the lung cancer patients was staged on the basis of histopathological examination. In addition, adequate tissue samples from bone biopsies allow more beneficial molecular tests to be performed (i.e. determination of EGFR mutation status and ALK mutation status), which may identify candidates for individualized treatment and targeted therapy. Materials and methods Patients This retrospective evaluation of collected data was approved by the ethics committee of our institution. All patients gave their written informed consent prior to the intervention. Between January 2013 and September 2015, 18F-FDG PET/ CT-guided bone biopsies of metabolically active lesions were performed in 51 consecutive patients (average age 59.7 years, range 41 – 83 years; 35 men, 16 women) who had undergone whole-body 18F-FDG PET/CT for suspected lung cancer. All the patients were biopsied as inpatients and were kept under observation for at least 2 h after the biopsy. view. The acquisition time was 3 min per table position. PET imaging datasets were reconstructed iteratively by applying the CT data for attenuation correction, and coregistered images were displayed on a workstation. 18 F-FDG PET/CT-guided bone biopsy After the whole-body 18F-FDG PET/CT scan the previous day, a board-certified interventional radiologist and nuclear medicine physician performed the bone biopsies in a PET/ CT suite dedicated to biopsy procedures. PET/CT-guided bone biopsies were performed using a step-by-step technique. In order to reduce radiation exposure to the medical staff during the biopsy procedures, bone biopsies were scheduled on separate days. Patients were positioned in a prone or supine position depending on factors such as target location, optimal needle path, and shortest skin-to-target distance. Interventions were performed under aseptic conditions after administration of local anaesthetic with lidocaine. The needle was introduced in a stepwise manner under fused PET/CT and CT imaging guidance. The bone biopsy needle, either a 16G (Magum, Bard, AZ) or an 11G (BMNB, SA Medical & Plastic Instruments Co., Ltd, Shanghai, China), was chosen depending on the nature of the lesion (i.e. whether it was an osteoblastic or osteolytic metastasis), and its location and depth. One sample was obtain (...truncated)