MCO Molecular and Clinical Oncology 2049-9450 2049-9469 D.A. Spandidos 10.3892/mco.2017.1329 MCO-0-0-1329 Articles Positron emission tomography/computed tomography for osseous and soft tissue sarcomas: A systematic review of the literature and meta-analysis MuheremuAikeremujiang MaJunyi AmudongAierken MaYong NiyaziMaimaitiaili OuYong MaYuan Department of Spinal Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region 86830001, P.R. China Correspondence to: Dr Yuan Ma, Department of Spinal Surgery, The Sixth Affiliated Hospital of Xinjiang Medical University, 39 Wuxing Nan Lu, Urumqi, Xinjiang Uyghur Autonomous Region 86830001, P.R. China, E-mail: xinjiangspine@163.com 09 2017 18 07 2017 7 3 461 467 18112016 22052017 Copyright © 2017, Spandidos Publications 2017

In order to elucidate the value of positron emission tomography (PET)/computed tomography (CT) in the clinical diagnosis and treatment of osseous and soft tissue malignancies, two authors independently searched the PubMed, Medline, Elsevier, Embase and Cochrane Library databases for literature published between January 2003 and February 2016, using the key words ‘PET/CT’, ‘positron emission tomography/computed tomography’, ‘osseous sarcoma’, ‘bone tumor’, ‘soft tissue sarcoma’ and ‘neoadjuvant’, to identify prospective and retrospective studies on the applicability of PET/CT on the clinical diagnosis of bone and soft tissue lesions, and evaluation of their response to neoadjuvant therapies. Data were independently extracted by the two authors and any disagreements were resolved by a third author when necessary. Extracted data were analyzed by Meta-Disc 1.6 software. As a result, 16 trials with a total of 883 patients and 2,214 lesions were included in the present study. The overall diagnostic accuracy of PET/CT exhibited a sensitivity and specificity of 0.90 (0.86–0.92) and 0.89 (0.85–0.92), respectively, and the effect of neoadjuvant therapy was assessed with a sensitivity and specificity of 0.79 (0.30–0.93) and 0.79 (0.69–0.89), respectively. Thus, it may be concluded from the present study that PET/CT is a reliable imaging method to be applied in the diagnosis and treatment of osseous and soft tissue malignancies.

 positron emission tomography/computed tomography meta-analysis diagnosis treatment bone tumors sarcoma Introduction

Osseous and soft tissue sarcomas are rare conditions that may easily be misdiagnosed. Apart from pathological observations of biopsies, imaging studies such as X-rays, whole-body bone scan, computed tomography (CT) and magnetic resonance imaging (MRI) are often used for diagnostic purposes in cases with osseous and soft tissue sarcomas. Positron emission tomography (PET) is an imaging method that semiquantitatively measures the metabolic rate of tissues by measuring the glucose intake level of cells in vivo. As malignant tumors normally have a higher metabolic rate compared with benign lesions and normal tissues, PET may theoretically be used to discriminate benign from malignant tumors and, by assessing the metabolic activity of tumor cells following neoadjuvant therapy, it may evaluate the treatment effect without invasive methods, such as biopsy. PET/CT is a combination of the CT and PET techniques, which is able to show the accurate anatomical structure and metabolic activity of the tissues in the whole body. As a new and sophisticated imaging diagnostic tool, PET/CT is gradually used in an increasing number of medical centers. In the current literature, extensive research has been performed on the application of PET/CT in the diagnosis of a variety of tumors, such as lung, colorectal and breast cancer, melanoma and lymphoma (1–3). However, due to the low incidence of primary malignant osseous sarcomas, there are only few reports with large patient samples on the diagnostic accuracy or treatment effect evaluation of PET/CT in osseous and soft tissue sarcomas.

 Data collection methods <sec> <title>Literature search

Two independent reviewers performed a computerized search of databases including PubMed (2003–2016), Medline (2003–2016), Embase (2003–2016), Elsevier (2003–2016) and the Cochrane Library (2008–2016) with the mesh words: ‘PET/CT’, ‘positron emission tomography/computed tomography’, ‘osseous sarcoma’, ‘bone tumor’, ‘soft tissue sarcoma’ and ‘neoadjuvant’, for randomized controlled trials, half-randomized controlled studies, prospective and retrospective cohort studies on the accuracy of PET/CT for the diagnosis of bone and soft tissue sarcomas, and the evaluation of response to neoadjuvant therapy. For studies whose eligibility for the inclusion criteria failed to reach consensus between the two authors, a third author was invited to settle the disputes.

 Study quality assessment

Two authors independently assessed the quality of the included studies by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool (4). Each study was scored as ‘+’ (positive), ‘-’ (negative) and ‘?’ (unclear). In case of disagreement, a third author made the final decision. Studies with <7 ‘+’ were considered to be of low methodological quality and high risk of bias. The methodological quality of the included trials is outlined in Table I.

 Data extraction

Data in the included trials, including the authors of each study, study design, patient sample size, patient age, origin, time of follow-up and intervention methods, were extracted by two independent reviewers. Patient numbers with true-positive, false-positive, true-negative and false-negative diagnosis and evaluations in each study were extracted and recorded in specific tables. In case that the same patients were analyzed in more than one study, they were extracted and analyzed as one patient population.

Data were analyzed and processed by Meta-Disc software (5). Two authors checked the data input to ensure no errors were made. Considering the possibility of publication bias between the studies, the analyses were performed using the random-effects modes. The I2 test was used to test heterogeneity and studies were considered to have significant heterogeneity if I2>50%. Subgroup or sensitivity analysis was used in case of significant heterogeneity due to the methodological quality of the included trials. The differences in each study were defined by odds ratios (ORs) with 95% confidence intervals (95% CIs) of the categorical outcome frequencies in the study groups and the control groups, respectively. The OR of each individual trial was shown in a forest plot.

 Results <sec> <title>Results of the study selection process

Of the 1,310 articles screened, 16 (6–21) were selected for the final analysis (Fig. 1). The meta-analysis included a total of 883 patients and 2,214 lesions (Tables II and III). The majority of the studies were proven to be of relatively high quality according to the QUADAS quality assessment tool (Table I).

 Results of the meta-analysis <sec> <title>Diagnostic accuracy

A total of 9 studies, including 738 patients with 2,069 lesions, investigated the diagnostic accuracy of PET/CT in osseous and soft tissue sarcomas (Table IV). On patient-based analysis, the overall sensitivity and specificity were 0.90 (0.86–0.92) and 0.89 (0.85–0.92). The area under the summary receiver operating characteristic (SROC) curve was 0.97, Q=0.91 (Fig. 2). On lesion-based analysis, the overall sensitivity and specificity were 0.96 (0.94–0.97) and 0.95 (0.93–0.96). The area under the SROC curve was 0.97, Q=0.88 (. 3). The meta-analysis indicated that PET/CT is able to diagnose osseous and soft tissue sarcomas with high sensitivity and specificity.

 Evaluation of response to neoadjuvant therapy

A total of 7 studies, including 145 patients, investigated the accuracy of PET/CT in assessing the treatment effect of neoadjuvant therapy on patients with osseous and soft tissue sarcomas (Table V). Generally, a ratio of maximum standardized uptake value (SUVmax) after therapy/SUVmax prior to therapy of <0.5 was considered as an indication of effective neoadjuvant therapy in the index test, and necrosis of >90% in the intraoperative specimen was considered as an indication of effective neoadjuvant therapy in the reference test. The overall sensitivity and specificity were 0.79 (0.30–0.93) and 0.79 (0.69–0.89), respectively. The area under the SROC curve was 0.87, Q=0.80 (Fig. 4). The meta-analysis indicated that PET/CT may be used to monitor the effect of neoadjuvant therapy in patients with osseous and soft tissue sarcomas with high sensitivity and specificity.

 Discussion

Imaging studies are important for the diagnosis of various tumors. Currently, radiographic tests such as X-ray, CT and MRI are widely applied for the diagnosis and treatment of musculoskeletal system malignancies (22).

18F-fluorodeoxyglucose (FDG) PET is used for the semiquantification of glucose consumption by cells in the body, which makes it possible to measure the enhancement of metabolic activity in cancer tissue. This is normally performed by calculating the SUVmax. 18F-FDG PET has been successfully used for the diagnosis of several types of cancer, such as lung cancer, melanoma, lymphoma, head and neck tumors, brain tumors, esophageal and colorectal cancer (23). The majority of the studies on the diagnostic value of PET in different types of tumors have concluded that it is a sensitive imaging modality for detection, staging and re-staging in oncology (24–26).

FDG-PET has been applied for diagnostic purposes in various malignant tumors since the early 90s (27). However, although 18F-FDG may locate abnormally functioning anatomical structures, the precise localization of the tumors may not be possible with PET alone. Combining PET with a high-resolution anatomical imaging modality, such as CT, addresses this issue, provided that the images from the two modalities are accurately co-registered. Since 2003, a combination of PET and CT in one imaging device has gained increasing popularity and is referred to as integrated PET/CT. Integrated PET/CT is superior to PET or CT alone, as it can accomplish morphological and functional imaging in one procedure, and the images obtained with PET/CT were more accurate regarding localization of the tumor compared with PET and CT alone, or the fusion of PET and CT with software (28).

There are several reports on predicting the aggressiveness of musculoskeletal tumors by measuring the glucose consumption level using PET/CT (29). However, due to the low incidence of primary malignant osseous sarcomas and the high cost of PRT/CT imaging, the majority of those studies included only a small number of patients; thus, the level of evidence obtained from those studies was greatly compromised.

The percentage of necrotic tissue following adjuvant therapy of tumors is one of the strongest prognostic factors of osteosarcoma (30). In the present study, PET/CT assessed the effect of neoadjuvant therapy with a sensitivity and specificity of 0.79 (0.30–0.93) and 0.79 (0.69–0.89), respectively, indicating that PET/CT may be a reliable non-invasive method for evaluating the effect of neoadjuvant therapy on patients with osseous and soft tissue sarcomas. However, as only 145 patients were included in the meta-analysis, a larger sample is required to reach a more reliable conclusion.

Although the present study provided evidence on the applicability of PET/CT on the diagnosis and evaluation of response to neoadjuvant therapy for osseous and soft tissue sarcomas using the SUVmax value, and the quality of the included studies was relatively high, the overall sample size may be insufficient. Considering that osseous as well as soft tissue sarcomas are malignancies with a low incidence, multicenter prospective studies with longer follow-up are required to investigate the full potential of PET/CT in the diagnosis and treatment of musculoskeletal tumors.

In conclusion, PET/CT may be a reliable method with high accuracy for the diagnosis and evaluation of treatment efficacy for bone and soft tissue sarcomas, although the present findings require verification by larger-sample studies.

 Acknowledgements

The present study did not directly involve any human or animal subjects. The study was approved by the Ethics Committee of The Sixth Affiliated Hospital of Xinjiang Medical University.

 References HohCKSchiepersCSeltzerMAGambhirSSSilvermanDHCzerninJMaddahiJPhelpsMEPET in oncology: Will it replace the other modalities?Semin Nucl Med2794106199710.1016/S0001-2998(97)80042-69144854 BrockCSMeikleSRPricePDoes fluorine-18 fluorodeoxyglucose metabolic imaging of tumors benefit oncology?Eur J Nucl Med24691705199710.1007/BF008414119169580 Bar-ShalomRValdiviaAYBlaufoxMDPET imaging in oncologySemin Nucl Med30150185200010.1053/snuc.2000.743910928381 WhitingPRutjesAWReitsmaJBBossuytPMKleijnenJThe development of QUADAS: A tool for the quality assessment of studies of diagnostic accuracy included in systematic reviewsBMC Med Res Methodol325200310.1186/1471-2288-3-2514606960 ZamoraJAbrairaVMurielAKhanKCoomarasamyAMeta-DiSc: A software for meta-analysis of test accuracy dataBMC Med Res Methodol631200610.1186/1471-2288-6-3116836745 TateishiUYamaguchiUSekiKTerauchiTAraiYKimEEBone and Soft-Tissue Sarcoma: Preoperative Staging with Fluorine 18Fluorodeoxyglucose PET/CT and Conventional ImagingRadiology245839847200710.1148/radiol.245306153818024454 StrobelKExnerUEStumpeKDHanyTFBodeBMendeKVeit-HaibachPvon SchulthessGKHodlerJThe additional value of CT images interpretation in the differential diagnosis of benign vs. malignant primary bone lesions with 18F-FDG-PET/CTEur J Nucl Med Mol Imaging3520002008200810.1007/s00259-008-0876-018712385 ShinDShonOJHanDSChoiJHChunKAChoIHThe clinical efficacy of (18)F-FDG-PET/CT in benign and malignant musculoskeletal tumorsAnn Nucl Med22603609200810.1007/s12149-008-0151-218756363 CharestMHickesonMLisbonaRNovales-DiazJADerbekyanVTurcotteREFDG PET/CT imaging in primary osseous and soft tissue sarcomas: A retrospective review of 212 casesEur J Nucl Med Mol Imaging3619441951200810.1007/s00259-009-1203-0 PiperkovaEMikhaeilMMousaviALibesRViejo-RullanFLinHRosenGAbdel-DayemHImpact of PET and CT in PET/CT studies for staging and evaluating treatment response in bone and soft tissue sarcomasClin Nucl Med34146150200910.1097/RLU.0b013e3181966f9d19352275 FugløHMJørgensenSMLoftAHovgaardDPetersenMMThe diagnostic and prognostic value of 18F-FDG PET/CT in the initial assessment of high-grade bone and soft tissue sarcoma a retrospective study of 89 patientsEur J Nucl Med Mol Imaging3914161424201210.1007/s00259-012-2159-z22699526 SharmaPKhangembamBCSumanKCSinghHRastogiSKhanSABakhshiSThulkarSBalCMalhotraAKumarRDiagnostic accuracy of 18F-FDG PET/CT for detecting recurrence in patients with primary skeletal Ewing sarcomaEur J Nucl Med Mol Imaging4010361043201310.1007/s00259-013-2388-923558689 XuRKidoSSugaKHiranoYTachibanaRMuramatsuKChagawaKTanakaSTexture analysis on (18)F-FDG PET/CT images to differentiate malignant and benign bone and soft-tissue lesionsAnn Nucl Med28926935201410.1007/s12149-014-0895-925107363 ByunBHKongCBLimIKimBIChoiCWSongWSChoWHJeonDGKohJSLeeSYLimSMComparison of (18)F-FDG PET/CT and (99 m) Tc-MDP bone metastasis in osteosarcomaSkeletal Radiol4216731681201310.1007/s00256-013-1714-423995264 IagaruAMasamedRChawlaSMenendezLRFedenkoAContiPSF-18 FDG PET and PET/CT Evaluation of Response to Chemotherapy in Bone and Soft Tissue SarcomasClin Nucl Med33813200810.1097/RLU.0b013e31815c4fd418097248 EvilevitchVWeberWATapWDAllen-AuerbachMChowKNelsonSDEilberFREckardtJJElashoffRMPhelpsMEReduction of glucose metabolic activity is more accurate than change in size at predicting histopathologic response to neoadjuvant therapy in high-grade soft-tissue sarcomasClin Cancer Res14715720200810.1158/1078-0432.CCR-07-176218245531 HamadaKTomitaYInoueAFujimotoTHashimotoNMyouiAYoshikawaHHatazawaJEvaluation of chemotherapy response in osteosarcoma with FDG-PETAnn Nucl Med238995200910.1007/s12149-008-0213-519205843 BenzMRCzerninJAllen-AuerbachMSTapWDDrySMElashoffDChowKEvilevitchVEckardtJJPhelpsMEFDG-PET/CT imaging predicts histopathologic treatment responses after the initial cycle of neoadjuvant chemotherapy in high-grade soft-tissue sarcomasClin Cancer Res1528562863200910.1158/1078-0432.CCR-08-253719351756 ImHJKimTSParkSYMinHSKimJHKangHGParkSEKwonMMYoonJHParkHJPrediction of tumour necrosis fractions using metabolic and volumetric 18F-FDG PET/CT indices, after one course and at the completion of neoadjuvant chemotherapy, in children and young adults with osteosarcomaEur J Nucl Med Mol Imaging393949201210.1007/s00259-011-1936-421953008 ByunBHKongCBLimIChoiCWSongWSChoWHJeonDGKohJSLeeSYLimSMCombination of 18F-FDG PET/CT and diffusion-weighted MR imaging as a predictor of histologic response to neoadjuvant chemotherapy: Preliminary results in osteosarcomaJ Nucl Med5410531059201310.2967/jnumed.112.11596423670899 ByunBHKimSHLimSMLimIKongCBSongWSChoWHJeonDGLeeSYKohJSChungSKPrediction of response to neoadjuvant chemotherapy in osteosarcoma using dual-phase (18)F-FDG PET/CTEur radiol2520152024201510.1007/s00330-015-3609-325680716 NishioJIdetaSIwasakiHNaitoMScapular osteochondrolipoma: Imaging features with pathological correlationOncol Lett6817820201324137417 BrennerWBohuslavizkiKHEaryJFPET Imaging of OsteosarcomaJ Nucl Med44930942200312791822 FletcherJWDjulbegovicBSoaresHPSiegelBALoweVJLymanGHColemanREWahlRPascholdJCAvrilNRecommendations on the use of 18F-FDG PET in oncologyJ Nucl Med49480508200810.2967/jnumed.107.04778718287273 ErdiYEThe use of PET for radiotherapyCurr Med Imaging Rev3316200710.2174/1573405610703010003 de G eus-OeiLFvan der HeijdenHFCorstensFHOyenWJPredictive and prognostic value of FDG-PET in nonsmall-cell lung cancer: A systematic reviewCancer11016541664200710.1002/cncr.2297917879371 HillnerBESiegelBAShieldsAFLiuDGareenIFHuntEColemanRERelationship between cancer type and impact of PET and PET/CT on intended management: Findings of the National Oncologic PET RegistryJ Nucl Med4919281935200810.2967/jnumed.108.05671318997054 BoellaardRO'DohertyMJWeberWAMottaghyFMLonsdaleMNStroobantsSGOyenWJKotzerkeJHoekstraOSPruimJFDG PET and PET/CT: EANM procedure guidelines for tumour PET imaging: Version 1.0Eur J Nucl Med Mol Imaging37181200201010.1007/s00259-009-1297-419915839 MuheremuANiuXPositron emission tomography/computed tomography for bone tumorsOncol Lett9522526201525621021 GlasserDBLaneJMHuvosAGMarcoveRCRosenGSurvival, prognosis and therapeutic response in osteogenic sarcoma: The Memorial Hospital experienceCancer69698708199210.1002/1097-0142(19920201)69:3<698::AID-CNCR2820690317>3.0.CO;2-G1730120

Flow chart of the selection of studies for the meta-analysis.

SROC curve of patient based analysis of the included studies. SROC, symmetric receiver operating characteristics curve; AUC, area under the curve; SE, standard error.

SROC curve of lesion based analysis of the included studies. SROC, symmetric receiver operating characteristics curve; AUC, area under the curve; SE, standard error.

SROC curve on the assessment on the of neoadjuvant therapy effect.

Results of quality assessment for 16 eligible studies (indicated by ref. nos.).

(Refs.)
Questions (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21)
Was the spectrum of patients representative of the patients who received the test in practice? + + + + + + + + + + + + + + + +
Were selection criteria clearly described? + + + + + + + + + + + + + + + +
Is the reference standard likely to help correctly classify the target condition? + + + + + + + + + + + + + + + +
Is the time between performance of reference standard and index test short enough? + + + + + + + + + + + + + + + +
Did the whole sample or a random selection of the sample receive verification by using a reference standard? + + + + + + + + + + + + + + + +
Did patients undergo examination with the same reference standard regardless of the index test result? − − − + + − − + − + + + + + + +
Was the reference standard performed independently of the index test? + + + + + + + + + + + + + + + +
Was the execution of the index test described in sufficient detail to permit replication of the test? + + + + + + + + + + + + + + + +
Was the execution of the reference standard described in sufficient detail to permit replication of the test? + + − + + − − + − + + + + + + +
Were the index test results interpreted without knowledge of the results of the reference standard? + + + + + + + + + + + + + + + +
Were the reference standard results interpreted without knowledge of the results of the index test? + + + + + + + + + + + + + + + +
Were the same clinical data available when test results were interpreted as would be available in practice? + + + + + + + + + + + + + + + +
Were uninterpretable and/or intermediate test results reported? + + + + + + + + + + + + + + + +
Were withdrawals from the study explained? + + + + + + + + + + + + + + + +

Demographic characteristics of the included studies.

Authors Patient no. Agea, years Study type Patient enrollment Time of study (Refs.)
Tateishi et al 117 42±21 Prospective Consecutive Unclear (6)
Strobel et al 50 36.9 (11–72) Prospective Consecutive Unclear (7)
Shin et al 91 42 (6–79) Retrospective Unclear 2004.5–2007.6 (8)
Charest et al 212 47±19.2 Retrospective Consecutive 2004.5–2008.4 (9)
Pepirkova et al 93 50.1±14.9 Retrospective Unclear 2004.1–2007.5 (10)
Fuglø et al 89 NA Retrospective Unclear 2001.12–2010.12 (11)
Sharma et al 53 20.1±10.5 Retrospective Unclear 2006.3–2012.1 (12)
Xu et al 103 59.1±18.6 Retrospective Unclear 2007.3–2013.2 (13)
Byun et al 206 15 (4–71) Retrospective Consecutive 2006.1–2011.11 (14)
Iagaru et al 14 36±14 Retrospective Consecutive 1999.1–2004.12 (15)
Evilevitch et al 42 17 (7–31) Prospective Consecutive 2005.1–2007.1 (16)
Hamada et al 11 17 (10.68) Prospective Consecutive 2002.6–2006.8 (17)
Benz et al 12 31.6±15.0 Prospective Consecutive 2005.2–2007.11 (18)
Im et al 20 15 (10–25) Prospective Consecutive 2003.8–2010.7 (19)
Byun et al 27 15 (10–23) Prospective Consecutive 2010.5–2012.3 (20)
Byun et al 31 15 (10–21) Prospective Consecutive 2010.5–2013.9 (21)

Presented as mean ± standard deviation of median (range). NA, not available.

Characteristics of PET/CT imaging and of reference standards.

Authors FDG (MBq) Measures Reference standard Potential verification bias (Refs.)
Tateishi et al 300–370 Visualization, SUV Histology and radiological follow-up Very limited (6)
Strobel et al 350–400 Visualization, SUV Histology, clinical and imaging follow-up Very limited (7)
Shin et al 8.1/kg Visualization, SUV Histology, clinical and imaging follow-up Limited (8)
Charest et al 370–500 Visualization, SUV Histology Very limited (9)
Pepirkova et al 370–555 Visualization, SUV Histology Very limited (10)
Fuglø et al 4.0/kg Visualization, SUV Histopathology, clinical and imaging follow-up Limited (11)
Sharma et al 370 Visualization, SUV Histopathology, clinical and imaging follow-up Limited (12)
Xu et al 3.5/kg Visualization, SUV Histopathological examination Very limited (13)
Byun et al 7.4/kg Visualization, SUV Histology, clinical and imaging follow-up Very limited (14)
Iagaru et al 550 Visualization, SUV Histopathological examination of surgical specimen Very limited (15)
Evilevitch et al 333–407 Visualization, SUV Histopathological examination of surgical specimen Very limited (16)
Hamada et al 370 Visualization, SUV Histopathological examination of surgical specimen Very limited (17)
Benz et al 7.8/kg Visualization, SUV Histopathological examination of surgical specimen Very limited (18)
Im et al 166–666 Visualization, SUV Histopathological examination of surgical specimen Very limited (19)
Byun et al 370 Visualization, SUV Histopathological examination of surgical specimen Very limited (20)
Byun et al 370 Visualization, SUV Histopathological examination of surgical specimen Very limited (21)

PET, positron emission tomography; CT, computed tomography; SUV, standardized uptake value.

Diagnostic accuracy of PET/CT on osseous and soft tissue sarcomas in the included studies.

Authors TP FP FN TN Sensitivity (95% CI) Specificity (95% CI) (Refs.)
Byun et al 52 15 3 763 0.95 (0.85–0.99) 0.98 (0.97–0.99) (20)
Charest et al 153 0 10 49 0.94 (0.89–0.97) 1.00 (0.93–1.00) (9)
Fuglø et al 20 1 3 64 0.87 (0.66–0.97) 0.98 (0.92–1.00) (11)
Pepirkova et al 424 0 3 71 0.99 (0.98–1.00) 1.00 (0.95–1.00) (10)
Sharma et al 38 4 2 27 0.95 (0.83–0.99) 0.87 (0.70–0.96) (12)
Shin et al 36 16 9 30 0.80 (0.65–0.90) 0.65 (0.50–0.79) (8)
Strobel et al 30 4 3 13 0.91 (0.76–0.98) 0.76 (0.50–0.93) (7)
Tateishi et al 44 4 6 69 0.88 (0.76–0.95) 0.95 (0.87–0.98) (6)
Xu et al 51 8 10 34 0.84 (0.72–0.92) 0.81 (0.66–0.91) (13)
All cases 372 37 43 286 0.90 (0.86–0.92) 0.89 (0.85–0.92)
All lesions 848 52 49 1,120 0.95 (0.93–0.96) 0.96 (0.94–0.97)

PET, positron emission tomography; CT, computed tomography; TP, true-positive; TN, true-negative; FP, false-positive; FN, false-negative; CI, confidence interval.

Accuracy of PET/CT assessment on the effect of neoadjuvant therapy on patients with osseous and soft tissue sarcomas in the included studies.

Authors TP FP FN TN Sensitivity (95% CI) Specificity (95% CI) (Refs.)
Benz et al 3 1 1 7 0.75 (0.19–0.99) 0.88 (0.47–1.00) (18)
Byun et al 8 2 4 13 0.67 (0.35–0.90) 0.87 (0.60–0.98) (20)
Byun et al 11 1 1 8 0.92 (0.62–1.00) 0.89 (0.52–1.00) (21)
Evilevitch et al 8 10 0 24 1.00 (0.63–1.00) 0.71 (0.53–0.85) (16)
Hamada et al 5 0 0 4 1.00 (0.48–1.00) 0.88 (0.40–1.00) (17)
Iagaru et al 3 1 3 7 0.50 (0.12–0.88) 0.88 (0.47–1.00) (15)
Im et al 6 4 3 7 0.67 (0.30–0.93) 0.64 (0.31–0.89) (19)
Total 44 19 12 70 0.79 (0.30–0.93) 0.79 (0.69–0.89)

PET, positron emission tomography; CT, computed tomography; TP, true-positive; TN, true-negative; FP, false-positive; FN, false-negative; CI, confidence interval.