Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography for the diagnosis of osteomyelitis related to diabetic foot: A systematic review and a meta-analysis

ObjectiveTo systematically review and meta-analyse published data about the diagnostic performance of Fluorine-18-Fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) and PET/computed tomography (PET/CT) in osteomyelitis related to diabetic foot.MethodsA comprehensive literature search of studies on ¹⁸F-FDG-PET and PET/CT in patients with diabetic foot was performed. Pooled sensitivity, specificity, positive and negative likelihood ratio (LR+ and LR?) and diagnostic odds ratio (DOR) and area under the summary ROC curve of ¹⁸F-FDG-PET and PET/CT in patients with osteomyelitis related to diabetic foot were calculated.ResultsNine studies comprising 299 patients with diabetic foot were included in the qualitative analysis (systematic review) and discussed. The quantitative analysis (meta-analysis) of four selected studies provided the following results on a per patient-based analysis: sensitivity was 74% [95% confidence interval (95%CI): 60–85%], specificity 91% (95%CI: 85–96%), LR+ 5.56 (95%CI: 2.02–15.27), LR? 0.37 (95%CI: 0.10–1.35), and DOR 16.96 (95%CI: 2.06–139.66). The area under the summary ROC curve was 0.874.ConclusionsIn patients with suspected osteomyelitis related to diabetic foot ¹⁸F-FDG-PET and PET/CT demonstrated a high specificity, being potentially useful tools if combined with other imaging methods such as MRI. Nevertheless, the literature focusing on the use of ¹⁸F-FDG-PET and PET/CT in this setting remains still limited.     

The value of 18F‐FDG PET/CT in diagnosing and localising deep sternal wound infection to guide surgical debridement

Deep sternal wound infection (DSWI) is a severe complication in patients after open heart surgery (OHS). But there is a lack of appropriate imaging tool to detect the infection sites, which may lead to incomplete debridement. The present study aims to investigate the value of ¹⁸F‐fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F‐FDG PET/CT) in comparison with CT scan in diagnosing and localising DSWI. A total of 102 patients with DSWI after OHS were retrospectively collected from January 2012 to December 2017 in our hospital. All the patients had surgical debridements for DSWI with pretreatment imaging of either ¹⁸F‐FDG PET/CT or CT scan. The sensitivity, specificity, and accuracy of localising infection sites were compared between PET/CT and CT groups, with surgical, microbiological, and histopathological findings as the gold standard. The length of hospital stays and the rate of recurrence were also compared. Ten patients in the PET/CT group had a follow‐up PET/CT scan after debridement, and the correlations between the changes of PET/CT findings and surgical outcomes were analysed. ¹⁸F‐FDG PET/CT is more accurate than CT in diagnosing and localising DSWI after OHS, which leads to a more successful surgical debridement with a lower rate of recurrence and a shorter length of hospital stay. In addition, follow‐up PET/CT after debridement could evaluate the treatment effect.     

The distinctive role of positron emission tomography/computed tomography in breast carcinoma with brown adipose tissue 2-fluoro-2-deoxy-d-glucose uptake

The diagnostic power of an integrated positron emission tomography/computed tomography (PET/CT) system for whole-body 2-fluoro-2-deoxy-d-glucose (FDG) imaging is clearly demonstrated in this case report. The precise anatomic localization of FDG uptake with CT in a PET/CT scan of a patient with known breast carcinoma helped identify a contralateral breast tumor with axillary lymph node metastasis despite the presence of extensive physiologic brown fat FDG uptake. Accordingly, the patient received appropriate surgical management and pathologic confirmation of the disease.     

Hybrid imaging with 99mTc‐WBC SPECT/CT to monitor the effect of therapy in diabetic foot osteomyelitis

This study sought to assess the utility of monitoring response to treatment of diabetic foot osteomyelitis (DFO) with Tc‐99m WBC‐labelled single photon emission computed tomography (SPECT/CT) imaging. This is a retrospective cohort study of 20 patients with DFO with sequential Tc‐99m WBC‐labelled SPECT/CT imaging. Radiologic findings of osteomyelitis were evaluated and imaging results were correlated with clinical outcomes subtracted from chart review. Successful treatment of osteomyelitis was defined by wound healing and/or lack of re‐admission for bone infection of the same site within 1 year. The sensitivity, specificity, positive predictive value and negative predictive value of SPECT/CT to determine osteomyelitis treatment remission were 90%, 56%, 69% and 83%, respectively. Tc‐99m WBC‐labelled SPECT/CT imaging may be useful to help determine treatment outcomes for DFO.     

18F-FDG PET/CT与多层螺旋CT在进展期胃癌术前TNM分期的对比研究

目的 应用18F-FDG PET/CT(PET/CT)与多层螺旋CT对进展期胃癌术前TNM分期进行对比研究,以期更客观地评估术前分期,指导治疗.方法 对术前行PET/CT检查的39例及MSCT检查的40例进展期胃癌,分别进行术前TNM分期,将检测结果与术中所见及病理进行对照.结果 PET/CT对原发灶、区域淋巴结、N3转移淋巴结的准确率分别为92.3%、66.7%、100.0%;而MSCT诊断的准确率分别为82.0%、50.0%、62.5%.结论 (1)PET/CT和多层螺旋CT对原发灶、区域淋巴结转移的准确率都较高,差异无统计学意义,由于多层螺旋CT临床应用广泛且费用远低于PET/CT,是首选的检测手段;(2)PET/CT对N3转移淋巴结、远处转移灶检测的准确率明显高于多层螺旋CT,为临床提供更为全面客观的术前分期,指导治疗;(3)由于PET/CT也存在一定假阴性,结合腹腔镜检可减少或避免不必要的剖腹术.     

Detection of incidental colorectal tumours with 18F‐labelled 2‐fluoro‐2‐deoxyglucose positron emission tomography/computed tomography scans: results of a prospective study

Aim This study assessed the clinical significance of incidental colorectal 2‐fluoro‐2‐deoxyglucose (FDG) uptake using ¹⁸F‐FDG positron emission tomography/computed tomography (PET/CT) scans and evaluated the importance of colonoscopy when incidental colorectal FDG uptake was observed. Method A prospective study was designed and conducted at a single institution over a 2‐year period. In patients undergoing PET/CT scans, all with FDG uptake in the colorectum were assigned to have colonoscopy and biopsy. The value of PET/CT scanning was studied by comparison with the colonoscopy and biopsy results. Results Among 10 978 PET/CT scans, one or more focal uptakes of FDG in the colorectum were observed in 148 (1.35%) patients. In 136 valid patients, malignant colorectal tumours and polyps were found in 23.5% and 20.5%, respectively,, while the colon in the other 56% was normal. A higher false‐positive rate was found in the right colon compared with the distal colorectum (66.2%vs 36.7%, P = 0.004). A significant increase of the maximum standardized uptake (SUVmax) value was found among normal, polyps and cancer groups. Multivariate analysis revealed that SUVmax was the risk factor for predicting colorectal cancer or polyps and FDG uptake in the right colon was a negative predictive factor for finding cancers or polyps. Conclusions Our study proves the necessity of colonoscopy when incidental FDG uptake is found on PET/CT imaging. The false‐positive FDG uptake is more commonly observed in the right colon. Although the SUVmax value is higher in cancer patients, a high SUVmax value does not necessarily result in malignancies.     

18F-FDG PET/CT in pancreatic adenocarcinoma: A role at initial imaging staging?

Pancreatic ductal adenocarcinoma represents 90% of all pancreatic tumors. The only hope for prolonged survival in patients with this condition still remains surgery with complete R0 resection. Initial imaging has a pivotal role to identify patients who are eligible to curative surgery and those who may benefit of neoadjuvant chemotherapy. This review provides an analysis of the recent literature on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in pancreatic adenocarcinoma. Performances of FDG PET in the detection of lymph node involvement and metastatic spread at initial staging and those in the assessment of response to treatment are described.     

Diagnosing osteomyelitis in the diabetic foot: a pilot study to examine the sensitivity and specificity of Tc99mwhite blood cell‐labelled single photon emission computed tomography/computed tomography

Diabetic foot ulceration poses a significant threat of osteomyelitis (OM) and subsequent amputation. The diagnosis of OM via imaging studies is difficult as radiographic findings do not present immediately and advanced imaging studies may be contraindicated or unavailable. A novel diagnostic tool has been developed which synthesises technetium‐99 white blood cell‐labelled single‐photon emission computed tomography and computed tomography (Tc^99mWBC labelled‐SPECT/CT) imaging, effectively enhancing anatomic detail. The aim of this pilot study was to determine the validity and reliability of this novel imaging technique in patients with diabetic foot ulcers in a Veterans Affairs healthcare facility. A retrospective review was performed on consecutive patients who met the inclusion criteria (n = 14) and underwent Tc^99mWBC‐labelled SPECT/CT for suspected OM. Histopathologic analysis of bone specimen (when available) and International Working Group on the Diabetic Foot consensus criteria were used as a reference standard. The sensitivity and specificity of Tc^99mWBC‐labelled SPECT/CT were 87·50% [confidence interval (CI): 64·58–110·42%] and 71·43% (CI: 37·96–104·90%), respectively. Negative predictive value (NPV) and positive predictive value (PPV) were 83·33% (CI: 53·51–113·15%) and 77·78% (CI: 50·62–104·94%), respectively, with a likelihood ratio (LR) of 3·063 and an accuracy of 80%. These findings suggest Tc^99mWBC‐labelled SPECT/CT can be useful in imaging OM in patients with diabetic foot ulcers.     

PET/CT检查注射~(18)F-FDG方法研究

目的比较PET/CT检查经留置针和头皮针注射~(18)F-2-氟-2-脱氧-D-葡萄糖(~(18)F-FDG)的差异,探讨预置留置针用于PET/CT检查的可行性。方法将120例行PET/CT检查患者按检查时间段分为对照组、模型1组和模型2组,对照组按常规方法采用头皮针注射18F-FDG,模型1组和模型2组采用留置针注射~(18)F-FDG,注射前生理盐水冲洗量均为3 mL,注射后分别为5 mL、5mL、10mL,比较三组残留放射性活度;同期选择45例已预置留置针的患者为实验组,采用留置针注射并不拔除留置针,注射前后生理盐水冲冼量分别为5mL、10mL,与对照组比较放射性浓聚、药物污染、受辐射时间的差异。结果对照组与实验组放射性浓聚及药物污染发生率、受辐射时间比较,差异无统计学意义(均P0.05);模型1组残留放射性活度显著高于对照组(P0.05)。结论 PET/CT检查可经预置留置针注射18F-FDG,使用时须增加冲洗管道的生理盐水量。     

Importance of adrenal incidentaloma in patients with a history of malignancy

BACKGROUND: Adrenal incidentaloma presents a frequent finding in patients with a history of malignancy. This study was carried out to determine whether imaging techniques can discriminate between a malignant and a benign adrenal tumor and subsequently select candidates for adrenal surgery. METHODS: Beginning in July 1995, oncologic patients with adrenal incidentaloma underwent abdominal ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and [ 18 ]fluoro-2-deoxy-D-glucose positron emission tomography (18-FDG-PET). Consecutively in all patients adrenalectomy was performed. Histologic findings were compared with the imaging results. RESULTS: In 42 patients, 33 to 79 years old (mean age, 58 years), 44 adrenal lesions were detectable. Two patients presented with bilateral adrenal masses. At operation, 43 adrenal resections and 3 biopsies were performed. Histologic examination revealed 31 metastases (71%) and 13 adrenal adenomas (29%). In metastases the sensitivity of ultrasonography, CT, MRI, and 18-FDG-PET was 66%, 81%, 100%, and 100%, respectively. For adrenal adenoma, the sensitivity of ultrasonography, CT, MRI, and 18-FDG-PET was 46%, 39%, 100%, and 54%, respectively. CONCLUSIONS: In oncologic patients with indeterminate adrenal tumors MRI and 18-FDG-PET provide accurate differentiation between metastases and benign adenomas. Positive results of these 2 imaging modalities are highly suggestive for metastatic disease. In cases of negative MRI and 18-FDG-PET results the adrenal lesion corresponds to a benign adenoma that needs no surgical intervention.     

Combined 18F‐fluorocholine and 18F‐fluoride positron emission tomography/computed tomography imaging for staging of high‐risk prostate cancer

Study Type – Diagnosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Positron emission tomography/computed tomography (PET/CT) with choline and fluoride for the detection of metastases in patients with prostate cancer have each been evaluated, with mixed results. Choline PET/CT has been evaluated against pelvic lymphadenectomy, generally with a low sensitivity but a high specificity; however, the study populations have been heterogenous. Fluoride PET/CT has been evaluated against other imaging methods, such as bone scan, single photon emission CT and MRI, and has been shown to have high specificity as well as sensitivity for bone metastases, but there are no studies with biopsy verification. This is the first study that evaluates the clinical use of both choline and fluoride PET/CT on the same patients in a well‐defined population of patients with high‐risk prostate cancer.

OBJECTIVE

• ? To investigate how often positron emission tomography/computed tomography (PET/CT) scans, with both ¹⁸F‐fluorocholine and ¹⁸F‐fluoride as markers, add clinically relevant information for patients with prostate cancer who have high‐risk tumours and a normal or inconclusive planar bone scan.

PATIENTS AND METHODS

• ? Patients with prostate cancer with prostate specific antigen (PSA) levels between 20 and 99 ng/mL and/or Gleason score 8–10 tumours, planned for treatment with curative intent based on routine staging with a negative or inconclusive bone scan, were further investigated with a ¹⁸F‐fluorocholine and a ¹⁸F‐fluoride PET/CT.
• ? None of the patients received hormonal therapy before the staging procedures were completed.

RESULTS

• ? For 50 of the 90 included patients (56%) one or both PET/CT scans indicated metastases.
• ? ¹⁸F‐fluorocholine PET/CT indicated lymph node metastases and/or bone metastases in 35 patients (39%).
• ? ¹⁸F‐fluoride PET/CT was suggestive for bone metastases in 37 patients (41%).
• ? In 18 patients (20%) the PET/CT scans indicated widespread metastases, leading to a change in therapy intent from curative to non‐curative.
• ? Of the patients with positive scans, 74% had Gleason score 8–10 tumours. Of the patients with Gleason score 8–10 tumours, 64% had positive scans.

CONCLUSIONS

• ? PET/CT scans with ¹⁸F‐fluorocholine and ¹⁸F‐fluoride commonly detect metastases in patients with high‐risk prostate cancer and a negative or inconclusive bone scan.
• ? For 20% of the patients the results of the PET/CT scans changed the treatment plan.

     

[18F]‐fluorocholine positron‐emission/computed tomography for lymph node staging of patients with prostate cancer: preliminary results of a prospective study

Study Type – Diagnostic (case series)
Level of Evidence 4

OBJECTIVES

To evaluate prospectively [¹⁸F]‐fluorocholine positron‐emission/computed tomography (FCH PET/CT) for lymph node staging of prostate cancer before intended curative therapy, and to determine whether imaging 15 or 60 min after radiotracer injection is preferable.

PATIENTS AND METHODS

In all, 25 consecutive patients with newly diagnosed prostate cancer (Gleason score >6, and/or a prostate‐specific antigen level of >10 ng/mL, and/or T3 cancer) were scanned before lymphadenectomy. Each patient was assessed twice with imaging, at 15 and 60 min after the injection with FCH. Images were compared with the results of histopathological examination of the surgically removed lymph nodes. Maximum standardized uptake values (SUV_max) at 15 and 60 min were also compared.

RESULTS

Histopathologically, metastases were present in removed lymph nodes from three patients. FCH PET/CT showed a high radiotracer uptake in four patients, the former three and a fourth. The sensitivity, specificity, positive and negative predictive value of FCH PET/CT for patient based lymph node staging of prostate cancer were 100%, 95%, 75% and 100%, respectively; the corresponding 95% confidence intervals were 29.2–100%, 77.2–99.9%, 19.4–99.4% and 83.9–100%, respectively. Values of SUV_max at early and late imaging were not significantly different.

CONCLUSIONS

This small series supports the use of FCH PET/CT as a tool for lymph node staging of patients with prostate cancer. Values of SUV_max at early and late imaging did not differ. However, larger prospective studies are needed to validate these findings.     

FDG‐PET proves to be reliable in the diagnostic workup of a rare cardiac hemangioma

The noninvasive characterization of cardiac tumors is of clinical importance for surgical resection planning. Conventional radiological examinations like cardiac computed tomography (CT) or magnetic resonance imaging (MRI) may be misleading as benign cardiac lesions can present features suspicious for malignancy. Moreover, the low prevalence of cardiac tumors may additionally hamper a sound diagnosis. However, fluorodeoxyglucose‐positron emission tomography (FDG‐PET) has proven to be a reliable tool for cardiac tumor characterization. Here, FDG‐PET/CT imaging of a 50‐year‐old man suffering from a cardiac tumor is presented. Despite CT and MRI signs of malignancy, FDG‐PET characterized the tumor as benign. Histology confirmed the FDG‐PET prediction and revealed a pericardial capillary hemangioma. Thereby, it seems important to integrate FDG‐PET in the diagnostic workup of cardiac tumors.     

La tomographie par émission de positons au 18F-FDG en pathologie rénale non oncologique : indications actuelles et perspectives

Positron emission tomography combined with computed tomography (PET/CT) is a nuclear imaging technique which provides anatomical and functional information. PET/CT is increasingly used in non-oncological nephrology since conventional radiological approaches after injection of contrast agents are relatively contra-indicated in patients with chronic kidney disease (CKD). PET/CT after i.v. injection of ¹⁸F-fluoro-deoxy-glucose (FDG) is not toxic and is characterized by a high sensitivity. The level of irradiation (∼5 mSv) is acceptable. CKD does not significantly influence tissue uptake of ¹⁸F-FDG. The purpose of the present review aims at detailing the non-oncological indications of ¹⁸F-FDG PET/CT in general nephrology and after kidney transplantation. Particularly, ¹⁸F-FDG PET/CT appears useful in the diagnosis of cyst infection in patients with autosomal dominant polycystic kidney disease, as well as in the characterization of retroperitoneal fibrosis. In kidney transplant recipients, ¹⁸F-FDG PET/CT may help in the diagnostic work-up of suspected acute rejection, thereby eventually avoiding unnecessary kidney transplant biopsy. Perspectives in ¹⁸F-FDG PET/CT imaging are discussed, including innovative approaches of image analysis.     

PET/CT Fusion Scan Enhances CT Staging in Patients with Pancreatic Neoplasms

Background  The role of fusion positron emission tomography/computed tomography scans (PET/CT) in staging of patients with pancreatic neoplasms (PN) is poorly defined. PET/CT may serve as an adjunct to standard imaging by increasing occult metastases detection. The purpose of this study was to assess the additional value, in relation to computed tomography (CT), of PET/CT imaging for patients with PN. Methods  Eighty-two patients with potentially resectable PN underwent staging with PET/CT and CT of the chest and abdomen. Sensitivity of diagnosing pancreatic cancer by PET/CT avidity was evaluated. The sensitivity of detecting metastases was compared between PET/CT, standard CT, and the combination of PET/CT and CT. The impact of PET/CT on patient management was estimated by calculating the percentage of patients whose treatment plan was altered due to PET/CT. Results  The sensitivity and specificity of PET/CT in diagnosing pancreatic cancer were 89% and 88%, respectively. Sensitivity of detecting metastatic disease for PET/CT alone, standard CT alone, and the combination of PET/CT and CT were 61%, 57%, and 87%, respectively. Findings on PET/CT influenced the clinical management in seven patients (11%), two with a supraclavicular lymph node (LN), two occult liver lesions, two peritoneal implants, and one peri-esophageal LN. Conclusion  This study evaluated PET/CT in the initial work-up of patients with PN. PET/CT increased sensitivity (87%) for detection of metastatic disease when combined with standard CT. In invasive cancer, PET/CT changed the management in 11% of our patients. PET/CT should be considered in the initial work-up of patients with potentially resectable pancreatic lesions.     

Hepatorenal Polycystic Disease and Fever: Diagnostic Contribution of Gallium Citrate Ga 67 Scan and Fluorine F 18 FDG-PET/CT

A cyst infection was suspected in a patient who was on haemodialysis for renal failure secondary to hepatorenal polycystic disease with persistent fever and pain in right hypochondrium despite antibiotherapy. Radiologic exams (ultrasonography, computed tomography [CT]), however, did not show signs of infection. For surgical removal of the infected cyst, a precise location was required.     

Clinical impact of, and prognostic stratification by, F-18 FDG PET/CT in head and neck mucosal squamous cell carcinoma

BACKGROUND: The aim of this study was to determine prospectively the incremental value of positron emission tomography/computed tomography (PET/CT) over conventional assessment (clinical examination and CT/MRI imaging). METHODS: All patients undergoing (18)F-fluorodeoxyglucose (FDG)-PET/CT for primary head and neck mucosal squamous cell carcinoma between January 2002 and December 2003 (inclusive) were included in this study provided they had undergone contemporaneous conventional assessment of the head and neck region and had 12 months minimum follow-up. RESULTS: Seventy-six patients underwent 100 PET/CT scans. The majority of patients (74%) were treated with definitive (chemo)radiotherapy. Median follow-up time was 28 months. PET/CT led to a TNM classification alteration in 34% (12/35), a change in radiotherapy planning technique and/or dose in 29% (10/35), and altered treatment response assessment in 43% (13/30). A complete metabolic response was predictive of overall survival (p = .037). CONCLUSION: Our results support incorporation of PET/CT into the management paradigm of head and neck mucosal squamous cell carcinoma.     

Role of PET/CT in muscle-invasive bladder cancer

The purpose of this study covered the diagnostic accuracy and usefulness of positron emission tomography/computed tomography (PET/CT) imaging in muscle invasive bladder cancer patients through previously published literature. Through 30 September, 2019, the PubMed database was searched for eligible articles that evaluated PET/CT imaging in bladder cancer patients. In general, FDG PET/CT, the most commonly used PET/CT imaging, does not show good performance for the detection of primary lesions; however, according to the literature it could accurately assess pelvic lymph node (LN) status better than other imaging technologies and it was especially helpful in determining extra-pelvic recurrences. More recently, non-FDG PET/CT imaging, such as C-11 acetate and C-11 choline, has been introduced. Although further research is required, preliminary results show the potential of these techniques to overcome the drawbacks of FDG. This concise study will overview the role of PET/CT when treating muscle-invasive bladder cancer (MIBC).     

Expanding role of 18F-fluoro-d-deoxyglucose PET and PET/CT in spinal infections

¹⁸F-fluoro-d-deoxyglucose positron emission tomography ([¹⁸F]-FDG PET) is successfully employed as a molecular imaging technique in oncology, and has become a promising imaging modality in the field of infection. The non-invasive diagnosis of spinal infections (SI) has been a challenge for physicians for many years. Morphological imaging modalities such as conventional radiography, computed tomography (CT), and magnetic resonance imaging (MRI) are techniques frequently used in patients with SI. However, these methods are sometimes non-specific, and difficulties in differentiating infectious from degenerative end-plate abnormalities or postoperative changes can occur. Moreover, in contrast to CT and MRI, FDG uptake in PET is not hampered by metallic implant-associated artifacts. Conventional radionuclide imaging tests, such as bone scintigraphy, labeled leukocyte, and gallium scanning, suffer from relatively poor spatial resolution and lack sensitivity, specificity, or both. Initial data show that [¹⁸F]-FDG PET is an emerging imaging technique for diagnosing SI. [¹⁸F]-FDG PET appears to be especially helpful in those cases in which MRI cannot be performed or is non-diagnostic, and as an adjunct in patients in whom the diagnosis is inconclusive. The article reviews the currently available literature on [¹⁸F]-FDG PET and PET/CT in the diagnosis of SI.