European Radiology

, Volume 29, Issue 4, pp 1903–1911 | Cite as

PET/CT features discriminate risk of metastasis among single-bone FDG lesions detected in newly diagnosed non-small-cell lung cancer patients

  • Chae Hong Lim
  • Tae Ran Ahn
  • Seung Hwan Moon
  • Young Seok Cho
  • Joon Young Choi
  • Byung-Tae Kim
  • Kyung-Han LeeEmail author



We investigated the capacity of fluorodeoxyglucose (FDG) PET/CT features for stratifying probability of metastasis for single-bone FDG lesions in non-small-cell lung cancer (NSCLC).


Subjects were 118 newly diagnosed NSCLC patients with a solitary bone FDG lesion and no evidence of other distant metastasis based on PET/CT, brain MRI, and contrast-enhanced chest CT. Bone lesion SUVmax and CT findings, primary tumor SUVmax, clinical T stage, and N stage were analyzed.


The bone lesions were determined by biopsy, characteristic MRI findings and clinical follow-up to be metastatic in 33 (28.0%) and benign in 85 cases (72.0%). A cutoff bone SUVmax of 4.3 showed good diagnostic performance (81.8% sensitivity, 84.7% specificity, and 83.9% accuracy), but there was considerable overlap. Bone lesion PET/CT features of SUVmax ≤ 2, osteosclerotic rim or fracture correctly diagnosed 20/20 benign, while SUVmax > 10, soft-tissue mass or bone destruction correctly diagnosed 18/18 metastatic cases. In the remaining 80 cases, bone features of SUVmax > 4.3 and osteolytic change, and lung tumor features of SUVmax > 6.4, ≥ T2 stage (n = 70), and ≥ N1 stage (n = 43) favored metastasis. The presence of one or less of these features correctly diagnosed 38/38 benign, while the presence of four or more features correctly diagnosed 5/5 metastatic cases. The 37 cases with two or three features had either benign (n = 27) or metastatic bone disease (n = 10).


Combining bone lesion and lung tumor PET/CT features can help stratify risk of bone metastasis in these patients.

Key Points

In NSCLC with a single-bone FDG lesion, lesion SUVmaxis useful for differential diagnosis.

CT features of the single-bone FDG lesions provide additional diagnostic value.

High NSCLC SUVmax, greater T stage, and FDG positive nodes also favor metastasis.


Lung cancer Positron-emission tomography Fluorodeoxyglucose Bone metastasis 



Area under the curve




Magnetic resonance imaging


Non-small-cell lung cancer


Positron-emission tomography/computed tomography


Receiver operating characteristic


Maximum standard uptake value



This study was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT, and Future Planning (NRF-2015R1A2A2A01006419 and 2016R1C1B2013411).

Compliance with ethical standards


The scientific guarantor of this publication is Kyung-Han Lee.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• Retrospective

• Diagnostic or prognostic study

• Performed at one institution


  1. 1.
    Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A (2015) Global cancer statistics, 2012. CA Cancer J Clin 65:87–108CrossRefPubMedGoogle Scholar
  2. 2.
    Coleman RE (2006) Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res 12:6243s–6249sCrossRefPubMedGoogle Scholar
  3. 3.
    Tsuya A, Kurata T, Tamura K, Fukuoka M (2007) Skeletal metastases in non-small cell lung cancer: a retrospective study. Lung Cancer 57:229–232CrossRefPubMedGoogle Scholar
  4. 4.
    Al Husaini H, Wheatley-Price P, Clemons M, Shepherd FA (2009) Prevention and management of bone metastases in lung cancer: a review. J Thorac Oncol 4:251–259CrossRefPubMedGoogle Scholar
  5. 5.
    Pfannschmidt J, Dienemann H (2010) Surgical treatment of oligometastatic non-small cell lung cancer. Lung Cancer 69:251–258CrossRefPubMedGoogle Scholar
  6. 6.
    Zhao T, Gao Z, Wu W, He W, Yang YI (2016) Effect of synchronous solitary bone metastasectomy and lung cancer resection on non-small cell lung cancer patients. Oncol Lett 11:2266–2270CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Komatsu T, Kunieda E, Oizumi Y, Tamai Y, Akiba T (2012) An analysis of the survival rate after radiotherapy in lung cancer patients with bone metastasis: is there an optimal subgroup to be treated with high-dose radiation therapy? Neoplasma 59:650–657CrossRefPubMedGoogle Scholar
  8. 8.
    Sugiura H, Yamada K, Sugiura T, Hida T, Mitsudomi T (2008) Predictors of survival in patients with bone metastasis of lung cancer. Clin Orthop Relat Res 466:729–736CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kay FU, Kandathil A, Batra K, Saboo SS, Abbara S, Rajiah P (2017) Revisions to the tumor, node, metastasis staging of lung cancer (8th edition): rationale, radiologic findings and clinical implications. World J Radiol 9:269–279CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Detterbeck FC, Boffa DJ, Kim AW, Tanoue LT (2017) The eighth edition lung cancer stage classification. Chest 151:193–203CrossRefPubMedGoogle Scholar
  11. 11.
    Bury T, Barreto A, Daenen F, Barthelemy N, Ghaye B, Rigo P (1998) Fluorine-18 deoxyglucose positron emission tomography for the detection of bone metastases in patients with non-small cell lung cancer. Eur J Nucl Med 25:1244–1247CrossRefPubMedGoogle Scholar
  12. 12.
    Qu X, Huang X, Yan W, Wu L, Dai K (2012) A meta-analysis of 18FDG-PET-CT, 18FDG-PET, MRI and bone scintigraphy for diagnosis of bone metastases in patients with lung cancer. Eur J Radiol 81:1007–1015CrossRefPubMedGoogle Scholar
  13. 13.
    Cheran SK, Herndon JE 2nd, Patz EF Jr (2004) Comparison of whole-body FDG-PET to bone scan for detection of bone metastases in patients with a new diagnosis of lung cancer. Lung Cancer 44:317–325Google Scholar
  14. 14.
    Lee SM, Goo JM, Park CM et al (2016) Preoperative staging of non-small cell lung cancer: prospective comparison of PET/MR and PET/CT. Eur Radiol 26:3850–3857CrossRefPubMedGoogle Scholar
  15. 15.
    Lee JW, Seo KH, Kim ES, Lee SM (2017) The role of 18F-fluorodeoxyglucose uptake of bone marrow on PET/CT in predicting clinical outcomes in non-small cell lung cancer patients treated with chemoradiotherapy. Eur Radiol 27:1912–1921CrossRefPubMedGoogle Scholar
  16. 16.
    Wu PS, Chiu NT, Lee BF, Yao WJ, W Chen HH (2002) Clinical significance of solitary rib hot spots on bone scans in patients with extraskeletal cancer: correlation with other clinical manifestations. Clin Nucl Med 27:567–571Google Scholar
  17. 17.
    Hur J, Yoon CS, Ryu YH, Yun MJ, Suh JS (2007) Accuracy of fluorodeoxyglucose-positron emission tomography for diagnosis of single bone metastasis: comparison with bone scintigraphy. J Comput Assist Tomogr 31:812–819CrossRefPubMedGoogle Scholar
  18. 18.
    Jacobson AF, Stomper PC, Jochelson MS, Ascoli DM, Henderson IC, Kaplan WD (1990) Association between number and sites of new bone scan abnormalities and presence of skeletal metastases in patients with breast cancer. J Nucl Med 31:387–392PubMedGoogle Scholar
  19. 19.
    Nakamoto Y, Cohade C, Tatsumi M, Hammoud D, Wahl RL (2005) CT appearance of bone metastases detected with FDG PET as part of the same PET/CT examination. Radiology 237:627–634CrossRefPubMedGoogle Scholar
  20. 20.
    Zhu SH, Zhang Y, Yu YH et al (2013) FDG PET-CT in non-small cell lung cancer: relationship between primary tumor FDG uptake and extensional or metastatic potential. Asian Pac J Cancer Prev 14:2925–2929CrossRefPubMedGoogle Scholar
  21. 21.
    Quint LE, Tummala S, Brisson LJ et al (1996) Distribution of distant metastases from newly diagnosed non-small cell lung cancer. Ann Thorac Surg 62:246–250CrossRefPubMedGoogle Scholar
  22. 22.
    Hanley JA, McNeil BJ (1983) A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 148:839–843CrossRefPubMedGoogle Scholar
  23. 23.
    Zhou Y, Yu QF, Peng AF, Tong WL, Liu JM, Liu ZL (2017) The risk factors of bone metastases in patients with lung cancer. Sci Rep 7:8970CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Choi HS, Yoo IeR, Park HL, Choi EK, Kim SH, Lee WH (2014) Role of 18FDG-PET/CT in differentiation of a benign lesion and metastasis on the ribs of cancer patients. Clin Imaging 38:109–114CrossRefPubMedGoogle Scholar
  25. 25.
    Meyer M, Gast T, Raja S, Hubner K (1994) Increased F-18 FDG accumulation in an acute fracture. Clin Nucl Med 19:13–14CrossRefPubMedGoogle Scholar
  26. 26.
    Aoki J, Watanabe H, Shinozaki T et al (2001) FDG PET of primary benign and malignant bone tumors: standardized uptake value in 52 lesions. Radiology 219:774–777CrossRefPubMedGoogle Scholar
  27. 27.
    Shin DS, Shon OJ, Byun SJ, Choi JH, Chun KA, Cho IH (2008) Differentiation between malignant and benign pathologic fractures with F-18-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography. Skeletal Radiol 37:415–421CrossRefPubMedGoogle Scholar
  28. 28.
    Aquino SL, Halpern EF, Kuester LB, Fischman AJ (2007) FDG-PET and CT features of non-small cell lung cancer based on tumor type. Int J Mol Med 19:495–499PubMedGoogle Scholar
  29. 29.
    de Geus-Oei LF, van Krieken JH, Aliredjo RP et al (2007) Biological correlates of FDG uptake in non-small cell lung cancer. Lung Cancer 55:79–87CrossRefPubMedGoogle Scholar
  30. 30.
    Strobel K, Exner UE, Stumpe KD et al (2008) The additional value of CT images interpretation in the differential diagnosis of benign vs. malignant primary bone lesions with 18F-FDG-PET/CT. Eur J Nucl Med Mol Imaging 35:2000–2008CrossRefPubMedGoogle Scholar
  31. 31.
    Costelloe CM, Chuang HH, Madewell JE (2014) FDG PET/CT of primary bone tumors. AJR Am J Roentgenol 202:W521–W531CrossRefPubMedGoogle Scholar
  32. 32.
    Sachs S, Bilfinger TV, Komaroff E, Franceschi D (2005) Increased standardized uptake value in the primary lesion predicts nodal or distant metastases at presentation in lung cancer. Clin Lung Cancer 6:310–313CrossRefPubMedGoogle Scholar
  33. 33.
    Li M, Liu N, Hu M et al (2009) Relationship between primary tumor fluorodeoxyglucose uptake and nodal or distant metastases at presentation in T1 stage non-small cell lung cancer. Lung Cancer 63:383–386CrossRefPubMedGoogle Scholar
  34. 34.
    Higashi K, Ueda Y, Ayabe K et al (2000) FDG PET in the evaluation of the aggressiveness of pulmonary adenocarcinoma: correlation with histopathological features. Nucl Med Commun 21:707–714CrossRefPubMedGoogle Scholar
  35. 35.
    Duhaylongsod FG, Lowe VJ, Patz EF Jr, Vaughn AL, Coleman RE, Wolfe WG (1995) Lung tumor growth correlates with glucose metabolism measured by fluoride-18 fluorodeoxyglucose positron emission tomography. Ann Thorac Surg 60:1348–1352Google Scholar
  36. 36.
    Higashi K, Ito K, Hiramatsu Y et al (2005) 18F-FDG uptake by primary tumor as a predictor of intratumoral lymphatic vessel invasion and lymph node involvement in non-small cell lung cancer: analysis of a multicenter study. J Nucl Med 46:267–273PubMedGoogle Scholar
  37. 37.
    Cho H, Kim SH, Kim H et al (2018) Lymph node with the highest FDG uptake predicts distant metastasis-free survival in patients with locally advanced nasopharyngeal carcinoma. Clin Nucl Med 43:e220–e225CrossRefPubMedGoogle Scholar
  38. 38.
    Walker R, Kessar P, Blanchard R et al (2000) Turbo STIR magnetic resonance imaging as a whole-body screening tool for metastases in patients with breast carcinoma: preliminary clinical experience. J Magn Reson Imaging 11:343–350CrossRefPubMedGoogle Scholar
  39. 39.
    Mehta RC, Marks MP, Hinks RS, Glover GH, Enzmann DR (1995) MR evaluation of vertebral metastases: T1-weighted, short-inversion-time inversion recovery, fast spin-echo, and inversion-recovery fast spin-echo sequences. AJNR Am J Neuroradiol 16:281–288PubMedGoogle Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Chae Hong Lim
    • 1
  • Tae Ran Ahn
    • 2
  • Seung Hwan Moon
    • 1
  • Young Seok Cho
    • 1
  • Joon Young Choi
    • 1
  • Byung-Tae Kim
    • 1
  • Kyung-Han Lee
    • 1
    Email author
  1. 1.Department of Nuclear Medicine, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulSouth Korea
  2. 2.Department of Radiology, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulSouth Korea

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