Current clinical use of 18FDG-PET/CT in patients with thoracic and systemic sarcoidosis

ACR Appropriateness Criteria® Diffuse Lung Disease

Diffuse lung disease, frequently referred to as interstitial lung disease, encompasses numerous disorders affecting the lung parenchyma. The potential etiologies of diffuse lung disease are broad with several hundred established clinical syndromes and pathologies currently identified. Imaging plays a critical role in diagnosis and follow-up of many of these diseases, although multidisciplinary discussion is the current standard for diagnosis of several DLDs. This document aims to establish guidelines for evaluation of diffuse lung diseases for 1) initial imaging of suspected diffuse lung disease, 2) initial imaging of suspected acute exacerbation or acute deterioration in cases of confirmed diffuse lung disease, and 3) clinically indicated routine follow-up of confirmed diffuse lung disease without acute deterioration. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Ocular sarcoidosis: clinical experience and recent pathogenetic and therapeutic advancements

Purpose

To describe the ocular manifestations in a cohort of patients with systemic sarcoidosis (SS). Recent advances in the pathophysiology, diagnosis, and therapy of SS are also discussed.

Methods

Data from 115 Italian patients diagnosed between 2005 and 2016 were retrospectively reviewed. All but the first 17 patients underwent a comprehensive ophthalmologic examination. The diagnosis was based on clinical features, the demonstration of non-caseating granulomas in biopsies from involved organs, and multiple imaging techniques. Data on broncho-alveolar lavage fluid analysis, calcemia, calciuria, serum angiotensin-converting enzyme levels and soluble interleukin-2 receptor levels were retrieved when available.

Results

Ocular involvement, detected in 33 patients (28.7%), was bilateral in 29 (87.9%) and the presenting feature in 13 (39.4%). Anterior uveitis was diagnosed in 12 patients (36.4%), Löfgren syndrome and uveoparotid fever in one patient each (3%), intermediate uveitis in 3 patients (9.1%), posterior uveitis in 7 (21.2%), and panuveitis in 9 (27.3%). First-line therapy consisted of corticosteroids, administered as eyedrops (10 patients), sub-Tenon’s injections (1 patient), intravitreal implants (9 patients), or systemically (23 patients). Second-line therapy consisted of steroid-sparing immunosuppressants, including methotrexate (10 patients) and azathioprine (10 patients). Based on pathogenetic indications that tumor necrosis factor (TNF)-α is a central mediator of granuloma formation, adalimumab, targeting TNF-α, was employed in 6 patients as a third-line agent for severe/refractory chronic sarcoidosis.

Conclusion

Uveitis of protean type, onset, duration, and course remains the most frequent ocular manifestation of SS. Diagnostic and therapeutic advancements have remarkably improved the overall visual prognosis. An ophthalmologist should be a constant component in the multidisciplinary approach to the treatment of this often challenging but intriguing disease.

Looking for Lepidic Component inside Invasive Adenocarcinomas Appearing as CT Solid Solitary Pulmonary Nodules (SPNs): CT Morpho-Densitometric Features and 18-FDG PET Findings

Objective

To investigate CT morphologic and densitometric features and 18-FDG PET findings of surgically excised lung adenocarcinomas "mixed subtype" with predominant lepidic component, appearing as solid solitary pulmonary nodules (SPNs) on CT scan.

Materials and Methods

Approval for this study was given from each local institutional review board according to its retrospective nature. Nodules pathologically classified as lung adenocarcinoma mixed subtype with bronchioloalveolar otherwise lepidic predominant component, in three different Italian institutions (Napoli; Varese; Parma), were retrospectively selected.

Results

22 patients were identified. The number of SPNs with smooth margins was significantly lower with respect to the number of SPNs with spiculated margins (p: 0.033), radiating spiculations (p: 0.019), and notch sign (p: 0.011). Mean contrast enhancement (CE) was 53.34 HU (min 5.5 HU, max 112 HU); considering 15 HU as cut-off value, CE was positive in 20/22 cases. No significant correlation was found between size and CE. Mean SUVmax was 2.21, ranging from 0.2 up to 7.5 units; considering 2.5 units as cut-off, SUVmax was positive in 7/22 cases. The number of SPNs with positive CE was significantly higher than the number of SPNs with positive SUVmax (p: 0.0005).

Conclusion

CT generally helps in identifying solid SPN suspicious for malignancy but 18-FDG PET may result in false-negative evaluation; when 18-FDG PET findings of a solid SPN are negative even though CT morphology and CE suggest malignancy, radiologist should consider that lepidic component may be present inside the invasive tumor, despite the absence of ground glass.

Diagnostic Performance of 18F-FDG PET/CT Semiquantitative Analysis in the Management of Sarcoidosis

Background:

Sarcoidosis is a multisystem granulomatous disorder of unknown origin characterized by nonspecific clinical symptomatology. 18F-FDG PET/CT can visualize activated inflammatory cells of sarcoidosis and simultaneously provide whole-body images. </P><P> Objective: To evaluate the clinical usefulness of 18F-FDG PET/CT and its semiquantitative parameters for the assessment of treatment efficacy in patients with sarcoidosis.

Methods:

Thirty-one consecutive patients who performed 18F-FDG PET/CT for sarcoidosis assessment were selected. All subjects performed 18F-FDG PET/CT before any treatment (PET1) and after 6-12 months (PET2). SUVmax and SUVmean on PET1 and PET2 were collected. SUVs values were employed to evaluate the ratios with the liver (R-LIVERmax, R-LIVERmean) and the blood (R-BLOODmax, R-BLOODmean). The difference between the PET1 and PET2 values was evaluated (&#916;SUVmax, &#916;SUVmean, &#916;R-LIVERmax, &#916;R-LIVERmean, &#916;R-BLOODmax, &#916;R-BLOODmean). Patients were classified as Responders (R), Partial-Responders (PR) and Non- Responders (NR).

Results:

Seventeen patients (54.8%) had a complete metabolic response (R), 4 (12.9%) were PR while 10 (32.3%) had no Metabolic Response (NR). The chi-square test showed that response groups were related neither to the stage of disease (p=0.59) nor to therapy performed (p<0.079). The comparison between each &#916; semiquantitative parameter showed a statistically significant decrease from PET1 to PET2 (0.0001 < p < 0.002). The comparison between &#916; mean values in relation to response groups showed to be statistically significant (0.001 < p < 0.005). Conversely, they did not show statistical significance in relation to the clinical stage groups and to the kind of therapy performed (p>0.05). Pearson’s coefficient demonstrated a reverse correlation between a number of sites still involved in disease after therapy and each &#916; semiquantitative parameters (p&#8804;0.0001).

Conclusion:

18F-FDG PET/CT should be considered a useful technique for the evaluation of sarcoidosis and semiquantitative parameters. Further studies are needed to determine the long-term impact of 18F-FDG PET/CT on clinical outcomes.

Clinical use of cardiac PET/MRI: current state-of-the-art and potential future applications

Combined PET/MRI is a novel imaging method integrating the advances of functional and morphological MR imaging with PET applications that include assessment of myocardial viability, perfusion, metabolism of inflammatory tissue and tumors, as well as amyloid deposition imaging. As such, PET/MRI is a promising tool to detect and characterize ischemic and non-ischemic cardiomyopathies. To date, the greatest benefit may be expected for diagnostic evaluation of systemic diseases and cardiac masses that remain unclear in cardiac MRI, as well as for clinical and scientific studies in the setting of ischemic cardiomyopathies. Diagnosis and therapeutic monitoring of cardiac sarcoidosis has the potential of a possible 'killer-application' for combined cardiac PET/MRI. In this article, we review the current evidence and discuss current and potential future applications of cardiac PET/MRI.

The importance of PET/CT findings and hematological parameters in prediction of progression in sarcoidosis cases

Aim: We aimed to reveal the correlation of NLR rate, RDW and MPV values and with the findings of PET/CT regarding the prediction of disease progression and the clinical characteristics. Materials and methods: The treatment naive sarcoidosis cases, of whose PET/CT have been taken due to mediastinal lymphadenopathy of whose diagnosis have been confirmed by biopsy, were included in the study. Hematological parameters, clinical, radiological and PET/CT findings are evaluated. Results: 40 sarcoidosis and 40 healthy control cases were included in the study. NLR, RDW, MPV and the sedimentation values in the sarcoidosis group were determined statistically significantly higher. In patients having parenchymal involvement in PET/CT, the values of FVC%, DLCO, DLCO%, DLCO/VA and DLCO/VA% were determined significantly lower. High NLR and PET/CT LAP SUVmax values and low DLCO% values are statistically significantly correlated with one-year disease progression. For predicting the progression, for the NLR cut-off value 3.20, the area under the curve was determined as 0.79 (CI 62.2-96.5), sensitivity as 80.0%, specificity as 76.7% and for the PET/CT SUVmax cut-off value 9.5, the area under the curve was determined as 0.71 (CI 46.6-95.9), sensitivity as 70.0%, specificity as 82.1%. Conclusion: We determined that the values observed in routine hematologic examinations such as NLR, RDW and MPV, were high in sarcoidosis cases. In addition, the values of NLR, DLCO% and PET/CT SUVmax might be used in predicting the progression. At the same, once again we showed that the lung parenchyma involvement in PET/CT correlates with many pulmonary function parameters. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 242-250)

Relationship between radiologic patterns, pulmonary function values and bronchoalveolar lavage fluid cells in newly diagnosed sarcoidosis

BACKGROUND

The aim of the present study was to identify specious radiologic and/or physiologic prognostic marker(s), which lead to optimize of the patient follow-up frequency.

METHODS

Eighty consecutive patients with newly diagnosed pulmonary sarcoidosis. Patients underwent chest radiography, high-resolution computed tomography (HRCT) examination, pulmonary function tests (PFT), bronchoscopy with bronchoalveolar lavage (BAL) and lung biopsy, and bronchoalveolar lavage fluid (BALF) cell examination.

RESULTS

The reduction in PFT values seen in radiological sarcoidosis stage III was greater than that seen in stages I and II. The percentage of neutrophils in the lungs was found to increase in stages II and III. PFT indices were correlated negatively with the consolidation and ground glass opacities CT scores, but not with the micronodule or macronodule scores. The rise in the percentage of BALF lymphocytes was associated with the restriction pattern of PFT. The diagnostic value of BALF for sarcoidosis was higher when the typical radiologic patterns of stage I disease were found and that smoking decreased the diagnostic value of CD4/CD8 ratio.

CONCLUSIONS

This study supports the opinion that the staging of the pulmonary sarcoidosis with chest X-rays is still valuable from the prognostic point of view, because significant correlations between the radiologic stages of sarcoidosis and PFT parameters were found. Chest HRCT was significantly superior to chest X-ray in detecting mediastinal and pulmonary parenchymal changes. However, the prognostic role of HRCT needs to be better investigated evaluating serial examinations. Only consolidation and ground glass scores (neither of which are frequently found in sarcoidosis) hold prognostic value, since these were negatively correlated with PFT parameters.

The Clinical Features of Sarcoidosis: A Comprehensive Review

Sarcoidosis has innumerable clinical manifestations, as the disease may affect every body organ. Furthermore, the severity of sarcoidosis involvement may range from an asymptomatic state to a life-threatening condition. This manuscript reviews a wide variety of common and less common clinical characteristics of sarcoidosis. These manifestations are presented organ by organ, although additional sections describe systemic and multiorgan presentations of sarcoidosis. The lung is the organ most commonly involved with sarcoidosis with at least 90 % of sarcoidosis patients demonstrating lung involvement in most series. The skin, eye, liver, and peripheral lymph node are the next most commonly clinically involved organs in most series, with the frequency of involvement ranging from 10 to 30 %. The actual frequency of sarcoidosis organ involvement is probably much higher as it is frequently asymptomatic and may avoid detection. This is particularly common with lung, liver, cardiac, and bone involvement. Cardiac sarcoidosis is present in 25 % of all sarcoidosis but only causes clinical problems in 5 % of them. Nevertheless, unlike sarcoidosis involvement of most other organs, it may be suddenly fatal. Therefore, it is important to screen for cardiac sarcoidosis in all sarcoidosis patients. All sarcoidosis patients should also be screened for eye involvement as asymptomatic patients may have eye involvement that may cause permanent vision impairment. Pulmonary fibrosis from sarcoidosis is usually slowly progressive but may be life-threatening because of the development of respiratory failure, pulmonary hypertension, or hemoptysis related to a mycetoma or bronchiectasis. Some manifestations of sarcoidosis are not organ-specific and probably are the result of a release of mediators from the sarcoid granuloma. Two such manifestations include small fiber neuropathy and fatigue syndromes, and they are observed in a large percentage of patients.

Venous thrombosis of sarcoidosis as an unusual incidental finding on 18F-fluorodeoxyglucose positron emission tomography/computed tomography

Sarcoidosis is defined as a multisystem granulomatous disorder of unknown cause. Venous thrombosis (VT) in the sarcoidosis is rare. The routine use of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) has resulted in clinicians detecting many incidental findings, which have proven to be clinically significant such as thrombosis. Here, we present a case with VT of sarcoidosis in the inferior vena cava and portal vein as an unusual incidental finding on 18F-FDG PET/CT.

Sarcoidosis manifesting as hepatic and splenic nodules mimicking ovarian cancer metastases: A case report

The current study presents a case of sarcoidosis manifesting as hepatic and splenic nodules, which was difficult to differentiate from ovarian cancer metastases. A 24-year-old female, who was previously diagnosed with right ovarian cancer and underwent surgery at the age of 21, was found to have two nodules in the spleen revealed by contrast-enhanced computed tomography (CT). ¹⁸F-fluorodeoxyglucose positron emission tomography/CT revealed two abnormal high uptake lesions in the spleen and one abnormal high uptake lesion in the liver. Under a diagnosis of hepatic and splenic metastases from right ovarian cancer, a laparoscopic splenectomy and partial hepatectomy were performed. Histopathological examination showed that a large number of non-caseating epithelioid cell granulomas formed these nodules, which was compatible with sarcoidosis. This case indicates that it is difficult to distinguish sarcoidosis from metastatic disease even using the latest modalities, and that laparoscopic surgery is a minimally invasive and useful tool for forming a differential diagnosis.

Historical transition of management of sarcoidosis

Sarcoidosis is a systemic granulomatous disease of undetermined etiology, and it primarily affects the lungs and lymphatic system but may involve other organs. Recently, there have been several new insights in Japanese patients. The frequency of cardiac, ocular, and cutaneous sarcoidosis has increased in Japan, whereas, the proportion of patients with bilateral hilar lymphadenopathy decreased from 1960 to 2004. Propionibacterium acnes (P. acnes) has been studied extensively as one of the causative microorganism for granuloma formation, particularly in Japan. P. acnes-specific monoclonal antibodies are useful for diagnosing sarcoidosis. The potential association between smoking and sarcoidosis has been evaluated in a Japanese study, which found a higher prevalence of sarcoidosis among young smokers than that in previous reports. Recently, ¹⁸F-fluorodeoxyglucose positron-emission tomography, which permits visualization of activated inflammation, and endobronchial ultrasonography-guided transbronchial needle aspiration have been increasingly used to diagnose sarcoidosis. Cardiac sarcoidosis is found to be the main cause of death in Japan. The 2006 revised Japanese guidelines for diagnosing cardiac sarcoidosis are useful, particularly for subclinical cardiac sarcoidosis patients. Further studies and international communication and evaluation are needed to determine the causes of sarcoidosis, identify the risk factors for progressive disease, and develop new and effective treatments.