This CPB has been revised to state that SPECT is …...Single photon emission computed tomography...
Transcript of This CPB has been revised to state that SPECT is …...Single photon emission computed tomography...
Prior Authorization ReviewPanel MCO Policy Submission
A separate copy of this form must accompany each policy submitted for review.
Policies submitted without this form will not be considered for review.
Plan: Aetna Better Health Submission Date: 09/04/2018
Policy Number: 0376 Effective Date: Revision Date: 08/01/2018
Policy Name: Single Photon Emission Computed Tomography (SPECT)
Type of Submission – Check all that apply: New Policy Revised Policy* Annual Review – No Revisions
*All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below:
CPB 376 Single Photon Emission Computed Tomography (SPECT)
06/14/2018 - This CPB has been revised to state that SPECT is considered experimental and investigational for the following: (i) evaluation of carotid stenosis, (ii) as an imaging marker of pre- diagnostic Parkinson's disease, and (iii) work-up of individuals undergoing non-cardiac surgery. 08/01/2018.- This CPB is revised to state that SPECT is considered medically necessary for the diagnosis of coronary artery disease and for the assessment of prognosis in persons with coronary artery disease except as outlined in exclusion criteria.
Name of Authorized Individual (Please type or print):
Dr. Bernard Lewin, M.D.
Signature of Authorized Individual:
www.aetnabetterhealth.com/pennsylvania Revised 08/01/2018
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Single Photon EmissionComputed Tomography (SPECT)
Clinical Policy Bulletins Medical Clinical Policy Bulletins
Polic y His t ory
Last Review
08/01/2018
Effective: 03/08/200
Next
Review: 04/11/2019
Review
History
Definitions
A ddit iona l Inform at ion
Number: 0376
*Please see amendment for Pennsylvania Medicaid at the end of this CPB.
Policy
I. Non-Cardiac Indications: Aetna considers single photon emission computed
tomography (SPECT) medically necessary for any of the following indications:
A. Assessment of osteomyelitis, to distinguish bone from soft tissue infection;
or
B. Detection of spondylolysis and stress fractures not visible from x-ray; or
C. Diagnosing and assessing hemangiomas of the liver; or
D. Diagnosing pulmonary embolism (by means of SPECT ventilation/perfusion
scintigraphy); or
E. Differentiation of necrotic tissue from tumor of the brain; or
F. Distinguishing Parkinson's disease from essential tremor (e.g., DaTSCAN
(Ioflupane I-123 injection); or
G. Imaging of parathyroids in parathyroid disease; or
H. Localization of abscess, for suspected or known localized infection or
inflammatory process; or
I. Lymphoma, to distinguish tumor from necrosis; or
J. Neuroendocrine tumors, diagnosis and staging; or
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K. Pre-surgical ictal detection of seizure focus in members with epilepsy (in
place of positron emission tomography (PET)).
II. Aetna considers SPECT experimental and investigational for all other non-
cardiac indications, including any of the following, because its diagnostic
value has not been established in the peer-reviewed medical literature in
these situations:
A. As an imaging marker of pre-diagnostic Parkinson's disease; or
B. Detection of air leak/pneumothorax; or
C. Diagnosis or assessment of members with attention deficit/hyperactivity
disorder (
CPB 0426 - Attention Deficit/Hyperactivity Disorder
(../400_499/0426.html) );
or
D. Diagnosis or assessment of members with autism (
CPB 0648 - Autism Spectrum Disorders (../600_699/0648.html)); or
E. Diagnosis or assessment of members with personality disorders (e.g.,
aggressive and violent behaviors, anti-social personality disorder including
psychopathy, schizotypal personality disorder, as well as borderline
personality disorder); or
F. Diagnosis or assessment of members with schizophrenia; or
G. Diagnosis or assessment of stroke members; or
H. Differential diagnosis of Parkinson's disease from other Parkinsonian
syndromes; or
I. Differentiating malignant from benign lung lesions; or
J. Evaluation of carotid stenosis; or
K. Evaluation of members with endoleak; or
L. Evaluation of members with generalized pain or insomnia; or
M. Evaluation of members with head trauma; or
N. Initial or differential diagnosis of members with suspected dementia (e.g.,
Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia,
and vascular dementia); or
O. Multiple sclerosis; or
P. Pre-surgical evaluation of members undergoing lung volume reduction
surgery; or
Q. Prosthetic graft infection; or
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R. Scanning of internal carotid artery during temporary balloon occlusion; or
S. Vasculitis; or
T. Work-up of individuals undergoing non-cardiac surgery.
III. Cardiac Indications: Aetna considers SPECT medically necessary for the
diagnosis of coronary artery disease and for the assessment of prognosis in
persons with coronary artery disease except as outlined in "exclusion
criteria" below."
IV. Aetna considers SPECT experimental and investigational for all other cardiac
indications because its effectiveness for indications other than the ones
listed above has not been established.
Exclusion criteria: Aetna considers SPECT myocardial perfusion imaging
experimental and investigational for the following indications for which the
study is considered “inappropriate” according to appropriateness
criteria from the American College of Cardiology (ACC):
A. As a routine screening evaluation after a percutaneous transluminal
coronary angioplasty (PTCA) with or without stenting or coronary artery
bypass surgery (CABG) prior to discharge from the acute care setting; or
B. As a routine screening evaluation after a re-vascularization procedure
(PTCA with stenting or CABG) at an interval of less than 2 years from the
procedure if there is no worsening in the members symptomatology and if
the member had symptoms prior to the intervention, and there is no history
of congestive heart failure. Note: If there is a history of congestive heart
failure and the member is status post re-vascularization, repeat nuclear
imaging as frequently as annually may be medically necessary; or
C. Assessment of vulnerable plaque; or
D. Evaluation of a member with an acute coronary event and hemodynamic
instability, shock, or mechanical complications of the event; or
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E. In the setting of acute chest pain or equivalent symptoms with a high
likelihood of being acute coronary syndrome, when there has been a
diagnosis of acute myocardial infarction, in the immediate post-thombolytic
period, or when there is a high pre-test likelihood of significant coronary
disease as demonstrated by marked ST segment elevation on the ECG; or
F. Prior to high-risk+ surgery when the member is asymptomatic and there was
a normal cardiac catheterization, coronary intervention (PTCA, stenting,
CABG), or normal nuclear stress test less than 1 year before the surgical
date; or
G. Prior to intermediate-risk+ non-cardiac surgery if the member is capable of,
and has no contraindication to standard stress testing*; or
H. Prior to low-risk+ non-cardiac surgery for risk assessment; or
I. Re-evaluation of members without chest pain or equivalent symptoms,
without known coronary disease, at high-risk for coronary disease (based
upon the Framingham score greater than 10)*, who have an initial negative
radionuclear imaging study, when it has been less than 2 years since the
last radionuclear study; or
J. Re-evaluation of members without chest pain or equivalent symptoms or
with stable symptoms, with known coronary disease as determined by prior
abnormal catheterization or SPECT cardiac study (but without prior
infarction), when it has been less than 1 year since the last radionuclear
study. Note: if the member has worsening symptoms or if the member had
silent ischemia, more frequent imaging or other diagnostic testing or
interventions may be medically necessary; or
K. Screening of members with chest pain or chest pain equivalent symptoms
when there is a low probability of coronary disease (Framingham score less
than 10)*, no history of diabetes, and there are no impediments or
contraindications to non-nuclear stress testing*; or
L. Screening of members without chest pain or equivalent symptoms when
there is a low probability of coronary disease (Framingham score less
than 10)* and no history of diabetes; or
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* A tool for calculating Framingham score is available from the National
Heart Lung and Blood Institute at the following website:
Framingham Score from National Heart Lung and Blood
Institute (http://cvdrisk.nhlbi.nih.gov/)
.
* According to ACC guidelines, the following are impediments or
contraindications to non-nuclear stress testing:
A. A history of physical impairments that would preclude physically performing
the exercise portion of a stress test; or
B. A history of prior proven ischemic cardiac events; or
C. Proven CAD by past SPECT or coronary catheterization; or
D. The member's ECG would prevent interpretation of a standard stress
testing by being “uninterpretable” during the test, i.e., left bundle branch
block (LBBB), paced rhythm, Wolf Parkinson White syndrome, left
ventricular hypertrophy (LVH) with ST segment depression, or digoxin
use.
+ Surgical risk categories.
▪ High-risk surgery (risk of cardiac death or myocardial infarction (MI) greater
than 5 %): emergent major operations (particularly in the elderly), aortic and
peripheral vascular surgery, prolonged surgical procedures associated with
large fluid shifts and/or blood loss.
▪ Intermediate-risk surgery (risk of cardiac death or MI 1 % to 5 %): carotid
endarterectomy, head and neck surgery, surgery of the chest or abdomen,
orthopedic surgery, prostate surgery.
▪ Low-risk surgery (cardiac death or MI less than 1 %): endoscopic
procedures, superficial procedures, cataract surgery, breast surgery.
V. Aetna considers myocardial sympathetic innervation imaging, with or
without SPECT, experimental and investigational because its effectiveness
has not been established.
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VI. Aetna considers SPECT-CT fusion medically necessary for parathyroid
imaging in persons with an enlarged parathyroid gland, parathyroid
hyperplasia or suspected parathyroid adenoma or carcinoma,
and laboratory evidence of hyperparathyroidism (parathyroid hormone
greater than 55 pg/ml and serum calcium greater than 10.2 mg/dL).
Aetna considers SPECT-CT fusion imaging as experimental and
investigational for other indications because of insufficient evidence of its
effectiveness.
VII. Aetna considers freehand SPECT/ultrasonography (US) fusion imaging in
persons with thyroid disease experimental and investigational because of
insufficient evidence of itseffectiveness.
B ac kgro und
Single photon emission computed tomography (SPECT) is a nuclear medicine
technique that uses radiopharmaceuticals, a rotating camera (single or multiple-
head), and a computer to produce images representing slices through the body in
different planes. Single photon emission computed tomography images are
functional in nature rather than being purely anatomical such as ultrasound,
computed tomography (CT), and magnetic resonance imaging (MRI).
SPECT for Myocardial Perfusion Imaging
Single photon emission computed tomography has been applied to the heart for
myocardial perfusion imaging. It is an effective non-invasive diagnostic technology
when evaluating patients for clinically significant coronary artery disease (CAD) in
the following circumstances: for diagnosing CAD in patients with an abnormal
resting electrocardiogram (ECG) and restricted exercise tolerance; or assessing
myocardial viability before referral for myocardial re-vascularization.
Single photon emission computed tomography has a far greater sensitivity for
detecting silent ischemia than stress ECG. Pooled data of exercise SPECT studies
in over 1,000 patients revealed a 90 % overall sensitivity for detecting CAD. In
assessing myocardial viability, studies indicate that, even in patients with severe
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irreversible thallium defects on standard exercise-redistribution imaging, thallium re-
injection provides information regarding myocardial viability that is comparable to
that provided by positron emission tomography (PET).
SPECT for Detection of Neurological Diseases
Single photon emission computed tomography examines cerebral function by
documenting regional blood flow and metabolism; SPECT of the brain is a useful
alternative to PET for the pre-surgical ictal detection of seizure focus. Effective
surgical treatment of patients with intractable epilepsy is dependent on accurate
localization of the epileptic focus and precise delineation of the epileptogenic
region. It is generally agreed that this requires EEG recording with
electrocorticography. This testing is designed to identify the source or sources of
the seizures, as well as an assessment of brain function. The search for non-
invasive and cost-effective means of seizure localization has been an important
area of research.
Seizures are associated with dramatic increases in blood flow, localized in partial
seizures and global during generalized seizures. Ictal SPECT uses the physiologic
increase in regional cerebral blood blow during seizures to potentially localize the
epileptogenic region. Ictal studies, although more difficult logistically, are reported
to have a sensitivity of 81 to 93 %. (Interictal SPECT demonstrates hypo-perfusion
and is reported to have a sensitivity ranging from 40 to 75 %).
Other imaging modalities help in localizing abnormal epileptogenic tissue.
Quantitative MRI has a sensitivity of 80 to 90 % for the lateralization of temporal
lobe epilepsy. However, there are instances where ictal SPECT has identified
lesions not detected by MRI. Depth electrocorticography and intra-operative
electrocorticography, though accurate in many forms of epilepsy, are both highly
invasive. In cortical developmental disorders, these EEG techniques often fail to
localize the epileptogenic area. Single photon emission computed tomography
imaging may offer a safe and accurate alternative.
Ictal SPECT testing requires that seizure activity be provoked through reduction of
anti-epileptic medications. Video EEG monitoring may also be performed. Due to
the nature of ictal SPECT, it should be performed in a hospital setting.
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Studies of SPECT in the inter-ictal or post-ictal detection of seizure focus,
determination of seizure subtypes and monitoring of drug therapy for epilepsy have
not established its efficacy for these indications.
Clinical studies indicate that SPECT is more accurate at detecting acute ischemia
than CT scan. By 8 hours after infarction, about 20 % of CT scans will be positive
but nearly 90 % of SPECT scans will be. Beyond 72 hours, the sensitivities of CT
and SPECT are nearly identical. In addition, the defects noted on SPECT are
frequently larger than those noted on CT studies.
Among the treatments of acute ischemic stroke, the use of tissue plasminogen
activator (t-PA) has been shown to reduce neurologic impairment if administered
within 3 hours of onset. This is administered when CT is negative for hemorrhage.
Single photon emission computed tomography can not detect hemorrhage in order
to rule out use of thrombolysis. Therefore, while SPECT is more sensitive than CT
in detecting ischemia, it has not been shown to be useful in detecting ischemia
early enough to play a role in the use of thrombolysis. Studies using SPECT in the
presence of cerebro-vascular accident (CVA) have timed its performance at less
than 6 hours to less than 14 days from the time of onset.
Studies have also reported on SPECT's value with regard to the assessment of
prognosis after stroke, determination of stroke type, monitoring therapies used
post-stroke, diagnosis of vasospasm following subarachnoid hemorrhage and in the
diagnosis/prognosis regarding transient ischemic attacks (TIAs). Single photon
emission computed tomography may prove to be helpful in these applications in the
future.
Single photon emission computed tomography has proven useful in distinguishing
recurrent brain tumor from radiation necrosis. Radiation necrosis needs to be
distinguished from recurrent brain tumor to determine whether chemotherapy is
necessary. Radiation necrosis is more common in brain tumor patients receiving
local boost irradiation. Radiation necrosis and brain tumor may have similar clinical
signs and symptoms, and are not reliably distinguished clinically.
Single photon emission computed tomography has been studied in the diagnosis of
patients with Alzheimer's disease AD). At present, the definitive diagnosis of AD
can only be made on pathologic examination of brain tissue. Alzheimer's disease is
largely a diagnosis of exclusion. The diagnostic evaluation of the demented patient
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is therefore aimed largely at identifying other potentially treatable causes of
cognitive impairment. A technology assessment of SPECT for dementia and AD
prepared by the Institute for Clinical Effectiveness and Health Policy (Ferrante,
2004) concluded: "SPECT has not clearly demonstrated its usefulness in assessing
patients with dementia, and it has no precise indications for diagnosis, evaluation of
prognosis or monitoring response to treatment."
In AD, SPECT shows decreased perfusion in the association cortex of the parietal
lobe and the posterior temporal regions. Frontal association cortex is
predominantly affected in some cases, but usually is not involved until late in the
course of the disease. The occipital lobes are less involved and the paracentral
cortex is spared. Although SPECT studies have been reported in over 500 patients
with AD, in most cases the diagnosis was made clinically and only in 53 patients it
was confirmed by autopsy. Controlled studies of SPECT in AD have shown a
sensitivity of this procedure to vary from 50 % to 95 %. The best results have been
reported in the more recent studies, using higher resolution equipment. In the 2001
practice parameter on the diagnosis of dementia, the American Academy of
Neurology does not recommend SPECT for routine use in either initial or differential
diagnosis of dementia (Knopman et al, 2001).
Neuroimaging markers are increasingly important in the early diagnosis of the
dementias, not only to detect the rare tumor, but also to differentiate the various
types of neurodegenerative dementias. The potential of MRI and PET as
surrogates for disease progression for therapeutic trials is being examined in a
large multi-center trial. However, SPECT has been reported to show specific
findings in both fronto-temporal dementia (FTD) and AD and is much more
available and less expensive than PET. McNeil et al (2007) evaluated the
diagnostic accuracy of technetium-99–labeled hexamethyl propylene amine oxime
SPECT images obtained at initial evaluation in 25 pathologically confirmed cases of
FTD and 31 pathologically confirmed cases of AD. A nuclear medicine physician,
blinded to the clinical findings, rated the images. Except in the case of 1 FTD
patient, for whom neuropsychological data were unavailable, the clinical and
neuropsychological evaluation was more accurate than SPECT alone in predicting
the histological diagnosis.
In a longitudinal, prospective study, Devanand and colleagues (2010) examined the
utility of SPECT to predict conversion from mild cognitive impairment (MCI) to AD.
A total of 127 patients with MCI and 59 healthy comparison subjects followed-up for
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1 to 9 years were included in this study. Diagnostic evaluation, neuropsychological
tests, social/cognitive function, olfactory identification, apolipoprotein E genotype,
MRI, and brain Tc hexamethyl-propylene-aminoxime SPECT scan with visual
ratings, and region of interest (ROI) analyses were done. Visual ratings of SPECT
temporal and parietal blood flow did not distinguish eventual MCI converters to AD
(n = 31) from non-converters (n = 96), but the global rating predicted conversion
(41.9 % sensitivity and 82.3 % specificity, Fisher's exact test p = 0.013). Blood flow
in each ROI was not predictive, but when dichotomized at the median value of the
patients with MCI, low flow increased the hazard of conversion to AD for parietal
(hazard ratio [HR]: 2.96, 95 % confidence interval [CI]: 1.16 to 7.53, p = 0.023) and
medial temporal regions (HR: 3.12, 95 % CI: 1.14 to 8.56, p = 0.027). In the 3-year
follow-up sample, low parietal (p < 0.05) and medial temporal (p < 0.01) flow
predicted conversion to AD, with or without controlling for age, Mini-Mental State
Examination, and apolipoprotein E ε4 genotype. These measures lost significance
when other strong predictors were included in logistic regression analyses: verbal
memory, social/cognitive functioning, olfactory identification deficits, hippocampal,
and entorhinal cortex volumes. The authors concluded that SPECT visual ratings
showed limited utility in predicting MCI conversion to AD. The modest predictive
utility of quantified low parietal and medial temporal flow using SPECT may
decrease when other stronger predictors are available.
Single photon emission computed tomography has also been reported to be used
in neoplasms (grading of gliomas), HIV encephalopathy, head trauma, Huntington's
chorea, persistent vegetative states and in diagnosing brain death. Based upon the
current evidence, SPECT has not proven to be established in any of these clinical
situations. More study is needed in these areas.
The Food and Drug Administration (FDA) has approved 4 radiopharmaceuticals for
imaging of the brain: I-123 isopropyliodoamphetamine (IMP, Spectamine); Tc-99m
HMPAO (hexamethyl propylamine oxime, Ceretec); Tc-99m ECD (ethyl cysteinate
dimer, Neurolite), and thallium 201 diethyldithiocarbamate (T1-DDC).
SPECT for the Liver
Hemangiomas are the most common benign lesion of the liver. It is important to
differentiate these lesions from others that may be malignant. Because of the risk
of hemorrhage inherent in a percutaneous biopsy of liver hemangiomas, non-
invasive modalities have been used for differentiation. Hepatic hemangiomas are
8
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so vascular that their blood pool is easily differentiated from other solid hepatic
masses by nuclear scanning with labeled red blood cells (RBCs). The labeled
RBCs are injected intravenously and resolution is markedly improved with SPECT.
Review articles and published studies support SPECT as an appropriate diagnostic
modality to differentiate hepatic lesions as hemangiomas.
SPECT for Neuroendocrine Tumors
Carcinoids and other neuroendocrine tumors have somatostatin receptors;
therefore, they can be imaged with somatostatin analogs (octreotide, pentetreotide)
tagged with an appropriate radioisotope (Khan and Jones, 2005). Single photon
emission computed tomography and subtraction techniques improve detection. An
assessment from the Australian Medical Services Advisory Committee stated that
SPECT is often performed in conjunction with antibody imaging (Octreoscan) of
neuroendocrine tumors, usually at 24 and occasionally at 48 hours after the
injection. The assessment explained that SPECT is able to differentiate more
easily between areas of pathological uptake and physiological uptake in the
abdomen. The assessment explained that SPECT can also help to discriminate
between mesenteric and bone lesions. The assessment noted that extra-planar
images may be obtained from areas of specific interest, using longer exposure time
for more easily interpreted imaging.
SPECT for Spondylolysis and Stress Fractures
The role of SPECT of the spine has changed in recent years with the wide
availability of MRI and especially contrast-enhanced MRI. Bone scanning with
SPECT of the spine may allow for visualization of lesions related to stress fractures
or stress reactions in the spine such as spondylolysis. Single photon emission
computed tomography has been accepted as extremely sensitive in detecting
incipient spondylolysis and stress/insufficiency fractures (Manaster et al, 2005).
Single photon emission computed tomography shows stress fractures days to
weeks earlier than radiographs in many instances, and differentiate between
osseous and soft tissue injury as well. However, in most cases bone scans lack
specificity and supplemental imaging may be necessary for conclusive diagnosis or
to avoid false positives. Single photon emission computed tomography continues
to be used in back pain, especially in children and adolescents, to detect incipient
spondylolysis that may not be detected by conventional imaging. Because of the
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sensitivity of SPECT scans, 80 % of all fractures show an abnormality 24 hours
post injury and 95 % at 72 hours. A normal scan generally excludes the diagnosis
of stress/insufficiency fracture, and the patient may return to normal activity.
SPECT for the Internal Carotid Artery
Internal carotid artery temporary balloon occlusion (TBO) test is a well-established
part of the preoperative evaluation of patients with aneurysm or tumor involving the
neck or skull base in whom arterial sacrifice or prolonged temporary occlusion is
considered a possible part of the surgical or endovascular therapy. Temporary
balloon occlusion is performed in conjunction with cerebral blood flow analysis to
identify those patients who will not tolerate permanent carotid occlusion.
Traditionally, xenon-enhanced CT has been used during TBO to detect signs of
ischemia; however, SPECT has recently been reported as a method to detect focal
hypo-perfusion during test occlusion. Several small studies in the published
literature report preliminary results that SPECT scanning during TBO is a safe and
effective method to assess cerebral blood flow. However, it is premature to
recommend SPECT over the conventional xenon-enhanced CT.
SPECT for the Diagnosis/Assessment of Attention Deficit/Hyperactivity Disorder
Functional neuroimaging such as PET and SPECT has been used to study patients
with attention deficit/hyperactivity disorder (ADHD). Although some studies have
shown differences in brain structure or function comparing children with and without
ADHD, these findings do not differentiate reliably between children with and without
this disorder (i.e., although group means may differ significantly, the overlap in
findings among children with and without ADHD results in high rates of false-
positives and false-negatives). As a result, SPECT should not be used as a
screening or diagnostic tool for children with ADHD. The American Academy of
Pediatrics' Practice Guideline on “Diagnosis and Evaluation of the Child with
Attention-Deficit/Hyperactivity Disorder” does not recommend neuroimaging studies
in the diagnosis of ADHD. An evidence review by McGough and Barkley (2004)
stated that there are insufficient scientific data to justify use of laboratory
assessment measures, including neuropsychological tests and brain imaging, in
diagnosing adult ADHD.
SPECT for the Diagnosis/Assessment of Autism
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The American Academy of Neurology (2000) stated that there is no evidence to
support a role of neuroimaging modalities such as SPECT in the clinical diagnosis
of autism.
SPECT for the Diagnosis of Pulmonary Embolism
In a prospective, observational study, Miles and colleagues (2009) compared
SPECT ventilation/perfusion (V/P) scintigraphy with multi-slice CT pulmonary
angiography (CTPA) in the diagnosis of pulmonary embolism (PE). A total of 100
patients who were 50 years of age or older were recruited; 79 underwent both
diagnostic 16-detector CTPA, and planar and SPECT V/P scintigraphy. The
agreement between the CTPA and the SPECT V/P scintigraphy for the diagnosis of
PE was calculated. The sensitivity and specificity of blinded SPECT scintigraphy
reporting was calculated against a reference diagnosis made by a panel of
respiratory physicians that was provided with CTPA and planar V/P scintigraphy
reports, clinical information, and 3-month follow-up data. The observed percentage
of agreement between SPECT V/P scintigraphy and CTPA data for the diagnosis of
PE was 95 %. When calculated against the respiratory physicians' reference
diagnosis, SPECT V/P scintigraphy had a sensitivity of 83 % and a specificity of 98
%. The authors concluded that these findings indicated that SPECT V/P
scintigraphy is a viable alternative to CTPA for the diagnosis of PE and has
potential advantages in that it was feasible in more patients and had fewer
contraindications; lower radiation dose; and, arguably, fewer non-diagnostic
findings than CTPA.
Gutte et al (2010) evaluated the diagnostic performance of 3-dimensional V/P
SPECT in comparison with planar V/P scintigraphy. Consecutive patients
suspected of acute PE were referred to a V/P SPECT, as the first-line imaging
procedure. Patients with positive D-dimer (greater than 0.5 mg/L) or after clinical
assessment with a Wells score of more than 2 were included and had a V/P
SPECT, low-dose CT, planar V/P scintigraphy, and pulmonary multi-detector CTPA
performed the same day. Ventilation studies were performed using Krypton (Kr).
Patient follow-up was at least 6 months. A total of 36 patient studies were
available for analysis, of which 11 (31 %) had PE. V/P SPECT had a sensitivity of
100 % and a specificity of 87 %. Planar V/P scintigraphy had a sensitivity of 64 %
and a specificity of 72 %. The authors concluded that V/P SPECT has a superior
diagnostic performance compared with planar V/P scintigraphy and should be
preferred when diagnosing PE.
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The European Association of Nuclear Medicine (EANM)'s practice guidelines on
ventilation/perfusion scintigraphy (Bajc et al, 2009a) stated that PE can only be
diagnosed with imaging techniques, which in practice is performed using V/P
scintigraphy or multi-detector computed tomography of the pulmonary arteries
(MDCT). The basic principle for the diagnosis of PE based upon V/P
scintigraphy is to recognize lung segments or subsegments without perfusion but
preserved ventilation, i.e., mismatch. Ventilation studies are in general performed
after inhalation of Kr-labelled or technetium-labelled aerosol of diethylene triamine
pentaacetic acid (DTPA) or Technegas. Perfusion studies are performed after
intravenous injection of macro-aggregated human albumin. Radiation exposure
using documented isotope doses is 1.2 to 2 mSv. Planar and tomographic
techniques (Planar V/P and SPECT V/P) are analyzed. Single photon emission
computed tomography V/P has higher sensitivity and specificity than Planar V/P.
The interpretation of either Planar V/P or SPECT V/P should follow holistic
principles rather than obsolete probabilistic rules. Pulmonary embolism should be
reported when mis-match of more than 1 subsegment is found. For the diagnosis
of chronic PE, V/P scintigraphy is of value. The additional diagnostic yield from V/P
scintigraphy includes chronic obstructive lung disease (COPD), heart failure and
pneumonia. Single photon emission computed tomography V/P is strongly
preferred to Planar V/P as the former permits the accurate diagnosis of PE even in
the presence of co-morbid diseases such as COPD and pneumonia.
The EANM's practice guidelines on VP scintigraphy also noted that to reduce the
costs, the risks associated with false-negative and false-positive diagnoses, and
unnecessary radiation exposure, pre-imaging assessment of clinical probability is
recommended. Diagnostic accuracy is approximately equal for MDCT and Planar
V/P and better for SPECT V/P, which is feasible in about 99 % of patients, while
MDCT is often contraindicated. As MDCT is more readily available, access to both
techniques is vital for the diagnosis of PE. Single photon emission computed
tomography V/P gives an effective radiation dose of 1.2 to 2 mSv. For SPECT V/P,
the effective dose is about 35 % to 40 % and the absorbed dose to the female
breast 4 % of the dose from MDCT performed with a dose-saving protocol. Thus,
SPECT V/P is recommended as a first-line procedure in patients with suspected
PE. It is particularly favored in young patients, especially females, during
pregnancy, and for follow-up and research (Bajc et al, 2009b).
Other Indications
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Single photon emission computed tomography has proven useful in distinguishing
lymphoma from necrosis in the chest and abdomen. It is also useful in localizing
abscesses, and distinguishing abscess from other infectious or inflammatory
processes. Single photon emission computed tomography is also useful in
osteomyelitis in distinguishing inflammation of soft tissue from bone.
Guidelines on parathyroid scintigraphy from the Society of Nuclear Medicine
(Greenspan et al, 2004) state that there is a developing consensus that SPECT
imaging is useful, because, when used in conjunction with planar imaging, SPECT
provides increased sensitivity and more precise anatomic localization. They note
that this is particularly true in detecting both primary and recurrent
hyperparathyroidism resulting from ectopic adenomas. In the mediastinum,
accurate localization may assist in directing the surgical approach, such as median
sternotomy versus left or right thoracotomy. The Parathyroid Task Group of the
EANM (Hindie et al, 2009) stated that the use of SPECT/CT has a major role for
obtaining anatomical details on ectopic foci. However, its use as a routine
procedure before target surgery is still investigational. Preliminary data suggest
that SPECT/CT has lower sensitivity in the neck area compared to pinhole imaging.
In a review on neuroimaging in psychopathy (including anti-social personality
disorder and violent behavior), Pridmore et al (2005) noted that functional
neuroimaging strongly suggests dysfunction of particular frontal and temporal lobe
structures in subjects with psychopathy. However, there are difficulties in selecting
homogeneous index cases and appropriate control groups. These investigators
stated that further studies are needed.
An assessment of SPECT for schizophrenia by the Institute for Clinical
Effectiveness and Health Policy (Pichon Riviere et al, 2004) found that SPECT has
identified increases in dopaminergic activity in the striated body and other areas of
the brain during the episodes of schizophrenia exacerbation. Single photon
emission computed tomography has also been able to identify decreases in frontal
cortex uptake that are associated with negative symptoms of schizophrenia. The
investigators, however, were unable to find substantial evidence for the role of
SPECT scans in therapeutic decision-making in schizophrenia. They concluded
that the use of SPECT scan in schizophrenia remains investigational.
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In the recent practice parameter on the diagnosis and prognosis of new onset
Parkinson's disease (PD) (an evidence-based review) by the American Academy of
Neurology (AAN), Suchowersky et al (2006) stated that SPECT scanning may not
be useful in differentiating PD from other parkinsonian syndromes.
In a meta-analysis of the literature on diagnostic accuracy of SPECT in
parkinsonian syndromes, Vlaar and colleagues (2007) concluded that SPECT with
pre-synaptic radiotracers is relatively accurate to differentiate patients with PD in an
early phase from normalcy, patients with PD from those with essential tremor, and
PD from vascular parkinsonism. The accuracy of SPECT with both pre-synaptic
and post-synaptic tracers to differentiate between PD and atypical parkinsonian
syndrome is relatively low.
The American College of Radiology's "Appropriateness Criteria® dementia and
movement disorders" (Wippold et al, 2010) stated that "[a] diminution of the width of
the pars compacta on MRI has been described in PD patients compared to
controls, with overlap between groups. This diminished width probably reflects
selective neuronal loss of the pars compacta. Other authors have found a normal
appearance of the substantia nigra on T2-weighted images in a majority of PD
patients. More recently, PET and SPECT tracer studies exploring the presynaptic
nigrostriatal terminal function and the postsynaptic dopamine receptors have
attempted to classify the various Parkinson syndromes although much of this work
remains investigational".
van der Vaart et al (2008) described the current applications of PET and SPECT as
a diagnostic tool for vascular disease as relevant to vascular surgeons. These
researchers noted that PET and SPECT may be used to assess plaque
vulnerability, biology of aneurysm progression, prosthetic graft infection, and
vasculitis. Moreover, the authors stated that considerable further information will be
needed to define whether and where PET or SPECT will fit in a clinical strategy.
The necessary validation studies represent an exciting challenge for the future but
also may require the development of inter-disciplinary imaging groups to integrate
expertise and optimize nuclear diagnostic potential.
A report by the New Zealand Health Services Assessment Collaboration (Smartt &
Campbell-Page, 2009) of combined CT and SPECT (SPECT-CT) scanning
in oncology concluded that SPECT-CT imaging in oncology requires further
assessment. The report stated that SPECT-CT imaging is being explored in a wide
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range of cancers for a variety of purposes, and , that there is some evidence of an
evolving role in specific areas such as lymph node assessment and mapping and
the identification of bone metastases. There is also a growing body of literature
comparing the effectiveness and roles of SPECT-CT and PET-CT imaging in
oncology which may be expected to mature in the next few years. "However, the
quality of the evolving evidence and the cost-effectiveness of combined CT and
nuclear imaging systems have yet to be fully assessed." The report stated that
there are a number of outstanding questions relating to the clinical and cost-
effectiveness of SPECT-CT in oncology. In particular there is a need to compare
the clinical utility of hybrid scanners using low performance X-ray scanners with the
newer multislice machines to assess the additional benefits of the new generation
scanners in clinical practice. The report stated that there is also a need to assess
the impact of SPECT-CT on patients’ outcomes and management in specific
indications where SPECT imaging/ planar scintigraphy are standard practice e.g.
functional imaging of bone (bone scans). Other research needs identified in the
report include: 1) research on the cost-effectiveness of SPECT-CT imaging for
specific purposes such as lymph-node mapping and sentinel node identification; 2)
research to assess the impact of SPECT-CT on patients’ outcomes and
management in specific indications where SPECT imaging/ planar scintigraphy are
standard practice, e.g. functional imaging of bone (bone scans).
The American College of Radiology’s clinical guideline on “Head trauma” (ACR,
2012) stated that “Advanced imaging techniques (perfusion CT, perfusion MRI,
SPECT, and PET) have utility in better understanding selected head-injured
patients but are not considered routine clinical practice at this time”.
Jamadar et al (1999) stated that ventilation/perfusion scans with single-photon
emission computed tomography (SPECT) were reviewed to determine their
usefulness in the evaluation of lung volume reduction surgery (LVRS) candidates,
and as a predictor of outcome after surgery. A total of 50 consecutive planar
ventilation (99mTc-DTPA aerosol) and perfusion (99mTc-MAA) scans with
perfusion SPET of patients evaluated for LVRS were retrospectively reviewed.
Technical quality and the severity and extent of radiotracer defects in the upper and
lower halves of the lungs were scored from visual inspection of planar scans and
SPET data separately. An emphysema index (EI) (extent x severity) for the upper
and lower halves of the lung, and an EI ratio for upper to lower lung were calculated
for both planar and SPET scans. The ratios were compared with post-LVRS
outcomes, 3, 6 and 12 months after surgery. All perfusion and SPET images were
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technically adequate. Forty-six percent of ventilation scans were not technically
adequate due to central airway tracer deposition. Severity, extent, EI scores and EI
ratios between perfusion and SPET were in good agreement (r = 0.52 to 0.68).
The mean perfusion EI ratio was significantly different between the 30 patients
undergoing bi-apical LVRS and the 17 patients excluded from LVRS (3.3 +/- 1.8
versus 1.2 +/- 0.7; p < 0.0001), in keeping with the anatomic distribution of
emphysema by which patients were selected for surgery by computed tomography
(CT). The perfusion EI ratio correlated moderately with the change in FEV1 at 3
months (r = 0.37, p = 0.04), 6 months (r = 0.36, p = 0.05), and 12 months (r = 0.42,
p = 0.03), and the transition dyspnea index at 6 months (r = 0.48, p = 0.014) after
LVRS. The authors concluded that patients selected to undergo LVRS have more
severe and extensive apical perfusion deficits than patients not selected for LVRS,
based on CT determination. Moreover, they stated that SPECT after aerosol V/Q
imaging does not add significantly to planar perfusion scans. Aerosol DTPA
ventilation scans are not consistently useful. Perfusion lung scanning may be
useful in selecting patients with successful outcomes after LVRS.
Inmai and colleagues (2000) noted that 99mTc-Technegas (Tcgas) SPECT is
useful for evaluating the patency of the airway and highly sensitive in detecting
regional pulmonary function in pulmonary emphysema. The aim of this study was
to evaluate regional ventilation impairment by this method pre- and post-
thoracoscopic LVRS in patients with pulmonary emphysema. There were 11
patients with pulmonary emphysema. The mean age of patients was 64.1 years.
All patients were males. LVRS was performed bilaterally in 8 patients and
unilaterally in 3 patients. Post-inhalation of Tcgas in the sitting position, the
subjects were placed in the supine position and SPECT was performed.
Distribution of Tcgas on axial images was classified into 4 types: (i) homogeneous
(ii) inhomogeneous (iii) hot spot, and (iv) defect. Three slices of axial SPECT
images, the upper, middle and lower fields were selected, and changes in
deposition patterns post LVRS were scored (Tcgas score). Post-LVRS, dyspnea
on exertion and pulmonary function tests were improved. Pre-LVRS,
inhomogeneous distribution, hot spots and defects were observed in all patients.
Post-LVRS, improvement in distribution was obtained not only in the surgical field
and other fields, but also in the contralateral lung of unilaterally operated patients.
In 5 patients some fields showed deterioration. The Tcgas score correlated with
improvements in FEV1.0, FEV1.0 % and % FEV1.0. The authors concluded that
Tcgas SPECT is useful for evaluating changes in regional pulmonary function post-
LVRS.
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Also, an UpToDate review on “Lung volume reduction surgery in COPD” (Martinez,
2014) does not mention the use of SPECT for pre-surgical evaluation.
Nakai et al (2014) reported the case of an 84-year old woman who presented with
persistent type II endoleak with sac expansion from 57 mm to 75 mm during 4-year
follow-up after endovascular abdominal aortic aneurysm repair. The patient
underwent trans-abdominal embolization with coils and N-butyl
cyanoacrylate/ethiodized oil mixture (2.5 ml). Because of the anticipated
embolization artifacts on follow-up computed tomography (CT), technetium-99m-
labeled human serum albumin diethylenetriamine pentaacetic acid single-photon
emission computed tomography ((99m)Tc-HSAD SPECT) was performed before
and after the intervention. Peri-graft accumulation on (99m)Tc-HSAD SPECT
corresponding to the endoleak disappeared after embolization. The authors noted
that CT scan performed 12 months after embolization showed no signs of sac
expansion; and they stated that (99m)Tc-HSAD SPECT may be useful for
evaluating therapeutic effect after embolization for endoleak.
The American College of Radiology Appropriateness Criteria on “Dementia and
movement disorders” (ACR, 2014) stated that “An evidence-based review
performed by the AAN concluded that SPECT imaging cannot be recommended for
either the initial or the differential diagnosis of suspected dementia because it has
not demonstrated superiority to clinical criteria. Also, compared with PET, SPECT
has a lower diagnostic accuracy and is inferior in its ability to separate healthy
controls from patients with true dementia”.
Freesmeyer et al (2014) reported an initial experience regarding the feasibility and
applicability of quasi-integrated freehand SPECT/ultrasonography (US) fusion
imaging in patients with thyroid disease. Local ethics committee approval was
obtained, and 34 patients were examined after giving written informed consent.
After intravenous application of 75 MBq of technetium 99m pertechnetate, freehand
3-D SPECT was performed. Data were reconstructed and transferred to a US
system. The combination of 2 independent positioning systems enabled real-time
fusion of metabolic and morphologic information during US examination. Quality of
automatic co-registration was evaluated visually, and deviation was determined by
measuring the distance between the center of tracer distribution and the center of
the US correlate. All examinations were technically successful. For 18 of 34
examinations, the automatic co-registration and image fusion exhibited very good
agreement, with no deviation. Only minor limitations in fusion offset occurred in 16
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patients (mean offset ± standard deviation, 0.67 cm ± 0.3; range of 0.2 to 1.0 cm).
SPECT artifacts occurred even in situations of clear thyroid findings (e.g., unifocal
autonomy). The authors concluded that the freehand SPECT/US fusion concept
proved feasible and applicable; however, technical improvements are needed.
Ryken et al (2014) determined which imaging techniques most accurately
differentiate true tumor progression from pseudo-progression or treatment-related
changes in patients with previously diagnosed glioblastoma. The authors stated
that the following recommendations apply to adults with previously diagnosed
glioblastoma who are suspected of experiencing progression of the neoplastic
process:
▪ Recommendation Level II: Magnetic resonance imaging (MRI) with and
without gadolinium enhancement is recommended as the imaging
surveillance method to detect the progression of previously diagnosed
glioblastoma.
▪ Recommendation Level II: Magnetic resonance spectroscopy (MRS) is
recommended as a diagnostic method to differentiate true tumor
progression from treatment-related imaging changes or pseudo-
progression in patients with suspected progressive glioblastoma.
▪ Recommendation Level III: The routine use of positron emission
tomography (PET) to identify progression of glioblastoma is not
recommended.
▪ Recommendation Level III: Single-photon emission computed tomography
(SPECT) imaging is recommended as a diagnostic method to differentiate
true tumor progression from treatment-related imaging changes or pseudo-
progression in patients with suspected progressive glioblastoma.
The National Comprehensive Cancer Network’s clinical practice guideline on
“Central nervous system cancers” (Version 2.2014) does not mention SPECT as a
management tool. Furthermore, an UpToDate review on “Management of recurrent
high-grade gliomas” (Batchelor et al, 2015) does not mention SPECT as a
management tool.
Detection of Fronto-Temporal Dementia
In a Cochrane review, Archer et al (2015) determined the diagnostic accuracy of
regional cerebral blood flow (rCBF) SPECT for diagnosing FTD in populations with
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suspected dementia in secondary/tertiary healthcare settings and in the differential
diagnosis of FTD from other dementia subtypes. The search strategy used 2
concepts: (i) the index test and (ii) the condition of interest. These investigators
searched citation databases, including MEDLINE (Ovid SP), EMBASE (Ovid SP),
BIOSIS (Ovid SP), Web of Science Core Collection (ISI Web of Science),
PsycINFO (Ovid SP), CINAHL (EBSCOhost) and LILACS (Bireme), using
structured search strategies appropriate for each database. In addition they
searched specialized sources of diagnostic test accuracy studies and reviews
including: MEDION (Universities of Maastricht and Leuven), DARE (Database of
Abstracts of Reviews of Effects) and HTA (Health Technology Assessment)
database. These researchers requested a search of the Cochrane Register of
Diagnostic Test Accuracy Studies and used the related articles feature in PubMed
to search for additional studies. They tracked key studies in citation databases
such as Science Citation Index and Scopus to ascertain any further relevant
studies. They identified “grey” literature, mainly in the form of conference abstracts,
through the Web of Science Core Collection, including Conference Proceedings
Citation Index and Embase. The most recent search for this review was run on the
June 1, 2013. Following title and abstract screening of the search results, full-text
papers were obtained for each potentially eligible study. These papers were then
independently evaluated for inclusion or exclusion. The authors included both
case-control and cohort (delayed verification of diagnosis) studies. Where studies
used a case-control design , these researchers included all participants who had a
clinical diagnosis of FTD or other dementia subtype using standard clinical
diagnostic criteria. For cohort studies, they included studies where all participants
with suspected dementia were administered rCBF SPECT at baseline. The authors
excluded studies of participants from selected populations (e.g., post-stroke) and
studies of participants with a secondary cause of cognitive impairment. Two review
authors extracted information on study characteristics and data for the assessment
of methodological quality and the investigation of heterogeneity. They assessed
the methodological quality of each study using the QUADAS-2 (Quality Assessment
of Diagnostic Accuracy Studies) tool. They produced a narrative summary
describing numbers of studies that were found to have high/low/unclear risk of bias
as well as concerns regarding applicability. To produce 2 x 2 tables, these
investigators dichotomized the rCBF SPECT results (scan positive or negative for
FTD) and cross-tabulated them against the results for the reference standard.
These tables were then used to calculate the sensitivity and specificity of the index
test. Meta-analysis was not performed due to the considerable between-study
variation in clinical and methodological characteristics.
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A total of 11 studies (1,117 participants) met inclusion criteria. These consisted of
6 case-control studies, 2 retrospective cohort studies and 3 prospective cohort
studies; 3 studies used single-headed camera SPECT while the remaining 8 used
multiple-headed camera SPECT. Study design and methods varied widely.
Overall, participant selection was not well-described and the studies were judged
as having either high or unclear risk of bias. Often the threshold used to define a
positive SPECT result was not pre-defined and the results were reported with
knowledge of the reference standard. Concerns regarding applicability of the
studies to the review question were generally low across all 3 domains (participant
selection, index test and reference standard). Sensitivities and specificities for
differentiating FTD from non-FTD ranged from 0.73 to 1.00 and from 0.80 to 1.00,
respectively, for the 3 multiple-headed camera studies. Sensitivities were lower for
the 2 single-headed camera studies; 1 reported a sensitivity and specificity of 0.40
(95 % CI: 0.05 to 0.85) and 0.95 (95 % CI: 0.90 to 0.98), respectively, and the other
a sensitivity and specificity of 0.36 (95 % CI: 0.24 to 0.50) and 0.92 (95 % CI: 0.88
to 0.95), respectively. Eight of the 11 studies which used SPECT to differentiate
FTD from Alzheimer's disease used multiple-headed camera SPECT. Of these
studies, 5 used a case-control design and reported sensitivities of between 0.52
and 1.00, and specificities of between 0.41 and 0.86. The remaining 3 studies used
a cohort design and reported sensitivities of between 0.73 and 1.00, and
specificities of between 0.94 and 1.00. The 3 studies that used single-headed
camera SPECT reported sensitivities of between 0.40 and 0.80, and specificities of
between 0.61 and 0.97. The authors concluded that they would not recommend
the routine use of rCBF SPECT in clinical practice because there is insufficient
evidence from the available literature to support this. They stated that further
research into the use of rCBF SPECT for differentiating FTD from other dementias
is needed. In particular, protocols should be standardized, study populations
should be well-described, the threshold for “abnormal” scans pre-defined and clear
details given on how scans are analyzed. The authors stated that more prospective
cohort studies that verify the presence or absence of FTD during a period of follow-
up should be undertaken.
Detection of Air Leak/Pneumothorax
Ceulemans et al (2012) reported on the case of a 61-year old man with severe
chronic obstructive pulmonary disease presented to the authors’ hospital with
recurrence of a right-sided spontaneous secondary pneumothorax. Thoracoscopic
abrasion of the parietal pleura was performed, but an important air leak persisted.
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Presumed to originate from a bulla in the right upper lobe, bullectomy and pleural
decortication were performed, but leakage remained. Lobectomy was considered,
and quantitative ventilation/perfusion SPECT was performed to predict the
functional outcome. Fused high-resolution CT/Tc Technegas images localized
leakage not only to a bleb in the right upper lobe but also to the subcutaneous
emphysema in the thoracic wall. The air leak resolved after conservative treatment.
An UpToDate review of “Imaging of pneumothorax” (Stark, 2016) mentions cheat
X-ray, CT, and ultrasound for imaging pneumothorax; it does not mention SPECT
scan.
Diagnosis of Lung Cancer
In a meta-analysis, Zhang and Liu (2016) examined the value of technetium-99m
methoxy isobutyl isonitrile (Tc-MIBI) SPECT in differentiating malignant from benign
lung lesions. The PubMed and Embase databases were comprehensively
searched for relevant articles that evaluated lung lesions suspicious for malignancy.
Two reviewers independently extracted the data on study characteristics and
examination results, and assessed the quality of each selected study. The data
extracted from the eligible studies were assessed by heterogeneity and threshold
effect tests. Pooled sensitivity, specificity, diagnostic odds ratio (DOR), and areas
under the summary receiver-operating characteristic curves (SROC) were also
calculated. A total of 14 studies were included in this meta-analysis. The pooled
sensitivity, specificity, positive and negative likelihood ratio, and DOR of Tc-MIBI
scan in detecting malignant lung lesions were 0.84 (95 % CI: 0.81 to 0.87), 0.83 (95
% CI: 0.77 to 0.88), 4.22 (95 % CI: 2.53 to 7.04), 0.20 (95 % CI: 0.12 to 0.31), and
25.71 (95 % CI: 10.67 to 61.96), respectively. The area under the SROC was
0.9062. Meta-regression analysis showed that the accuracy estimates were
significantly influenced by ethnic groups (p < 0.01), but not by image analysis
methods, mean lesion size, or year of publication. Deek funnel plot asymmetry test
for the overall analysis did not raise suspicion of publication bias (p = 0.50). The
authors concluded that these findings indicated that Tc-MIBI scan is a promising
diagnostic modality in predicting the malignancy of lung lesions.
This meta-analysis had several drawbacks: (i) the studies varied in year of
publication, sample size, continuity of patients enrolled, and ethnic groups as
well as lesion size. In addition, 99mTc-MIBI SPECT images were performed
under variable conditions, including tracer dose, image analysis methods, the
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interval time between tracer injection and scanning (ii) it is impossible for these
researchers to identify all studies of 99mTc-MIBI SPECT for lung cancer
diagnosis, especially unpublished studies. Since articles reporting significant
results are more likely to be published than those reporting non-significant results,
publication bias is a major concern in meta-analysis. However, the Deek funnel
plot asymmetry test for the overall analysis did not raise suspicion of publication
bias. In addition, the authors adopted rigid inclusion criteria and they selected only
articles that included at least 10 patients who performed MIBI imaging for lung
lesions, which may bring about selection bias, and (iii) it was not clear whether
SPECT or PET is superior in differentiating malignant from benign lesions. Two
recent published meta-analyses were performed to evaluate the diagnostic
accuracy of FDG-PET for detecting lung cancer with a sensitivity of 94 % to 96 %
and specificity of 78 % to 86 %. However, a direct comparison between PET and
SPECT is absent. Only 2 of the studies comparing SPECT with PET were included
in this meta-analysis, but the results were generally inconclusive. According to
Santini et al, 99mTc-MIBI SPECT was similar to FDG-PET in the detection of lung
malignancies and represents an alternative if PET was not available.
Furthermore, National Comprehensive Cancer Network’s clinical practice guidelines
on “Small cell lung cancer” (Version 2.2017) and “Non-small cell lung
cancer” (Version 4.2017) do not mention SPECT as a diagnostic tool.
Evaluation of Carotid Stenosis:
Sato and Matsumoto (2017) stated that multi-phase arterial spin labeling (ASL),
which obtains the imaged slices with various post-labeling delays, allows for the non-
invasive assessment of cerebral hemodynamics that cannot be adequately acquired
by SPECT imaging. These investigators described the clinical usefulness of multi-
phase ASL in a patient with symptomatic carotid stenosis by comparison with
SPECT at rest using iodo-amphetamine. A 75-year old man was referred to the
authors’ hospital with severe stenosis of the left internal carotid artery (ICA).
While SPECT showed no significant laterality of CBF, multi-phase ASL
demonstrated relatively delayed perfusion in the left ICA territory. The patient
underwent stent placement for the left ICA stenosis. Post-operatively, while
SPECT demonstrated no significant laterality of CBF, multi-phase ASL revealed
improved perfusion in the left ICA territory. The authors concluded that this case
showed that multi-phase ASL could accurately evaluate the cerebral hemodynamic
status that could not be detected using pre- and post-operative SPECT.
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Imaging Marker of Pre-Diagnostic Parkinson's Disease:
Noyce and colleagues (2018) examined if pre-diagnostic features of PD were
associated with changes in dopamine re-uptake transporter-SPECT and
transcranial sonography. Pre-diagnostic features of PD (risk estimates, University
of Pennsylvania Smell Identification Test, Rapid Eye Movement Sleep Behavior
Disorder Screening Questionnaire, and finger-tapping scores) were assessed in a
large cohort of older U.K. residents. A total of 46 participants were included in
analyses of pre-diagnostic features and MDS-UPDRS scores with the striatal
binding ratio on dopamine reuptake transporter-SPECT and nigral hyper-
echogenicity on transcranial sonography. The striatal binding ratio was associated
with PD risk estimates (p = 0.040), University of Pennsylvania Smell Identification
Test (p = 0.002), Rapid Eye Movement Sleep Behavior Disorder Screening
Questionnaire scores (p = 0.024), tapping speed (p = 0.024), and MDS-UPDRS
motor scores (p = 0.009). Remotely collected assessments explained 26 % of
variation in the striatal binding ratio. The inclusion of MDS-UPDRS motor scores
did not explain additional variance. The size of the nigral echogenic area on
transcranial sonography was associated with risk estimates (p < 0.001) and MDS-
UPDRS scores (p = 0.03) only. The authors concluded that the dopamine re-
uptake transporter-SPECT results correlated with motor and non-motor features of
pre-diagnostic PD, supporting its potential use as a marker in the prodromal phase
of PD; transcranial sonography results also correlated with risk scores and motor
signs.
Work-Up of Individuals Undergoing Non-Cardiac Surgery:
Al-Oweidi and colleagues (2017) noted that the prevalence and predictors of
myocardial ischemia before non-cardiac surgery are unknown. In addition the
predictive value of myocardial perfusion SPECT before non-cardiac in individual
patients is uncertain. In a retrospective study, these researchers evaluated the
prevalence and predictors of myocardial ischemia before non-cardiac surgery, and
determined the post-operative cardiac outcome based on results of myocardial
perfusion SPECT. These investigators reviewed the records of adult patients
diagnosed with myocardial ischemia by myocardial perfusion SPECT who were
undergoing non-cardiac surgery. Myocardial perfusion SPECT had been
performed within 4 weeks prior to non-cardiac surgery requiring general
anesthesia. Main outcome measures included prevalence of abnormal myocardial
perfusion SPECT results on pre-operative evaluation; abnormal myocardial
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perfusion SPECT results as a predictor for post-operative cardiac events such as
cardiac death, non-fatal MI, and unstable angina. Of 131 patients who underwent
non-cardiac surgery from February 2015 to April 2016, 84 (64 %) patients were
women and the mean (SD) age was 64.1 (13.6) years. The prevalence of
abnormal myocardial perfusion SPECT was 18 % (24 of 131). Normal myocardial
perfusion SPECT was highly predictive (up to 100 %), but a positive myocardial
perfusion SPECT had low positive predictive value (PPV; 4 %). Variables
associated with an abnormal myocardial perfusion SPECT included ischemic heart
disease, congestive heart failure, American Society of Anesthesiology physical
status classification score of 3 or more, limited exercise capacity (less than 4
metabolic equivalents [METs]), male sex, hypercholesterolemia, hypertension,
smoking, and abnormal ECG. In a multi-variable analysis, history of ischemic heart
disease and history of smoking were significant predictors of abnormal myocardial
perfusion SPECT (p = 0.001, and 0.029, respectively). The authors concluded that
because of the low PPV of myocardial perfusion SPECT, utilization of the technique
in the work-up of cardiac patients undergoing non-cardiac surgery has been
inappropriate. They stated that myocardial perfusion SPECT should be restricted
to only clearly defined appropriate use criteria.
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Code Code Description
Noncardiac indications:
CPT codes covered if selection criteria are met:
78071 Parathyroid planar imaging (including subtraction, when performed); with
tomographic (SPECT)
78072 Parathyroid planar imaging (including subtraction, when performed); with
tomographic (SPECT), and concurrently acquired computed tomography
(CT) for anatomical localization
78205 Liver imaging (SPECT)
78206 with vascular flow
78320 Bone and/or joint imaging; tomographic (SPECT)
78607 Brain imaging, complete study; tomographic (SPECT)
78647 Cerebrospinal fluid flow, imaging (not including introduction of material);
tomographic (SPECT)
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Code Code Description
78803 Radiopharmaceutical localization of tumor or distribution of
radiopharmaceutical agent(s); tomographic (SPECT)
78807 Radiopharmaceutical localization of inflammatory process; tomographic
(SPECT)
Other CPT codes related to the CPB:
78608 - 78609 Brain imaging, positron emission tomography (PET)
HCPCS codes covered if selection criteria are met:
A9584 Iodine I-123 Ioflupane, diagnostic, per study dose, up to 5 millicuries
Other HCPCS codes related to the CPB:
A9500 Technetium tc-99m sestamibi, diagnostic, per study dose
ICD-10 codes covered if selection criteria are met:
C16.0 - C16.9 Malignant neoplasm of stomach [carcinoid or neuroendocrine tumors]
C25.0 - C25.9 Malignant neoplasm of pancreas [VIPoma, Islet cell tumors]
C33 Malignant neoplasm of trachea
C70.0 - C70.9 Malignant neoplasm of cerebral meninges [meningioma]
C71.0 - C71.9 Malignant neoplasm of brain [differentiation of necrotic tissue from
tumor]
C74.00 - C74.92 Malignant neoplasm of adrenal gland [paragangliomas,
pheochromocytomas]
C75.0 - C75.2 Malignant neoplasm of parathyroid gland, pituitary gland and
craniopharyngeal duct
C75.5 Malignant neoplasm of aortic body and other paraganglia
C7A.00 - C7B.8 Malignant neuroendocrine tumors
C79.31, C79.49 Secondary malignant neoplasm of brain and nervous system
[differentiation of necrotic tissue from tumor of the brain]
C81.00 - C88.9 Lymphoma [to distinguish tumor from necrosis]
D13.7 Benign neoplasm of endocrine pancreas [gastrinomas, glucagonomas,
Islet cell tumors]
D18.03 Hemangioma of intra-abdominal structures [liver]
D32.0 - D32.9 Benign neoplasm of meninges [meningioma]
D33.0 - D33.2 Benign neoplasm of brain [differentiation of necrotic tissue from tumor]
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Code Code Description
D35.00 - D35.02 Benign neoplasm of adrenal gland [paragangliomas,
pheochromocytomas]
D35.1 - D35.3 Benign neoplasm of parathyroid gland, pituitary gland and
craniopharyngeal duct (pouch)
D35.6 Benign neoplasm of aortic body and other paraganglia
D37.1 - D37.5 Neoplasm of uncertain behavior of stomach, intestines, and rectum
D37.8 - D37.9 Neoplasm of uncertain behavior of other and unspecified digestive
organs
D38.1 Neoplasm of uncertain behavior of trachea, bronchus, and lung
D42.0 - D42.9 Neoplasm of uncertain behavior of meninges
D43.0 - D43.4 Neoplasm of uncertain behavior of brain and spinal cord [differentiation
of necrotic tissue from tumor of the brain]
D44.0 - D44.9 Neoplasm of uncertain behavior of endocrine glands
E20.0 - E21.5 Disorders of parathyroid gland
E34.0 Carcinoid syndrome
G20 Parkinson's disease
G40.001 -
G40.919
Epilepsy and recurrent seizures [presurgical ictal detection of seizure
focus in place of PET]
I26.01 - I26.99 Pulmonary embolism
K12.2 Cellulitis and abscess of mouth
L02.01, L02.11
L02.211
L02.219
L02.31
L02.411
L02.419
L02.511
L02.519
L02.611
L02.619
L02.811
L02.818
L02.91
Other cutaneous abscess [localization for suspected or known localized
infection or inflammatory process]
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Code Code Description
L03.111
L03.119
L03.121
L03.129
L03.211
L03.213
L03.221
L03.222
L03.311
L03.319
L03.321
L03.329
L03.818
L03.891
L03.898
L03.90 -L03.91
Other cellulitis [localization for suspected or known localized infection or
inflammatory process]
L98.3 Eosinophillic cellulitis [Wells]
M46.20 -
M46.28
Osteomyelitis of vertebra [to distinguish bone from soft tissue infection]
M46.30 -
M46.39
Infection of intervertebral disc (pyogenic) [to distinguish bone from soft
tissue infection]
M48.40x+
M48.48x+
M84.30x+
M84.38x+
M84.361+ -
M84.369+
M84.374+ -
M84.379+
Stress fractures
M86.011 -
M86.9
Osteomyelitis, periostitis, and other infections involving bone [to
distinguish bone from soft tissue infection]
M89.60 -
M89.69
Osteopathy after poliomyelitis [to distinguish bone from soft tissue
infection]
M90.80 -
M90.89
Osteopathy in diseases classified elsewhere
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Code Code Description
Q76.2 Congenital spondylolisthesis
R56.1 Post traumatic seizures [presurgical ictal detection of seizure focus in
place of PET]
ICD-10 codes not covered for indications listed in the CPB:
E00.0 - E07.9 Disorders of thyroid gland
F01.50 - F01.51 Vascular dementia
F02.80 - F02.81 Dementia in other diseases classified elsewhere with or without
behavioral disturbance
F06.0 - F06.8 Other mental disorders due to known physiological condition
F10.282,
F10.982
Alcohol use with alcohol-induced sleep disorder
F11.182,
F11.282
F11.982
F13.182,
F13.282
F13.982
F14.182,
F14.282
F14.982
F15.182,
F15.282
F15.982
F19.182,
F19.282
F19.982
Drug induced sleep disorders
F20.0 - F21 Schizophrenia
F51.0 - F51.9 Sleep disorders not due to a substance or known physiological condition
F60.0 - F69 Disorders of adult personality and behaivor
F84.0 - F89 Pervasive developmental disorders
F90.0 - F90.9 Attention-deficit hyperactivity disorder
G30.0 - G30.9 Alzheimer's disease
G31.01 - G31.09 Frontotemporal dementia
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Code Code Description
G31.83 Dementia with Lewy bodies
G35 Multiple sclerosis
G47.0 - G47.9 Sleep disorders
I63.011 - I66.9 Occlusion and stenosis of precerebral arteries, occlusion of cerebral
arteries, and transient cerebral ischemia
I77.3 Arterial fibromuscular dysplasia
I77.6 Arteritis, unspecified
I77.89 Other specified disorders of arteries and arterioles
J93.0 - J93.9 Pneumothorax and air leak
M30.1 Polyarteritis with lung involvement [Churg-Strauss]
M31.0 - M31.9 Other necrotizing vasculopathies
R52 Pain, unspecified
R91.8 Other nonspecific abnormal finding of lung field
S02.0XX+
S02.42X+
S02.600+
S02.92X+
Fracture of skull and facial bones
S06.0x0+ -
S06.0x9+
Concussion
S06.310+ -
S06.339+
Contusion and laceration of cerebrum
S06.340+ -
S06.369+
Traumatic hemorrhage of cerebrum
S06.4X0+ -
S06.6X9+
Epidural and traumatic subdural hemorrhage
S06.890+ -
S06.9X9+
Other and unspecified intracranial injury
S09.8XX+ -
S09.90X+
Specified and unspecified head injury
T82.898+ Other specified complication of vascular prosthetic devices, implants
and grafts, initial encounter [endoleak]
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Code Code Description
T82.6xx+
T82.7xx+,
T83.51x+ -
T83.69x+,
T84.50x+ -
T84.60x+,
T84.63x+ -
T84.7xx+
T85.71x+ -
T85.79x+
Infection and inflammatory reaction due to internal prosthetic device,
implant, and graft
Z01.818 Encounter for other preprocedural examination
Cardiac Indications:
CPT codes covered if selection criteria are met:
78451 Myocardial perfusion imaging, tomographic (SPECT) (including
attenuation correction, qualitative or quantitative wall motion, ejection
fraction by first pass or gated technique, additional quantification, when
performed); single study, at rest or stress (exercise or pharmacologic)
78452 multiple studies, at rest and/or stress (exercise or pharmacologic)
and/or redistribution and/or rest reinjection
78453 Myocardial perfusion imaging, planar (including qualitative or
quantitative wall motion, ejection fraction by first pass or gated
technique, additional quantification, when performed); single study, at
rest or stress (exercise or pharmacologic)
78454 multiple studies, at rest and/or stress (exercise or pharmacologic)
and/or redistribution and/or rest reinjection
78469 Myocardial imaging, infarct avid, planar; tomographic SPECT with or
without quantification
CPT codes not covered for indications listed in the CPB:
0331T Myocardial sympathetic innervation imaging, planar qualitative and
quantitative assessment
0332T Myocardial sympathetic innervation imaging, planar qualitative and
quantitative assessment; with tomographic SPECT
Other CPT codes related to the CPB:
33140 - 33141 Transmyocardial revascularization
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Code Code Description
ICD-10 codes covered if selection criteria are met:
I25.10 - I25.9 Atherosclerotic heart disease of antive coronary artery
ICD-10 codes not covered for indications listed in the CPB:
I21.01 - I24.1 ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial
infarction
R57.0 - R57.9 Shock, not elsewhere classified
Z13.6 Encounter for screening for cardiovascular disorders
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan
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Copyright © 2001-2018 Aetna Inc.
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AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number:
0376 Single Photon Emission Computed Tomography (SPECT) There are no amendments for Medicaid.
www.aetnabetterhealth.com/pennsylvania revised 08/01/2018