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Diagnosis and assessment of the treatment response in a case of giant cell arteritis using 18F-FDG PET/CT
Diagnóstico y evaluación de la respuesta al tratamiento en un caso de arteritis de células gigantes con 18F-FDG-PET/TC
I. Martínez-Rodríguez
, R. Del Castillo-Matos, A. Rubio-Vassallo, F. Ortega-Nava, N.A. Martínez-Amador, J.M. Carril
Corresponding author
Servicio de Medicina Nuclear, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
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array:22 [ "pii" => "S2253654X12000595" "issn" => "2253654X" "doi" => "10.1016/j.remn.2012.01.007" "estado" => "S300" "fechaPublicacion" => "2012-07-01" "aid" => "17" "copyright" => "Elsevier España, S.L. and SEMNIM" "copyrightAnyo" => "2012" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Rev Esp Med Nucl Imagen Mol. 2012;31:233-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1681 "formatos" => array:3 [ "EPUB" => 9 "HTML" => 1391 "PDF" => 281 ] ] "itemAnterior" => array:18 [ "pii" => "S2253654X12000972" "issn" => "2253654X" "doi" => "10.1016/j.remn.2012.03.008" "estado" => "S300" "fechaPublicacion" => "2012-07-01" "aid" => "32" "copyright" => "Elsevier España, S.L. and SEMNIM" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Rev Esp Med Nucl Imagen Mol. 2012;31:231-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1709 "formatos" => array:3 [ "EPUB" => 8 "HTML" => 1417 "PDF" => 284 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Interesting images</span>" "titulo" => "Multimodality imaging in biochemical recurrence of prostate cancer: Utility of <span class="elsevierStyleSup">18</span>F-NaF PET/CT in early detection of metastasis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "231" "paginaFinal" => "232" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Imágenes multimodales en la recurrencia bioquímica del cáncer de próstata: utilidad de <span class="elsevierStyleSup">18</span>F-NaF PET/TAC en la detección precoz de metástasis" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2118 "Ancho" => 2667 "Tamanyo" => 346217 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Demonstration of widespread osseous metastatic disease with <span class="elsevierStyleSup">18</span>F-NaF PET/CT: maximum intensity projection images of <span class="elsevierStyleSup">18</span>F-NaF PET/CT (A) at baseline, (B) at 6 months after start of therapy, (C) transaxial CT and fused <span class="elsevierStyleSup">18</span>F-NaF PET/CT appearance of a lesion in L4 at baseline and at 6 months with demonstration of therapy-induced decline in lesion <span class="elsevierStyleSup">18</span>F-NaF uptake and increase in sclerosis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Desai, M.E. Gross, H. Jadvar" "autores" => array:3 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Desai" ] 1 => array:2 [ "nombre" => "M.E." "apellidos" => "Gross" ] 2 => array:2 [ "nombre" => "H." "apellidos" => "Jadvar" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253654X12000972?idApp=UINPBA00004N" "url" => "/2253654X/0000003100000004/v1_201305061109/S2253654X12000972/v1_201305061109/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Interesting images</span>" "titulo" => "Diagnosis and assessment of the treatment response in a case of giant cell arteritis using <span class="elsevierStyleSup">18</span>F-FDG PET/CT" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "233" "paginaFinal" => "235" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "I. Martínez-Rodríguez, R. Del Castillo-Matos, A. Rubio-Vassallo, F. Ortega-Nava, N.A. Martínez-Amador, J.M. Carril" "autores" => array:6 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Martínez-Rodríguez" "email" => array:1 [ 0 => "mimartinez@humv.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Del Castillo-Matos" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Rubio-Vassallo" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Ortega-Nava" ] 4 => array:2 [ "nombre" => "N.A." "apellidos" => "Martínez-Amador" ] 5 => array:2 [ "nombre" => "J.M." "apellidos" => "Carril" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diagnóstico y evaluación de la respuesta al tratamiento en un caso de arteritis de células gigantes con <span class="elsevierStyleSup">18</span>F-FDG-PET/TC" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3083 "Ancho" => 2163 "Tamanyo" => 274254 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sagittal PET and PET/CT fused images of the pretreatment study (A, upper row) show a well-defined lineal uptake along the vessel walls of the thoracic aorta. Sagittal PET and PET/CT fused images 4 months after therapy (B, lower row) show a decrease in the intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake in the thoracic aorta wall.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 56-year-old woman complained of a five months history of low-grade fever, headache, cough, weight loss, backache, weakness and muscle pain in the lower extremities with progressive difficulties of gait. Physical examination was normal. Biochemical data showed an erythrocyte sedimentation rate (ESR) of 94<span class="elsevierStyleHsp" style=""></span>mm/h, a C-reactive protein (CRP) of 4.2<span class="elsevierStyleHsp" style=""></span>mg/dl, and a normocytic anemia with hemoglobin of 11.3<span class="elsevierStyleHsp" style=""></span>g/dl. All other laboratory tests, including thyroid hormones, tumour markers, rheumatoid factor, total complement level, anti-streptolysin O (ASLO), virus serology, antinuclear antibody (ANA), antiproteinase-3, antimyeloperoxidase antibody and angiotensin-converting enzyme (ACE) were negative.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Chest X-ray, abdominal ultrasonography, and thoracic and abdominal CT were performed and reported as normal. Therefore, a <span class="elsevierStyleSup">67</span>Ga-citrate scan was requested but planar whole-body views and thoracic SPECT showed no abnormality.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this context, and as giant cell arteritis (GCA) and/or polymyalgia rheumatica was suspected, an <span class="elsevierStyleSup">18</span>F-FDG PET/CT scan was requested. <span class="elsevierStyleSup">18</span>F-FDG PET/CT was performed 90<span class="elsevierStyleHsp" style=""></span>min after intravenous injection of 7 MBq/kg of <span class="elsevierStyleSup">18</span>F-FDG. Basal glucose serum level was 91<span class="elsevierStyleHsp" style=""></span>mg/dl. First, a low-dose CT scan was acquired and data were used for attenuation correction and anatomical localization purposes. Following the CT scan, a whole-body PET scan including extremities was acquired (2<span class="elsevierStyleHsp" style=""></span>min per bed). The images were reconstructed using an iterative OSEM algorithm (2 iterations and 8 subsets) and a Gaussian filter of 5<span class="elsevierStyleHsp" style=""></span>mm. The images obtained revealed a well defined increased <span class="elsevierStyleSup">18</span>F-FDG lineal uptake along the walls of the supra-aortic trunks, thoracic and abdominal aorta (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1A, 2A and B</a>), initial part of the iliac arteries, and femoral and tibioperoneal arteries (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). Based on <span class="elsevierStyleSup">18</span>F-FDG PET/CT findings and increased levels of ESR and CRP, a diagnosis of GCA was established.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A biopsy of the right temporal artery performed after PET/CT was reported as myointimal fibrosis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment with oral prednisone (40<span class="elsevierStyleHsp" style=""></span>mg daily) and methotrexate (2.5<span class="elsevierStyleHsp" style=""></span>mg) was initiated and an early clinical improvement was evident, with remission of fever, headache, muscle pain and weakness and also ESR and CRP returned to normal levels.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleSup">18</span>F-FDG PET/CT scan was repeated 4 months later to evaluate the response to therapy, following the same protocol as the previous one. At this time, the patient was receiving a decreasing regimen of prednisone (25<span class="elsevierStyleHsp" style=""></span>mg daily) and metotrexate (2.5<span class="elsevierStyleHsp" style=""></span>mg). The images obtained showed a reduction in the intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake in all vascular regions affected (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1B, 2C and D</a>), especially marked in the femoral and tibioperoneal arteries (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B), related to a good response to treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Several studies have demonstrated that <span class="elsevierStyleSup">18</span>F-FDG PET/CT is a useful non-invasive functional imaging technique for assessing the activity and extent of large vessel vasculitis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In our case, <span class="elsevierStyleSup">18</span>F-FDG PET/CT examination contributed to the management of the patient in two ways. First, for the diagnosis of GCA in a setting where non-specific symptoms of the disease were present and temporal artery biopsy was negative, something which is not rare. Second, and in addition, the follow-up <span class="elsevierStyleSup">18</span>F-FDG PET/CT proved its value to assess the treatment response by showing a decrease of the uptake by the vessel walls in the vascular regions involved, as it has been previously reported.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-01-25" "fechaAceptado" => "2012-01-29" "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3083 "Ancho" => 2163 "Tamanyo" => 274254 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sagittal PET and PET/CT fused images of the pretreatment study (A, upper row) show a well-defined lineal uptake along the vessel walls of the thoracic aorta. Sagittal PET and PET/CT fused images 4 months after therapy (B, lower row) show a decrease in the intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake in the thoracic aorta wall.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1233 "Ancho" => 3000 "Tamanyo" => 171406 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Thoracic (A) and abdominal (B) axial PET and PET/CT fused images of the pretreatment study. Thoracic (C) and abdominal (D) axial PET and PET/CT fused images after treatment show an important decrease of the <span class="elsevierStyleSup">18</span>F-FDG uptake in the aorta wall.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1583 "Ancho" => 1952 "Tamanyo" => 79099 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">MIP images of the lower extremities. The pretreatment PET/CT scan (A) shows a very intense <span class="elsevierStyleSup">18</span>F-FDG uptake along the femoral and tibioperoneal arteries. The PET/CT performed after treatment (B) reveals a striking decrease of the uptake.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The value of [18F]FDG-PET in the diagnosis of large-vessel vasculitis and the assessment of activity and extent of disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.A. Walter" 1 => "R.A. Melzer" 2 => "C. Schindler" 3 => "J. Müller-Brand" 4 => "A. Tyndall" 5 => "E.U. Nitzsche" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00259-004-1757-9" "Revista" => array:6 [ "tituloSerie" => "Eur J Nucl Med Mol Imaging" "fecha" => "2005" "volumen" => "32" "paginaInicial" => "674" "paginaFinal" => "681" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15747154" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of 18F-FDG PET/TAC in the evaluation of large-vessel vasculitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Del Castillo-Matos" 1 => "I. Martínez-Rodríguez" 2 => "I. Banzo" 3 => "R. Quirce" 4 => "J. Jimenez-Bonilla" 5 => "M. De Arcocha" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Nucl Med Mol Imaging" "fecha" => "2011" "volumen" => "38" "numero" => "Suppl. 2" "paginaInicial" => "S196" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Repetitive <span class="elsevierStyleSup">18</span>F-fluorodeoxyglucose positron emission tomography in giant cell arteritis: a prospective study of 35 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D. Blockmans" 1 => "L. de Ceuninck" 2 => "S. Vanderschueren" 3 => "D. Knockaert" 4 => "L. Mortelmans" 5 => "H. Bobbaers" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/art.21699" "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "2006" "volumen" => "55" "paginaInicial" => "131" "paginaFinal" => "137" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16463425" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/2253654X/0000003100000004/v1_201305061109/S2253654X12000595/v1_201305061109/en/main.assets" "Apartado" => array:4 [ "identificador" => "7962" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Imágenes de interés" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/2253654X/0000003100000004/v1_201305061109/S2253654X12000595/v1_201305061109/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253654X12000595?idApp=UINPBA00004N" ]
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