Trovremenska scintigrafija kosti u utvrđivanju lokalnog recidiva bolesti kod osteosarkoma i sarkoma Ewing donjih ekstremiteta

Balenović, Antonija (2011) Trovremenska scintigrafija kosti u utvrđivanju lokalnog recidiva bolesti kod osteosarkoma i sarkoma Ewing donjih ekstremiteta. PhD thesis, Sveučilište u Zagrebu.

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Abstract

The aim of the study was to assess diagnostic usefulness of early phases of three phase bone scan (angioscintigraphy and blood pool) during follow-up of local region in patients with osteosarcoma and sarcoma Ewing of lower extremities. Eighty-three patients were included, average follow-up period was 73.8 months (median 58.0 months) and average patients age was 13.8 years (median 13.0 years). In 36 patients (43.4%) metastasis spread was noticed and the most frequent region involved were lungs (88.9%). Local relapse was noticed in 18 patients (21.7%). Overall survival of all patients during follow-up period was 61.4%, while in the patients with metastatic disease overall survival was lower (16.7%) and in patients with local relapse was lower as well (27.8%). In all patients local relapse was detected by three-phase bone scan of local region and local x-ray was positive only in one patient. Contribution of each phase of three phase-bone scan (angioscintigraphy, blood pool and late images) in assessing local relapse was analyzed and no correlation was confirmed between angioscintigraphy and local relapse (P=0.566), but correlation between blood pool (P<0.001) or late images (P<0.001) and local relapses were confirmed. Besides malignant changes of local region (local relapses) generally the most frequent reasons for pathologic changes of bone scans in all patients were benign changes (25.3%) and 8.4% reports were falsely positive (nor benign neither malignant changes confirmed during whole follow-up period). Sensitivity and specificity of each phase to detect local relapse was analyzed: angioscintigraphy 38.9% and 70.8%; blood pool 94.4% and 56.9%; late images 89.9% and 67.7%. Excluding patients with known benign reasons for positive bone scans we could obtain better specificity. Blood pool specificity increased to 84.1% and for late images specificity increased to 86.4%. Since we had relatively small group of patients we analyzed each case separately («case based reasoning») and established that in two patients local 93 relapse (which was in soft tissues of the region) was missed by late images and was confirmed particularly as a result of positive blood pool images (11.1%). Our results suggest that sensitivity of the late phase of bone scan is not sufficient to detect early local relapse in soft tissue. Early phases of bone scan complement to late phase so we would recommend them in the follow-up of local region in patients with osteosarcoma and sarcoma Ewing to achieve significantly better sensitivity of the procedure.

Abstract in Croatian

Svrha studije bila je utvrditi dijagnostičku korist nalaza dobivenih u prva dva vremena snimanja kod trovremenske scintigrafije kosti lokalne regije u bolesnika sa osteogenim sarkomom i sarkomom Ewing u području donjih ekstremiteta, a tijekom praćenja bolesnika. Obuhvaćeno je ukupno 83 bolesnika prosječne dobi 13.8 godina (medijan 13 godina) koji su prosječno praćeni 73,8 mjeseci (medijan 58,0 mjeseci). U 36 bolesnika (43,4%) došlo je do širenja bolesti u druge organe (najčešće u pluća, 88,9%), a u 18 bolesnika (21,7%) registriran je lokalni recidiv bolesti. Ukupno preživljenje tijekom medijana praćenja od 58,0 mjeseci bilo je 61,4%, u skupini bolesnika sa metastazama preživljenje je bilo 16,7%, a u skupini bolesnika sa lokalnim recidivom također slabije (27,8%). U svih bolesnika sa lokalnim recidivom na bolest se posumnjalo učinjenom trovremenskom scitnigrafijom lokalne regije, a rentgen lokalne regije bio je pozitivan u samo jednog bolesnika. Analizirani su doprinosi pojedinih vremena scintigrafije kosti i utvrđeno da nema povezanosti između prvog vremena snimanja (protok) i pojave lokalnog recidiva (P= 0,566), dok je potvrđena stastistički značajna povezanost između drugog vremena snimanja (krvni prostor) i lokalnog recidiva (P<0.001), te kasnih statičkih scintigrama i lokalnog recidiva (P<0.001). Patološki nalaz scintigrafije kosti u većine bolesnika bio je uzrokovan benignim promjenama u lokalnoj regiji (25,3%), a utvrđeno je i 8,4% lažno pozitivnih nalaza. Analizom osjetljivosti i specifičnosti pojedinih vremena snimanja za dokazivanje lokalnog recidiva utvrđena je vrlo slaba osjetljivost (38,9%) i loša specifičnost prvog vremena snimanja (70,8%), a slaba specifičnost drugog vremena (56,9%) i kasnih statičkih scintigrama (67,7%) uz visoku osjetljivost tih metoda (94,4% i 89,9%). Isključivanjem bolesnika s pozitivnim nalazom radi poznatih benignih uzroka dobivena je nešto bolja specifičnost i ranih i kasnih statičkih scintigrama (84,1% i 86,4%) uz istu osjetljivost. Obzirom da se radilo o malom uzorku bolesnika analizirani su pojedini dijagnostički slučajevi i utvrđeno je da je u dvoje bolesnika s negativnim kasnim 91 statičkim scintigramima (11,1%) lokalni recidiv u mekim čestima regije bio detektiran isključivo zahvaljujući ranim statičkim scintigramima. Rezultati ukazuju da je trovremenska scintigrafija skeleta u praćenju lokalne regije nedvojbeno korisna metoda, te da se pojedina vremena snimanja komplementarno nadopunjuju, čime se postiže značajno bolja osjetljivost i specifičnost postupka.

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