The Cost-Effective Use of 18F-FDG PET in the Presurgical Evaluation of Medically Refractory Focal Epilepsy
Terence J. O'Brien 1*,
Ken Miles 2,
Robert Ware 3,
Mark J. Cook 4,
David S. Binns 3,
and
Rodney J. Hicks 3
1 Departments of Medicine, Surgery, and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
2 Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
3 Centre for Molecular Imaging, Peter MacCallum Cancer Institute, Victoria, Australia
4 Centre for Clinical Neuroscience and Neurological Research, St. Vincent's Hospital, Melbourne, Australia
* To whom correspondence should be addressed. E-mail: obrientj{at}unimelb.edu.au.
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Abstract |
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This study applied decision tree analysis to evaluate the sensitivity, specificity, and cost-effectiveness of clinical algorithms that incorporate 18F-FDG PET. Methods: A cohort of 176 patients was studied. The localization rate, accuracy, therapeutic impact on the presurgical decision-making process, and correlation with the postsurgical outcome were assessed for the tests commonly performed for seizure localization. Decision tree sensitivity analysis compared 3 imaging strategies with a baseline strategy of medical therapy for all: video-electroencephalography monitoring (VEM)/MRI strategy, in which patients underwent VEM and brain MRI only, and +SPECT and +PET strategies, in which patients with an indeterminate VEM/MRI result underwent ictal SPECT or interictal 18F-FDG PET, respectively. Results: The localization rates for VEM, MRI, 18F-FDG PET, ictal SPECT, and intracranial electroencephalography (EEG) were 62.2%, 35.8%, 75.0%, 60.0%, and 93.8%. The VEM/MRI strategy had the lowest cost per class I/II outcome, but the additional costs per class I/II outcome for the +PET and +SPECT strategies were always below the minimum reported cost savings for a class I/II outcome. There were no valid conditions in which the +SPECT strategy had a lower cost per class I/II outcome than the +PET strategy. Within the range of cost savings estimated to be associated with a class I/II outcome, all decision strategies produced net cost savings; however, these were significantly higher for the +PET and the +SPECT strategies. Conclusion: 18F-FDG PET is cost-effective in the presurgical evaluation, particularly when used in patients with a nonlocalizing or nonconcordant VEM or MRI result.
Key Words:
neurology, PET, decision tree analysis, epilepsy, epilepsy surgery, FDG, PET
