number: 0376 *please see amendment for pennsylvania ......single photon emission computed tomography...
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Number: 0376
Policy
*Please see amendment for Pennsylvania Medicaid at the
end of this CPB.
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
Last Review 04/13/2017
Effective: 03/08/2000
Next Review: 04/12/2018
Review History
Definitions
Clinical Policy Bulletin Notes
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with epilepsy (in place of positron emission tomography
(PET)).
K. Pre‐surgical ictal detection of seizure focus in members
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. Detection of air leak/pneumothorax; or
B. Diagnosis or assessment of members with attention
deficit/hyperactivity disorder (CPB 0426 ‐ Attention
Deficit/Hyperactivity Disorder (../400_499/0426.html)); or
C. Diagnosis or assessment of members with autism (CPB
0648 ‐ Autism Spectrum Disorders (../600_699
/0648.html)); or
D. 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
E. Diagnosis or assessment of members with schizophrenia; or
F. Diagnosis or assessment of stroke members; or
G. Differential diagnosis of Parkinson's disease from other
Parkinsonian syndromes; or
H. Differentiating malignant from benign lung lesions; or
I. Evaluation of members with endoleak; or
J. Evaluation of members with generalized pain or insomnia;
or
K. Evaluation of members with head trauma; or
L. Initial or differential diagnosis of members with suspected
dementia (e.g., Alzheimer's disease, dementia with Lewy
bodies, frontotemporal dementia, and vascular dementia);
or
M. Multiple sclerosis; or
N. Pre‐surgical evaluation of members undergoing lung
volume reduction surgery; or
O. Prosthetic graft infection; or
P. Scanning of internal carotid artery during temporary
balloon occlusion; or
Q. Vasculitis.
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III. Cardiac Indications: Aetna considers SPECT medically
necessary for the following indications for members who do
not meet any of the exclusion criteria below:
A. Assessing myocardial viability before referral for myocardial
revascularization procedures; or
B. Diagnosis of coronary artery disease (CAD) in members
with an uninterpretable resting electrocardiogram (ECG)
and restricted exercise tolerance.
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) (Brindis et al, 2005):
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
E. In the setting of acute chest pain or equivalent symptoms
with a high likelihood of being acute coronary syndrome,
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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: http://cvdrisk.nhlbi.nih.gov/
(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.
Source: ACC (2005).
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 its
effectiveness.
Background
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
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90 % overall sensitivity for detecting CAD. In assessing myocardial
viability, studies indicate that, even in patients with severe
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
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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.
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.
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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 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
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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 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
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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 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 Tu mors
Carcinoids and other neuroendocrine tumors have somatostatin
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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
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.
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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.
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SPECT for the Diagnosis/Assessment of Autism
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).
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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.
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.
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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
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
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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.
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
18 of 47
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 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’
19 of 47
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
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
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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.
Also, an UpToDate review on “Lung volume reduction surgery in
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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
22 of 47
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 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.
23 of 47
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‐Te mporal 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 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
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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.
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
25 of 47
(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. 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
26 of 47
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 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
27 of 47
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.
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 "+":
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)
28 of 47
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)
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 ‐ C34.92 Malignant neoplasm of trachea, bronchus and lung
[carcinoid]
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
29 of 47
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]
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
30 of 47
E34.0 Carcinoid syndrome
G20 Parkinson's disease
G40.001 ‐ Epilepsy and recurrent seizures [presurgical ictal
G40.919 detection of seizure focus in place of PET]
I26.01 ‐
I26.99
Pulmonary embolism
K12.2 Cellulitis and abscess of mouth
L02.01, Other cutaneous abscess [localization for suspected or
L02.11 known localized infection or inflammatory process]
L02.211 ‐
L02.219
L02.31
L02.411 ‐
L02.419
L02.511 ‐
L02.519
L02.611 ‐
L02.619
L02.811 ‐
L02.818
L02.91
L03.111 ‐ Other cellulitis [localization for suspected or known
L03.119 localized infection or inflammatory process]
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
31 of 47
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+ ‐ Stress fractures
M48.48x+
M84.30x+ ‐
M84.38x+
M84.361+ ‐
M84.369+
M84.374+ ‐
M84.379+
M86.011 ‐
M86.9
Osteomyelitis, periostitis, and other infections
involving bone [to distinguish bone from soft tissue
infection]
M89.60 ‐ Osteopathy after poliomyelitis [to distinguish bone
M89.69 from soft tissue infection]
M90.80 ‐
M90.89
Osteopathy in diseases classified elsewhere
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 ‐ Dementia in other diseases classified elsewhere with
F02.81 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
32 of 47
F11.182, Drug induced sleep disorders
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
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
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
33 of 47
M30.1 Polyarteritis with lung involvement [Churg‐Strauss]
M31.0 ‐
M31.9
Other necrotizing vasculopathies
R52 Pain, unspecified
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]
T82.6xx+ ‐ Infection and inflammatory reaction due to internal
T82.7xx+, prosthetic device, implant, and graft
T83.51x+ ‐
T83.69x+,
T84.50x+ ‐
T84.60x+,
T84.63x+ ‐
T84.7xx+
T85.71x+ ‐
T85.79x+
Z01.818 Encounter for other preprocedural examination
Cardiac Indica'tions:
CPT codes covered if selection criteria are met:
34 of 47
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
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
35 of 47
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan
benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a
partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide
health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are
independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating
providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be
updated and therefore is subject to change.
Copyright © 2001‐2017 Aetna Inc.
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 06/09/2017