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Singh SB, Bhandari S, Bhandari S, Bhandari S, Singh R, Raynor WY, Hess S, Werner TJ, Alavi A, Revheim ME. Role of PET/CT in diagnosing and monitoring disease activity in rheumatoid arthritis: a review. Ann Nucl Med 2024; 38:165-175. [PMID: 38277115 PMCID: PMC10884090 DOI: 10.1007/s12149-023-01896-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024]
Abstract
Rheumatoid Arthritis (RA) is a systemic inflammatory disorder that commonly presents with polyarthritis but can have multisystemic involvement and complications, leading to increased morbidity and mortality. The diagnosis of RA continues to be challenging due to its varied clinical presentations. In this review article, we aim to determine the potential of PET/CT to assist in the diagnosis of RA and its complications, evaluate the therapeutic response to treatment, and predict RA remission. PET/CT has increasingly been used in the last decade to diagnose, monitor treatment response, predict remissions, and diagnose subclinical complications in RA. PET imaging with [18F]-fluorodeoxyglucose ([18F]-FDG) is the most commonly applied radiotracer in RA, but other tracers are also being studied. PET/CT with [18F]-FDG, [18F]-NaF, and other tracers might lead to early identification of RA and timely evidence-based clinical management, decreasing morbidity and mortality. Although PET/CT has been evolving as a promising tool for evaluating and managing RA, more evidence is required before incorporating PET/CT in the standard clinical management of RA.
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Affiliation(s)
- Shashi B Singh
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Sambhawana Bhandari
- Department of Medicine, Division of Rheumatology, Washington University in St Louis, St Louis, MO, USA
| | | | | | | | - William Y Raynor
- Department of Radiology, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB#404, New Brunswick, NJ, 08901, USA
| | - Soren Hess
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Mona-Elisabeth Revheim
- The Intervention Center, Division of Technology and Innovation, Oslo University Hospital, Rikshospitalet, Nydalen, Post Box 4950, 0424, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Blindern, Post Box 1078, 0316, Oslo, Norway.
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2
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Noversa de Sousa R, Tascilar K, Corte G, Atzinger A, Minopoulou I, Ohrndorf S, Waldner M, Schmidkonz C, Kuwert T, Knieling F, Kleyer A, Ramming A, Schett G, Simon D, Fagni F. Metabolic and molecular imaging in inflammatory arthritis. RMD Open 2024; 10:e003880. [PMID: 38341194 PMCID: PMC10862311 DOI: 10.1136/rmdopen-2023-003880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
It is known that metabolic shifts and tissue remodelling precede the development of visible inflammation and structural organ damage in inflammatory rheumatic diseases such as the inflammatory arthritides. As such, visualising and measuring metabolic tissue activity could be useful to identify biomarkers of disease activity already in a very early phase. Recent advances in imaging have led to the development of so-called 'metabolic imaging' tools that can detect these changes in metabolism in an increasingly accurate manner and non-invasively.Nuclear imaging techniques such as 18F-D-glucose and fibroblast activation protein inhibitor-labelled positron emission tomography are increasingly used and have yielded impressing results in the visualisation (including whole-body staging) of inflammatory changes in both early and established arthritis. Furthermore, optical imaging-based bedside techniques such as multispectral optoacoustic tomography and fluorescence optical imaging are advancing our understanding of arthritis by identifying intra-articular metabolic changes that correlate with the onset of inflammation with high precision and without the need of ionising radiation.Metabolic imaging holds great potential for improving the management of patients with inflammatory arthritis by contributing to early disease interception and improving diagnostic accuracy, thereby paving the way for a more personalised approach to therapy strategies including preventive strategies. In this narrative review, we discuss state-of-the-art metabolic imaging methods used in the assessment of arthritis and inflammation, and we advocate for more extensive research endeavours to elucidate their full field of application in rheumatology.
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Affiliation(s)
- Rita Noversa de Sousa
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Serviço de Medicina Interna, Hospital Pedro Hispano, Matosinhos, Portugal
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Koray Tascilar
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Giulia Corte
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Armin Atzinger
- Department of Nuclear Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Ioanna Minopoulou
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Sarah Ohrndorf
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Waldner
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Christian Schmidkonz
- Department of Nuclear Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Institute for Medical Engineering, Ostbayerische Technische Hochschule Amberg-Weiden, Amberg, Germany
| | - Torsten Kuwert
- Department of Nuclear Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Ferdinand Knieling
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Kleyer
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Ramming
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - David Simon
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Filippo Fagni
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Deutsches Zentrum fuer Immuntherapie (DZI), Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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3
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Reddy N, Raynor WY, Werner TJ, Baker JF, Alavi A, Revheim ME. 18F-FDG and 18F-NaF PET/CT Global Assessment of Large Joint Inflammation and Bone Turnover in Rheumatoid Arthritis. Diagnostics (Basel) 2023; 13:2149. [PMID: 37443544 DOI: 10.3390/diagnostics13132149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Rheumatoid arthritis (RA) involves chronic inflammation of synovial joints, causing pain, stiffness, and limited mobility. 18F-sodium fluoride (NaF) is a PET tracer whose uptake reflects bone turnover, while 18F-fludeoxyglucose (FDG) shows glucose metabolism and can serve as a marker for inflammation. The aim of this study is to determine the feasibility of calculating the FDG and NaF mean standardized uptake value (SUVmean) in the knee joint, hip joint, and sacroiliac (SI) joint of RA patients and to determine their association with patient characteristics. Prospective FDG-PET/CT as well as NaF-PET/CT imaging was performed on 18 RA patients. The global SUVmean was calculated on FDG-PET/CT and NaF-PET/CT images using a semiautomated CT-based method of segmentation. FDG and NaF uptake were found to be significantly correlated in the knee (r = 0.77, p < 0.001), but not in the hip and SI joints. In the knee, both NaF SUVmean and FDG SUVmean were significantly correlated with body weight, BMI, leptin, and sclerostin levels (p < 0.05). NaF SUVmean was significantly positively correlated with BMI and leptin for both the hip and SI joints (p < 0.05). No significant correlation was observed between either PET parameter and age, height, erythrocyte sedimentation rate (ESR), and interleukins 1 and 6 (IL-1 and IL-6); however, FDG was correlated with inflammatory markers such as C-reactive protein (CRP) and patient global visual analogue scale (VAS-PtGlobal) in some joints. In this study, both FDG and NaF uptake were quantified in large joints of patients with RA using CT segmentation. NaF and FDG SUVmean were correlated with clinical variables related to body weight and adiposity, suggesting that degenerative joint disease may play a larger role in influencing the uptake of these tracers in large joints than RA disease activity. FDG and its correlation with markers of inflammation such as CRP and VAS-PtGlobal suggests that this tracer may serve as a more specific marker for RA disease activity than NaF. Larger prospective and longitudinal data are necessary to gain a better understanding of the roles of FDG and NaF in evaluating RA joint activity in these joints.
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Affiliation(s)
- Natasha Reddy
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - William Y Raynor
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Joshua F Baker
- Division of Rheumatology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
- Division of Rheumatology, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
- Department of Epidemiology and Biostatistics, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Mona-Elisabeth Revheim
- The Intervention Center, Division of Technology and Innovation, Oslo University Hospital, Sognsvannsveien 20, 0372 Oslo, Norway
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Sognsvannsveien 20, 0372 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Problemveien 7, 0315 Oslo, Norway
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4
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Simonsen JA, Thøgersen KF, Hvidsten S, Gerke O, Høilund-Carlsen PF, Diederichsen LP. Treatment-naïve idiopathic inflammatory myopathy: disease evaluation by fluorodeoxyglucose versus pyrophosphate. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00822-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Imaging of idiopathic inflammatory myopathies (IIMs) is challenging, and no pathognomonic signs exist. Different tracers have been tested for this purpose, mainly inflammation markers including technetium-99m-pyrophosphate (PYP). We aimed to examine the utility of fluorine-18-fluorodeoxyglucose (FDG) relative to PYP in idiopathic inflammatory myopathy (IIM).
Methods
Using visual grading and CT-guided muscular segmentation and standardized uptake values (SUVs), we assessed muscular tracer uptake qualitatively and quantitatively, comparing FDG uptake in eight patients with recent-onset IIM and 24 healthy control persons and FDG and PYP uptake in seven patients.
Results
Muscular FDG and PYP uptake was increased in all patients. However, uptake distribution and signal intensity differed considerably. FDG scans revealed clear involvement of certain muscle groups including core and swallowing muscles and, in addition, abnormality in diseased extra-muscular organs. PYP was mainly visible in bones, whereas muscular PYP uptake was generally discrete and primarily located in the extremities. Quantitatively, FDG uptake was significantly higher in patients than in controls; the volume-weighted SUVmean for all right-side muscles was 0.84 versus 0.60 g/ml (95% confidence interval (CI) for mean difference 0.14–0.34, p = 0.0001). FDG SUVmean values were up to four times higher than PYP mean values in upper limb muscles (95% CI for the mean ratio 2.37–3.77, p = 0.0004) and two–three times higher in lower limb muscles (95% CI for the mean ratio 2.28–2.71, p < 0.0001).
Conclusions
Muscular FDG uptake was higher in treatment-naïve IIM patients than in healthy controls and more distinct than PYP uptake in patients with a potential to reveal extra-muscular IIM involvement and malignancy. Thus, FDG appears to be superior to PYP in the diagnostic evaluation of IIM.
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Graham RN, Panagiotidis E. [18F]FDG PET/CT in rheumatoid arthritis. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2022; 66:234-244. [PMID: 36066112 DOI: 10.23736/s1824-4785.22.03461-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
[18F]fluorodeoxyglucose (FDG) PET/CT can be used to image the inflammation in rheumatoid arthritis. Specifically, the synovial metabolic activity can be evaluated visually and measured using standard uptake values. Fluorine-18-labeled Sodium fluoride (NaF) PET/CT can be used to determine synovial osteoblastic activity. Response assessment using FDG PET/CT is routine in many cancers and this is now an emerging technique for rheumatoid arthritis. Vasculitis in rheumatoid arthritis (RA) can be also studied with FDG PET/CT and aortic calcification with NaF PET/CT. These techniques could be useful in determining RA disease severity. FDG PET/CT is a useful technique to exclude underlying malignancy when RA does not follow the expected course. A number of novel tracers are being studied with regard to their applicability in rheumatoid arthritis and some of these could even be used in a theranostic manner in the future.
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Affiliation(s)
- Richard N Graham
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK -
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6
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Verweij NJF, de Jongh J, Wee MMT, Zwezerijnen GJC, Yaqub M, Voskuyl AE, Lammertsma AA, van Schaardenburg D, Boers M, Lems WF, van der Laken CJ. Whole-Body Macrophage Positron Emission Tomography Imaging for Disease Activity Assessment in Early Rheumatoid Arthritis. J Rheumatol 2022; 49:871-877. [PMID: 35428723 DOI: 10.3899/jrheum.210928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To investigate the potential of whole-body positron emission tomography/computed tomography (PET/CT) with a macrophage tracer to image arthritis in patients with early rheumatoid arthritis (RA). METHODS Thirty-five previously untreated, clinically active patients with early RA underwent whole-body PET/CT scanning with the macrophage tracer (R)-[11C]PK11195 in addition to clinical assessment (Disease Activity Score in 44 joints [DAS44]). Tracer uptake was assessed quantitatively as standardized uptake values (SUVs). In addition, 2 readers blinded to clinical assessment visually scored tracer uptake in joints. Clinical and PET variables were compared using Cohen , linear regression/correlation, and t tests, where appropriate. RESULTS All but 1 patient showed enhanced tracer uptake in at least 1 joint. Twelve percent of all joints (171/1470) were visually positive on the PET scan, most frequently the small joints in feet (40%) and hands (37%), followed by wrists (15%). Correlations of visual scores with clinical findings both at patient and joint levels were absent or weak. In contrast, average SUVs in the hands, feet, and whole body showed significant correlations with DAS44 scores, with the best correlation seen in the feet (R2 = 0.29, P < 0.01). CONCLUSION Clinically active patients with early RA had increased joint uptake of a macrophage PET tracer, especially in the feet. Quantitative, but not visual PET measures of whole body and joint groups, particularly the feet, showed moderate and statistically significant correlations with clinical outcome.
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Affiliation(s)
- Nicki J F Verweij
- N.J.F. Verweij, MD, J. de Jongh, MSc, A.E. Voskuyl, MD, Professor, WF. Lems, MD, Professor, C.J. van der Laken, MD, PhD, Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit
| | - Jerney de Jongh
- N.J.F. Verweij, MD, J. de Jongh, MSc, A.E. Voskuyl, MD, Professor, WF. Lems, MD, Professor, C.J. van der Laken, MD, PhD, Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit
| | - Marieke M Ter Wee
- M.M. ter Wee, PhD, M. Boers, MD, Professor, Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, and Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit
| | - Gerben J C Zwezerijnen
- G.J.C. Zwezerijnen, MD, M. Yaqub, PhD, A.A. Lammertsma, PhD, Professor, Department of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit
| | - Maqsood Yaqub
- G.J.C. Zwezerijnen, MD, M. Yaqub, PhD, A.A. Lammertsma, PhD, Professor, Department of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit
| | - Alexandre E Voskuyl
- N.J.F. Verweij, MD, J. de Jongh, MSc, A.E. Voskuyl, MD, Professor, WF. Lems, MD, Professor, C.J. van der Laken, MD, PhD, Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit
| | - Adriaan A Lammertsma
- G.J.C. Zwezerijnen, MD, M. Yaqub, PhD, A.A. Lammertsma, PhD, Professor, Department of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit
| | - Dirkjan van Schaardenburg
- D. van Schaardenburg, MD, Professor, Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade, Amsterdam, the Netherlands
| | - Maarten Boers
- M.M. ter Wee, PhD, M. Boers, MD, Professor, Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, and Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit
| | - Willem F Lems
- N.J.F. Verweij, MD, J. de Jongh, MSc, A.E. Voskuyl, MD, Professor, WF. Lems, MD, Professor, C.J. van der Laken, MD, PhD, Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit
| | - Conny J van der Laken
- N.J.F. Verweij, MD, J. de Jongh, MSc, A.E. Voskuyl, MD, Professor, WF. Lems, MD, Professor, C.J. van der Laken, MD, PhD, Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit
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Rosato E. The role of 18F-FDG PET-CT in rheumatoid arthritis patients tapering TNFi. Rheumatology (Oxford) 2021; 61:SI1-SI3. [PMID: 34919664 DOI: 10.1093/rheumatology/keab932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/11/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome
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Wang L, Li L, Fu L, Zheng Y. Ectopic Pancreatitis in the Gastric Antrum Mimicking Malignancy on FDG PET/CT. Clin Nucl Med 2021; 46:664-666. [PMID: 33512951 DOI: 10.1097/rlu.0000000000003519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT A 34-year-old man suffered intermittent abdominal pain for 1 month, especially after drinking or eating. Enhancement CT was performed to determine the cause, which detected a soft tissue mass in the gastric antrum, suggestive of possible malignancy. FDG PET/CT scan was undertaken for staging, which showed increased metabolism in the known gastric mass, also suggestive of malignancy. However, this lesion was confirmed as ectopic pancreatitis pathologically.
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Affiliation(s)
- Ling Wang
- From the Department of Nuclear Medicine, China-Japan Friendship Hospital, Beijing, China
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9
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Park HJ, Chang SH, Lee JW, Lee SM. Clinical utility of F-18 sodium fluoride PET/CT for estimating disease activity in patients with rheumatoid arthritis. Quant Imaging Med Surg 2021; 11:1156-1169. [PMID: 33816157 DOI: 10.21037/qims-20-788] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The present study aimed to investigate the clinical implication of F-18 sodium fluoride (NaF) positron emission tomography/computed tomography (PET/CT) for assessing the disease activity of rheumatoid arthritis. Methods Seventeen patients with rheumatoid arthritis according to the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria were prospectively enrolled. All enrolled patients underwent F-18 NaF PET/CT along with physical examination, blood test, and ultrasonography. On PET/CT images, two quantitative parameters, F-18 NaF uptake of the joint (joint SUV) and joint-to-bone uptake ratio, were measured for each of the 28 joints included in calculating the disease activity score in 28 joints using erythrocyte sedimentation rate (DAS28-ESR). The relationship between PET/CT parameters and clinical factors and the predictive values of PET/CT parameters for joints with synovitis and high disease activity were evaluated. Results Tender joints (joint SUV, 13.6±8.4; joint-to-bone uptake ratio, 1.70±1.02) and both tender and swollen joints (joint SUV, 13.9±5.4; joint-to-normal bone uptake ratio, 1.81±0.76) had significantly higher joint SUV and joint-to-bone uptake ratio than joints without synovitis (joint SUV, 6.0±2.4; joint-to-bone uptake ratio, 0.74±0.31; P<0.001). On correlation analysis, summed joint SUV (P=0.002, correlation coefficient=0.705) and summed joint-to-bone uptake ratio (P<0.001, correlation coefficient=0.861) of 28 joints showed strong positive correlation with DAS28-ESR after adjustment for age and body mass index. Summed joint SUV showed significant positive correlations with ultrasonography findings (grey scale ultrasonography: P=0.047, correlation coefficient =0.468; power Doppler ultrasonography: P=0.045, correlation coefficient =0.507). On the receiver operating characteristic curve analysis, the sensitivity and specificity for predicting synovitis were 83.2% and 92.7%, respectively, for joint SUV and 81.5% and 90.7%, respectively, for joint-to-bone uptake ratio. Moreover, the summation of both PET/CT parameters of 28 joints showed a diagnostic accuracy of 100.0% for predicting high disease activity in rheumatoid arthritis. Conclusions Summed joint uptake on F-18 NaF PET/CT had a strong positive correlation with DAS28-ESR and accurately predicted high disease activity. F-18 NaF PET/CT parameters might be used as an imaging biomarker for disease activity in rheumatoid arthritis. Trial registration This study was registered at the Clinical Research Information Service of the Korea (CRIS, http://cris.nih.go.kr/cris/en; registry number, KCT0002597; registered November 2017).
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Affiliation(s)
- Hee Jin Park
- Division of Rheumatology, Department of Internal Medicine, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, 25, Simgok-ro 100-gil, Seo-gu, Incheon, Korea
| | - Sung Hae Chang
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan, Chungcheongnam-do, Korea
| | - Jeong Won Lee
- Department of Nuclear Medicine, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, 25, Simgok-ro 100-gil, Seo-gu, Incheon, Korea
| | - Sang Mi Lee
- Department of Nuclear Medicine, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan, Chungcheongnam-do, Korea
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10
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Raynor WY, Borja AJ, Hancin EC, Werner TJ, Alavi A, Revheim ME. Novel Musculoskeletal and Orthopedic Applications of 18F-Sodium Fluoride PET. PET Clin 2021; 16:295-311. [PMID: 33589389 DOI: 10.1016/j.cpet.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PET imaging with 18F-sodium fluoride (NaF), combined with computed tomography or magnetic resonance, is a sensitive method of assessing bone turnover. Although NaF-PET is gaining popularity in detecting prostate cancer metastases to bone marrow, osseous changes represent secondary effects of cancer cell growth. PET tracers more appropriate for assessing prostate cancer metastases directly portray malignant activity and include 18F-fluciclovine and prostatic specific membrane antigen ligands. Recent studies investigating NaF-PET suggest utility in the assessment of benign musculoskeletal disorders. Emerging applications in assessing traumatic injuries, joint disease, back pain, orthopedic complications, and metabolic bone disease are discussed.
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Affiliation(s)
- William Y Raynor
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Drexel University College of Medicine, 2900 West Queen Lane, Philadelphia, PA 19129, USA
| | - Austin J Borja
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Emily C Hancin
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Lewis Katz School of Medicine at Temple University, 3500 North Broad Street, Philadelphia, PA 19140, USA
| | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Mona-Elisabeth Revheim
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Division of Radiology and Nuclear Medicine, Oslo University Hospital, Sognsvannsveien 20, Oslo 0372, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Problemveien 7, Oslo 0315, Norway.
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11
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Chaudhari AJ, Raynor WY, Gholamrezanezhad A, Werner TJ, Rajapakse CS, Alavi A. Total-Body PET Imaging of Musculoskeletal Disorders. PET Clin 2021; 16:99-117. [PMID: 33218607 PMCID: PMC7684980 DOI: 10.1016/j.cpet.2020.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Imaging of musculoskeletal disorders, including arthritis, infection, osteoporosis, sarcopenia, and malignancies, is often limited when using conventional modalities such as radiography, computed tomography (CT), and MR imaging. As a result of recent advances in Positron Emission Tomography (PET) instrumentation, total-body PET/CT offers a longer axial field-of-view, higher geometric sensitivity, and higher spatial resolution compared with standard PET systems. This article discusses the potential applications of total-body PET/CT imaging in the assessment of musculoskeletal disorders.
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Affiliation(s)
- Abhijit J Chaudhari
- Department of Radiology, University of California Davis, 4860 Y Street, Sacramento, CA 95825, USA.
| | - William Y Raynor
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Drexel University College of Medicine, 2900 West Queen Lane, Philadelphia, PA 19129, USA
| | - Ali Gholamrezanezhad
- Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Los Angeles, CA 90033, USA
| | - Thomas J Werner
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Abass Alavi
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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12
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Tamal M. Intensity threshold based solid tumour segmentation method for Positron Emission Tomography (PET) images: A review. Heliyon 2020; 6:e05267. [PMID: 33163642 PMCID: PMC7610228 DOI: 10.1016/j.heliyon.2020.e05267] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 05/14/2020] [Accepted: 10/12/2020] [Indexed: 12/02/2022] Open
Abstract
Accurate, robust and reproducible delineation of tumour in Positron Emission Tomography (PET) is essential for diagnosis, treatment planning and response assessment. Since standardized uptake value (SUV) – a normalized semiquantitative parameter used in PET is represented by the intensity of the PET images and related to the radiotracer uptake, a SUV based threshold method is a natural choice to delineate the tumour. However, determination of an optimum threshold value is a challenging task due to low spatial resolution, and signal-to-noise ratio (SNR) along with finite image sampling constraint. The aim of the review is to summarize different fixed and adaptive threshold-based PET image segmentation approaches under a common mathematical framework Advantages and disadvantages of different threshold based methods are also highlighted from the perspectives of diagnosis, treatment planning and response assessment. Several fixed threshold values (30%–70% of the maximum SUV of the tumour (SUVmaxT)) have been investigated. It has been reported that the fixed threshold-based method is very much dependent on the SNR, tumour to background ratio (TBR) and the size of the tumour. Adaptive threshold-based method, an alternative to fixed threshold, can minimize these dependencies by accounting for tumour to background ratio (TBR) and tumour size. However, the parameters for the adaptive methods need to be calibrated for each PET camera system (e.g., scanner geometry, image acquisition protocol, reconstruction algorithm etc.) and it is not straight forward to implement the same procedure to other PET systems to obtain similar results. It has been reported that the performance of the adaptive methods is also not optimum for smaller volumes with lower TBR and SNR. Statistical analysis carried out on the NEMA thorax phantom images also indicates that regions segmented by the fixed threshold method are significantly different for all cases. On the other hand, the adaptive method provides significantly different segmented regions only for low TBR with different SNR. From this viewpoint, a robust threshold based segmentation method that will be less sensitive to SUVmaxT, SNR, TBR and volume needs to be developed. It was really challenging to compare the performance of different threshold-based methods because the performance of each method was tested on dissimilar data set with different data acquisition and reconstruction protocols along with different TBR, SNR and volumes. To avoid such difficulties, it will be desirable to have a common database of clinical PET images acquired with different image acquisition protocols and different PET cameras to compare the performance of automatic segmentation methods. It is also suggested to report the changes in SNR and TBR while reporting the response using threshold based methods.
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Affiliation(s)
- Mahbubunnabi Tamal
- Department of Biomedical Engineering, Imam Abdulrahman Bin Faisal University, PO Box 1982, Dammam, 31441, Saudi Arabia
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13
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FDG PET/CT Suggesting Pulmonary Artery Involvement of Takayasu Arteritis. Clin Nucl Med 2020; 45:732-734. [PMID: 32604110 DOI: 10.1097/rlu.0000000000003149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pulmonary artery involvement can occur in about half of the patients suffering Takayasu arteritis. Increased FDG activity in the aorta and its main branches in patients with Takayasu arteritis on PET/CT had been well-reported. However, the FDG PET/CT appearance of pulmonary artery involvement in Takayasu arteritis is less known. We present FDG PET/CT findings in a 37-year-old patient with known Takayasu arteritis. The images showed rim-like FDG activity in opacities in the left lung, which was later proven due to narrowed left main pulmonary artery.
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14
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Saboury B, Morris MA, Nikpanah M, Werner TJ, Jones EC, Alavi A. Reinventing Molecular Imaging with Total-Body PET, Part II: Clinical Applications. PET Clin 2020; 15:463-475. [PMID: 32888545 PMCID: PMC7462547 DOI: 10.1016/j.cpet.2020.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Total-body PET scans will initiate a new era for the PET clinic. The benefits of 40-fold effective sensitivity improvement provide new capabilities to image with lower radiation dose, perform delayed imaging, and achieve improved temporal resolution. These technical features are detailed in the first of this 2-part series. In this part, the clinical impacts of the novel features of total-body PET scans are further explored. Applications of total-body PET scans focus on the real-time interrogation of systemic disease manifestations in a variety of practical clinical contexts. Total-body PET scans make clinical systems biology imaging a reality.
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Affiliation(s)
- Babak Saboury
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892, USA; Department of Computer Science and Electrical Engineering, University of Maryland, Baltimore County, Baltimore, MD, USA; Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
| | - Michael A Morris
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892, USA; Department of Computer Science and Electrical Engineering, University of Maryland, Baltimore County, Baltimore, MD, USA
| | - Moozhan Nikpanah
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
| | - Elizabeth C Jones
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.
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15
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Tse JJ, Brunet SC, Salat P, Hazlewood GS, Barnabe C, Manske SL. Multi-Modal Imaging to Assess the Interaction Between Inflammation and Bone Damage Progression in Inflammatory Arthritis. Front Med (Lausanne) 2020; 7:545097. [PMID: 33102498 PMCID: PMC7544988 DOI: 10.3389/fmed.2020.545097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/26/2020] [Indexed: 12/12/2022] Open
Abstract
Combining results from multiple imaging techniques (i.e., multi-modal imaging) through image registration can result in the better characterization of joint tissue characteristics. In the context of inflammatory arthritis conditions, high-resolution peripheral quantitative computed tomography (HR-pQCT) provides excellent bone contrast while magnetic resonance imaging (MRI) provides superior contrast and resolution of soft tissue and inflammatory characteristics. Superimposing these imaging results upon each other provides a robust characterization of the joint. In a preliminary study of nine rheumatoid arthritis (RA) participants in clinical remission, we acquired HR-pQCT and MR images of their 2nd and 3rd metacarpophalangeal (MCP) joints at two timepoints 6 months apart. We present the benefits of a multi-modal imaging approach, in which we demonstrate the ability to localize regions of inflammation with subtle changes in bone erosion volume. Using HR-pQCT and MRI to visualize bone damage and inflammation, respectively, will improve our understanding of the impact that subclinical inflammation has on bone damage progression, and demonstrating if bone repair occurs where inflammation is resolved. The presented multi-modal imaging technique has the potential to study the progression of bone damage in relation to inflammation that otherwise would not be possible with either imaging technique alone. The multi-modal image registration technique will be helpful to understanding the development and pathogenesis of RA-associated bone erosions. Additionally, multi-modal imaging may provide a technique to probe the tissue-level changes that occur as a result of treatment regimes.
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Affiliation(s)
- Justin J Tse
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Scott C Brunet
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Biomedical Engineering Graduate Program, Schulich School of Engineering, University of Calgary, Calgary, AB, Canada
| | - Peter Salat
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Glen S Hazlewood
- Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cheryl Barnabe
- Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sarah L Manske
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.,Biomedical Engineering Graduate Program, Schulich School of Engineering, University of Calgary, Calgary, AB, Canada
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16
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Zhang V, Koa B, Borja AJ, Padmanhabhan S, Bhattaru A, Raynor WY, Rojulpote C, Seraj SM, Werner TJ, Rajapakse C, Alavi A, Revheim ME. Diagnosis and Monitoring of Osteoporosis with Total-Body 18F-Sodium Fluoride-PET/CT. PET Clin 2020; 15:487-496. [PMID: 32768370 DOI: 10.1016/j.cpet.2020.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In recent years, 18F-Sodium Fluoride (NaF)-PET/CT has seen its role in the detection and management of osteoporosis increase. This article reviews the extent of this application in the literature, its efficacy compared with other comparable imaging tools, and how total-body PET/CT combined with global disease assessment can revolutionize measurement of total osteoporotic disease activity. NaF-PET/CT eventually can be the modality of choice for metabolic bone disorders, especially with these advances in technology and computation.
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Affiliation(s)
- Vincent Zhang
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin Koa
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Drexel University College of Medicine, Philadelphia, PA, USA
| | - Austin J Borja
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sayuri Padmanhabhan
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Abhijit Bhattaru
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - William Y Raynor
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Drexel University College of Medicine, Philadelphia, PA, USA
| | - Chaitanya Rojulpote
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | | | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Chamith Rajapakse
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Mona-Elisabeth Revheim
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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18
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Khaw TH, Raynor WY, Borja AJ, Al-Zaghal A, Jonnakuti VS, Cheng N, Houshmand S, Werner TJ, Alavi A. Assessing the effects of body weight on subchondral bone formation with quantitative 18F-sodium fluoride PET. Ann Nucl Med 2020; 34:559-564. [PMID: 32524505 DOI: 10.1007/s12149-020-01482-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/30/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The aim of this study was to quantify subchondral bone remodeling in the elbows, hands, knees, and feet using volumetric and metabolic parameters derived from 18F-sodium fluoride positron emission tomography (NaF-PET) and to assess the convergent validity of these parameters as an index of joint degeneration and preclinical osteoarthritis. METHODS A retrospective analysis was conducted in 34 subjects (32 males, 2 females) with metastatic bone disease who underwent full-body NaF-PET/CT scans. An adaptive contrast-oriented thresholding algorithm was applied to segment NaF-avid regions in the bilateral elbows, hands, knees, and feet of each subject, and metabolically active volume (MAV), maximum standardized uptake value (SUVmax), mean metabolic volumetric product (MVPmean), and partial volume-corrected MVPmean (cMVPmean) of the segmented regions were calculated. Global parameters for MAV, SUVmax, MVPmean, and cMVPmean were defined as the sum of the corresponding values in all the joints of a subject. Inter-rater reliability was determined with Lin's concordance correlation, and associations of global values with subject body weight and age were assessed with Pearson correlation and Spearman correlation analyses. RESULTS Inter-rater reliability was observed to be the highest in SUVmax (ρc = 0.99), followed by MVPmean (ρc = 0.96), cMVPmean (ρc = 0.93), and MAV (ρc = 0.93). MAV, MVPmean, and cMVPmean were observed to significantly increase with weight (all p < 0.0001) determined by Pearson correlation. In addition, Spearman rank-order analysis demonstrated a significant correlation between SUVmax and weight in addition to MAV, MVPmean, and cMVPmean and weight (all p < 0.01). No significant association between age and any PET parameter was observed. CONCLUSIONS These preliminary data demonstrate the feasibility and reliability of assessing bone turnover at the joints using quantitative NaF-PET. Our findings corroborate the fact that biomechanical factors including mechanical loading and weight-bearing are contributors to osteoarthritis disease progression.
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Affiliation(s)
- Tiffany H Khaw
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - William Y Raynor
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Austin J Borja
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Abdullah Al-Zaghal
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Venkata S Jonnakuti
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Nina Cheng
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Sina Houshmand
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
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