Takeuchi Motoki, Dahabreh Issa J, Nihashi Takashi, Iwata Mitsunaga, Varghese George M, Terasawa Teruhiko
Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Japan
Center for Evidence-based Medicine, Brown University, Providence, Rhode Island.
J Nucl Med. 2016 Dec;57(12):1913-1919. doi: 10.2967/jnumed.116.174391. Epub 2016 Jun 23.
Several studies have assessed nuclear imaging tests for localizing the source of fever in patients with classic fever of unknown origin (FUO); however, the role of these tests in clinical practice remains unclear. We systematically reviewed the test performance, diagnostic yield, and management decision impact of nuclear imaging tests in patients with classic FUO.
We searched PubMed, Scopus, and other databases through October 31, 2015, to identify studies reporting on the diagnostic accuracy or impact on diagnosis and management decisions of F-FDG PET alone or integrated with CT (F-FDG PET/CT), gallium scintigraphy, or leukocyte scintigraphy. Two reviewers extracted data. We quantitatively synthesized test performance and diagnostic yield and descriptively analyzed evidence about the impact on management decisions.
We included 42 studies with 2,058 patients. Studies were heterogeneous and had methodologic limitations. Diagnostic yield was higher in studies with higher prevalence of neoplasms and infections. Nonneoplastic causes, such as adult-onset Still's disease and polymyalgia rheumatica, were less successfully localized. Indirect evidence suggested that F-FDG PET/CT had the best test performance and diagnostic yield among the 4 imaging tests; summary sensitivity was 0.86 (95% confidence interval [CI], 0.81-0.90), specificity 0.52 (95% CI, 0.36-0.67), and diagnostic yield 0.58 (95% CI, 0.51-0.64). Evidence on direct comparisons of alternative imaging modalities or on the impact of tests on management decisions was limited.
Nuclear imaging tests, particularly F-FDG PET/CT, can be useful in identifying the source of fever in patients with classic FUO. The contribution of nuclear imaging may be limited in clinical settings in which infective and neoplastic causes are less common. Studies using standardized diagnostic algorithms are needed to determine the optimal timing for testing and to assess the impact of tests on management decisions and patient-relevant outcomes.
多项研究评估了核成像检查在不明原因发热（FUO）典型患者中定位发热源的作用；然而，这些检查在临床实践中的作用仍不明确。我们系统回顾了核成像检查在典型FUO患者中的检查性能、诊断率及对管理决策的影响。
我们检索了截至2015年10月31日的PubMed、Scopus及其他数据库，以识别报告F-FDG PET单独或与CT联合（F-FDG PET/CT）、镓闪烁显像或白细胞闪烁显像诊断准确性或对诊断及管理决策影响的研究。两名审阅者提取数据。我们对检查性能和诊断率进行了定量综合分析，并对有关对管理决策影响的证据进行了描述性分析。
我们纳入了42项研究，共2058例患者。研究具有异质性且存在方法学局限性。在肿瘤和感染患病率较高的研究中，诊断率较高。非肿瘤性病因，如成人斯蒂尔病和风湿性多肌痛，定位成功率较低。间接证据表明，在这4种成像检查中，F-FDG PET/CT具有最佳的检查性能和诊断率；汇总敏感性为0.86（95%置信区间[CI]，0.81 - 0.90），特异性为0.52（95%CI，0.36 - 0.67），诊断率为0.58（95%CI，0.51 - 0.64）。关于替代成像模式直接比较或检查对管理决策影响的证据有限。
核成像检查，尤其是F-FDG PET/CT，在识别典型FUO患者的发热源方面可能有用。在感染性和肿瘤性病因不太常见的临床环境中核成像的贡献可能有限。需要使用标准化诊断算法的研究来确定最佳检查时机，并评估检查对管理决策和患者相关结局的影响。
