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Singh P, Kandula KK, Patel RK, Parida GK, Agrawal K. Incidental 68 Ga-PSMA Uptake in the Benign Enchondroma-A Rare Finding on 68 Ga-PSMA PET/CT. Clin Nucl Med 2024; 49:e525-e527. [PMID: 38934470 DOI: 10.1097/rlu.0000000000005361] [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: 06/28/2024]
Abstract
ABSTRACT 68 Ga-PSMA (prostate-specific membrane antigen)-HBED-CC (N,N'-bis[2-hydroxy-5-(carboxyethyl)benzyl]ethylenediamine-N,N'-diacetic acid) PET/CT is the new advancement in oncological imaging. However, false-positive uptake can be seen in benign lesions on 68 Ga-PSMA PET/CT. We describe a rare case of intense 68 Ga-PSMA uptake in an enchondroma confirmed on MRI.
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Affiliation(s)
| | | | - Ranjan Kumar Patel
- Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, India
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2
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Pozzessere C, Cicone F, Barberio P, Papa A, Coppolino G, Biagini R, Cascini GL. Cross-sectional evaluation of FGD-avid polyostotic fibrous dysplasia: MRI, CT and PET/MRI findings. Eur J Hybrid Imaging 2022; 6:19. [PMID: 36184649 PMCID: PMC9527265 DOI: 10.1186/s41824-022-00139-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
A 42-year-old male with left hip pain was diagnosed of several right femoral and tibial bone tumours. All lesions were osteolytic with sclerotic margins. The symptomatic lesion in the proximal femur also showed bone expansion and focal cortical thinning. Whole-body [18F]-fluorodeoxyglucose (FDG) PET/CT and segmental PET/MRI of the left hip and femur were performed for metabolic characterization of the lesions and for biopsy guidance. The lesions showed a heterogenous degree of FDG uptake corresponding to different metabolic stages of the disease. A biopsy of the tumour portion showing the highest FDG uptake revealed a fibrous dysplasia (FD). In conclusion, although generally affecting paediatric and adolescent subjects, polyostotic FD may be detected in the adulthood. Despite the benign nature of the disease, increased glucose metabolism can be seen in some lesions. Hybrid imaging combining morphological and functional information may help guide biopsy and better define the treatment strategy.
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Affiliation(s)
- Chiara Pozzessere
- grid.416367.10000 0004 0485 6324Radiology Unit, AUSL Toscana Centro San Giuseppe Hospital, Empoli, Italy
| | - Francesco Cicone
- grid.488515.5Nuclear Medicine Unit, University Hospital “Mater Domini”, Catanzaro, Italy ,grid.411489.10000 0001 2168 2547Department of Experimental and Clinical Medicine, “Magna Graecia” University of Catanzaro, Catanzaro, Italy ,grid.411489.10000 0001 2168 2547PET/MR Unit, Neuroscience Research Centre, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Paolo Barberio
- grid.411489.10000 0001 2168 2547PET/MR Unit, Neuroscience Research Centre, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Annalisa Papa
- grid.488515.5Nuclear Medicine Unit, University Hospital “Mater Domini”, Catanzaro, Italy
| | - Giuseppe Coppolino
- grid.411489.10000 0001 2168 2547Nephrology and Dialysis Unit, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Roberto Biagini
- grid.417520.50000 0004 1760 5276Oncological Orthopaedics Department, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Lucio Cascini
- grid.488515.5Nuclear Medicine Unit, University Hospital “Mater Domini”, Catanzaro, Italy ,grid.411489.10000 0001 2168 2547Department of Experimental and Clinical Medicine, “Magna Graecia” University of Catanzaro, Catanzaro, Italy ,grid.411489.10000 0001 2168 2547PET/MR Unit, Neuroscience Research Centre, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
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3
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Dondi F, Albano D, Treglia G, Bertagna F. Paget Disease as Common Pitfall on PET with Different Radiopharmaceuticals in Oncology: Not All That Glitters Is Gold! J Clin Med 2022; 11:jcm11185372. [PMID: 36143015 PMCID: PMC9506271 DOI: 10.3390/jcm11185372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Francesco Dondi
- Division of Nuclear Medicine, ASST Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Domenico Albano
- Division of Nuclear Medicine, Università degli Studi di Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Giorgio Treglia
- Clinic of Nuclear Medicine, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, 1015 Lausanne, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Correspondence:
| | - Francesco Bertagna
- Division of Nuclear Medicine, Università degli Studi di Brescia and ASST Spedali Civili di Brescia, 25123 Brescia, Italy
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Bahouth SM, Yeboa DN, Ghia AJ, Tatsui CE, Alvarez-Breckenridge CA, Beckham TH, Bishio AJ, Li J, McAleer MF, North RY, Rhines LD, Swanson TA, Chenyang W, Amini B. Multidisciplinary management of spinal metastases: what the radiologist needs to know. Br J Radiol 2022; 95:20220266. [PMID: 35856792 PMCID: PMC9815745 DOI: 10.1259/bjr.20220266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/17/2022] [Accepted: 07/11/2022] [Indexed: 01/13/2023] Open
Abstract
The modern management of spinal metastases requires a multidisciplinary approach that includes radiation oncologists, surgeons, medical oncologists, and diagnostic and interventional radiologists. The diagnostic radiologist can play an important role in the multidisciplinary team and help guide assessment of disease and selection of appropriate therapy. The assessment of spine metastases is best performed on MRI, but imaging from other modalities is often needed. We provide a review of the clinical and imaging features that are needed by the multidisciplinary team caring for patients with spine metastases and stress the importance of the spine radiologist taking responsibility for synthesizing imaging features across multiple modalities to provide a report that advances patient care.
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Affiliation(s)
- Sarah M Bahouth
- Musculoskeletal Imaging and Intervention Department, Brigham and Women’s Hospital, Boston MA, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio E Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Thomas H Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishio
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert Y North
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wang Chenyang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Behrang Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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5
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Cheung H, Yechoor A, Behnia F, Abadi AB, Khodarahmi I, Soltanolkotabi M, Shafiei M, Chalian M. Common Skeletal Neoplasms and Nonneoplastic Lesions at 18F-FDG PET/CT. Radiographics 2021; 42:250-267. [PMID: 34919467 DOI: 10.1148/rg.210090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Numerous primary and metastatic osseous lesions and incidental osseous findings are encountered at fluorine 18 (18F) fluorodeoxyglucose (FDG) PET/CT. These lesions show varying degrees of FDG uptake. Malignancies are generally more FDG avid than are benign lesions, but many exceptions exist. Although aggressive lesions tend to be more FDG avid than nonaggressive lesions, this concept holds true particularly for lesions of the same histologic subtype. In addition, some benign osseous processes such as Paget disease have variable degrees of FDG avidity on the basis of disease metabolic activity. This creates a diagnostic dilemma for radiologists and clinicians, especially in patients with known malignancies, and can result in unnecessary diagnostic imaging or interventions for incidental osseous lesions. Evaluation of morphologic CT characteristics of osseous lesions at FDG PET/CT can be a valuable adjunct to metabolic analysis to further characterize lesions, enhance diagnostic and staging accuracy, and avoid unnecessary invasive biopsy procedures. The authors review the common primary and metastatic bone lesions at FDG PET/CT, with an emphasis on morphologic CT assessment of lesions to help narrow the differential diagnosis. Imaging manifestations of common incidental nonneoplastic bone lesions at FDG PET/CT are discussed to provide information on differentiation of these lesions from osseous neoplasms. The guidelines of the National Comprehensive Cancer Network (NCCN) for common primary osseous malignancies are also summarized. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Hoiwan Cheung
- From the Department of Radiology, Divisions of Musculoskeletal Imaging and Intervention (H.C., A.Y., A.B.A., M. Shafiei, M.C.) and Nuclear Medicine (F.B.), University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA 98105; Department of Radiology, Division of Musculoskeletal Imaging, NYU Langone Health, New York, NY (I.K.); and Department of Radiology, Division of Musculoskeletal Imaging, University of Utah, Salt Lake City, Utah (M. Soltanolkotabi)
| | - Alekhya Yechoor
- From the Department of Radiology, Divisions of Musculoskeletal Imaging and Intervention (H.C., A.Y., A.B.A., M. Shafiei, M.C.) and Nuclear Medicine (F.B.), University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA 98105; Department of Radiology, Division of Musculoskeletal Imaging, NYU Langone Health, New York, NY (I.K.); and Department of Radiology, Division of Musculoskeletal Imaging, University of Utah, Salt Lake City, Utah (M. Soltanolkotabi)
| | - Fatemeh Behnia
- From the Department of Radiology, Divisions of Musculoskeletal Imaging and Intervention (H.C., A.Y., A.B.A., M. Shafiei, M.C.) and Nuclear Medicine (F.B.), University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA 98105; Department of Radiology, Division of Musculoskeletal Imaging, NYU Langone Health, New York, NY (I.K.); and Department of Radiology, Division of Musculoskeletal Imaging, University of Utah, Salt Lake City, Utah (M. Soltanolkotabi)
| | - Alireza Behrad Abadi
- From the Department of Radiology, Divisions of Musculoskeletal Imaging and Intervention (H.C., A.Y., A.B.A., M. Shafiei, M.C.) and Nuclear Medicine (F.B.), University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA 98105; Department of Radiology, Division of Musculoskeletal Imaging, NYU Langone Health, New York, NY (I.K.); and Department of Radiology, Division of Musculoskeletal Imaging, University of Utah, Salt Lake City, Utah (M. Soltanolkotabi)
| | - Iman Khodarahmi
- From the Department of Radiology, Divisions of Musculoskeletal Imaging and Intervention (H.C., A.Y., A.B.A., M. Shafiei, M.C.) and Nuclear Medicine (F.B.), University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA 98105; Department of Radiology, Division of Musculoskeletal Imaging, NYU Langone Health, New York, NY (I.K.); and Department of Radiology, Division of Musculoskeletal Imaging, University of Utah, Salt Lake City, Utah (M. Soltanolkotabi)
| | - Maryam Soltanolkotabi
- From the Department of Radiology, Divisions of Musculoskeletal Imaging and Intervention (H.C., A.Y., A.B.A., M. Shafiei, M.C.) and Nuclear Medicine (F.B.), University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA 98105; Department of Radiology, Division of Musculoskeletal Imaging, NYU Langone Health, New York, NY (I.K.); and Department of Radiology, Division of Musculoskeletal Imaging, University of Utah, Salt Lake City, Utah (M. Soltanolkotabi)
| | - Mehrzad Shafiei
- From the Department of Radiology, Divisions of Musculoskeletal Imaging and Intervention (H.C., A.Y., A.B.A., M. Shafiei, M.C.) and Nuclear Medicine (F.B.), University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA 98105; Department of Radiology, Division of Musculoskeletal Imaging, NYU Langone Health, New York, NY (I.K.); and Department of Radiology, Division of Musculoskeletal Imaging, University of Utah, Salt Lake City, Utah (M. Soltanolkotabi)
| | - Majid Chalian
- From the Department of Radiology, Divisions of Musculoskeletal Imaging and Intervention (H.C., A.Y., A.B.A., M. Shafiei, M.C.) and Nuclear Medicine (F.B.), University of Washington, UW Radiology-Roosevelt Clinic, 4245 Roosevelt Way NE, Box 354755, Seattle, WA 98105; Department of Radiology, Division of Musculoskeletal Imaging, NYU Langone Health, New York, NY (I.K.); and Department of Radiology, Division of Musculoskeletal Imaging, University of Utah, Salt Lake City, Utah (M. Soltanolkotabi)
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Benz MR, Crompton JG, Harder D. PET/CT variants and pitfalls in bone and soft tissue sarcoma. Semin Nucl Med 2021; 51:584-592. [PMID: 34238508 DOI: 10.1053/j.semnuclmed.2021.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sarcomas are rare tumors of mesenchymal origin and comprise only around 1% of adult cancers. The abundance of sarcoma histiotypes, with distinct imaging characteristics, biology, clinical behavior and treatment strategy, result in a complex disease presentation, requiring management by multidisciplinary specialized sarcoma centers. Oncologic and musculoskeletal radiology guidelines provide minimal guidance and only fragmentary information on the indications of 18F-FDG PET/CT in sarcoma. Therefore, knowledge of various phenotypes with preference for bone and lymph node metastases or higher incidence of local and distant recurrence is essential to select the appropriate diagnostic imaging tests and its interpretation. Benign and malignant soft tissue and bone tumors often share common radiographic and metabolic imaging characteristics. In addition, metastases of various histiotypes might exhibit a spectrum of atypical imaging appearances. Therefore, imaging specialists need to be aware of these variants and associated pitfalls of sarcoma imaging.
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Affiliation(s)
- Matthias R Benz
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, CA; Department of Radiology, University of California, Los Angeles, CA; Department of Nuclear Medicine, University of Duisburg-Essen, Essen, Germany.
| | - Joseph G Crompton
- Division of Surgical Oncology, University of California, Los Angeles, CA
| | - Dorothee Harder
- Clinic of Radiology and Nuclear Medicine, University Hospital of Basel, Switzerland
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Elsobky S, Nathan M, Robertson N, Wagner T. Bone Infarction Mimicking a Bone Metastasis on 18F-Prostate-Specific Membrane Antigen PET/CT. Clin Nucl Med 2021; 46:e250-e252. [PMID: 33323731 DOI: 10.1097/rlu.0000000000003455] [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: 11/27/2022]
Abstract
ABSTRACT 18F-prostate-specific membrane antigen (PSMA) PET/CT imaging is increasingly used in staging, assessment of biochemical recurrence, and treatment response in men with prostate cancer. We present a case report of a 70-year-old man who underwent 18F-PSMA PET/CT imaging to investigate biochemical recurrence following radical prostatectomy for prostate adenocarcinoma. New focal moderate PSMA uptake was identified in the left femur. A previous PSMA study, performed 5 months earlier, was normal. A subsequent MRI scan demonstrated that the PSMA avidity corresponded to a new femoral bone infarct. An English literature search revealed no previous cases of PSMA tracer uptake in bone infarction.
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8
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Abstract
We present a review of several bone (osteoid)-forming tumors including enostosis, osteoid osteoma, osteoblastoma, and osteosarcoma. These entities were chosen because they are reasonably common-neither seen every day nor rare. When applicable, recent information about the lesions is included.
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Affiliation(s)
- Behrang Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Raul Fernando Valenzuela
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Justin E Bird
- Department of Orthopaedic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tamara Miner Haygood
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
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Abstract
We will provide an imaging-focused discussion of 3 benign bone tumors that do not fit in the categories of cartilaginous tumors or osteoid tumors. We have chosen giant cell tumor of bone, unicameral bone cyst, and fibrous dysplasia. All 3 of these entities are common enough that one does not have to be a musculoskeletal radiologist in a cancer hospital to encounter them occasionally, but none of them should be seen frequently.
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Affiliation(s)
- Tamara Miner Haygood
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Behrang Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
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Chen B, Feng H, Xie J, Li C, Zhang Y, Wang S. Differentiation of soft tissue and bone sarcomas from benign lesions utilizing 18F-FDG PET/CT-derived parameters. BMC Med Imaging 2020; 20:85. [PMID: 32711449 PMCID: PMC7382845 DOI: 10.1186/s12880-020-00486-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/16/2020] [Indexed: 01/07/2023] Open
Abstract
Background Accurate differentiation between malignant and benign changes in soft tissue and bone lesions is essential for the prevention of unnecessary biopsies and surgical resection. Nevertheless, it remains a challenge and a standard diagnosis modality is urgently needed. The objective of this study was to evaluate the usefulness of 18F-fluorodeoxyglucose (18F-FDG) PET/CT-derived parameters to differentiate soft tissue sarcoma (STS) and bone sarcoma (BS) from benign lesions. Methods Patients who had undergone pre-treatment 18F-FDG PET/CT imaging and subsequent pathological diagnoses to confirm malignant (STS and BS, n = 37) and benign (n = 33) soft tissue and bone lesions were retrospectively reviewed. The tumor size, PET and low-dose CT visual characteristics, maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and heterogeneous factor (HF) of each lesion were measured. Univariate and multivariate logistic regression analyses were conducted to determine the significant risk factors to distinguish sarcoma from benign lesions. To establish a regression model based on independent risk factors, and the receiver operating characteristic curves (ROCs) of individual parameters and their combination were plotted and compared. Conventional imaging scans were re-analyzed, and the diagnostic performance compared with the regression model. Results Univariate analysis results revealed that tumor size, SUVmax, MTV, TLG, and HF of 18F-FDG PET/CT imaging in the STS and BS group were all higher than in the benign lesions group (all P values were < 0.01). The differences in the visual characteristics between the two groups were also all statistically significant (P < 0.05). However, the multivariate regression model only included SUVmax and HF as independent risk factors, for which the odds ratios were 1.135 (95%CI: 1.026 ~ 1.256, P = 0.014) and 7.869 (95%CI: 2.119 ~ 29.230, P = 0.002), respectively. The regression model was constructed using the following expression: Logit (P) = − 2.461 + 0.127SUVmax + 2.063HF. The area under the ROC was 0.860, which was higher than SUVmax (0.744) and HF (0.790). The diagnostic performance of the regression model was superior to those of individual parameters and conventional imaging. Conclusion The regression model including SUVmax and HF based on 18F-FDG PET/CT imaging may be useful for differentiating STS and BS from benign lesions.
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Affiliation(s)
- Bo Chen
- Department of Radiology, The Second Affiliated Hospital of Dalian Medical University, Shahekou district, Zhongshan road, NO.467, Dalian, Liaoning Province, People's Republic of China.,Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Xigang district, Zhongshan road, No.222, Dalian, China
| | - Hongbo Feng
- Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Xigang district, Zhongshan road, No.222, Dalian, China
| | - Jinghui Xie
- Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Xigang district, Zhongshan road, No.222, Dalian, China
| | - Chun Li
- Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Xigang district, Zhongshan road, No.222, Dalian, China
| | - Yu Zhang
- Department of Radiology, The Second Affiliated Hospital of Dalian Medical University, Shahekou district, Zhongshan road, NO.467, Dalian, Liaoning Province, People's Republic of China
| | - Shaowu Wang
- Department of Radiology, The Second Affiliated Hospital of Dalian Medical University, Shahekou district, Zhongshan road, NO.467, Dalian, Liaoning Province, People's Republic of China.
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