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Abnormal accumulation of [18F]fluorodeoxyglucose in the aortic wall

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  • ron072754
    Some good pictures at site! http://www.jsnm.org/files/paper/anm/ams205/ANM20-5-05.pdf Vol. 20, No.
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      Some good pictures at site!

       

      http://www.jsnm.org/files/paper/anm/ams205/ANM20-5-05.pdf

       

      Vol. 20, No. 5, 2006 Case Report

      361

      Annals of Nuclear Medicine Vol. 20, No. 5, 361–364, 2006

      CASE REPORT

      Received December 9, 2005, revision accepted March 3,

      2006.

      For reprint contact: Miwako Takahashi, M.D., Department of

      Radiology, The University of Tokyo, Graduate School of Medicine,

      Hongo, Bunkyo-ku, Tokyo 113–0033, JAPAN.

      INTRODUCTION

      FDG-PET imaging has played an important role in the

      diagnosis of various malignant tumors. Increased glucose

      transporter protein (GLUT) expression in various malignant

      tumors has been reported and it is suggested that

      increased GLUT expression contributes to increased FDG

      uptake in PET imaging.

      1–5

      Increased FDG uptake, however, is also observed in

      various kinds of inflammatory lesions,

      6,7 which suggests

      that FDG-PET imaging can be useful in localizing

      inflammatory lesions in patients who show unspecific

      general inflammatory and infectious findings.

      8–13

      In this report, we show three cases with FDG uptake in

      the arterial wall. The common features of these three cases

      provide insight into the pathological changes that contribute

      to intense FDG uptake and enhance the usefulness for

      diagnosis of inflammatory diseases.

      FDG-PET protocol

      Fluorine-18-labeled deoxyglucose (FDG) positron emission

      tomography (PET) scan of the whole body was

      performed after a 6-hour fast. The scans started 60 minutes

      after FDG injection at a dose of 296 MBq. Images

      were reconstructed with OSEM methods.

      CASE REPORTS

      Case 1

      A 57-year-old woman presented with a 3-month history of

      fever, dizziness and cough. The patient was initially

      treated with an antifebrile; however, her condition did not

      improve. At the time of her presentation at our facility, she

      had persistent elevation of C-reactive protein (CRP; 8.8

      mg/d

      l), an accelerated erythrocyte sedimentation rate

      (ESR; 116 mm), and elevated IL-2R (589 U/m

      l). PANCA,

      C-ANCA and rheumatoid factors were negative.

      Complement levels were slightly elevated. FDG-PET

      scan showed increased FDG uptake in the thoracic and

      abdominal aortic wall, and the uptake continued to the

      main branches of the thoracic aorta (Fig. 1a, b, d). A

      contrast-enhanced CT scan was taken 2 weeks after the

      FDG-PET scan and demonstrated thickening of the aortic

      wall (Fig. 1c). The localization of her inflammation in the

      arterial wall by FDG-PET yielded a diagnosis of Takayasu

      Abnormal accumulation of [

      18F]fluorodeoxyglucose

      in the aortic wall related to inflammatory changes:

      three case reports

      Miwako T

      AKAHASHI, Toshimitsu MOMOSE, Masashi KAMEYAMA and Kuni OHTOMO

      Department of Radiology, The University of Tokyo, Graduate School of Medicine

      We present 3 cases with abnormal accumulation of FDG in the aortic wall. Their clinical

      manifestations were vague or asymptomatic, and laboratory data were consistent with inflammatory

      reaction. These 3 patients were diagnosed with Takayasu arteritis, inflammatory aortic aneurysm

      (IAA), and retroperitoneal fibrosis (RF), respectively. FDG-PET and CT images showed the intense

      FDG uptake corresponding to the arterial walls and/or the soft tissue density surrounding the artery.

      It was deduced that FDG was probably taken up by inflammatory cells which infiltrated the arterial

      walls and/or the soft tissue mass. These cases indicated that FDG-PET is a useful method for

      localization of inflammatory lesion in patients with unspecific clinical findings and laboratory data.

      Key words:

      Takayasu arteritis, inflammatory aortic aneurysm, retroperitoneal fibrosis, FDG,

      inflammation

      362

      Miwako Takahashi, Toshimitsu Momose, Masashi Kameyama and Kuni Ohtomo Annals of Nuclear Medicine

      arteritis. The diagnosis was confirmed by laboratory data

      and improvement of her symptoms with the administration

      of steroids.

      Case 2

      A 54-year-old female underwent an FDG PET scan to

      determine the possibility of an underlying residual malignant

      lesion and distant metastasis at 4 years after liver

      surgery for rectal cancer metastasis. FDG-PET showed

      intense uptake of FDG in the aortic arch, and no other

      abnormal findings were seen (Fig. 2a, b). CT showed a

      dilated aortic arch and wall thickening, corresponding to

      the intense uptake area on FDG PET (Fig. 2c, d). At the

      time of the FDG-PET scan, her CRP was 1.5 mg/d

      l. She

      had not complained of any inflammatory symptoms, such

      as abdominal or back pain. After excluding possible

      primary causes, diagnosis of inflammatory aortic aneurysm

      was confirmed by typical radiological findings,

      namely a thickened and dilated aneurysmal wall with

      enhancement on contrast-enhanced CT.

      14

      Case 3

      A 56-year-old male was referred to hospital for abdominal

      pain. He received antibiotics initially; however, his symptoms

      did not improve. CT showed abdominal aortic wall

      thickening surrounded by soft tissue density. The soft

      tissue density was enhanced and extended to the adjacent

      structures. His laboratory data showed slightly elevated

      C-reactive protein (CRP; 1.5 mg/d

      l) and an accelerated

      erythrocyte sedimentation rate (ESR; 43 mm). He was

      diagnosed with retroperitoneal fibrosis based on his clinical

      and radiological findings. FDG-PET demonstrated

      abnormal accumulation of FDG around the abdominal

      aorta (Fig. 3a, b), and the intense uptake of FDG corresponding

      to the arterial wall and the soft tissue densities

      on his CT (Fig. 3c, d).

      Fig. 1

      a, b: FDG-PET images show continuing uptake in the thoracic abdominal aorta, brachiocephalic

      artery, common carotid arteries, and subclavian arteries. (a, maximum intensity projection (MIP); b,

      coronal view.) c, d: CT images demonstrate aortic wall thickening (c). Intense abnormal FDG

      accumulation is noted in the aortic wall (d). (c, contrast-enhanced CT; d, FDG-PET axial views

      corresponding to the CT images.)

      Fig. 2

      a, b: FDG-PET images demonstrate abnormal FDG accumulation in the aortic arch. Moderate

      diffuse uptake is seen in the stomach (

      arrowhead). No other abnormal FDG uptake is seen. c, d: CT

      images show a dilated thoracic aorta with wall thickening. FDG-PET demonstrates intense uptake

      corresponding to the aneurysmal wall. (c, contrast-enhanced CT; d, FDG-PET axial views corresponding

      to the CT images.)

      Vol. 20, No. 5, 2006 Case Report

      363

      DISCUSSION

      We experienced 3 cases in which FDG uptake was shown

      in aortic walls. All FDG-PET scans started 60 minutes

      after the injection. It is reported that the amount of activity

      remaining in the circulation after this time is minimal.

      15

      Therefore, the FDG uptake in the aortic wall suggested

      increased glucose metabolism due to pathological processes.

      After administration, FDG is transported into glucoseconsuming

      cells, metabolized by hexokinase, and accumulated.

      FDG accumulation is not specific for malignant

      tumors. Recent investigations have reported increased

      accumulation of FDG in inflammatory lesions. Mochizuki

      et al. reported that GLUTs expression was detected by

      immunohistochemical study in inflammatory tissue, and

      the inflammatory tissue showed [

      14C]FDG uptake higher

      than that of normal control muscle.

      16 Therefore, FDG

      accumulation in the aortic wall suggested the existence of

      an inflammatory condition.

      In Takayasu arteritis, the histological signs are focal

      dissection and infiltration with epithelioid cell granulomas

      and focal lymphoplasmocellular infiltration of the

      adventitia and the peripheral layers of the media.

      17 The

      inflammation, whose etiology is still unknown, primarily

      involves the aorta and its major branches.

      18 Idiopathic

      retroperitoneal fibrosis (IRF) and inflammatory aortic

      aneurysms (IAA) include chronic periaortitis, which is a

      spectrum of idiopathic disease characterized by a fibroinflammatory

      reaction. Histological signs of the chronic

      periaortitis are inflammatory infiltrate of the aortic

      adventitial and retroperitoneum. In IRF, the aorta is

      undilated and the retroperitoneal fibroinflammatory tissue

      may or may not involve neighboring structures; in

      IAA, the mass develops around a dilated aorta and usually

      does not cause obstructions. Inflammatory changes are

      found in all chronic periaortitis, regardless of the presence

      of aneurysmal dilatation.

      19

      In our cases, FDG was probably taken up by inflammatory

      cells which infiltrated the aortic walls and/or the soft

      tissue density around the artery. The higher accumulation

      demonstrated the distribution of inflammatory cells, and

      probably correlated with the grade of inflammatory activities.

      Meller et al. suggested that FDG-PET was more

      reliable than MRI in monitoring disease activity of aortitis

      during immunosuppressive therapy.

      20

      Takayasu arteritis and chronic periaortitis have a

      chronic-relapsing course and usually progress. As these

      diseases progress, arterial stenosis or the involvement of

      adjacent structures may occur. The severe complications

      of IAA or RF can be associated with eventual rupture.

      Early diagnosis is important for the proper initiation of

      treatment and can avoid these complications and manifestations.

      21

      In RF, FDG-PET can help to detect the presence

      of active inflammatory foci in the residual mass at the time

      of disease relapse. We could identify inflammatory lesions

      in the arterial wall of patients who showed unspecific

      inflammatory symptoms, even in an asymptomatic state.

      Therefore, FDG-PET has been proposed as a useful tool

      for the detection of inflammatory changes in the arterial

      wall.

      ACKNOWLEDGMENTS

      We gratefully acknowledge the excellent technical assistance of

      Tomohiko Saito, Hiroshi Kaibasawa, Syojiro Koyama, Yukihiro

      Takeuchi, Seiji Kato, Department of Radiology, The University

      of Tokyo Hospital.

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      Fig. 3

      a, b: FDG-PET shows intense FDG uptake surrounding the abdominal aorta. c, d: CT images

      show a soft tissue density area around the abdominal aorta and expanding to the inferior vena cava. Axial

      view of FDG-PET demonstrates intense FDG accumulation corresponding to soft tissue density.

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      364

      Miwako Takahashi, Toshimitsu Momose, Masashi Kameyama and Kuni Ohtomo Annals of Nuclear Medicine

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