Atypical Brown Fat Distribution in Young Males Demonstrated on PET/CT

Effect of celecoxib in treatment of burn-induced hypermetabolism

Background: Cyclooxygenase-2 (COX-2) catalyzes the rate-limiting step of prostanoid biosynthesis. Under pathologic conditions, COX-2 activity can produce reactive oxygen species and toxic prostaglandin metabolites that exacerbate injury and metabolic disturbance. The present study was performed to investigate the effect of Celecoxib (the inhibitor of COX-2) treatment on lipolysis in burn mice.

Methods: One hundred male BALB/c mice were randomly divided into sham group, burn group, celecoxib group, and burn with celecoxib group (25 mice in each group). Thirty percent total body surface area (TBSA) full-thickness injury was made for mice to mimic burn injuries. Volume of oxygen uptake (VO₂), volume of carbon dioxide output (VCO₂), respiratory exchange ratio (RER), energy expenditure (EE), COX-2 and uncoupled protein-1 (UCP-1) expression in brown adipose tissue (BAT) were measured for different groups.

Results: Adipose tissue (AT) activation was associated with the augmentation of mitochondria biogenesis, and UCP-1 expression in isolated iBAT mitochondria. In addition, VO₂, VCO₂, EE, COX-2, and UCP-1 expression were significantly higher in burn group than in burn with celecoxib group (P<0.05).

Conclusion: BAT plays important roles in burn injury-induced hypermetabolism through its morphological changes and elevating the expression of UCP-1. Celecoxib could improve lipolysis after burn injury.

18F-2-fluoro-2-deoxyglucose uptake in white adipose tissue on pediatric oncologic positron emission tomography (PET)/computed tomography (CT)

BACKGROUND

Altered biodistribution of [F-18]2-fluoro-2-deoxyglucose (FDG) is sometimes encountered in pediatric patients undergoing chemotherapy for lymphoma on post-induction positron emission tomography (PET) imaging. A characteristic pattern of increased FDG uptake in white adipose tissue can be seen, particularly in the buccal regions, body wall and gluteal regions, with a shift of radiotracer away from the blood pool and liver. This altered biodistribution has been attributed to effects of corticosteroids in pediatric and adult patients and is important to recognize because of its potential for limiting the diagnostic quality of the PET scan and interfering with therapeutic response assessment.

OBJECTIVE

In contrast to the well-known metabolically active brown fat seen on up to one-third of pediatric PET scans, white fat is usually non-metabolically active. We sought to determine the incidence of altered distribution of FDG in subcutaneous white adipose tissue in pediatric patients undergoing PET imaging and to assess the association with corticosteroid use.

MATERIALS AND METHODS

We reviewed the medical records and imaging for four children in whom altered biodistribution in white adipose tissue was present on post-induction FDG PET/CT, identified during routine clinical practice. All four were receiving corticosteroids as part of their chemotherapy. We then retrospectively reviewed oncology FDG PET/CT scans over a 2-year period (1,361 scans in 689 patients) to determine the incidence of uptake in white fat by qualitative visual assessment. In the children identified with altered biodistribution, we measured maximum standard uptake value (SUV_max) and mean standard uptake value (SUV_mean) in areas of subcutaneous white fat, the buccal regions, body wall or gluteal soft-tissue regions, liver and blood pool. We reviewed all medical records, including medication lists. We summarize the relevant clinical and imaging findings of 13 pediatric patients, including the 4 index patients.

RESULTS

We determined the incidence of FDG uptake in white fat to be rare, found in 9 of 1,361 (0.6%) PET scans performed for pediatric cancer evaluation. FDG uptake was increased in subcutaneous adipose tissue, particularly in the buccal regions, body wall and gluteal regions, with a shift of radiotracer away from the blood pool and liver. The degree of increased uptake in peripheral white fat varied from marked to mild, and the biodistribution was distinct from that of brown adipose tissue. Children with this altered biodistribution were uniformly receiving corticosteroids as part of induction treatment for their cancer, and these findings were only identified on post-induction PET/CT. Follow-up PET/CT documented resolution of this effect after treatment with corticosteroids ceased.

CONCLUSION

Our findings support the current understanding that characteristic uptake of FDG in white adipose tissue is mediated by corticosteroid effect. Although this altered biodistribution is rare (<1% of PET scans) it could impair the diagnostic quality of the scan, affecting image interpretation, and should be recognized when present.

18F-FDG PET/CT of Brown Adipose Tissue Hyperactivation Associated With Pregnancy and Paraganglioma

This 32-year-old woman presented with pregnancy-related arterial hypertension unresponsive to antihypertensive therapy. During cesarean delivery, a lobulated retroperitoneal mass was discovered. F-FDG PET/CT performed 18 days postpartum demonstrated the hyperactive retroperitoneal mass and extensive hyperactivated brown adipose tissue. The mass was surgically removed, revealing a para-aortic multicentric paraganglioma. After surgery, blood pressure normalized, and serum chromogranin A and urinary metanephrines normalized. Brown adipose tissue hypermetabolism disappeared on follow-up FDG PET. Her initial FDG PET demonstrated brown adipose tissue hyperactivation, which may have been caused by the combination of hormonal changes in pregnancy and the paraganglioma.

The effects of thyroid hormones on brown adipose tissue in humans: a PET-CT study

BACKGROUND

Brown adipose tissue (BAT) is important for energy expenditure through thermogenesis, although its regulatory factors are not well known in humans. There is evidence suggesting that thyroid hormones affect BAT functions in some mammals, but the effects of thyroid hormones on BAT activity in humans are still unclear. The aim of this study was to investigate the effects of thyroid hormones on glucose metabolism of BAT and other organs in humans.

METHODS

Nine Graves' disease-caused hyperthyroid patients who were newly diagnosed and untreated were studied. Putative brown adipose tissue activity was determined by the integrated ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron-emission tomography and computed tomography (PET-CT). All hyperthyroid patients were treated with methimazole and had been monitored until their symptoms disappeared and thyroid hormone levels returned to normal. At the end, a second PET-CT scan was performed. The average follow-up period was 77 days. Meanwhile, compared with a group of seventy-five brown adipose tissue-negative controls, thyroid hormones of seventy-five BAT-positive healthy subjects were measured.

RESULTS

Active brown adipose tissue was not present in any of the hyperthyroid patients. However, one patient with normalized thyroid function showed active BAT after therapy. The free T3 levels and free T4 levels were significantly lower in the 75 BAT-positive subjects than in the BAT-negative subjects. All hyperthyroid patients showed symmetrically increased uptake of fluorodeoxyglucose in skeletal muscles before treatment, whereas, the standardized uptake value was substantially decreased after treatment.

CONCLUSIONS

Abnormally high circulating thyroid hormone levels may not increase brown adipose tissue activity, which may be limited by the increased obligatory thermogenesis of muscle in adult humans.

Intense FDG activity in the brown adipose tissue in omental and mesenteric regions in a patient with malignant pheochromocytoma

A 39-year-old man who had a history of surgical excision of left adrenal pheochromocytoma 3 years ago underwent an FDG PET/CT scan to evaluate possible metastatic/recurrent disease. In addition to multiple FDG-avid lesions typical of hypermetabolic malignant disease and the FDG uptake in regions rich in brown adipose tissue, there was also intense FDG activity in the omental and mesenteric regions, which are not common locations of elevated FDG activity. On the repeat FDG PET/CT scan 3 days later after the patient was prepared with propranolol, the omental and mesenteric FDG activity was diminished.

Triiodothyronine stimulates glucose transport in bone cells

Thyroid hormones increase energy expenditure and bone turnover in vivo. To study whether 3,3',5-triiodo-l-thyronine (T₃) stimulates the uptake of glucose in osteoblastic cells, PyMS (a cell line derived from rat bone) cells were kept in serum-free culture medium and treated with T₃. We measured [1-¹⁴C]-2-deoxy-D: -glucose (2DG) uptake and looked for expression of the high-affinity glucose transporters GLUT1 and GLUT3 by northern and western analysis. T₃ did not influence the cell number but slightly (1.3-fold) increased the protein content of the cell cultures. 2DG uptake was low in serum-deprived cell cultures and was increased by T₃ (up to 2.5-fold at 1 nmol l⁻¹ after 4 days) in a dose- and time-dependent manner. Triiodothyronine at 1 nmol l⁻¹ increased GLUT1 and GLUT3 abundance in membranes. Therefore, increased glucose uptake induced by T₃ in osteoblasts may be mediated by the known high-affinity glucose transporters GLUT1 and GLUT3.

Determinants of physiologic 18F-FDG uptake in brown adipose tissue in sequential PET/CT examinations

PURPOSE

The aim of this study was to assess independent predictors of 2-deoxy-2-[(18)F]fluoro-D-glucose ((18)F-FDG) uptake in brown adipose tissue (BAT) in patients undergoing repeated positron emission tomography (PET)/computed tomography (CT) scans.

PROCEDURES

Eight hundred forty-eight (mean age 50.9 ± 16 years) patients in whom PET/CT scan was repeated (mean interval 5 ± 1.5 months) constituted the study group. (18)F-FDG uptake in characteristic areas of BAT, with CT density of adipose tissue, greater than background soft-tissue activity was considered as evidence of BAT uptake. Both distribution and maximum standardized uptake values (SUVmax) were registered. Clinical and anamnestic data were collected for each patient.

RESULTS

(18)F-FDG uptake in BAT was present in 8.6% patients at first scan. Independent predictors of presence of uptake were age (younger), gender (female), body mass index (lower), and maximum outdoor temperature (lower). Age was the only independent predictor of BAT (18)F-FDG uptake distribution, while SUVmax was related to both age and outdoor temperature. Independent determinants of persistence of BAT (18)F-FDG uptake at second PET/CT were outdoor temperature at time of second scan and extension of metabolically active BAT at first scan.

CONCLUSIONS

Age, body mass index, and outdoor temperature are significant determinants of BAT evidence at (18)F-FDG PET/CT. Moreover, extension of BAT and outdoor temperature are the strongest determinants of persistence of BAT evidence on (18)F-FDG PET/CT in repeated scan.

[Contribution of FDG-PET in the management of pediatric sarcomas in 2011]

FDG-PET has boomed in recent years for diagnosis, staging and the search for recurrence of a large number of tumors. This is particularly true for soft tissue sarcomas and musculoskeletal sarcomas, for which the first publications on the potential role of FDG-PET dating back to the early 1990s. The majority of published studies on adult sarcomas confer, possibly a mixed population. Studies dedicated to pediatrics population are much rarer. The "Standards, Options and Recommendations" of the French Federation of Anticancer Centers published in 2003 on "The use of FDG-PET in oncology" and make recommendations and expert advices as part sarcomas of adult patients. After a first part dedicated to the particular interpretation of FDG PET in children, the purpose of this paper is to review the potential contribution of this exam in the treatment of pediatric sarcomas.

White fat, factitious hyperglycemia, and the role of FDG PET to enhance understanding of adipocyte metabolism

The development of a hybrid PET/CT led to the recognition of the enhanced glycolysis in brown fat. We report a previously unrecognized mechanism for altered fluorodeoxyglucose (FDG) biodistribution with diffuse white adipose tissue uptake. This occurred during a restaging scan for cervical cancer following administration of insulin in the setting of measured hyperglycemia. The patient's blood sugar normalized, but she experienced symptoms and signs of hypoglycemia. A subsequent history indicated that the patient received intravenous high-dose vitamin C just prior to arrival. Ascorbic acid is a strong reducing agent and can cause erroneous false positive portable glucometer readings. Accordingly, it is likely the patient was euglycemic on arrival and was administered FDG during a period of insulin-induced hypoglycemia. Prominent diffuse white adipose tissue, gastric mucosal, myocardial, and very low hepatic and muscle activity were observed. The case provides insight into the metabolic changes that occur during hypoglycemia and the potential danger of relying on portable glucometer readings. We discuss the potential biological basis of this finding and provide recommendations on the avoidance of this complication.

Cutaneous and subcutaneous imaging on FDG-PET: benign and malignant findings

F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) has been shown to be useful in the evaluation of many tumors due to its high sensitivity and specificity. However, false-positive interpretations may occur from benign subcutaneous and cutaneous etiologies. At our institution we have encountered FDG-PET scans which demonstrated a variety of cutaneous and subcutaneous lesions including stomas, hernias, rhinophyma, dose infiltrations, physiologic muscle uptake, and tophaceous gout. Additionally, malignant cutaneous and subcutaneous malignant lesions may also demonstrate substantial F-18 FDG uptake on PET scans, including lymphoma, skin metastases, and melanoma. The purpose of this atlas article is to demonstrate and review key features of various cutaneous and subcutaneous lesions, both benign and malignant, which can result in hypermetabolism on FDG-PET or PET-CT scans.

Thyroid hormone induced brown adipose tissue and amelioration of diabetes in a patient with extreme insulin resistance

CONTEXT

Brown adipose tissue (BAT) found by positron emission/computed tomography (PET-CT) using flouro-deoxyglucose (FDG) is inducible by cold exposure in men. Factors leading to increased BAT are of great interest for its potential role in the treatment of diabetes and obesity.

OBJECTIVE

We tested whether thyroid hormone (TH) levels are related to the volume and activity of BAT in a patient with a mutation in the insulin receptor gene. DESIGN/SETTING/INTERVENTION: Our work was based on the case report of a patient in an observational study at the National Institutes of Health.

PATIENT

The patient discontinued insulin and oral antidiabetics after thyroidectomy and suppressive-dose levothyroxine therapy for thyroid cancer. PET-CT uptake in BAT was confirmed by histology and molecular analysis.

OUTCOMES

PET-CT studies were performed, and we measured hemoglobin A1c and resting energy expenditure before and after levothyroxine discontinuation for thyroid cancer testing. Molecular studies of BAT and white adipose samples are presented.

RESULT

Supraclavicular and periumbilical sc adipose tissue demonstrated molecular features of BAT including uncoupling protein-1, type 2 deiodinase, and PR domain containing 16 by quantitative PCR. Activity of type 2 deiodinase activity was increased. The discontinuation of levothyroxine resulted in decreased FDG uptake and diminished volume of BAT depots accompanied by worsening of diabetic control.

CONCLUSIONS

This case demonstrates the TH effect on BAT activity and volume in this patient and an association between BAT activity and glucose levels in this patient. Because the contribution of TH on skeletal muscle energy expenditure and fuel metabolism was not assessed, an association between BAT activity and glucose homeostasis can only be suggested.

Constant ambient temperature of 24 degrees C significantly reduces FDG uptake by brown adipose tissue in children scanned during the winter

PURPOSE

The aim of this study was to determine if warming patients prior to and during (18)F-FDG uptake by controlling the room temperature could decrease uptake by brown adipose tissue (BAT).

METHODS

A group of 40 children underwent (18)F-FDG PET after being kept in the injection room at a constant temperature of 24 degrees C for half an hour before and 1 hour after intravenous tracer administration. The rate of uptake by BAT in this group was compared to the uptake in a control group of 45 patients who underwent PET when the injection room temperature was 21 degrees C.

RESULTS

Uptake by BAT occurred in 5% of studies in the temperature-controlled room compared to 31% of studies performed when the injection room temperature was 21 degrees C (p<0.002).

CONCLUSION

Maintaining room temperature at a constant 24 degrees C, half an hour prior to and during the period of FDG uptake significantly decreases accumulation of FDG in BAT in children.

Impact of [18f] fluorodeoxyglucose positron emission tomography on staging and management of early-stage follicular non-hodgkin lymphoma

PURPOSE

Accurate staging is critical to select patients with early-stage (I-II) follicular lymphoma (ESFL) suitable for involved-field radiotherapy (IFRT) and to define the radiotherapy portal. We evaluated the impact of fluorodeoxyglucose (FDG) PET on staging, treatment, and outcome for patients with ESFL on conventional staging.

METHODS AND MATERIALS

Forty-two patients with untreated ESFL (World Health Organization Grade I-IIIa, or "low grade") following a minimum of physical examination, computerized tomography, and bone marrow examination (conventional assessment) and who had staging PET from June 1997 to June 2006 were studied retrospectively. Stage allocation was based on routine imaging reports. Disease sites, stage, and management plan were recorded based on conventional assessment or conventional assessment plus PET.

RESULTS

FDG avidity was demonstrated in 97% of patients in whom disease was evident on conventional assessment after biopsy. PET findings suggested a change of stage or management in 19 patients: 13 (31%) who were upstaged to Stage III-IV, altering ideal management from IFRT to systemic therapy, and 6 (14%) who had the involved field enlarged, including 4 upstaged from Stage I to II. Of these 19 cases, PET findings were considered true positive in 8 patients, indeterminate in 10, and false positive in only 1 patient.

CONCLUSIONS

Our data confirm that ESFL is usually FDG-avid. In routine practice, PET has the potential to upstage and thereby alter management in a high proportion of patients with apparent ESFL.