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Research ArticleCLINICAL INVESTIGATIONS

Sensitivity and Specificity of Perfusion Scintigraphy Combined with Chest Radiography for Acute Pulmonary Embolism in PIOPED II

H. Dirk Sostman, Massimo Miniati, Alexander Gottschalk, Fadi Matta, Paul D. Stein and Massimo Pistolesi
Journal of Nuclear Medicine November 2008, 49 (11) 1741-1748; DOI: https://doi.org/10.2967/jnumed.108.052217
H. Dirk Sostman
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Massimo Miniati
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Alexander Gottschalk
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Fadi Matta
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Paul D. Stein
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Massimo Pistolesi
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    Selection of patients from those enrolled in PIOPED II was based on presence of defined diagnostic reference standard and availability of interpretable scintigraphic images. Of 1,090 patients enrolled in PIOPED II, 180 were not eligible for inclusion in our analysis: 28 did not undergo CTA, 37 did not undergo V/Q scanning, 74 of those who did not have a DSA diagnosis either did not have a CTA diagnosis or did not have a Wells' score, and in another 41 of those who did not have a DSA diagnosis, CTA diagnosis and Wells' score were discordant. Discordance between CTA and Wells' score was defined according to PIOPED II (14) criteria: low clinical probability (Wells' score < 2) with CTA positive for PE, or high clinical probability (Wells' score > 6) with CTA negative for PE. Finally, in 21 cases that met selection criteria, films could not be located for rereading. In this flow chart, both CTA and DSA were of pulmonary arteries.

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    TABLE 1

    Modified PIOPED II and PISAPED Scintigraphic Criteria

    Criteria
    FindingModified PIOPED IIPISAPED
    PE presentHigh probability (2 or more segments of perfusion–chest radiograph mismatch)One or more wedge-shaped perfusion defects
    PE absentNormal perfusionNormal perfusion
    Very low probability
     Nonsegmental lesion, for example, prominent hilum, cardiomegaly, elevated diaphragm, linear atelectasis, or costophrenic angle effusion with no other perfusion defect in either lung radiographic lesionNear normal
     Perfusion defect smaller than radiographic lesionContour defect caused by enlarged heart, mediastinum, or diaphragm
     1–3 small segmental defectsPerfusion defect, not wedge-shaped
     Solitary chest radiograph–perfusion matched defect in mid or upper lung zone confined to single segment
     Stripe sign around perfusion defect (best tangential view)
     Pleural effusion in at least one third of pleural cavity, with no other perfusion defect in either lung
    Not diagnosticAll other findingsCannot classify as PE-positive or PE-negative
    • View popup
    TABLE 2

    Diagnostic Results

    Modified PIOPED IIPISAPED
    IndexReader 1Reader 2Reader 1Reader 2
    Sensitivity84.9% (107/126)85.0% (113/133)81.7% (138/169)79.3%(134/169)
     95% CI77.6%−90.1%77.9%−90.0%75.1%−86.7%72.5%−84.7%
    Specificity89.4% (512/573)96.0% (557/580)96.7% (696/720)96.5% (695/720)
     95% CI86.6%−91.6%94.1%−97.3%95.1%−97.7%94.9%−97.6%
    Nondiagnostic readings21% (190/889)20% (176/889)0% (0/889)0% (0/889)
    • View popup
    TABLE 3

    V/Q Scan Results Compared with Perfusion Scan Results

    Perfusion Scan†
    IndexPIOPED II V/Q Scan*Modified PIOPED IIPISAPED
    Sensitivity77.4% (89/115)84.9% (220/259)80.5% (272/338)
     95% CI69.7%−85.0%80.1%−88.8%75.9%−84.3%
    Specificity97.7% (541/554)92.7% (1,069/1,153)96.6% (1,391/1,440)
     95% CI96.4%−98.9%91.1%−94.1%95.5%−97.4%
    Nondiagnostic readings26.5% (241/910)20.6% (366/1,778)0.0% (0/1,778)
     95% CI23.6%−29.3%18.8%−22.5%0.0%−0.2%
    • ↵* Data from Sostman et al. (9).

    • ↵† Pooled data for 2 readers.

    • View popup
    TABLE 4

    Predictive Values of Perfusion Scan Compared with CTA

    TestPPVNPVNot diagnostic
    Modified PIOPED perfusion scan*72.4% (220/304)96.5% (1,069/1,108)20.6% (366/1,778)
    PISAPED perfusion scan*84.7% (272/321)95.5% (1,391/1,457)0.0% (0/1,778)
    CTA†85.7% (150/175)94.8% (567/598)6.2% (51/824)
    • ↵* Pooled data for 2 readers.

    • ↵† Data from Stein et al., Table 4 (14).

    • View popup
    TABLE 5

    Perfusion Scan Results According to Patient Age*

    IndexModified PIOPED IIPISAPED
    Age < 50 y
     Sensitivity79.1% (87/110)83.3% (110/132)
      95% CI70.5%−85.6%76.0%−88.7%
     Specificity94.7% (573/605)97.0% (685/706)
      95% CI92.6%−96.2%95.5%−98.0%
    Age ≥ 50 y
     Sensitivity89.3% (133/149)78.6% (162/206)
      95% CI83.2%−93.2%72.5%−83.7%
     Specificity90.5% (496/548)96.2% (706/734)
      95% CI(87.8%−92.7%)(94.5%−97.3%)
    • ↵* Pooled data for 2 readers.

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Journal of Nuclear Medicine: 49 (11)
Journal of Nuclear Medicine
Vol. 49, Issue 11
November 2008
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Sensitivity and Specificity of Perfusion Scintigraphy Combined with Chest Radiography for Acute Pulmonary Embolism in PIOPED II
H. Dirk Sostman, Massimo Miniati, Alexander Gottschalk, Fadi Matta, Paul D. Stein, Massimo Pistolesi
Journal of Nuclear Medicine Nov 2008, 49 (11) 1741-1748; DOI: 10.2967/jnumed.108.052217

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Sensitivity and Specificity of Perfusion Scintigraphy Combined with Chest Radiography for Acute Pulmonary Embolism in PIOPED II
H. Dirk Sostman, Massimo Miniati, Alexander Gottschalk, Fadi Matta, Paul D. Stein, Massimo Pistolesi
Journal of Nuclear Medicine Nov 2008, 49 (11) 1741-1748; DOI: 10.2967/jnumed.108.052217
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