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COMMENTARY
Year : 2020  |  Volume : 35  |  Issue : 1  |  Page : 4-5  

18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in Large Vessel Vasculitis: Standardization is the Way Forward


Department of Nuclear Medicine and PET-CT, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India

Date of Submission14-Oct-2019
Date of Acceptance16-Oct-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Punit Sharma
Department of Nuclear Medicine and PET-CT, Apollo Gleneagles Hospitals, 58, Canal Circular Road, Kolkata - 700 054, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_185_19

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How to cite this article:
Sharma P. 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in Large Vessel Vasculitis: Standardization is the Way Forward. Indian J Nucl Med 2020;35:4-5

How to cite this URL:
Sharma P. 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in Large Vessel Vasculitis: Standardization is the Way Forward. Indian J Nucl Med [serial online] 2020 [cited 2020 Jul 11];35:4-5. Available from: http://www.ijnm.in/text.asp?2020/35/1/4/274375



Large vessel vasculitis (LVV) is defined as inflammatory pathology predominantly affecting the large arteries. The most common subtypes are Takayasu arteritis and giant cell arteritis (GCA). GCA in patient is often associated with polymyalgia rheumatica (PMR), as both belong to the same disease spectrum.[1]18 F-fluorodeoxyglucose (FDG) positron-emission tomography-computed tomography (PET-CT) is a functional hybrid imaging method which is an established tool in oncology and has also demonstrated its potential in various inflammatory pathologies such as LVV. It has been employed in LVV for diagnosis in patients with clinical suspicion as well as in fever of unknown origin, for monitoring response to immunosuppressive therapy and detecting relapse.[2],[3] The underlying mechanism is based on the ability of FDG PET-CT to detect enhanced glucose uptake from high glycolytic activity of inflammatory cells in inflamed arterial walls and synovia/bursa.[4]

The main hindrance to FDG PET-CT becoming a standardized diagnostic tool in LVV is the lack of internationally accepted visual and quantitative parameters. Several visual and semiquantitative methods have been proposed, from simple standardized uptake value metrics to target-to-background ratios.[5] A joint EANM, SNNMI, PIG, and ASNC working committee have addressed this issue and proposed two criterions for better standardization of PET-CT interpretation.[6] These include the use of a standardized 0–3 grading system: 0 = no uptake (≤mediastinum); 1 = low-grade uptake (<liver); 2 = intermediate-grade uptake (= liver), 3 = high-grade uptake (>liver), with Grade 2 possibly indicative and Grade 3 considered positive for active LVV. Another parameter, the total vascular score (TVS) can also be used, at seven different vascular regions (thoracic aorta, abdominal aorta, subclavian arteries, axillary arteries, carotid arteries, iliac arteries, and femoral arteries) as negative (0) or positive, further scored semiquantitatively as 1 (minimal but not negligible FDG uptake), 2 (clearly increased FDG uptake), or 3 (very marked FDG uptake). Therefore, a TVS could be calculated ranging from 0 (no vascular FDG uptake in any of the seven vascular regions) to 21 (vascular FDG uptake scored 3 in all seven territories). In one prospective study, by Blockmans and Bley, FDG PET-CT images were acquired at baseline and after 3 and 6 months of steroid treatment in LVV. It was seen that the TVS decreased significantly at 3 months (P< 0.0005), but no further decrease was seen at 6 months. As PMR and GCA frequently overlap, typical FDG joint uptake patterns should be reported, including uptake in glenohumeral synovia, subacromial-subdeltoid bursa, supraspinatus tendinitis and biceps synovitis (shoulder), trochanteric/ischial bursa, hip synovia, interspinous regions of the cervical and lumbar vertebrae, or the synovial tissue of the knees if present, including the use of a standardized 0–3 grading system.

In the current issue of Indian Journal of Nuclear Medicine, Malik et al. have addressed the standardization of FDG PET-CT in LVV. They have employed the TVS proposed previously and validated its use in the Indian population. In their retrospective study with FDG PET-CT images of 106 patients with LVV, not only TVS was seen to clinically useful, it also correlated with other markers of disease activity such as ESR. Furthermore, TVS was found to be very useful for the assessment of response to immunosuppressive therapy. Interestingly, associated joint inflammation due to PMR was picked up in 17% of this cohort of patients. Through their study, Malik et al. have addressed the gap in our knowledge regarding this important topic and must be congratulated for that. Further prospective studies with the goal toward standardizing FDG PET-CT for evaluation of LVV are warranted to decipher this complex but crucial subject.



 
   References Top

1.
Jennette JC, Falk RJ, Bacon PA, Basu N, Cid MC, Ferrario F, et al. 2012 revised international chapel hill consensus conference nomenclature of vasculitides. Arthritis Rheum 2013;65:1-1.  Back to cited text no. 1
    
2.
Blockmans D, Bley T, Schmidt W. Imaging for large-vessel vasculitis. Curr Opin Rheumatol 2009;21:19-28.  Back to cited text no. 2
    
3.
Karunanithi S, Sharma P, Bal C, Kumar R. (18)F-FDG PET/CT for diagnosis and treatment response evaluation in large vessel vasculitis. Eur J Nucl Med Mol Imaging 2014;41:586-7.  Back to cited text no. 3
    
4.
Lavado-Pérez C, Martínez-Rodríguez I, Martínez-Amador N, Banzo I, Quirce R, Jiménez-Bonilla J, et al. (18)F-FDG PET/CT for the detection of large vessel vasculitis in patients with polymyalgia rheumatica. Rev Esp Med Nucl Imagen Mol 2015;34:275-81.  Back to cited text no. 4
    
5.
Lee YH, Choi SJ, Ji JD, Song GG. Diagnostic accuracy of 18F-FDG PET or PET/CT for large vessel vasculitis: A meta-analysis. Z Rheumatol 2016;75:924-31.  Back to cited text no. 5
    
6.
Slart RH, Writing group, Reviewer group, Members of EANM Cardiovascular, Members of EANM Infection & Inflammation, Members of Committees, SNMMI Cardiovascular. et al. FDG-PET/CT (A) imaging in large vessel vasculitis and polymyalgia rheumatica: Joint procedural recommendation of the EANM, SNMMI, and the PET interest group (PIG), and endorsed by the ASNC. Eur J Nucl Med Mol Imaging 2018;45:1250-69.  Back to cited text no. 6
    




 

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