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Cabrera, A.L. Caicedo, A. Elena, MªP. Garrastachu, F. Cañete, R. Ramírez" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Cabrera" "email" => array:1 [ 0 => "acvillegas@riojasalud.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A.L." "apellidos" => "Caicedo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Elena" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "MªP." 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"apellidos" => "Ramírez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, CIBIR, Hospital de San Pedro, Logroño, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital de San Pedro, Logroño, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "PET-TAC con <span class="elsevierStyleSup">18</span>F-FDG en el diagnóstico de la arteritis de Takayasu y la valoración del tratamiento" ] ] "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" => 906 "Ancho" => 1302 "Tamanyo" => 123170 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Details of a sagittal section in the initial pre-treatment scan equivalent to the axial slices at the level of the abdominal aorta and its bifurcation, with tracer deposits visible on vascular walls (A). There are no visible tracer deposits in the second scan (B).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Diagnosis of Takayasu's arteritis is mainly clinical but has an anatomopathological background. This form of vasculitis is characterized by inflammation in the vessel walls, thickening of the adventitia, and infiltration of the tunica media by inflammatory cells. This process results in the destruction of local muscle cells and elastin, intimal hyperplasia and fibrosis. Scarring and granulomas appear in the walls of the affected vessels, which, in time, cause stenosis and localized or segmental vasodilation. It is precisely these changes that cause symptoms that can lead to diagnosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The wide clinical spectrum presented by the patients (approximately 40% of patients have nonspecific symptoms that do not meet diagnostic criteria) and various diagnostic limitations often result in a delay in diagnosis and treatment. The analytical parameters are sometimes normal or do not show significant changes. The erythrocyte sedimentation rate (ESR) is normal in up to 30% of patients, with the disease proven by biopsy.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Computed tomography (CT) and magnetic resonance imaging (MRI) can reveal dilatations and stenosis and detect inflammatory changes in the vascular wall, such as edema and thickening of the wall, even when conventional angiography is negative. However, these changes are often found at a late stage and do not correlate with disease activity.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Doppler ultrasound tests can quantify blood flow and its variation due to vascular stenosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recent studies suggest that positron emission tomography (PET) and PET-CT with <span class="elsevierStyleSup">18</span>F-fluorodeoxyglucose (<span class="elsevierStyleSup">18</span>F-FDG) allow early diagnosis of the disease. These methods, because of the functional nature of the exploration, can be also used to monitor the inflammatory activity in the vascular walls and the therapeutic effect of the treatment.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We present a case of a patient with no specific clinical symptoms, who was diagnosed with Takayasu's arteritis on the basis of the results of imaging analysis and positive biopsy. After initial treatment, PET with <span class="elsevierStyleSup">18</span>F-FDG was used to assess the therapeutic efficacy of the treatment.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was a 64-year-old woman, heavy smoker until 3 months before the examination, with dyslipidemia, hypertension, chronic conjunctivitis and sinusitis. Previous examination of the patient (using echocardiogram and CT) had revealed a dilatation of the aortic root and ascending aorta and a secondary aortic insufficiency; however, she remained asymptomatic.</p><p id="par0035" class="elsevierStylePara elsevierViewall">After replacement of her aortic valve prosthesis, pathological examination of the surgical specimen showed granulomatous giant cell aortitis compatible with Takayasu's disease and atherosclerosis. The patient did not suffer from vascular pain, syncope, dizziness, or shortness of breath.</p><p id="par0040" class="elsevierStylePara elsevierViewall">CT examination performed 18 months after the surgical intervention showed an increase in the diameter of the descending aorta in comparison with the previous results, suggesting a silent progression of the disease. As the results of this new examination indicated a continuing inflammatory activity, it has been decided to carry out a further study of the patient. The study, described in this report, was designed to assess the severity of the inflammatory activity, establish an appropriate treatment, and evaluate its efficacy.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient did not present any systemic, neurological, digestive, or cutaneous symptoms; she did not fulfill clinical criteria for Takayasu's arteritis. The diagnosis was made on the basis of the histological examination of the surgical specimen. The levels of acute phase reactants remained normal.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We conducted a PET-CT scan with <span class="elsevierStyleSup">18</span>F-FDG, following the usual protocol.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The images showed an accumulation of the tracer along the wall of the first part of the abdominal aorta (SUV max: 4.48), with a linear craniocaudal extension of 10.5<span class="elsevierStyleHsp" style=""></span>cm. We also observed an increased deposition of the tracer, in a linear pattern, in the aortic bifurcation and the first part of common iliac arteries, with an extension of 3.2<span class="elsevierStyleHsp" style=""></span>cm on the right-hand side (SUV max.: 3.67). Both cases were assessed as visual arteritis grade III (Meller scale) (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1A, 2A, and 3A</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The level of C-reactive protein (CRP) was elevated (16<span class="elsevierStyleHsp" style=""></span>mg/L; normal range: up to 10<span class="elsevierStyleHsp" style=""></span>mg/L). The ESR was within normal limits (11<span class="elsevierStyleHsp" style=""></span>mm/h; normal: 0–30<span class="elsevierStyleHsp" style=""></span>mm/h).</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient was treated with prednisone (60<span class="elsevierStyleHsp" style=""></span>mg/day) and methotrexate (10<span class="elsevierStyleHsp" style=""></span>mg/week) for four weeks. Subsequently, the dose of prednisone was gradually reduced (by 5<span class="elsevierStyleHsp" style=""></span>mg/week) to a maintenance dose of 15<span class="elsevierStyleHsp" style=""></span>mg/day. The dose of methotrexate was increased (after 4 weeks of 10<span class="elsevierStyleHsp" style=""></span>mg/week treatment) to 20<span class="elsevierStyleHsp" style=""></span>mg/week. Then, we repeated the analysis and found that the normalized levels of C-reactive protein (below 1) and ESR remained average.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The patient underwent the second PET scan (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1B, 2B, and 3B</a>) three months after the first. We found that the <span class="elsevierStyleSup">18</span>F-FDG uptake (clearly visible in the first scan, in the posterior wall of the descending aorta and at the level of iliac bifurcation) disappeared.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Takayasu arteritis is an inflammatory disease of unknown etiology that affects arteries of large and medium size. The inflammatory mechanism in this disease is associated with the proliferation of vasa vasorum and influx of inflammatory cells into the vessel walls. Antigen-presenting cells play a key role in the pathophysiology of the process. These cells are activated in response to a still-unidentified antigen and trigger the production of inflammatory mediators and activation of lymphocytes and macrophages.</p><p id="par0075" class="elsevierStylePara elsevierViewall">There are reports demonstrating that <span class="elsevierStyleSup">18</span>F-FDG PET can be used in the diagnosis of vasculitis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> with high sensitivity and specificity. This technique also provides information on the location and extent of vascular involvement. The main advantage of the method is the ability to detect early stages of the disease in patients with nonspecific symptoms associated with vasculitis, before the onset of symptoms of vascular stenosis and hypertension. Some studies have demonstrated the superiority of this method over CT and MRI.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Diagnostic criteria of PET imaging are based on visual analysis of the tracer deposits in the vascular wall, its semiology, distribution, and intensity.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake in the large vessels is graded visually (and compared to the uptake by the liver<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>).</p><p id="par0085" class="elsevierStylePara elsevierViewall">The criteria for the diagnosis of active inflammation are uptake grade II or III in the thoracic aorta and any visible uptake in other segments. In the case presented here, the severity of inflammation in the vessels was higher than that in the liver (grade III on Meyer scale). The uptake was linearly distributed in the vessel walls and had a patchy distribution in the abdominal aorta. These deposits had a maximum SUV of 4.48. Another diagnostic approach is a semiquantitative assessment using SUV (Standardized Uptake Value), although there is no consensus on threshold SUV value for diagnosing vasculitis. Some authors have proposed a SUV of 1.3 as diagnostic value for patients with temporal arteritis and SUV of 2.7 or higher as a criterion for intense inflammatory activity.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However, there is a strong correlation between SUV and visual diagnostic criteria<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>; a visual analysis might be sufficient for correct diagnosis.</p><p id="par0090" class="elsevierStylePara elsevierViewall">A recently published report has concluded that a delayed acquisition scan (180<span class="elsevierStyleHsp" style=""></span>min) provides a more detailed view of the vessel walls than the conventional acquisition procedure (60<span class="elsevierStyleHsp" style=""></span>min). This delayed acquisition scan has shown the disappearance of inflammatory activity in the vascular pool, helping in a correct diagnosis of vasculitis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In our case, arteritis had been already diagnosed using histopathological methods; therefore, the results of the late analysis were not as critical. A pattern of diffuse activity in the large vessels that might correspond to vascular background activity or arteriosclerosis was not found either.</p><p id="par0095" class="elsevierStylePara elsevierViewall">ESR and CRP monitoring has been utilized in the assessment of disease activity and response to therapy in some patients. However, the analysis of the acute phase response often gives unreliable indicators. Histological studies show that, in up to 44% of alleged responders, the acute phase reactants can normalize and the symptoms might disappear while inflammatory activity persists.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The usefulness of <span class="elsevierStyleSup">18</span>F-FDG PET is not limited to the diagnosis of vasculitis and the assessment of its severity. There is also accumulating evidence that this technique can be used in the evaluation of therapeutic efficacy.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Anti-inflammatory therapy responders have shown a reduction in the tracer uptake, and a correlation with the analytical parameters has been demonstrated (and was also observed in our case).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Furthermore, the reduction in the tracer uptake is observed before the morphological changes in the vascular walls (such as edema or thickening) can be visualized using other techniques.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In conclusion, PET-CT with <span class="elsevierStyleSup">18</span>F-FDG is fast becoming an ideal tool for the management of patients with vasculitis.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres362361" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec342050" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres362360" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec342051" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-08-29" "fechaAceptado" => "2013-11-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec342050" "palabras" => array:4 [ 0 => "Vasculitis" 1 => "Takayasu" 2 => "<span class="elsevierStyleSup">18</span>F-FDG" 3 => "PET-CT" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec342051" "palabras" => array:4 [ 0 => "Vasculitis" 1 => "Takayasu" 2 => "<span class="elsevierStyleSup">18</span>F-FDG" 3 => "PET-TAC" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We present a patient without specific symptoms of vasculitis and with normal acute phase reactants. The patient was diagnosed of Takayasu's arteritis on the basis of anatomopathological findings and was referred for <span class="elsevierStyleSup">18</span>F-FDG PET/CT examination. The results demonstrated inflammatory activity in the vessel walls of the aorta. After 3-month treatment, a second <span class="elsevierStyleSup">18</span>F-FDG PET/CT scan was performed to assess the therapeutic response. We discuss the contribution of <span class="elsevierStyleSup">18</span>F-FDG PET/CT to the management of this pathological entity.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos un caso clínico de una paciente sin síntomas específicos de vasculitis, con reactantes de fase aguda normales, pero con el diagnóstico anatomopatológico de arteritis de Takayasu que nos fue remitida para realizar un PET-TAC con <span class="elsevierStyleSup">18</span>F-FDG. Los hallazgos de la exploración permitieron constatar actividad inflamatoria en las paredes vasculares de la aorta y tras la instauración del tratamiento adecuado, una segunda exploración con <span class="elsevierStyleSup">18</span>F-FDG, valoró la respuesta terapéutica correctamente. Se discute las aportaciones de la PET-TAC con <span class="elsevierStyleSup">18</span>F-FDG en el manejo de esta entidad patológica.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cabrera A, Caicedo AL, Elena A, Garrastachu MP, Cañete F, Ramírez R. PET-TAC con 18F-FDG en el diagnóstico de vasculitis de Takayasu y la valoración del tratamiento. Rev Esp Med Nucl Imagen Mol. 2014;33:302–305.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1653 "Ancho" => 915 "Tamanyo" => 106366 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Coronal sections in the initial PET scan (A) showing <span class="elsevierStyleSup">18</span>F-FDG uptake along the posterior wall of the abdominal aorta and at the bifurcation (arrows). Coronal sections in the second scan (B), carried out after treatment, show lack of inflammatory activity in the vascular walls.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 906 "Ancho" => 1302 "Tamanyo" => 123170 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Details of a sagittal section in the initial pre-treatment scan equivalent to the axial slices at the level of the abdominal aorta and its bifurcation, with tracer deposits visible on vascular walls (A). There are no visible tracer deposits in the second scan (B).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1193 "Ancho" => 1502 "Tamanyo" => 212061 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Details of axial slices; overlay of the initial (A) and final scan (B).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of imaging studies in the diagnosis and follow-up of large-vessel vasculitis: an update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N. 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18F-FDG PET/CT in the diagnosis of Takayasu's arteritis and the assessment of response to therapy
PET-TAC con 18F-FDG en el diagnóstico de la arteritis de Takayasu y la valoración del tratamiento