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JU INSIGHT Role of Technetium-99m-Sestamibi Imaging in Differentiating Oncocytic Tumors vs Renal Cell Carcinoma
By: Jared P. Schober, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Avery Braun, DO, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Kevin B. Ginsburg, MD, MS, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Spencer Bell, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Alberto Andres Castro Bigalli, MD, MS, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Michelle Chen, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Robert Wang, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Diana Magee, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Laura Bukavina, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Elizabeth Handorf, PhD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Jian Q. Yu, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; David Y. T. Chen, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Richard E. Greenberg, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Marc C. Smaldone, MD, MSHP, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Rosalia Viterbo, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Andres F. Correa, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Robert G. Uzzo, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Alexander Kutikov, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania | Posted on: 19 Sep 2023
Schober JP, Braun A, Ginsburg KB, et al. Clinical performance of technetium-99m-sestamibi SPECT/CT imaging in differentiating oncocytic tumors from renal cell carcinoma in routine clinical practice. J Urol. 2023;210(3):438-445.
Study Need and Importance
Benign oncocytomas and hybrid oncocytic/chromophobe tumors (HOCTs) often undergo resection due to the inability to identify these low-risk lesions with conventional imaging. Initial reports suggest (99mTc)-sestamibi could improve the ability to accurately identify HOCTs. Prior studies defined testing characteristics of (99mTc)-sestamibi, but little is known about its utility and accuracy when integrated into real world clinical practice.
What We Found
We present the first series of the integration of (99mTc)-sestamibi into clinical practice in a high-volume tertiary referral urologic oncology practice. Sixty patients were found to have “cold” masses concerning for renal cell carcinoma with biopsy or surgical pathology available for 45 masses. Pathologic concordance with imaging for cold masses was 80%, which is well below our institution’s historical benign resection rate. Eleven patients had “hot” masses (consistent with benign oncocytoma or HOCTs) with an 85.7% pathologic concordance rate demonstrated in the 7 masses with pathology (see Table).
Table. Relationship Between “Hot” and “Cold” Masses and the Concordance/Discordance Rates at Pathological Assessment (Biopsy or Surgery)
| Hot mass | Cold mass | |
|---|---|---|
| All interventions, No./total No. (%) | ||
| Concordant | 6/7 (86) | 36/45 (80) |
| Discordant | 1/7 (14) | 9/45 (20) |
| Surgical pathology, No./total No. (%) | ||
| Concordant | 4/4 (100) | 35/40 (88) |
| Discordant | 0/4 (0) | 5/40 (12) |
| Biopsy pathology, No./total No. (%) | ||
| Concordant | 2/3 (67) | 1/5 (20) |
| Discordant | 1/3 (33) | 4/5 (80) |
Limitations
Our data capture the integration of (99mTc)-sestamibi into real-world clinical practice, and its generalizability is limited by our institutional case mix and nonstandardized management strategy, including the decision to obtain (99mTc)-sestamibi imaging and decision for intervention. Yet, our study provides insight into the strengths and limitations of (99mTc)-sestamibi in clinical practice. Not all patients in our series underwent pathologic sampling, thus the accuracy of (99mTc)-sestamibi imaging could not be defined from our data.
Interpretation for Patient Care
Our institutional series reporting pathologic concordance rates and patient management strategies after the integration of (99mTc)-sestamibi imaging into clinical practice indicates the utility of this imaging entity in real-world practice remains poorly defined. Our findings of 80% pathologic concordance for cold masses indicate (99mTc)-sestamibi is not ready to replace renal mass biopsy in clinical practice.
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