Diagnosis of bone metastasis: recent comparative studies of imaging modalities.

Various imaging modalities are currently available to diagnose bone metastasis. The two main anatomical modalities are computed tomography (CT) and magnetic resonance imaging (MRI), with many variants proposed for the MRI procedure, including diffusion-weighted imaging. The two main functional modalities are scintigraphy and PET, also with many variants in the radiopharmaceutical, from the "all purpose" 99mTc labelled bisphosphonates to very selective radiopharmaceuticals for rare neoplasia. The diagnostic strategy will become more and more individually tailored according to the patient's clinical and biological data (primary cancer type, phase of the evolution, markers of aggressiveness, serum levels of biological tracers of bone metabolism, circulating or disseminating tumour cells …). If imaging is indicated, the diagnostic strategy will also depend on the availability and the diagnostic performance of the imaging modalities. Assessment of diagnostic performance requires comparative studies, performed with an adequate methodology. The main methodological weaknesses encountered in studies intending to compare imaging modalities for diagnosing bone metastasis are summarised. Comparative studies have been reviewed, which address the initial diagnosis of skeletal metastases in solid tumours except primary bone cancers. The results of more than 140 such comparative studies are then summarised and briefly commented, according to the type of the primary cancer, and according to the compared imaging modalities.