1
|
Sköld C, Sörensen J, Brüggemann A, Hailer NP. Is 18F-fluoride PET/CT an Accurate Tool to Diagnose Loosening After Total Joint Arthroplasty? Clin Orthop Relat Res 2024:00003086-990000000-01724. [PMID: 39293088 DOI: 10.1097/corr.0000000000003228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 07/29/2024] [Indexed: 09/20/2024]
Abstract
BACKGROUND Several studies using positron emission tomography (PET) show highly elevated periprosthetic bone uptake of fluorine-18 sodium fluoride (18F-fluoride), suggestive of implant loosening after arthroplasty. Focus so far has been on qualitative but not on quantitative assessment. There is also a lack of intraoperative confirmation of preoperative 18F-fluoride PET findings. Although the method seems to have acceptable accuracy and high sensitivity, an attempt to improve the specificity and an overall validation of the method appear warranted. QUESTIONS/PURPOSES (1) Is there a difference in 18F-fluoride uptake around loose versus well-fixed THA and TKA components? (2) Can 18F-fluoride uptake measures provide a threshold that differentiates loose from well-fixed implants undergoing revision for a variety of septic and aseptic indications? (3) In a population restricted to THA and TKA undergoing revision for aseptic indications, can measurement of 18F-fluoride uptake still distinguish loose from well-fixed components? (4) What is the interrater reliability of measuring 18F-fluoride uptake? METHODS This was a retrospective assessment of a diagnostic test, 18F-fluoride PET/CT, which was performed prior to revision surgery. We included 63 patients with 31 THAs and 32 TKAs. Sixty-five percent of patients were female, and the mean age at 18F-fluoride PET/CT was 66 years. The THA had different modes of fixation (cemented, cementless, and hybrid; 45%, 32%, and 23%, respectively), whereas all TKAs were cemented. Imaging was conducted using routine protocols 1 hour after tracer injection. The interobserver reproducibility was analyzed using Spearman rank correlations and Bland-Altman analyses. Two independent observers were trained separately by a nuclear physician to measure maximal periprosthetic standardized uptake values (SUVmax) for each arthroplasty component (n = 126). Findings at surgery (whether the components were well fixed or loose, as well as the presence or absence of infection) were used as a reference. Presence of periprosthetic joint infection was retrospectively determined based on the criteria suggested by the European Bone and Joint Infection Society (EBJIS): clinical features in combination with blood analysis, synovial fluid cytologic analysis, and microbiology test results. Receiver operating characteristic (ROC) curves were plotted to assess the area under the curve (AUC) for each investigated component separately, indicating suitable SUVmax thresholds that differentiate loose from well-fixed components. After excluding patients with confirmed or suspected PJI per the EBJIS criteria (n = 12), the above analysis was repeated for the remaining patients with aseptic loosening (n = 51). RESULTS We found higher 18F-fluoride uptake around loose versus well-fixed components in all but femoral TKA components (median [range] SUVmax for well-fixed versus loose THA cups 10 [7 to 30] versus 22 [6 to 64], difference of medians 12; p = 0.003; well-fixed versus loose TKA femoral components 14 [4 to 41] versus 19 [9 to 42], difference of medians 5; p = 0.38). We identified favorable ROC curves for all investigated components except femoral TKA components (THA cups AUC 0.81 [best threshold 13.9]; THA femoral stems AUC 0.9 [best threshold 17.3]; femoral TKA components AUC 0.6 [best threshold 14.3]; tibial TKA components AUC 0.83 [best threshold 15.8]). 18F-fluoride was even more accurate at diagnosing loosening when we limited the population to those patients believed not to have prosthetic joint infection (THA cups AUC 0.87 [best threshold 14.2]; THA femoral stems AUC 0.93 [best threshold 15.0]; femoral TKA components AUC 0.65 [best threshold 15.8]; tibial TKA components AUC 0.86 [best threshold 14.7]). We found strong interrater correlation when assessing SUVmax values, with Spearman ρ values ranging from 0.96 to 0.99 and Bland-Altman plots indicating excellent agreement between the two independent observers. CONCLUSION Measuring SUVmax after 18F-fluoride PET/CT is a useful adjunct in the diagnostic evaluation for suspected implant loosening after THA and TKA. The method appears to be both accurate and reliable in diagnosing implant loosening for all components except femoral TKA components. In a real-world mixed population with both low-grade infection and aseptic loosening, the method seems to be fairly easy to learn and helpful to subspecialized arthroplasty clinicians. When infection can be ruled out, the method probably performs even better. Further prospective studies are warranted to explore the reason why femoral TKA component loosening was more difficult to ascertain using this novel technique. LEVEL OF EVIDENCE Level III, diagnostic study.
Collapse
Affiliation(s)
- Caroline Sköld
- Department of Surgical Sciences/Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Jens Sörensen
- Department of Surgical Sciences/Nuclear Medicine and PET, Uppsala University, Uppsala, Sweden
| | - Anders Brüggemann
- Department of Surgical Sciences/Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Nils P Hailer
- Department of Surgical Sciences/Orthopaedics, Uppsala University, Uppsala, Sweden
| |
Collapse
|
2
|
Watanabe S, Kamono E, Choe H, Ike H, Inaba Y, Kobayashi N. Differences in Diagnostic Sensitivity of Cultures Between Sample Types in Periprosthetic Joint Infections: A Systematic Review and Meta-Analysis. J Arthroplasty 2024; 39:1939-1945. [PMID: 38490568 DOI: 10.1016/j.arth.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Differences between the bacterial culture results of the preoperative fluid, intraoperative tissue, and sonication fluid of implants in the diagnosis of periprosthetic joint infection (PJI) are important issues in clinical practice. This study aimed to identify the differences in pooled diagnostic accuracy between culture sample types for diagnosing PJI by performing a systematic review and meta-analysis. METHODS This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. A comprehensive literature search of PubMed, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library databases was performed. Data extraction and study assessment using the quality assessment of diagnostic accuracy studies were performed independently by two reviewers. The pooled sensitivity, specificity, summary receiver operating characteristic curve, and area under the summary receiver operating characteristic curve were estimated for each sample type. RESULTS There were thirty-two studies that were included in the analysis after screening and eligibility assessment. The pooled sensitivities of preoperative fluid, intraoperative tissue, and sonication fluid for the diagnosis of PJI were 0.63 (95% confidence interval [CI] 0.56 to 0.70), 0.71 (95% CI 0.63 to 0.79), and 0.78 (95% CI 0.68 to 0.85), while the specificities were 0.96 (95% CI 0.93 to 0.98), 0.92 (95% CI 0.86 to 0.96), and 0.91 (95% CI 0.83 to 0.95), respectively. The area under the curves for preoperative fluid, intraoperative tissue, and sonication fluid were 0.86, 0.88, and 0.90, respectively. CONCLUSIONS Sonication fluid culture demonstrated better sensitivity compared with the conventional culture method, and preoperative fluid culture provided lower sensitivity in diagnosing PJI.
Collapse
Affiliation(s)
- Shintaro Watanabe
- Department of Orthopedic Surgery, Yokohama City University, Yokohama, Japan
| | - Emi Kamono
- Department of Orthopedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Hyonmin Choe
- Department of Orthopedic Surgery, Yokohama City University, Yokohama, Japan
| | - Hiroyuki Ike
- Department of Orthopedic Surgery, Yokohama City University, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopedic Surgery, Yokohama City University, Yokohama, Japan
| | - Naomi Kobayashi
- Department of Orthopedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| |
Collapse
|
3
|
Choe H, Kamono E, Abe K, Hieda Y, Ike H, Kumagai K, Kobayashi N, Inaba Y. Accuracy of Albumin, Globulin, and Albumin-Globulin Ratio for Diagnosing Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:7512. [PMID: 38137581 PMCID: PMC10743640 DOI: 10.3390/jcm12247512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most intractable orthopedic diseases, partly because of the difficulty in differentiating septic from aseptic conditions. We aimed to evaluate and consolidate the diagnostic accuracy of the quantitative assessment of serum albumin (Alb), globulin (Glb), and albumin-globulin ratio (AGR), alone or in combination with the inflammatory marker, C-reactive protein (CRP), for PJI. We searched the PubMed, CINAHL, and Cochrane Library databases for studies that quantitatively measured Alb, Glb, or AGR for the diagnosis of PJI up until the 30 April 2023. A total of 2339 patients were included from 10 studies, including 845 patients with a definitive diagnosis of PJI and 1494 with non-PJI. The pooled sensitivity, specificity, and area under the curve (AUC) in the summary receiver-operating characteristic curve were as follows: 0.625, 0.732, and 0.715 for Alb; 0.815, 0.857, and 0.887 for Glb; 0.753, 0.757, and 0.875 for AGR; 0.788, 0.837, and 0.876 for CRP; 0.879, 0.890, and 0.917 for the CRP-Alb ratio; and 0.845, 0.855, and 0.908 for the CRP-AGR ratio. Serum Alb, Glb, and AGR levels are feasible and accurate diagnostic markers for PJI, and the combination of these markers with CRP levels may potentially improve preoperative serum diagnostic accuracy. Future prospective studies are required to verify these findings because of the small numbers of included studies.
Collapse
Affiliation(s)
- Hyonmin Choe
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Emi Kamono
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urahune-cho, Minami-ku, Yokohama City 232-0024, Japan; (E.K.); (N.K.)
| | - Koki Abe
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Yuta Hieda
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Hiroyuki Ike
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Ken Kumagai
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Naomi Kobayashi
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urahune-cho, Minami-ku, Yokohama City 232-0024, Japan; (E.K.); (N.K.)
| | - Yutaka Inaba
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| |
Collapse
|
4
|
Weissman BN, Palestro CJ, Fox MG, Bell AM, Blankenbaker DG, Frick MA, Jawetz ST, Kuo PH, Said N, Stensby JD, Subhas N, Tynus KM, Walker EA, Kransdorf MJ. ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty. J Am Coll Radiol 2023; 20:S413-S432. [PMID: 38040462 DOI: 10.1016/j.jacr.2023.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
This article reviews evidence for performing various imaging studies in patients with total hip prostheses. Routine follow-up is generally performed with radiography. Radiographs are also usually the initial imaging modality for patients with symptoms related to the prosthesis. Following acute injury with pain, noncontrast CT may add information to radiographic examination regarding the presence and location of a fracture, component stability, and bone stock. Image-guided joint aspiration, noncontrast MRI, and white blood cell scan and sulfur colloid scan of the hip, are usually appropriate studies for patients suspected of having periprosthetic infection. For evaluation of component loosening, wear, and/or osteolysis, noncontrast CT or MRI are usually appropriate studies. Noncontrast MRI is usually appropriate for identifying adverse reaction to metal debris related to metal-on-metal articulations. For assessing patients after hip arthroplasty, who have trochanteric pain and nondiagnostic radiographs, ultrasound, or MRI are usually appropriate studies. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Collapse
Affiliation(s)
| | | | | | - Angela M Bell
- Rush University Medical Center, Chicago, Illinois; American College of Physicians
| | - Donna G Blankenbaker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | - Phillip H Kuo
- University of Arizona, Tucson, Arizona; Commission on Nuclear Medicine and Molecular Imaging
| | - Nicholas Said
- Duke University Medical Center, Durham, North Carolina
| | | | | | - Katherine M Tynus
- Northwestern Memorial Hospital, Chicago, Illinois; American College of Physicians
| | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | |
Collapse
|
5
|
Wang Y, Yuan L, Du Y, Liu H, Li Q, Chang Y, Shi Y, Wang Y, Meng X, Zhou Y, Yao S, Tian J. Performance characteristics of 18F-fluorodeoxyglucose in non-infected hip replacement. Front Med (Lausanne) 2023; 9:1043812. [PMID: 36698792 PMCID: PMC9870722 DOI: 10.3389/fmed.2022.1043812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023] Open
Abstract
Purpose The aim of this study was to retrospectively analyze 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/ computed tomography (CT) images of non-infected hip arthroplasty patients and summarize findings that may be useful for clinical practice. Methods 18F-FDG PET/CT images of non-infected hip arthroplasty patients were collected from September 2009 to August 2021. The region of interest was independently delineated by two physicians and maximum standardized uptake values (SUVmax) were recorded and compared. Serologic data were also collected and the correlation between SUVmax and serologic parameters was analyzed, while the images were classified based on the 18F-FDG uptake pattern in the images using the diagnostic criteria proposed by Reinartz et al. (9). The interval between hip replacement and PET/CT was classified by year and the characteristics of the two groups were compared. The images of patients who underwent PET/CT multiple times were analyzed dynamically. Results A total of 121 examinations were included; six patients underwent PET/CT twice and two patients had three scans. There were no significant correlations between SUVmax and serologic results. The interobserver agreement between the two physicians in the classification according to the criteria of Reinartz et al. (9) was 0.957 (P < 0.005). Although there was non-specific uptake in cases with an arthroplasty-to-PET/CT interval this was non-significant. Additionally, 18F-FDG showed potential utility for dynamic observation of the condition of the hip. Conclusion SUVmax provided information independent of serologic results, meanwhile 18F-FDG showed potential applicability to the dynamic monitoring of hip arthroplasty-related diseases. However, the presence of blood vessels and muscles affected image interpretation and the specificity of 18F-FDG was not optimal. A more specific radionuclide is needed to maximize the benefits of using PET/CT for the assessment of periprosthetic joint infection (PJI).
Collapse
Affiliation(s)
- Yiqun Wang
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Beijing Key Laboratory of Sports Injuries, Department of Sports Medicine, Institute of Sports Medicine of Peking University, Peking University Third Hospital, Beijing, China
| | - Lulu Yuan
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yinqiao Du
- Department of Orthopedics Surgery, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Department of Orthopedics Surgery, The Fourth Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Honghong Liu
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Qingxiao Li
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yan Chang
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Yan Chang,
| | - Yuanyuan Shi
- Beijing Key Laboratory of Sports Injuries, Department of Sports Medicine, Institute of Sports Medicine of Peking University, Peking University Third Hospital, Beijing, China
| | - Yanmei Wang
- General Electric (GE) Healthcare China, Shanghai, China
| | - Xiaolin Meng
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yonggang Zhou
- Department of Orthopedics Surgery, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Department of Orthopedics Surgery, The Fourth Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,*Correspondence: Yonggang Zhou,
| | - Shulin Yao
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Shulin Yao,
| | - Jiahe Tian
- Department of Nuclear Medicine, The First Medical Centre, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China,Jiahe Tian,
| |
Collapse
|
6
|
PET-Computed Tomography in Bone and Joint Infections. PET Clin 2023; 18:49-69. [DOI: 10.1016/j.cpet.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
7
|
Rachh SS, Basu S, Alavi A. Fluorodeoxyglucose PET/Computed Tomography in Evaluation of Prosthetic Joints and Diabetic Foot: A Comparative Perspective with Other Functional Imaging Modalities. PET Clin 2022; 17:517-531. [PMID: 35717105 DOI: 10.1016/j.cpet.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Infection imaging has been an important part of nuclear medicine practice. Infections in prosthetic joints and diabetic foot are associated with devastating complications, posing substantial challenge for both diagnosis and overall management. For many years, conventional nuclear medicine techniques have been used to frame a painful joint arthroplasty or diabetic foot infection. The various functional nuclear imaging modalities used include labeled leukocyte imaging, combined leukocyte-marrow scintigraphy, antigranulocyte antibody scintigraphy, 3-phase bone scintigraphy, and fluorodeoxyglucose PET/computed tomography, yet no single method has proved to be highly sensitive and specific and at the same time safe, simple, and time-effective.
Collapse
Affiliation(s)
- Swati Sodagar Rachh
- Department of Nuclear Medicie, Gujarat Cancer & Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad 380016, India; Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India; Homi Bhabha National Institute, Mumbai, India.
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
8
|
Kimura M, Kaku N, Kubota Y, Tagomori H, Tsumura H. Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography and Magnetic Resonance Imaging for Adverse Local Tissue Reactions near Metal Implants after Total Hip Arthroplasty: A Preliminary Report. Clin Orthop Surg 2021; 13:320-328. [PMID: 34484624 PMCID: PMC8380523 DOI: 10.4055/cios20228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/24/2020] [Accepted: 12/28/2020] [Indexed: 11/06/2022] Open
Abstract
Background Plain computed tomography (CT) and magnetic resonance imaging (MRI) are useful for diagnosing adverse local tissue reactions after metal-on-metal total hip arthroplasty (THA), but metal artifacts can hamper radiological assessments near the implants. We sought to clarify the usefulness of 18F-fluorodeoxyglucose positron-emission tomography (18F-FDG-PET) CT and MRI in the periprosthetic region, which is difficult to assess after THA due to metal artifacts. Methods We performed preoperative 18F-FDG-PET/CT and 18F-FDG-PET/MRI, as well as plain CT and MRI, in 11 metal-on-metal THA patients who underwent revision surgery. Results Most patients showed high FDG uptake in the metal artifact areas and pseudotumors in the 18-F-FDG-PET/CT and 18-F-FDG-PET/MRI scans. Intraoperative intra-articular macroscopic and histopathological intra-articular granulation tissue findings were suggestive of adverse local tissue reaction. Conclusions The enhanced uptake in the metal artifact areas seemed to reflect adverse local tissue reaction. Therefore, 18F-FDG-PET/CT and 18-F-FDG-PET/MRI can be useful for the auxiliary diagnosis of adverse local tissue reactions after metal-on-metal THA.
Collapse
Affiliation(s)
- Makoto Kimura
- Department of Orthopedic Surgery, Faculty of Medicine, Oita University, Yufu, Japan
| | - Nobuhiro Kaku
- Department of Orthopedic Surgery, Faculty of Medicine, Oita University, Yufu, Japan
| | - Yuta Kubota
- Department of Orthopedic Surgery, Faculty of Medicine, Oita University, Yufu, Japan
| | - Hiroaki Tagomori
- Department of Orthopedic Surgery, Faculty of Medicine, Oita University, Yufu, Japan
| | - Hiroshi Tsumura
- Department of Orthopedic Surgery, Faculty of Medicine, Oita University, Yufu, Japan
| |
Collapse
|
9
|
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.
Collapse
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.
| |
Collapse
|
10
|
Kimura M, Kaku N, Tagomori H, Tsumura H. Effectiveness of 18F-fluoro-deoxyglucose Positron Emission Tomography/Computed Tomography and Magnetic Resonance Imaging to Detect Iliopsoas Tendonitis after Total Hip Arthroplasty: A Case Report. Hip Pelvis 2020; 32:223-229. [PMID: 33335871 PMCID: PMC7724025 DOI: 10.5371/hp.2020.32.4.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/24/2020] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Abstract
Disorders involving artificial joints are difficult to evaluate due to metal artifacts hindering plain computed tomography (CT) or magnetic resonance imaging (MRI). In the current case study 18F-fluoro-deoxyglucose positron emission tomography (18F-FDG-PET)/CT and MRI were used to confirm iliopsoas tendonitis within the metal artifact area following total hip arthroplasty (THA). The patient was a 61-year-old woman who developed hip pain on flexion of the ipsilateral hip after THA. Imaging studies were performed to evaluate for iliopsoas tendonitis due to impingement with the cup. Assessment of the iliopsoas muscle near the artificial joint was difficult due to the metal artifact on plain CT and MRI. Imaging using 18F-FDG-PET/CT and 18F-FDG-PET/MRI showed uptake along the iliopsoas muscle. Therefore, revision was performed to resolve iliopsoas tendon impingement, and the preoperative pain resolved. The result of the current case study suggest 18F-FDG-PET/CT or 18F-FDG-PET/MRI will be useful to detect iliopsoas tendonitis within metal artifact areas after THA.
Collapse
Affiliation(s)
- Makoto Kimura
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Yufu City, Japan
| | - Nobuhiro Kaku
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Yufu City, Japan
| | - Hiroaki Tagomori
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Yufu City, Japan
| | - Hiroshi Tsumura
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Yufu City, Japan
| |
Collapse
|
11
|
Diagnosis of peri-prosthetic loosening of total hip and knee arthroplasty using 18F-Fluoride PET/CT. Oncotarget 2019; 10:2203-2211. [PMID: 31040911 PMCID: PMC6481340 DOI: 10.18632/oncotarget.26762] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 02/01/2019] [Indexed: 11/25/2022] Open
Abstract
Periprosthetic loosening, either aseptic or induced by periprosthetic joint infection remains a major long term complication and challenge in orthopedics and trauma surgery. Sensitivity of potential loosening of the material and other causes of a painful prosthesis is essential for choosing the respective treatment option and providing the needed resources. 18F-Fluoride is a radiopharmaceutical which shows a high affinity to bone and a rapid blood clearance. The objective of this study was to assess 18F-Fluoride PET/CT´s sensitivity and specificity in diagnosing periprosthetic loosening in total hip and knee arthroplasty. We included 26 patients with 24 hip and 13 knee prostheses in our retrospective study with radiological or clinical suspicion of peri-prosthetic loosening at least one year after implantation. Results of 18F-Fluoride PET/CT imaging were compared with surgical results or clinical follow-up if surgery was not performed. On the basis of our data we found a sensitivity of 95.00 %, a specificity of 87.04 % and an accuracy of 89.19 % for 18F-Fluoride PET/CT. The results of our study show that 18F-Fluoride PET/CT is a useful and promising technique in diagnosing periprosthetic loosening of total hip and knee arthroplasties. Further investigation should focus on different uptake patterns of the isotope in periprosthetic joint infection and therefore distinguishing aseptic from septic loosening and enhancing the diagnostic value of this imaging method.
Collapse
|
12
|
|
13
|
Molecularly specific detection of bacterial lipoteichoic acid for diagnosis of prosthetic joint infection of the bone. Bone Res 2018; 6:13. [PMID: 29707402 PMCID: PMC5916877 DOI: 10.1038/s41413-018-0014-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 12/25/2017] [Accepted: 03/01/2018] [Indexed: 12/18/2022] Open
Abstract
Discriminating sterile inflammation from infection, especially in cases of aseptic loosening versus an actual prosthetic joint infection, is challenging and has significant treatment implications. Our goal was to evaluate a novel human monoclonal antibody (mAb) probe directed against the Gram-positive bacterial surface molecule lipoteichoic acid (LTA). Specificity and affinity were assessed in vitro. We then radiolabeled the anti-LTA mAb and evaluated its effectiveness as a diagnostic imaging tool for detecting infection via immunoPET imaging in an in vivo mouse model of prosthetic joint infection (PJI). In vitro and ex vivo binding of the anti-LTA mAb to pathogenic bacteria was measured with Octet, ELISA, and flow cytometry. The in vivo PJI mouse model was assessed using traditional imaging modalities, including positron emission tomography (PET) with [18F]FDG and [18F]NaF as well as X-ray computed tomography (CT), before being evaluated with the zirconium-89-labeled antibody specific for LTA ([89Zr]SAC55). The anti-LTA mAb exhibited specific binding in vitro to LTA-expressing bacteria. Results from imaging showed that our model could reliably simulate infection at the surgical site by bioluminescent imaging, conventional PET tracer imaging, and bone morphological changes by CT. One day following injection of both the radiolabeled anti-LTA and isotype control antibodies, the anti-LTA antibody demonstrated significantly greater (P < 0.05) uptake at S. aureus-infected prosthesis sites over either the same antibody at sterile prosthesis sites or of control non-specific antibody at infected prosthesis sites. Taken together, the radiolabeled anti-LTA mAb, [89Zr]SAC55, may serve as a valuable diagnostic molecular imaging probe to help distinguish between sterile inflammation and infection in the setting of PJI. Future studies are needed to determine whether these findings will translate to human PJI. A new imaging technique distinguishes bacterial infection at the site of joint implants from less-serious postoperative inflammation, saving patients from unnecessary and invasive treatments. Daniel Thorek of Johns Hopkins University School of Medicine and colleagues used an antibody that binds to lipoteichoic acid on the cell wall of Staphylococcus bacteria to detect infection at joint implant sites. The antibody was labeled with a radioactive agent and injected into mice that simulated infection of a knee replacement site. A PET scan conducted 1 day after antibody injection showed that it gathered at the infected joint significantly more than it did at the uninfected implant sites in other mice. This method could improve the diagnosis of joint implant infection, which necessitates removal of the prosthetic and all infected tissues, followed by prolonged antibiotic therapy.
Collapse
|
14
|
Abstract
The use of (18)F-sodium fluoride ((18)F-NaF) with PET/CT is increasing. This resurgence of an old tracer has been fueled by several factors including superior diagnostic performance over standard (99m)Tc-based bone scintigraphy, growth in the availability of PET/CT imaging systems, increase in the number of regional commercial distribution centers for PET radiotracers, the recent concerns about potential recurring shortages with (99m)Tc-based radiotracers, and the recent decision by the Centers for Medicare and Medicaid Services to reimburse for (18)F-NaF PET/CT for evaluation of patients with known or suspected bone metastases through the National Oncologic PET Registry. The major goal of this article is to review the current evidence on the diagnostic utility of (18)F-NaF in the imaging assessment of the bone and joint in a variety of clinical conditions.
Collapse
Affiliation(s)
- Hossein Jadvar
- PET/CT Imaging Science Center, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Bhushan Desai
- PET/CT Imaging Science Center, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Peter S Conti
- PET/CT Imaging Science Center, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| |
Collapse
|
15
|
Choe H, Inaba Y, Kobayashi N, Miyamae Y, Ike H, Yukizawa Y, Saito T. (18)F-fluorodeoxy glucose and (18)F fluoride PET for detection of inflammation focus in periprosthetic hip joint infection cases. Mod Rheumatol 2014; 25:322-4. [PMID: 25036230 DOI: 10.3109/14397595.2014.931505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Hyonmin Choe
- Department of Orthopaedic Surgery, Yokohama City University , Yokohama , Japan
| | | | | | | | | | | | | |
Collapse
|
16
|
Comparative uptake of ¹⁸F-FEN-DPAZn2, ¹⁸F-FECH, ¹⁸F-fluoride, and ¹⁸F-FDG in fibrosarcoma and aseptic inflammation. Appl Radiat Isot 2014; 90:158-64. [PMID: 24751349 DOI: 10.1016/j.apradiso.2014.03.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/18/2014] [Accepted: 03/30/2014] [Indexed: 11/20/2022]
Abstract
The aim of this study is to evaluate uptake of 2-(18)F-fluoroethyl-bis(zinc(II)-dipicolylamine) ((18)F-FEN-DPAZn2) as a promising cell death imaging agent, a choline analog (18)F-fluoroethylcholine ((18)F-FECH), (18)F-fluoride as a bone imaging agent, and a glucose analog 2-(18)F-fluoro-2-deoxy-d-glucose ((18)F-FDG) in the combined S180 fibrosarcoma and turpentine-induced inflammation mice models. The results showed that (18)F-FDG had the highest tumor-to-blood uptake ratio and tumor-to-muscle ratio, and high inflammation-to-blood ratio and inflammation-to-muscle ratio. (18)F -FECH showed moderate tumor-to-blood ratio and tumor-to-muscle ratio, and low inflammation-to-blood ratio and inflammation-to-muscle ratio. However, accumulation of (18)F FEN-DPAZn2 in tumor was similar to that in normal muscle. Also, (18)F-FEN-DPAZn2 and (18)F-fluoride exhibited the best selectivity to inflammation. (18)F-FECH positron emission tomography (PET) imaging demonstrates some advantages over (18)F-FDG PET for the differentiation of tumor from inflammation. (18)F FEN-DPAZn2 and (18)F-fluoride can be used for PET imaging of aseptic inflammation.
Collapse
|
17
|
Choe H, Aota Y, Kobayashi N, Nakamura Y, Wakayama Y, Inaba Y, Saito T. Rapid sensitive molecular diagnosis of pyogenic spinal infections using methicillin-resistant Staphylococcus-specific polymerase chain reaction and 16S ribosomal RNA gene-based universal polymerase chain reaction. Spine J 2014; 14:255-62. [PMID: 24231777 DOI: 10.1016/j.spinee.2013.10.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Accepted: 10/19/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Rapid diagnosis and accurate detection of etiological agents in pyogenic spinal infection (PSI) patients are important. PURPOSE The purpose of this study was to evaluate the clinical usefulness of methicillin-resistant Staphylococcus-specific polymerase chain reaction (MRS-PCR) and broad-range universal PCR (U-PCR) for diagnosing PSI. STUDY DESIGN A prospective diagnostic study. PATIENTS Thirty-two clinically suspect PSI patients and six control patients who underwent computerized tomography-guided biopsy and/or surgical treatment were enrolled. METHODS Tissue samples were examined by microbiological culture, histopathology, and real-time PCR (MRS-PCR and U-PCR). The diagnostic accuracy of real-time PCR was analyzed based on the definitive diagnosis of infection, defined as a positive result from microbiological culture or histopathology. RESULTS All six control subjects were negative for PSI for all analyses. Twelve clinically suspect PSI subjects received definitive diagnoses (PSI group). The non-PSI group consisted of six control subjects plus the remaining 20 patients from the PSI clinically suspect group. MRS-PCR results were positive for all MRS-cultured PSI subjects. U-PCR was positive for all subjects in the PSI group with one discrepancy between real-time PCR and microbiological culture results in differentiation between gram-positive and gram-negative bacteria. In the non-PSI group, MRS-PCR and U-PCR were positive in three and seven cases, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of MRS-PCR for diagnosing MRS infection were 1.00, 0.91, 0.57, and 1.00, respectively; those for the diagnosis of bacterial infection with U-PCR were 1.00, 0.73, 0.63, and 1.00, respectively. CONCLUSION Identification of MRS infection and ability to differentiate between gram-positive and gram-negative bacteria is rapidly achieved using MRS-PCR and U-PCR. Real-time PCR provides a sensitive molecular diagnosis of PSI and may contribute to antibiotic selection.
Collapse
Affiliation(s)
- Hyonmin Choe
- Yokohama City University School of Medicine, Department of Orthopaedic Surgery, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Yoichi Aota
- Yokohama City University School of Medicine, Department of Orthopaedic Surgery, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Naomi Kobayashi
- Yokohama City University School of Medicine, Department of Orthopaedic Surgery, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Yushi Nakamura
- Yokohama City University School of Medicine, Department of Orthopaedic Surgery, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Yusuke Wakayama
- Yokohama City University School of Medicine, Department of Orthopaedic Surgery, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Yutaka Inaba
- Yokohama City University School of Medicine, Department of Orthopaedic Surgery, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Tomoyuki Saito
- Yokohama City University School of Medicine, Department of Orthopaedic Surgery, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| |
Collapse
|
18
|
Girma A, Paycha F. Place de la scintigraphie osseuse planaire et TEMP/TDM dans l’exploration des prothèses de hanche douloureuses. MEDECINE NUCLEAIRE-IMAGERIE FONCTIONNELLE ET METABOLIQUE 2013. [DOI: 10.1016/j.mednuc.2013.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
19
|
Abstract
The potential value of multiplexed positron emission tomography (PET) tracers in mice with turpentine-induced inflammation was evaluated and compared with 2-[18F]fluoro-2-deoxy-D-glucose ([18F]FDG) for glucose metabolism imaging. These PET tracers included [18F]fluoromethylcholine ([18F]FCH) for choline metabolism imaging, (S-[11C]methyl)-D-cysteine ([11C]DMCYS) for amino acid metabolism imaging, [11C]bis(zinc(II)-dipicolylamine) ([11C]DPA-Zn2+) for apoptosis imaging, 2-(4-N-[11C]-methylaminophenyl)-6-hydroxybenzothiazole ([11C]PIB) for β amyloid binding imaging, and [18F]fluoride (18F−) for bone metabolism imaging. In mice with turpentine-induced inflammation mice, the biodistribution of all the tracers mentioned above at 5, 15, 30, 45, and 60 min postinjection was determined. Also, the time-course curves of the tracer uptake ratios for inflammatory thigh muscle (IM) to normal uninflammatory thigh muscle (NM), IM to blood (BL), IM to brain (BR), and IM to liver (LI) were acquired, respectively. Moreover, PET imaging with the tracers within 60 min postinjection on a clinical PET/CT scanner was also conducted. [18F]FDG and 18F− showed relatively higher uptake ratios for IM to NM, IM to BL, IM to BR, and IM to LI than [18F]FCH, [11C]DPA-Zn2+, [11C]DMCYS and [11C]PIB, which were highly consistent with the results delineated in PET images. The results demonstrate that 18F− seems to be a potential PET tracer for inflammation imaging. [18F]FCH and [11C]DMCYS, with lower accumulation in inflammatory tissue than [18F]FDG, are not good PET tracers for inflammation imaging. As a promising inflammatory tracer, the chemical structure of [11C]DPA-Zn2+ needs to be further optimized.
Collapse
|
20
|
Strobel K, Vali R. (18)F NaF PET/CT Versus Conventional Bone Scanning in the Assessment of Benign Bone Disease. PET Clin 2012; 7:249-61. [PMID: 27157456 DOI: 10.1016/j.cpet.2012.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Nuclear physicians in many centers nowadays have the choice of using different nuclear bone-imaging modalities. (18)F-labeled sodium fluoride (NaF) PET with computed tomography (PET/CT) is a promising tool for the evaluation of benign bone disease. The indications for NaF PET/CT in clinical practice are probably the same as those established for (99m)Tc-labeled methylene diphosphonate bone scintigraphy and single-photon emission computed tomography (SPECT)/CT. At present only preliminary data, often with a limited number of patients and lacking comparison with (99m)Tc-MDP SPECT/CT, are available. This article reviews the available literature and summarizes the authors' experience with NaF PET/CT in benign bone disease.
Collapse
Affiliation(s)
- Klaus Strobel
- Department of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, 6000 Lucerne 16, Switzerland
| | - Reza Vali
- Department of Radiology and Nuclear Medicine, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| |
Collapse
|
21
|
Saboury B, Ziai P, Parsons M, Zhuang H, Basu S, Alavi A. Promising Roles of PET in Management of Arthroplasty-Associated Infection. PET Clin 2012; 7:139-50. [PMID: 27157232 DOI: 10.1016/j.cpet.2012.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A number of diagnostic tests is often necessary to differentiate aseptic loosening from periprosthetic infection in most clinical settings. The accuracy of [(18)F]Fluorodeoxyglucose examined with positron emission tomography imaging (FDG PET) in diagnosing periprosthetic infection has been determined by a number of investigations. In general, Images are considered positive for infection if they demonstrate increased FDG activity at the bone-prosthesis interface of the prostheses. Based on the large number of reports in the literature the sensitivity and specificity for FDG PET are about 85-90%. The overall accuracy of this non-invasive imaging modality is superior to the other existing imaging techniques. Therefore, FDG PET appears a very promising and accurate diagnosing tool for distinguishing septic from aseptic painful hip prostheses.
Collapse
Affiliation(s)
- Babak Saboury
- Department of Radiology, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Pouya Ziai
- Department of Radiology, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Molly Parsons
- Department of Radiology, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Hongming Zhuang
- Division of Nuclear Medicine, Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Parel, Bombay 400012, India
| | - Abass Alavi
- Department of Radiology, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| |
Collapse
|