Annals of Nuclear Medicine

, Volume 23, Issue 9, pp 783–791 | Cite as

Whole-body FDG-PET/CT on rheumatoid arthritis of large joints

  • Kazuo Kubota
  • Kimiteru Ito
  • Miyako Morooka
  • Takuya Mitsumoto
  • Kyoko Kurihara
  • Hiroyuki Yamashita
  • Yuko Takahashi
  • Akio Mimori
Original Article

Abstract

Objective

Fluorodeoxyglucose (FDG) uptake in joint lesions in patients with rheumatoid arthritis (RA) reportedly represents the degree of synovial inflammation. Most previous studies have focused on small joints, and the application of whole-body positron emission tomography (PET) combined with computed tomography (CT) (PET/CT) for the evaluation of inflammatory activity in large joints has not been well studied.

Methods

Eighteen patients with RA underwent FDG-PET/CT. FDG uptake in the knee, hip, carpal, wrist, elbow, shoulder, and atlanto-axial joint (total of 13 joints) and in the axillary lymph nodes was evaluated by calculating the maximum standardized uptake value (SUVmax) and the visual uptake scores as follows: 0, no uptake; 1, slight uptake; 2, moderate uptake (same as in liver); 3, higher than in liver; 4, highest uptake. The number of painful/swollen joints, the white blood cell (WBC) count, and the C-reactive protein (CRP) level were also evaluated.

Results

Whole-body FDG-PET/CT delineated large-joint lesions in patients with RA, and the metabolic activity of inflammation was accurately overlaid on the joint anatomy. The total FDG score for all 13 joints was significantly correlated with the CRP level (r = 0.653, p < 0.01, n = 18). The total SUVmax and the CRP level were weakly, but not significantly, correlated (r = 0.377, p > 0.05). The WBC count was not correlated with any other parameter. The mean number of joints per patient with an FDG uptake score of 2 or more was significantly larger than the mean number of painful/swollen joints (6.2 ± 3.3 vs. 3.1 ± 2.7, n = 18, p < 0.01) and both parameters were strongly correlated (r = 0.588, p < 0.01, n = 18). Also, FDG uptake score and SUV of painful/swollen joints were significantly higher than these of not painful/swollen joints. FDG uptake was significantly different from patients of remission and patients of active arthritis. Uptake in the atlanto-axial joint was observed in five (mostly asymptomatic) patients (5/18, 28%), and the uptake score was significantly correlated with the total FDG score (r = 0.669, p < 0.01, n = 18). The axillary lymph nodes score was correlated with the arm joints score.

Conclusion

FDG-PET/CT represents the inflammatory activity in large joints in patients with RA accurately and sensitively and may be helpful for early evaluations of the extent of RA throughout the whole body including high risk lesion of atlanto-axial joint. Furthermore, the visual FDG uptake score may be useful for evaluating arthritis in large joints.

Keywords

Rheumatoid arthritis FDG PET/CT Large joint Atlanto-axial joint 

Introduction

The recent development of biologics such as tumor necrotic factor blocking agents for the treatment of rheumatoid arthritis (RA) has revolutionized treatment strategies by aiming for complete remission. To optimize results, the timing of this expensive but powerful therapy has become important, enhancing the value of accurate evaluations of arthritic inflammatory activity [1]. Magnetic resonance imaging (MRI), especially for finger lesions, has become important by enabling synovial inflammation to be delineated as contrast-enhanced lesions with excellent anatomical resolution [2]. However, arthritis in RA often involves not only the fingers, but also large joints throughout the whole body. Unfortunately, MRI’s application to multiple joint lesions is limited.

The usefulness of positron emission tomography (PET) using fluorine-18-labeled fluorodeoxyglucose (FDG) (FDG-PET) has been well established for the diagnosis, staging, and evaluation of therapy for various types of cancer throughout the whole body. However, elevated glucose metabolism is observed not only in cancer cells, but also in inflammatory cells [3, 4, 5]. While this phenomenon has been a source of false-positive problems in oncological diagnosis, it could be actively applied for the diagnosis of inflammatory disease [6].

FDG uptake in patients with RA has been shown to represent the activity of synovial inflammation [7, 8, 9, 10]. Most of previous studies have evaluated fingers, wrist, and knee joints; however, the application of whole-body PET combined with computed tomography (CT) (PET/CT) for the evaluation of inflammatory activity in large joints has not yet been well studied in patients with RA.

Here, we studied FDG-PET/CT to delineate large-joint lesions including atlanto-axial joint in patients with RA and examined the correlation between FDG uptake and markers or symptoms of inflammation.

Subjects and methods

Subjects

Between May 2006 and April 2008, 33 patients with arthritis underwent FDG-PET/CT. Among these patients, 12 were diagnosed as having arthritis associated with a collagen disease other than RA or infection [psoriasis, Behçet’s disease, systemic lupus erythematosis (n = 2), temporal arteritis, Takayasu arteritis, myalgia rheumatica (n = 2), sclerosing spondylitis (n = 2), SAPHO syndrome, tuberculosis] and were excluded from the present study. Three patients with active malignancies (lymphoma, lung cancer, and ovarian cancer) were also excluded. Consequently, 18 patients (17 female, 1 male; mean age 67 ± 11 years) with RA who met the RA criteria of the American Rheumatism Association [11] were enrolled in the present study. Predominance of women population in this study reflected the epidemiology that several times women are affected by RA than men. The study protocol was approved by the Institutional Review Board, and informed consent was obtained from each patient.

Methods

Fluorodeoxyglucose was synthesized using in-house cyclotron and automated synthesis system (F100, Sumitomo Heavy Industry) using the authorized procedure. After 5 h of fasting, the blood glucose level of each patient was measured and the patient was intravenously injected with 370 MBq of FDG. One hour after FDG injection, PET/CT imaging from the vertex to the knee joints (with the arms in a downward position) was performed using a dedicated PET/CT scanner (Biograph 16; Siemens) with a 3-min emission scan/bed and CT attenuation correction. The PET data were reconstructed using a Gaussian filter with an ordered-subset expectation maximization algorithm (3 iterations, 8 subsets).

FDG uptake in bilateral knees, hips, carpals, wrists, elbows, and shoulder joints as well as the atlanto-axial joint (total of 13 joints) and bilateral axillary lymph nodes was evaluated by using a dedicated work station to draw regions of interest (ROI) covering each joint and calculating the maximum standardized uptake value (SUVmax) of each joint. FDG uptake in large joints and lymph nodes was also visually evaluated using a scoring system as follows: 0, no uptake (same as in bone); 1, slight uptake; 2, moderate uptake (same as in liver); 3, higher than in liver; 4, highest uptake (over SUV 4). The system was modified from the scoring system of Goerres et al. [10]. Then total SUVmax and FDG scores of 13 joints, and of the joints in each arm were calculated. The number of joints out of 13 with an FDG uptake score of 2 or more was recorded. The finger joints were included in the ROI of the carpal joint, and the details of each small joint were not evaluated because of the limited resolution of finger lesions in the whole-body scanning mode of PET/CT. In this study, we have not focused on the small joints of hands, but on the large-joint lesions of RA where we consider PET/CT may show unique value compared to MRI, despite the comparison of PET/CT and MRI is not the purpose of this study.

The number of painful/swollen joints, the white blood cell (WBC) count, and the C-reactive protein (CRP) level were evaluated within 5 days of the PET/CT examination. WBC and CRP are popular markers of inflammation. The disease activity score (DAS) was not used in the present study because some patients had disease in their small joints, such as fingers, that elevated the DAS and other clinical RA scores but was not reflected well in the FDG-PET images in our imaging protocol, which focused on large joints throughout the whole body. For the evaluation of finger lesions in detail, additional separate scanning only for hands may be essential as reported [8], but was not the purpose of this study and not performed.

Results

Table 1 shows detailed clinical data for all the patients. Among the 18 patients, 4 patients exhibited benign small lung nodules, 3 exhibited pleural effusion, 2 exhibited mild interstitial pneumonitis, and 1 exhibited chronic thyroiditis, but none of these conditions were thought to influence the evaluation of arthritis in the large joints. Regarding the RA disease status, 4 patients were in remission according to the criteria for RA remission [12] and 14 patients had active arthritis (including 3 early after onset). FDG uptake by large joints, total score, total SUVmax, and the mean number of joints per patient with an FDG uptake score of 2 or more were significantly different from patients of remission and patients of active arthritis (Table 2).
Table 1

Clinical data of patients

No.

Age

Sex

Time from onset

RA status

Treatment

CRP

WBC

Glucose

Painful/swollen joints

FDG uptake

Additional findings

Joints ≥ score 2

Arm score

Axilla LN score

AA joint score

Total score

Total SUV

1

49

F

16 y

Remission

Rimatil

NSAID

0.21

4.98

82

0

0

2

0

0

4

20.05

Pleural effusion

2

47

F

5 y

Remission

Rimatil

Predonine

0.2

5.75

82

0

1

8

0

0

12

24.41

Pleural effusion

3

61

F

20 y

Remission

None

0.2

5.92

81

0

4

13

0

0

15

21.64

Chronic thyroiditis

4

78

F

2 y

Remission

Rimatil

0.36

5.74

107

0

4

12

1

0

13

21.84

 

5

57

F

21 y

Active

Predonine

NSAID

4.9

7.7

95

0

8

15

1

0

18

19.71

Pleural effusion

6

69

F

15 y

Active

Rimatil

NSAID

1.36

8.54

78

2

6

16

2

0

19

26.66

Lung N. benign

7

74

F

3 y

Active

Predonine

MTX

4.59

9.82

95

4

3

10

2

1

16

35.55

Lung N. benign

8

81

F

13 y

Active

Azulfidine

6.68

4.62

74

2

7

23

7

2

32

32.36

 

9

66

F

27 y

Active

Rimatil

MTX

4.09

9.91

107

2

6

14

0

0

20

19.46

Interstitial pneu.

10

77

F

14 y

Active

Predonine

NSAID

7.01

6.5

135

2

5

15

1

0

15

24.23

Interstitial pneu.

11

74

F

15 y

Active

Predonine

1.7

9.82

81

6

8

22

2

2

26

43.41

 

12

71

F

7 y

Active

MTX

Predonine

10.02

5.64

102

6

11

25

6

3

38

44.68

 

13

74

F

3.5 y

Active

Rimatil

NSAID

9.11

7.4

109

7

12

25

4

1

42

59.08

Lung N. benign

14

47

F

25y

Active

Predonine

1.4

7.17

91

8

4

7

1

0

13

23.5

 

15

73

F

1 m

Active

None

5.09

6.38

102

2

5

9

0

0

15

19.84

 

16

75

F

5y

Active

None

4.1

8.6

96

4

9

13

3

0

27

40.99

Lung N. benign

17

61

M

7 m

Active

None

2.39

7.55

78

4

9

13

2

0

25

45.61

 

18

86

F

3 m

Active

NSAID

16.28

9.89

126

6

9

17

2

0

29

31.95

 

Mean

67.78

F17

10.69

  

4.43

7.33

95.61

3.06

6.17

14.39

1.89

0.5

21.61

30.83

 

SD

11.71

M1

8.86

  

4.25

1.77

16.98

2.67

3.26

6.31

2.09

0.92

10.99

11.65

 

Normal data in our institution; CRP 0–0.3 mg/dl, WBC 3.5–8.5 × 103/μl, glucose 80–110 mg/dl

Table 2

FDG uptake by large joints of RA, difference of active arthritis and remission status (mean and SD per patient)

 

Total scorea

Total SUVmaxa

Number of FDG uptake jointsb

Remission of RA (n = 4)

11 ± 4.8

22.0 ± 1.8

2.3 ± 2.1

Active arthritis (n = 14)

23.9 ± 8.9

33.4 ± 12.1

7.3 ± 2.6

p < 0.001 for each parameters from remission and active arthritis

aTotal score/total SUVmax of 13 joints, bilateral knee, hip, carpal, wrist, elbow, shoulder, and atlanto-axial joint

bThe mean number of joints per patient with an FDG uptake score of 2 or more, out of 13 joints

Figure 1a shows a typical FDG-PET/CT image of large joints arthritis in a patient with recurrent RA (patient no. 13 in Table 1). A maximum intensity projection (MIP) image showed elevated FDG uptake in multiple large joints. Wrist, elbow, and knee joints can be interpreted in detail easily using the coronal and axial views of PET even without CT correlation. However, large joints especially hip and shoulder joints are more complicated because of the structure and FDG uptake by enthesopathies, inflammation of ligamentous or muscular attachments to bone that must be discriminated from sinovitis of RA (Fig. 1b–d). So in these joints, PET images with anatomical correlation to CT are essential for accurate evaluation of sinovitis of RA. CT correlation is also important for accurate evaluation of atlanto-axial joint lesion (Fig. 2a, b). To evaluate the total SUVmax in the large joints, a workstation running a three-dimensional ROI program was used where the metabolic activity of inflammation was accurately overlaid on the joint anatomy provided by CT.
Fig. 1

A 74-year-old woman with 3.5-year history of RA who experienced a recurrence and was being considered for infliximab therapy (patient No. 13 in Table 2). a Anterior MIP image obtained using FDG-PET/CT showed typical RA lesions in the large joints. The FDG uptake scores were as follows: right and left knees, both 4; right and left hips, both 4; right and left carpals, both 3; right and left wrists, both 4; right and left elbows, both 2; right and left shoulders, 4 and 3, respectively; and atlanto-axial joint, 1; total score 42. b, c Axial PET–CT fusion image of hip joint of the same patient. Large arrows indicated RA lesion of sinovitis at acetabulum and femoral head. Small arrows indicated enthesopathies at ischium and grater throcanter. d Axial PET–CT fusion image of hip joint of another patient not included in this study, showing only enthesopathies at grater throcanter, ischial tuberosity, and pubic symphysis

Fig. 2

A 71-year-old woman with a 7-year history of RA who experienced a recurrence (patient No. 12 in Table 2). a Anterior and right lateral views of MIP images obtained using FDG-PET/CT. b Axial images at the atlanto-axial joint (PET, CT, and fused image: top to bottom). Strong FDG uptake was seen in the atlanto-axial joint (score 3), the right and left axillary lymph nodes (3, 3), the right and left knees (4, 4), the right and left hips (1, 1), the right and left carpals (2, 2), the right and left wrists (3, 3), the right and left elbows (4, 3), and the right and left shoulders (4, 4)

Figure 3 shows the correlations between the CRP/WBC levels and the total FDG score/total SUVmax. The CRP level and the total FDG score showed a significant linear correlation (Fig. 3a; r = 0.658, p = 0.003, n = 18), while the CRP level and the total SUVmax were weakly, but not significantly, correlated (Fig. 3b; r = 0.377, p = 0.123). The WBC count was not significantly correlated with the total FDG score (r = 0.131, p = 0.605), the WBC count, with the total SUVmax (r = 0.222, p = 0.376).
Fig. 3

a Correlation between the C-reactive protein (CRP) level (X axis) and the total FDG uptake score in the large joints (r = 0.658, p < 0.01, n = 18). b Correlation between the CRP level (X axis) and the total SUVmax (r = 0.377, p > 0.05, n = 18)

Figure 2 shows the FDG-PET/CT images for patient no. 12. Both the MIP image (Fig. 2a) and the axial images (Fig. 2b) showed typical FDG uptake in the atlanto-axial joint and axillary lymph nodes, in addition to the large-joint lesions. Figure 4a shows a significant correlation between the total FDG uptake scores for the arm joints and the axillary lymph nodes (r = 0.731, p = 0.000004, n = 36; note that the right and left arms were evaluated separately). FDG uptake in the atlanto-axial joint was observed in five patients (5/18, 28%). Figure 4b shows a significant correlation between the total FDG uptake score and FDG uptake in the atlanto-axial joint (r = 0.669, p = 0.0024, n = 18). The CRP level and the FDG uptake in the atlanto-axial joint were weakly, but not significantly, correlated (r = 0.310, p = 0.21).
Fig. 4

a Correlation between the total FDG uptake scores for the total arm joints (X) and the axillary lymph nodes (Y) (r = 0.731, p < 0.01, n = 369). b Correlation between the total FDG uptake score (X) and FDG uptake scores in the atlanto-axial joint (Y) (r = 0.669, p < 0.01, n = 18)

The correlation between joint symptoms and FDG uptake is shown in Fig. 5. The number of painful/swollen joints (out of the 13 large joints that were examined; see “Methods”) was significantly correlated with the number of joints with an FDG uptake score of 2 or more (r = 0.588, p = 0.0103, n = 18). The mean number of joints per patient with an FDG uptake score of 2 or more was significantly larger than the mean number of painful/swollen joints (6.2 ± 3.3 vs. 3.1 ± 2.7, n = 18, p = 0.0002). Also, FDG uptake score and SUVmax of painful/swollen joints were significantly higher than those of not painful/swollen joints (Table 3).
Fig. 5

Correlation between the number of painful/swollen joints (X) (among 13 large joints) and the number of joints with an FDG uptake score of 2 or more (Y) (r = 0.588, p < 0.01, n = 18)

Table 3

FDG uptake by painful/swollen joints and not painful/swollen joints (mean and SD per joint)

 

FDG uptake sore/joint

SUVmax/joint

Painful/swollen joints (n = 55)

2.96 ± 0.80

5.53 ± 3.89

Not painful/swollen joints (n = 179)

1.29 ± 0.64

2.09 ± 0.77

p < 0.001 for each parameters from painful and not painful

Discussion

In this study, whole-body FDG-PET/CT clearly delineated large-joint lesions of RA showing the metabolic activity of inflammation overlaid on the joint anatomy by CT. FDG uptake in the large joints, as evaluated using visual scoring, was significantly correlated with the CRP level but not with the WBC count. PET/CT also showed greater FDG uptake in painful/swollen joints, and both of these parameters were strongly correlated with each other. These findings suggest that whole-body FDG-PET/CT sensitively represents the disease activity in large joints affected by RA.

Our present results extended the findings of previous reports on finger joints, knee joints, and wrist joints over whole-body large joints. Beckers et al. [8] studied finger and knee lesions of RA using SUVmax and found a strong correlation between FDG uptake and markers of inflammation, such as the CRP level and the clinical DAS. In our study, the total FDG uptake score for large joints throughout the whole body showed similar correlations, but the total SUVmax was not as useful as in the previous publication. We paid careful attention to quality control for the PET/CT imaging, including a cross-calibration of the dose meter. Also, as the blood glucose level of the patients was 96 ± 17 mg/dl (mean and SD) (range 74–135 mg/dl), it did not significantly affect the total SUVmax of the joint lesions. Consequently, the lower utility of the total SUVmax evaluation, compared with the previous study, is unlikely to have been by a technical problem with the PET study. Instead, it might be the result of an over-evaluation of the background activity caused by, for example, FDG uptake in muscles adjacent to painful large joints. Visual evaluations would likely overlook the background activity and any resulting artifacts. Goerres et al. [10] studied whole-body FDG-PET in patients with RA using a visual evaluation score and concluded that FDG uptake was significantly correlated with clinical evaluations of disease activity in patients with RA before and after treatment with infliximab. While they clearly showed the utility of a visual scoring system, they neither calculate the total SUVmax nor use PET/CT. Further study to clarify the differences between visually assessed scores and total SUVmax in whole-body PET/CT is needed. Practically, a visual scoring system is simple and clinically feasible, and the method used to score FDG uptake in the present study (modified from the scoring system of Goerres et al.) reflected both the inflammatory activity and the symptoms of large joints. Both the reproducibility and inter-observer variability of this system were about 85%.

In our study, patients with a higher total FDG uptake in their arm joints also exhibited uptake in their axillary lymph nodes, reflecting the inflammatory activity of RA. Seldin et al. [13] previously reported the visualization of axillary lymph nodes on FDG-PET examinations performed in patients with RA, but this finding was not significantly correlated with uptake in wrist lesions. Their group had reviewed a large number of oncology PET data records for patients with benign FDG avid lymphadenopathy and had observed this phenomenon in 9 patients with RA. In contrast, our study focused on patients with RA at various disease stages who did not have any malignancies; our study protocol may have yielded clearer results for this reason. Our finding is also consistent with a report that more than half of RA patients exhibited axillary lymphadenopathy, especially during the active inflammatory phase of RA [14].

Our PET/CT study showed that the number of joints with positive FDG uptake was larger than the number of symptomatic joints. Also, we found that patients with a higher FDG uptake in their large joints throughout the whole body tended to have positive FDG uptake in their atlanto-axial joint. These results suggested that FDG-PET can identify joints with active RA inflammation more sensitively than the clinical signs/symptoms of RA. Cervical involvement, especially of the atlanto-axial joint, is common in patients with RA and can result in the compression of the spinal cord and brain stem, leading to serious complications. Neva et al. [15] reported that RA patients with cervical spine subluxations cannot be distinguished based on their symptoms and that a high prevalence of asymptomatic cervical spine subluxation exists in patients with RA waiting for orthopedic surgery. Kaneta et al. [16] reported a case in which FDG-PET/CT detected atlanto-axial joint involvement in a patient with RA. In our study, 28% of the patients showed positive FDG uptake in the atlanto-axial joint, and most of these patients were asymptomatic. These observations may represent the early stage of joint disease that will ultimately progress to subluxation. Linn-Rasker et al. examined the predictive value of the distribution of inflamed joints at first presentation for the severity and disease course of RA using physical examination and various laboratory parameters. They concluded that the presence of arthritis in large joints, particularly arthritis in the knee joint, was predictive of a destructive disease course [17]. The evaluation of large joints with arthritis using whole-body FDG-PET/CT may be helpful for identifying patients with RA who may have a potentially severe disease course, including subluxation of the atlanto-axial joint, thereby contributing to considerations of therapeutic strategies. Also, FDG-PET/CT may be useful for monitoring such therapies, especially those involving the use of biologic agents.

As a conventional imaging, bone scan has been used for RA. A few of our patients also have bone scan, but the number is not enough for systemic comparison to FDG-PET/CT and remained to be studied. The direct comparison of bone scan and PET has not been reported, while a study comparing the MRI, bone scan, ultrasound, and radiography for finger joint RA showed that bone scan is sensitive for bone erosion but non-specific, also not sensitive for sinovitis [18]. It could be estimated that FDG-PET may be more sensitive for sinovitis, and may reflect the disease activity better than that of bone scan.

The final goal of our study is to demonstrate that FDG-PET/CT helps to determine the optimal timing of biologics therapy aiming for complete remission of RA. In order to have the complete evidence of this, therapy intervention study including large number of patients involved multiple institution may be necessary. We think the current study, showing the characteristics and possibility of whole-body PET/CT, may be the first step to achieve this goal.

Limitation

Matrix metalloprotainase-3 (MMP-3) is known to be a specific marker of synovial inflammation, but data on MMP-3 were not available for all the subjects in this study. Reportedly, MMP-3 was significantly correlated with the CRP level in patients with RA, but not in patients with other forms of arthritis [19]. Since all of the patients in this study were diagnosed as having RA according to standard criteria, we speculated that the CRP level could be used to represent the inflammatory activity of RA with satisfactory accuracy.

RA is characterized by the early and frequent involvement of the proximal interphalangeal joint, the metacarpophalangeal joint, and the wrist joint. These joints have been extensively evaluated using MRI and have been shown to exhibit a strong correlation with the inflammatory activity of RA [20]. Especially, the recent development of low-field dedicated extremity MRI has facilitated the use of MRI with sufficient accuracy [20, 21]. In our whole-body imaging setting with the arms in a downward position, hands and arms were seen in the sides of the body, and individual finger joints were difficult to evaluate in detail. We have tested the hands imaging mode that both hands were extended overhead in prone position and fixed in an applicator and imaged using head-mode scan. That produced high-resolution hands images enable finger joints evaluation accurately. But we can have these images of few patients only, and we did not used in this study. The advantage of PET/CT in this study is that it enables the whole-body evaluation of inflammatory RA activity, possibly helping with the accurate evaluation of the extent of the disease even at subclinical levels, as shown in this study. The indications for dedicated extremity MRI and PET/CT in patients with RA remain to be elucidated.

Conclusion

FDG-PET/CT represents the inflammatory activity in large joints in patients with RA accurately and sensitively and may be helpful for early evaluations of the extent of RA throughout the whole body. Furthermore, the visual FDG uptake score may be useful for evaluating arthritis in large joints.

Notes

Acknowledgments

We would like to thank Kazuhiko Nakajima, M.Sc., Yasuhiro Kashimura, BS, and Akio Ishibashi, BS, for their excellent technical assistance. Part of this study was supported by a Grant-in-aid for cancer research (No. 17-12) from the Ministry of Health, Labor and Welfare and by a Grant for International Health Research (21A126) from the Ministry of Health, Labor and Welfare.

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Copyright information

© The Japanese Society of Nuclear Medicine 2009

Authors and Affiliations

  • Kazuo Kubota
    • 1
  • Kimiteru Ito
    • 3
  • Miyako Morooka
    • 1
  • Takuya Mitsumoto
    • 1
  • Kyoko Kurihara
    • 1
  • Hiroyuki Yamashita
    • 2
  • Yuko Takahashi
    • 2
  • Akio Mimori
    • 2
  1. 1.Department of Radiology, Division of Nuclear MedicineInternational Medical Center of Japan Toyama HospitalTokyoJapan
  2. 2.Department of Internal Medicine, Division of Collagen DiseasesInternational Medical Center of Japan Toyama HospitalTokyoJapan
  3. 3.Department of Nuclear MedicineSaitama Medical University, International Medical CenterSaitamaJapan

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