Meller J, Sahlmann C O, Gürocak O, Liersch T, Meller B
Department of Nuclear Medicine, University of Göttingen, Göttingen, Germany.
Q J Nucl Med Mol Imaging. 2009 Feb;53(1):51-63.
This review analyzes the impact of 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) in the diagnostic work-up of classic fever of unknown origin (FUO) according to the criteria first proposed by Petersorf in 1961 and later modified by Durack et al. in 1991. Algorithms currently used in this diagnostic process are not strictly evidence based up to now. FDG accumulates in malignant tissues, but also in inflammatory cells by the overexpression of facultative glucose transporter-isotypes (mainly GLUT-1 and GLUT-3) and by an overproduction of glycolytic enzymes. Therefore, this technique covers a broad spectrum of possible etiologies for FUO. Once imaged, these lesions can be further investigated by other (e.g. invasive) and more specific methods. Until now, four prospective studies using FDG-PET in patients with classic FUO, encompassing 167 patients in total are published. Three retrospective studies with 125 patients are also available. These studies are discussed and weighted according to the control of selection-bias that was performed. An interstudy-bias may also be present resulting from a considerable variability in causes of FUO. A low number of diagnostic scans in a study may sometimes be related to a high rate of fevers caused by miscellaneous disorders or to a high rate of undiagnosed patients. In these disease categories, focal pathologies that can be imaged with FDG-PET, are rare. A high number of diagnostic scans is always related to a high prevalence of patients with medium- and large-vessel vasculitis. Available data indicate that FDG-PET has the potential to play an important role as a second line procedure in the management of about 1/3 of patients with classic FUO. It is expected that hybrid imaging (PET/computed tomography [CT]; PET/magnetic resonance imaging [MRI]) will improve the diagnostic impact of FDG-PET further, but prospective data about the value of this methods are currently not available. The question as to how these new techniques can be implemented into an evidence based diagnostic algorithm, can only be resolved within a multidisciplinary setting, avoiding both selection- and interstudy-bias whenever possible.
本综述根据1961年彼得索夫首次提出、1991年杜拉克等人修订的标准,分析了2-[(18)F]氟-2-脱氧-D-葡萄糖(FDG)-正电子发射断层扫描(PET)在经典不明原因发热(FUO)诊断检查中的影响。目前在这一诊断过程中使用的算法至今并非严格基于证据。FDG在恶性组织中积聚,但也通过兼性葡萄糖转运体亚型(主要是GLUT-1和GLUT-3)的过表达以及糖酵解酶的过量产生而在炎症细胞中积聚。因此,这项技术涵盖了FUO的广泛可能病因。一旦成像,这些病变可以通过其他(如侵入性)更具特异性的方法进一步研究。到目前为止,已发表了四项在经典FUO患者中使用FDG-PET的前瞻性研究,总共涉及167例患者。还有三项涉及125例患者的回顾性研究。根据所进行的选择偏倚控制对这些研究进行了讨论和加权。由于FUO病因存在相当大的变异性,可能也存在研究间偏倚。一项研究中诊断扫描数量少有时可能与多种疾病引起的高热率或未确诊患者的高比例有关。在这些疾病类别中,可通过FDG-PET成像的局灶性病变很少见。诊断扫描数量多总是与中、大血管血管炎患者的高患病率有关。现有数据表明,FDG-PET有潜力在约1/3的经典FUO患者管理中作为二线程序发挥重要作用。预计混合成像(PET/计算机断层扫描[CT];PET/磁共振成像[MRI])将进一步提高FDG-PET的诊断效果,但目前尚无关于该方法价值的前瞻性数据。关于如何将这些新技术纳入基于证据的诊断算法的问题,只能在多学科环境中解决,尽可能避免选择偏倚和研究间偏倚。