In the JournalsPerspective

FDG PET/CT may aid diagnosis of GCA in patients prior to glucocorticoid exposure

The diagnosis of giant cell arteritis may be aided by the use of fluorodeoxyglucose positron emission tomography/CT in patients who have not been exposed to glucocorticoids, according to recently published research.

Researchers acquired fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT images from 18 patients with giant cell arteritis (GCA) who were scanned between November 2009 and December 2012 in a retrospective study. Patients with GCA were matched for age and sex with 18 patients with elevated C-reactive protein (CRP) to compare with another inflammatory group, with 19 patients with a vascular calcification score on low-dose CT (LDCT) greater than 2 and matched for sex only with 16 patients with no inflammation or vascular calcification on LDCT.

All FDG PET/CT scans were performed on a Siemans Biograph mCT camera system following a standard protocol. Two of the study authors, blinded to patient data, interpreted the images with high interoperator agreement. Three methods and subsets were used: method 1a was visual only, 1b was graded 0 to 4 and compared vascular vs. liver uptake, method 2a used a quantitative standardized uptake value (SUVmax) of the aorta, method 2b used a quantitative SUVmax ratio of the aorta to the liver, method 2c used a quantitative SUVmax ratio of the aorta to the superior caval vein and method 2d used a quantitative SUVmax ratio of the aorta to the inferior caval vein.

Significantly higher uptake in the vascular region of patients with GCA was observed compared to patients in the control groups. Uptake between patients in the three control groups did not vary significantly.

The sensitivity of method 1a, based on expert opinion, had 56% sensitivity and 98% specificity. When patients who received glucocorticoids were excluded, sensitivity increased to 75%. Method 1b yielded the highest diagnostic accuracy when the definition of a positive scan included the presence of an arterial structure with higher visual uptake than the liver. The sensitivity was 83%, specificity was 91% and exclusion of patients who received glucocorticoids resulted in a sensitivity increase to 92%. When a positive judgement was made in the presence of a vascular FDG uptake similar to the liver, the sensitivity was 100% while specificity was decreased to 51%.

“Based on our results, a visual grading method with an arterial FDG uptake higher than the liver FDG uptake has the highest diagnostic accuracy for GCA,” the researchers wrote. “It is also important to score the pattern of FDG uptake (focal vs. diffuse) and to correct for the presence of atherosclerosis.” – by Shirley Pulawski

Disclosure: The researchers report no relevant financial disclosures.

The diagnosis of giant cell arteritis may be aided by the use of fluorodeoxyglucose positron emission tomography/CT in patients who have not been exposed to glucocorticoids, according to recently published research.

Researchers acquired fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT images from 18 patients with giant cell arteritis (GCA) who were scanned between November 2009 and December 2012 in a retrospective study. Patients with GCA were matched for age and sex with 18 patients with elevated C-reactive protein (CRP) to compare with another inflammatory group, with 19 patients with a vascular calcification score on low-dose CT (LDCT) greater than 2 and matched for sex only with 16 patients with no inflammation or vascular calcification on LDCT.

All FDG PET/CT scans were performed on a Siemans Biograph mCT camera system following a standard protocol. Two of the study authors, blinded to patient data, interpreted the images with high interoperator agreement. Three methods and subsets were used: method 1a was visual only, 1b was graded 0 to 4 and compared vascular vs. liver uptake, method 2a used a quantitative standardized uptake value (SUVmax) of the aorta, method 2b used a quantitative SUVmax ratio of the aorta to the liver, method 2c used a quantitative SUVmax ratio of the aorta to the superior caval vein and method 2d used a quantitative SUVmax ratio of the aorta to the inferior caval vein.

Significantly higher uptake in the vascular region of patients with GCA was observed compared to patients in the control groups. Uptake between patients in the three control groups did not vary significantly.

The sensitivity of method 1a, based on expert opinion, had 56% sensitivity and 98% specificity. When patients who received glucocorticoids were excluded, sensitivity increased to 75%. Method 1b yielded the highest diagnostic accuracy when the definition of a positive scan included the presence of an arterial structure with higher visual uptake than the liver. The sensitivity was 83%, specificity was 91% and exclusion of patients who received glucocorticoids resulted in a sensitivity increase to 92%. When a positive judgement was made in the presence of a vascular FDG uptake similar to the liver, the sensitivity was 100% while specificity was decreased to 51%.

“Based on our results, a visual grading method with an arterial FDG uptake higher than the liver FDG uptake has the highest diagnostic accuracy for GCA,” the researchers wrote. “It is also important to score the pattern of FDG uptake (focal vs. diffuse) and to correct for the presence of atherosclerosis.” – by Shirley Pulawski

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Leonard H. Calabrese

    Leonard H. Calabrese

    The diagnosis of giant cell arteritis is a constant challenge. For patients with classic clinical presentation and signs or symptoms of cranial arteritis with appropriate labs, the diagnosis is straightforward and often does not even absolutely require a biopsy. On the other hand, it is challenging for patients without signs or symptoms of cranial arteritis and those who have nonspecific findings (i.e., fever, weight loss and unexplained pain, and elevated acute phase proteins, etc.). It has been estimated that the sensitivity of temporal artery biopsy in such patients may be less than 50%. Accordingly, better techniques are needed to accommodate the fact that giant cell arteritis may not be centered in the head and neck and large vessel involvement is far more frequent than once believed.

    The current study, using detailed methodology, demonstrated that FDG PET/CT is indeed a powerful tool in such patients and scoring is adequate by visually comparing uptake in the aorta and the liver. If the uptake, visually appraised by the observer, is greater in the aorta compared with that in liver and its diffuse, then the test-operating characteristics suggest sensitivity can reach 90% (if not treated prior with steroids) and specificity can approach 95% even when the comparator are patients with atherosclerosis.

    From this study, I reaffirm my personal experience that this test operates poorly after even brief glucocorticoid exposure given its false negative results. I no longer order it in such situations given the cost factor. On the other hand, for patients with non-specific but intermediate pre-test probability presentations (i.e., FUO), it can be highly revealing. Furthermore, it does not require fancy algorithms or technology but can be visually apprised.

    • Leonard H. Calabrese, DO
    • Consulting Medical Editor, Healio.com/Rheumatology Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University RJ Fasenmyer Chair of Clinical Immunology Theodore F. Classen, DO Chair of Osteopathic Research and Education Vice Chairman, Department of Rheumatic and Immunologic Diseases Cleveland Clinic Cleveland @LCalabreseDO

    Disclosures: Calabrese reports he is a consultant for Genentech, Pfizer, Bristol-Myers Squibb, GlaxoSmithKline, Sanofi, Jansen and Abbvie; and is on the speakers bureau for Genentech, Abbvie and Bristol-Myers Squibb and Crescendo Bioscience.