FDG PET-CT findings of extra-thoracic sarcoid are associated with cardiac sarcoid: A rationale for using FGD PET-CT for cardiac sarcoid evaluation

Abstract

Purpose

This retrospective study investigates the relationship between cardiac and extra-thoracic sarcoid findings on FDG PET-CT using a 72-hour pretest high-fat, high-protein, and very low-carbohydrate (HFHPVLC) diet.

Patients and methods

A total of 196 consecutive FDG PET-CT scans with 72-hour HFHPVLC diet preparation were performed between December 2014 and December 2015 in known sarcoid patients. Of these scans, 5 were excluded for non-adherence to diet preparation or underlying cancer. Cardiac and extra-thoracic sarcoid lesions were categorized and measured for radiotracer uptake.

Results

A total of 188 patients had 191 eligible FDG PET/CT scans (3 follow-up scans), of which there were 20 (10%) positive, 6 indeterminate (3%), and 165 (86%) negative for CS. Among the 20 scans positive for CS, 8 (40%) had findings of both cardiac and extra-thoracic sarcoid.

Conclusion

Our study shows that 40% of CS patients also have FDG PET-CT findings of extra-thoracic sarcoid. This makes an intriguing case for FDG PET-CT use with pretest diet prep over cardiac MRI (CMR) for cardiac sarcoid evaluation, given that CMR is likely to overlook these extra-thoracic sites of disease.

This is a preview of subscription content, log in to check access.

Figure 1
Figure 2
Figure 3
Figure 4

Abbreviations

HFHPVLC:

High-fat, high-protein, and very low-carbohydrate

CS:

Cardiac sarcoid

CMR:

Cardiac MRI

IRB:

Institutional review board

References

  1. 1.

    Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med 2007;357:2153-65.

    Article  CAS  PubMed  Google Scholar 

  2. 2.

    Sharma OP, Maheshwari A, Thaker K. Myocardial sarcoidosis. Chest 1993;103:253-8.

    Article  CAS  PubMed  Google Scholar 

  3. 3.

    Albert CM, Chae CU, Grodstein F, Rose LM, Rexrode KM, Ruskin JN, et al. Prospective study of sudden cardiac death among women in the United States. Circulation 2003;107:2096-101.

    Article  PubMed  Google Scholar 

  4. 4.

    Cooper LT, Baughman KL, Feldman AM, Frustaci A, Jessup M, Kuhl U, et al. The role of endomyocardial biopsy in the management of cardiovascular disease: A scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology. J Am Coll Cardiol 2007;50:1914-31.

    Article  PubMed  Google Scholar 

  5. 5.

    Hamzeh NY, Wamboldt FS, Weinberger HD. Management of cardiac sarcoidosis in the United States: A Delphi study. Chest 2012;141:154-62.

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    Hulten E, Aslam S, Osborne M, Abbasi S, Bittencourt MS, Blankstein R. Cardiac sarcoidosis-state of the art review. Cardiovasc Diagn Ther 2016;6:50-63.

    PubMed  PubMed Central  Google Scholar 

  7. 7.

    Mantini N, Williams B, Stewart J, Rubinsztain L, Kacharava A. Cardiac sarcoid: A clinician’s review on how to approach the patient with cardiac sarcoid. Clin Cardiol 2012;35:410-5.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Schatka I, Bengel FM. Advanced imaging of cardiac sarcoidosis. J Nucl Med 2014;55:99-106.

    Article  PubMed  Google Scholar 

  9. 9.

    Williams G, Kolodny GM. Suppression of myocardial 18F-FDG uptake by preparing patients with a high-fat, low-carbohydrate diet. Am J Roentgenol 2008;190:W151-6.

    Article  Google Scholar 

  10. 10.

    Langah R, Spicer K, Gebregziabher M, Gordon L. Effectiveness of prolonged fasting 18f-FDG PET-CT in the detection of cardiac sarcoidosis. J Nucl Cardiol 2009;16:801-10.

    Article  PubMed  Google Scholar 

  11. 11.

    Harisankar CN, Mittal BR, Agrawal KL, Abrar ML, Bhattacharya A. Utility of high fat and low carbohydrate diet in suppressing myocardial FDG uptake. J Nucl Cardiol 2011;18:926-36.

    Article  PubMed  Google Scholar 

  12. 12.

    Ishida Y, Yoshinaga K, Miyagawa M, Moroi M, Kondoh C, Kiso K, et al. Recommendations for (18)F-fluorodeoxyglucose positron emission tomography imaging for cardiac sarcoidosis: Japanese Society of Nuclear Cardiology recommendations. Ann Nucl Med 2014;28:393-403.

    Article  PubMed  Google Scholar 

  13. 13.

    Morooka M, Moroi M, Uno K, Ito K, Wu J, Nakagawa T, et al. Long fasting is effective in inhibiting physiological myocardial 18F-FDG uptake and for evaluating active lesions of cardiac sarcoidosis. EJNMMI Res 2014;4:1.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Okumura W, Iwasaki T, Toyama T, Iso T, Arai M, Oriuchi N, et al. Usefulness of fasting 18F-FDG PET in identification of cardiac sarcoidosis. J Nucl Med 2004;45:1989-98.

    PubMed  Google Scholar 

  15. 15.

    Soussan M, Brillet PY, Nunes H, Pop G, Ouvrier MJ, Naggara N, et al. Clinical value of a high-fat and low-carbohydrate diet before FDG-PET/CT for evaluation of patients with suspected cardiac sarcoidosis. J Nucl Cardiol 2013;20:120-7.

    Article  PubMed  Google Scholar 

  16. 16.

    Lu Y, Grant C, Xie K, Sweiss NJ. Suppression of myocardial 18F-FDG uptake through prolonged high-fat, high-protein, and very-low-carbohydrate diet before FDG-PET/CT for evaluation of patients with suspected cardiac sarcoidosis. Clin Nucl Med 2017;42:88-94.

    Article  PubMed  Google Scholar 

  17. 17.

    Dilsizian V, Bacharach SL, Beanlands RS, Bergmann SR, Delbeke D, Dorbala S, et al. ASNC imaging guidelines/SNMMI procedure standard for positron emission tomography (PET) nuclear cardiology procedures. J Nucl Cardiol 2016;23:1187-226.

    Article  Google Scholar 

  18. 18.

    Ito K, Okazaki O, Morooka M, Kubota K, Minamimoto R, Hiroe M. Visual findings of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with cardiac sarcoidosis. Intern Med 2014;53:2041-9.

    Article  PubMed  Google Scholar 

  19. 19.

    Ohira H, Tsujino I, Ishimaru S, Oyama N, Takei T, Tsukamoto E, et al. Myocardial imaging with 18F-fluoro-2-deoxyglucose positron emission tomography and magnetic resonance imaging in sarcoidosis. Eur J Nucl Med Mol Imaging 2008;35:933-41.

    Article  PubMed  Google Scholar 

  20. 20.

    Lu Y, Sweiss NJ. MRI and FDG PET/CT imaging manifestations of cardiac sarcoidosis. Clin Nucl Med 2015;40:973-4.

    Article  PubMed  Google Scholar 

  21. 21.

    Soejima K, Yada H. The work-up and management of patients with apparent or subclinical cardiac sarcoidosis: With emphasis on the associated heart rhythm abnormalities. J Cardiovasc Electrophysiol 2009;20:578-83.

    Article  PubMed  Google Scholar 

  22. 22.

    Rose AS, Tielker MA, Knox KS. Hepatic, ocular, and cutaneous sarcoidosis. Clin Chest Med 2008;29:509-24, ix.

  23. 23.

    Singh G, Sangolli P, Dash K, Grove S. Cutaneous sarcoidosis without systemic involvement. Indian J Dermatol Venereol Leprol 2000;66:43-4.

    CAS  PubMed  Google Scholar 

  24. 24.

    Okamoto H, Mizuno K, Ohtoshi E. Cutaneous sarcoidosis with cardiac involvement. Eur J Dermatol 1999;9:466-9.

    CAS  PubMed  Google Scholar 

  25. 25.

    Mana J, Marcoval J, Graells J, Salazar A, Peyri J, Pujol R. Cutaneous involvement in sarcoidosis. Relationship to systemic disease. Arch Dermatol 1997;133:882-8.

    Article  CAS  PubMed  Google Scholar 

  26. 26.

    Marchell RM, Judson MA. Chronic cutaneous lesions of sarcoidosis. Clin Dermatol 2007;25:295-302.

    Article  PubMed  Google Scholar 

  27. 27.

    Warshauer DM, Lee JK. Imaging manifestations of abdominal sarcoidosis. Am J Roentgenol 2004;182:15-28.

    Article  Google Scholar 

  28. 28.

    Judson MA. Extrapulmonary sarcoidosis. Semin Respir Crit Care Med 2007;28:83-101.

    Article  PubMed  Google Scholar 

  29. 29.

    CerfPayrastre I, Liote F. Bone, joint, and muscle involvement in sarcoidosis. Sem Hop Paris 1997;73:945-52.

    Google Scholar 

  30. 30.

    Holmes J, Lazarus A. Sarcoidosis: Extrathoracic manifestations. Dis Mon 2009;55:675-92.

    Article  PubMed  Google Scholar 

  31. 31.

    James DG, Sharma OP. Extrathoracic sarcoidosis. Proc R Soc Med 1967;60:992-4.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Blankstein R, Osborne M, Naya M, Waller A, Kim CK, Murthy VL, et al. Cardiac positron emission tomography enhances prognostic assessments of patients with suspected cardiac sarcoidosis. J Am Coll Cardiol 2014;63:329-36.

    Article  PubMed  Google Scholar 

  33. 33.

    Youssef G, Leung E, Mylonas I, Nery P, Williams K, Wisenberg G, et al. The use of 18F-FDG PET in the diagnosis of cardiac sarcoidosis: A systematic review and metaanalysis including the Ontario experience. J Nucl Med 2012;53:241-8.

    Article  CAS  PubMed  Google Scholar 

  34. 34.

    Ohira H, Tsujino I, Sato T, Yoshinaga K, Manabe O, Oyama N, et al. Early detection of cardiac sarcoid lesions with (18)F-fluoro-2-deoxyglucose positron emission tomography. Intern Med 2011;50:1207-9.

    Article  PubMed  Google Scholar 

  35. 35.

    Smedema JP, Snoep G, van Kroonenburgh MP, van Geuns RJ, Dassen WR, Gorgels AP, et al. Evaluation of the accuracy of gadolinium-enhanced cardiovascular magnetic resonance in the diagnosis of cardiac sarcoidosis. J Am Coll Cardiol 2005;45:1683-90.

    Article  PubMed  Google Scholar 

  36. 36.

    Gropler RJ, Siegel BA, Lee KJ, Moerlein SM, Perry DJ, Bergmann SR, et al. Nonuniformity in myocardial accumulation of fluorine-18-fluorodeoxyglucose in normal fasted humans. J Nucl Med 1990;31:1749-56.

    CAS  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Yang Lu MD, PhD.

Ethics declarations

Disclosure

All the authors, Darshan C. Patel, Senthil S. Gunasekaran, Christopher Goettl, Nadera J. Sweiss, and Yang Lu, state that they have nothing to disclose.

Additional information

The authors of this article have provided a PowerPoint file, available for download at SpringerLink, which summarizes the contents of the paper and is free for re-use at meetings and presentations. Search for the article DOI on SpringerLink.com.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PPTX 211 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Patel, D.C., Gunasekaran, S.S., Goettl, C. et al. FDG PET-CT findings of extra-thoracic sarcoid are associated with cardiac sarcoid: A rationale for using FGD PET-CT for cardiac sarcoid evaluation. J. Nucl. Cardiol. 26, 486–492 (2019). https://doi.org/10.1007/s12350-017-0962-4

Download citation

Keywords

  • Cardiac
  • Extra-thoracic
  • Sarcoid
  • Sarcoidosis
  • FDG PET-CT