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This prospective study aims to assess the diagnostic test characteristics of Na[18F]F PET/CT for the skeletal staging of cancer in morbidly obese patients compared with 99mTc-methylene diphosphonate (MDP), whole-body planar (WBS), SPECT, and SPECT/CT acquisitions. One hundred seventeen obese patients (BMI 46.5 ± 6.1 kg/m2 and mean age, 59.0 years; range 32–89 years) with BMI > 40 kg/m2 were prospectively enrolled and underwent [99mTc]Tc-MDP WBS, SPECT, SPECT/CT, and Na[18F]F PET/CT within two weeks for the osseous staging of a malignancy. Images were assessed qualitatively using a 3-point scale. Patient and lesion-based diagnostic test characteristics were estimated using an optimistic and pessimistic dichotomization method. Bone metastases were confirmed in 44 patients. Patient-based optimistic diagnostic test characteristics were (sensitivity, specificity, overall accuracy): Na[18F]F PET/CT (95.5%, 95.9%, 95.7%), [99mTc]Tc-MDP WBS (52.3%, 71.2%, 64.1%), SPECT (61.4%, 80.8%, 73.5%) and SPECT/CT (65.9%, 91.8%, 82.1%). Lesion-based optimistic diagnostic test characteristics were: Na[18F]F PET/CT (97.7%, 97.9%, 97.7%), [99mTc]Tc-MDP WBS (39%, 67%, 48.9%), SPECT (52.9%, 93.6%, 67.3%) and SPECT/CT (65.9%, 91.8%, 82.1%). There was no significant difference in the specificity of Na[18F]F and SPECT/CT. All other pairwise comparisons were significant (p18F]F with significantly higher AUCs for Na[18F]F PET/CT compared to [99mTc]Tc-MDP WBS, SPECT, and SPECT/CT on both patient and lesion-based analysis (p18F]F PET/CT changed patient management in 38% of patients. Na[18F]F PET/CT may be the preferred imaging modality for skeletal staging in morbidly obese patients. The technique provides excellent diagnostic test characteristics superior to [99mTc]Tc-MDP bone scan (including SPECT/CT), impacts patient management, has an acceptable radiation exposure profile, and is well-tolerated. Further cost-effectiveness evaluations are warranted.

Purpose This prospective study aims to assess the diagnostic test characteristics of Na[F-18]F PET/CT for the skeletal staging of cancer in morbidly obese patients compared with Tc-99m-methylene diphosphonate (MDP), whole-body planar (WBS), SPECT, and SPECT/CT acquisitions. Material and methods One hundred seventeen obese patients (BMI 46.5 +/- 6.1 kg/m(2) and mean age, 59.0 years; range 32-89 years) with BMI > 40 kg/m(2) were prospectively enrolled and underwent [Tc-99m]Tc-MDP WBS, SPECT, SPECT/CT, and Na[F-18]F PET/CT within two weeks for the osseous staging of a malignancy. Images were assessed qualitatively using a 3-point scale. Patient and lesion-based diagnostic test characteristics were estimated using an optimistic and pessimistic dichotomization method. Results Bone metastases were confirmed in 44 patients. Patient-based optimistic diagnostic test characteristics were (sensitivity, specificity, overall accuracy): Na[F-18]F PET/CT (95.5%, 95.9%, 95.7%), [Tc-99m]Tc-MDP WBS (52.3%, 71.2%, 64.1%), SPECT (61.4%, 80.8%, 73.5%) and SPECT/CT (65.9%, 91.8%, 82.1%). Lesion-based optimistic diagnostic test characteristics were: Na[F-18]F PET/CT (97.7%, 97.9%, 97.7%), [Tc-99m]Tc-MDP WBS (39%, 67%, 48.9%), SPECT (52.9%, 93.6%, 67.3%) and SPECT/CT (65.9%, 91.8%, 82.1%). There was no significant difference in the specificity of Na[F-18]F and SPECT/CT. All other pairwise comparisons were significant (p

F-18-NaF PET/CT has a rapid single-pass extraction and fast clearance from soft tissues, resulting in a good target-to-background ratio. This study aimed to establish the optimum acquisition time and dosimetry for F-18-NaF PET/CT to evaluate bone metastases in obese patients. A secondary objective was to evaluate the impact of acquisition time on image quality, lesion detection rate, noise level, and radiation burden in this patient group. Methods: In total, 60 patients were included in the study (20 patients with a body mass index (BMI) of 30.0-34.9 kg/m2, 20 with a BMI of 35-39.9 kg/m2, and 20 with a BMI of >40 kg/m2). Images were acquired after intravenous injection of a 2.2 MBq/kg (0.06 mCi/kg) dose of F-18-NaF. Data were acquired in list mode using ordered subset expectation maximization reconstruction. The raw data were rebinned to simulate scans with acquisition times of 2, 2.5, and 3 min per bed position. The scans were visually analyzed by 2 observers and scored by rank against a panel of parameters (overall image quality, noise level, background soft tissue, and lesion detectability), and the contrast-to-noise ratio (CNR) was calculated. Results: The mean CNR was 20.19 +/- 8.39 for a 2-min acquisition, 21.03 +/- 8.35 for 2.5 min, and 22.16 +/- 8.37 for 3 min. There were no statistically significant differences in CNR among the 3 different acquisition durations (P > 0.05). Lesion delineation was excellent and independent of the acquisition time. All relevant lesions could be identified with all 3 acquisition times. A mean activity of 215.4 +/- 31.3 MBq was injected, with estimated mean effective absorbed doses of 4.09 +/- 0.59 mSv for F-18-NaF PET and 7.88 +/- 1.66 mSv for CT alone. Conclusion: F-18-NaF PET/CT can be beneficial in obese patients because of its good pharmacokinetics. Optimal osseous staging can be achieved with relatively low doses and radiation burden. Lesion delineation was excellent regardless of acquisition time. However, it is recommended that an acquisition of 3 min per bed position be used in patients with a BMI of more than 40.

Objective: A new Bayesian penalized likelihood reconstruction algorithm for positron emission tomography (PET) (Q.Clear) is now in clinical use for fludeoxyglucose (FDG) PET/CT. However, experience with non-FDG tracers and in special patient populations is limited. This pilot study aims to compare Q.Clear to standard PET reconstructions for F-18 sodium fluoride (F-18-NaF) PET in obese patients. Methods: 30 whole body F-18-NaF PET/CT scans (10 patients with BMI 30-40 Kg/m(2) and 20 patients with BMI >40 Kg/m(2)) and a NEMA image quality phantom scans were analyzed using ordered subset expectation maximization (OSEM) and Q.Clear reconstructions methods with B400, 600, 800 and 1000. The images were assessed for overall image quality (IQ), noise level, background soft tissue, and lesion detectability, contrast recovery (CR), background variability (BV) and contrast-to-noise ratio (CNR) for both algorithms. Results: CNR for clinical cases was higher for Q.Clear than OSEM (p < 0.05). Mean CNR for OSEM was (21.62 +/- 8.9), and for Q.Clear B400 (31.82 +/- 14.6), B600 (35.54 +/- 14.9), B800 (39.81 +/- 16.1), and B1000 (40.9 +/- 17.8). As the beta value increased the CNR increased in all clinical cases. B600 was the preferred beta value for reconstruction in obese patients. The phantom study showed Q.Clear reconstructions gave lower CR and lower BV than OSEM. The CNR for all spheres was significantly higher for Q.Clear (independent of beta) than OSEM (p < 0.05), suggesting superiority of Q.Clear. Conclusion: This pilot clinical study shows that Q.Clear reconstruction algorithm improves overall IQ of F-18-NaF PET in obese patients. Our clinical and phantom measurement results demonstrate improved CNR and reduced BV when using Q.Clear. A beta value of 600 is preferred for reconstructing F-18-NaF PET/CT with Q.Clear in obese patients. Advances in knowledge: F-18-NaF PET/CT is less susceptible to artifacts induced by body habitus. Bayesian penalized likelihood reconstruction with F-18-NaF PET improves overall IQ in obese patients. Advances in knowledge: F-18-NaF PET/CT is less susceptible to artifacts induced by body habitus. Bayesian penalized likelihood reconstruction with F-18-NaF PET improves overall IQ in obese patients.