Advances in PET Imaging of Sarcoidosis

  • Yang LuEmail author
  • Homer A. Macapinlac
Molecular Imaging (J Wu and P Nguyen, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Molecular Imaging


Purpose of Review

The purpose of this paper is to provide an updated review of recent advances in protocols for positron emission tomography (PET) or PET/computed tomography (PET/CT) imaging in patients with sarcoidosis.

Recent Findings

There has been more research focused on developing newer and improved PET imaging modalities to diagnose and follow-up cardiac sarcoidosis (CS). Fluorine-18-fluorodeoxyglucose (18F- FDG)-PET are widely used to diagnose CS, with or without concurrent rest nuclear myocardial perfusion study. There have been various patient preparation strategies for FDG PET/CT in CS. Interpretation criteria for cardiac FDG PET/CT in diagnosing CS also varies. There are emerging data utilizing new PET radiotracers (i.e., 68Ga-DOTATATE, 18F-Flurpiridaz) and PET/MRI imaging for CS diagnosis.


Based on published imaging data, patient preparation with a 72-h high-fat, high-protein, and very-low-carbohydrate diet protocol generates the most promising results in suppression of physiological myocardial FDG uptake in cardiac PET/CT. The “focal-on-diffuse uptake” pattern on myocardial uptake is not convincing and should not be interpreted as active CS. Nuclear myocardial perfusion test might not be needed to diagnose CS if optimal suppression of myocardial background uptake of FDG is achieved. FDG PET/MRI with optimal patient preparation may increase diagnostic confidence. More data will be needed for new tracers to be used for CS diagnosis.


Cardiac sarcoidosis Sarcoidosis PET; PET/CT 


Compliance with Ethical Standards

Conflict of Interest

Yang Lu and Homer A. Macapinlac declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

For the retrospective studies involve human participants performed by the authors, informed consent is not required. No animal research involved.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med. 2007;357(21):2153–65.PubMedGoogle Scholar
  2. 2.
    Valeyre D, Prasse A, Nunes H, Uzunhan Y, Brillet PY, Muller-Quernheim J. Sarcoidosis. Lancet. 2014;383(9923):1155–67.PubMedGoogle Scholar
  3. 3.
    Sharma OP, Maheshwari A, Thaker K. Myocardial sarcoidosis. Chest. 1993;103(1):253–8.PubMedGoogle Scholar
  4. 4.
    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(16):2096–101.PubMedGoogle Scholar
  5. 5.
    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(19):1914–31.PubMedGoogle Scholar
  6. 6.
    Hamzeh NY, Wamboldt FS, Weinberger HD. Management of cardiac sarcoidosis in the United States: a Delphi study. Chest. 2012;141(1):154–62.PubMedGoogle Scholar
  7. 7.
    Hulten E, Aslam S, Osborne M, Abbasi S, Bittencourt MS, Blankstein R. Cardiac sarcoidosis-state of the art review. Cardiovasc Diagn Ther. 2016;6(1):50–63.PubMedPubMedCentralGoogle Scholar
  8. 8.
    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(7):410–5.PubMedGoogle Scholar
  9. 9.
    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(5):578–83.PubMedGoogle Scholar
  10. 10.
    Patel MR, Cawley PJ, Heitner JF, Klem I, Parker MA, Jaroudi WA, et al. Detection of myocardial damage in patients with sarcoidosis. Circulation. 2009;120(20):1969–77.PubMedPubMedCentralGoogle Scholar
  11. 11.
    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(2):241–8.PubMedGoogle Scholar
  12. 12.
    Mostard RL, van Kroonenburgh MJ, Drent M. The role of the PET scan in the management of sarcoidosis. Curr Opin Pulm Med. 2013;19(5):538–44.PubMedGoogle Scholar
  13. 13.
    Treglia G, Annunziata S, Sobic-Saranovic D, Bertagna F, Caldarella C, Giovanella L. The role of 18F-FDG-PET and PET/CT in patients with sarcoidosis: an updated evidence-based review. Acad Radiol. 2014;21(5):675–84.PubMedGoogle Scholar
  14. 14.
    Piekarski E, Benali K, Rouzet F. Nuclear imaging in sarcoidosis. Semin Nucl Med. 2018;48(3):246–60.PubMedGoogle Scholar
  15. 15.
    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(4):393–403.PubMedGoogle Scholar
  16. 16.
    • Chareonthaitawee P, Beanlands RS, Chen W, Dorbala S, Miller EJ, Murthy VL, et al. Joint SNMMI-ASNC expert consensus document on the role of (18)F-FDG PET/CT in cardiac sarcoid detection and therapy monitoring. J Nucl Med. 2017;58(8):1341–53 It is the latest expert consensus from SNMMI-ASNC, but one should be aware that it is not a scientific data-based conclusion. Additional comments about this expert consensus can be found in reference no. 43. PubMedGoogle Scholar
  17. 17.
    Williams G, Kolodny GM. Suppression of myocardial 18F-FDG uptake by preparing patients with a high-fat, low-carbohydrate diet. AJR Am J Roentgenol. 2008;190(2):W151–6.PubMedGoogle Scholar
  18. 18.
    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(5):801–10.PubMedGoogle Scholar
  19. 19.
    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(5):926–36.PubMedGoogle Scholar
  20. 20.
    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):1.PubMedPubMedCentralGoogle Scholar
  21. 21.
    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(12):1989–98.PubMedGoogle Scholar
  22. 22.
    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(1):120–7.PubMedGoogle Scholar
  23. 23.
    Scholtens AM, Verberne HJ, Budde RP, Lam MG. Additional heparin preadministration improves cardiac glucose metabolism suppression over low-carbohydrate diet alone in (1)(8)F-FDG PET imaging. J Nucl Med. 2016;57(4):568–73.PubMedGoogle Scholar
  24. 24.
    Osborne MT, Hulten EA, Murthy VL, Skali H, Taqueti VR, Dorbala S, et al. Patient preparation for cardiac fluorine-18 fluorodeoxyglucose positron emission tomography imaging of inflammation. J Nucl Cardiol. 2017;24(1):86–99.PubMedGoogle Scholar
  25. 25.
    Atterton-Evans V, Turner J, Vivanti A, Robertson T. Variances of dietary preparation for suppression of physiological (18)F-FDG myocardial uptake in the presence of cardiac sarcoidosis: a systematic review. J Nucl Cardiol. 2018.Google Scholar
  26. 26.
    Manabe O, Yoshinaga K, Ohira H, Masuda A, Sato T, Tsujino I, et al. The effects of 18-h fasting with low-carbohydrate diet preparation on suppressed physiological myocardial (18)F-fluorodeoxyglucose (FDG) uptake and possible minimal effects of unfractionated heparin use in patients with suspected cardiac involvement sarcoidosis. J Nucl Cardiol. 2016;23(2):244–52.PubMedGoogle Scholar
  27. 27.
    Lu Y, Patel DC, Sweiss N. Using and interpreting (18)F-FDG PET/CT images in patients referred for assessment of cardiac sarcoidosis: the devil is in the details. J Nucl Med. 2017;58(12):2039.PubMedGoogle Scholar
  28. 28.
    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(4):329–36.PubMedGoogle Scholar
  29. 29.
    Shao D, Tian XW, Gao Q, Liang CH, Wang SX. Preparation methods prior to PET/CT scanning that decrease uptake of 18F-FDG by myocardium, brown adipose tissue, and skeletal muscle. Acta Radiol. 2017;58(1):10–8.PubMedGoogle Scholar
  30. 30.
    Wykrzykowska J, Lehman S, Williams G, Parker JA, Palmer MR, Varkey S, et al. Imaging of inflamed and vulnerable plaque in coronary arteries with 18F-FDG PET/CT in patients with suppression of myocardial uptake using a low-carbohydrate, high-fat preparation. J Nucl Med. 2009;50(4):563–8.PubMedGoogle Scholar
  31. 31.
    Ambrosini V, Zompatori M, Fasano L, Nanni C, Nava S, Rubello D, et al. (18)F-FDG PET/CT for the assessment of disease extension and activity in patients with sarcoidosis: results of a preliminary prospective study. Clin Nucl Med. 2013;38(4):e171–7.PubMedGoogle Scholar
  32. 32.
    •• 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(2):88–94 This is so far the largest reported CS FDG PET/CT patient data with minimal variance. The paper provided a thorough description of an effective and simple patient preparation protocol, and straightforward interpretation criteria for CS FDG PET/CT. PubMedGoogle Scholar
  33. 33.
    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(18):2041–9.PubMedGoogle Scholar
  34. 34.
    Tezuka D, Terashima M, Kato Y, Toriihara A, Hirasawa K, Sasaoka T, et al. Clinical characteristics of definite or suspected isolated cardiac sarcoidosis: application of cardiac magnetic resonance imaging and 18F-Fluoro-2-deoxyglucose positron-emission tomography/computerized tomography. J Card Fail. 2015;21(4):313–22.PubMedGoogle Scholar
  35. 35.
    Yokoyama R, Miyagawa M, Okayama H, Inoue T, Miki H, Ogimoto A, et al. Quantitative analysis of myocardial 18F-fluorodeoxyglucose uptake by PET/CT for detection of cardiac sarcoidosis. Int J Cardiol. 2015;195:180–7.PubMedGoogle Scholar
  36. 36.
    Ohira H, Mc Ardle B, deKemp RA, Nery PB, Juneau D, Renaud JM, et al. Inter- and intra- observer agreement of FDG-PET/CT image interpretation in patients referred for assessment of cardiac sarcoidosis. J Nucl Med. 2017;58:1324–9.PubMedGoogle Scholar
  37. 37.
    Lebasnier A, Legallois D, Bienvenu B, Bergot E, Desmonts C, Zalcman G, et al. Diagnostic value of quantitative assessment of cardiac (18)F-fluoro-2-deoxyglucose uptake in suspected cardiac sarcoidosis. Ann Nucl Med. 2018;32(5):319–27.PubMedGoogle Scholar
  38. 38.
    Bremer W, Sweiss NJ, Serial LY. FDG-PET/CT imaging in the management of cardiac sarcoidosis. Clin Nucl Med. 2018;43(2):e50–e2.PubMedGoogle Scholar
  39. 39.
    Lu Y, Sweiss NJ. MRI and FDG PET/CT imaging manifestations of cardiac sarcoidosis. Clin Nucl Med. 2015;40(12):973–4.PubMedGoogle Scholar
  40. 40.
    Patel D, Xie K, Sweiss NJ, Lu Y. Sarcoid pericarditis and large vessel vasculitis detected on FDG PET/CT. Clin Nucl Med. 2016;41(8):661–3.PubMedGoogle Scholar
  41. 41.
    Miller CT, Sweiss NJ, Lu Y. FDG PET/CT evidence of effective treatment of cardiac sarcoidosis with adalimumab. Clin Nucl Med. 2016;41(5):417–8.PubMedGoogle Scholar
  42. 42.
    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(5):1187–226.PubMedGoogle Scholar
  43. 43.
    Lu Y, Sweiss N. Role of (18)F-FDG PET/CT in cardiac sarcoid detection and therapy monitoring: addition to the expert consensus. J Nucl Med. 2018.Google Scholar
  44. 44.
    Birnie DH, Sauer WH, Bogun F, Cooper JM, Culver DA, Duvernoy CS, et al. HRS expert consensus statement on the diagnosis and management of arrhythmias associated with cardiac sarcoidosis. Heart Rhythm. 2014;11(7):1305–23.PubMedGoogle Scholar
  45. 45.
    Rose AS, Tielker MA, Knox KS. Hepatic, ocular, and cutaneous sarcoidosis. Clin Chest Med. 2008;29(3):509–24 ix.PubMedGoogle Scholar
  46. 46.
    Holmes J, Lazarus A. Sarcoidosis: extrathoracic manifestations. Dis Mon. 2009;55(11):675–92.PubMedGoogle Scholar
  47. 47.
    • Patel DC, Gunasekaran SS, Goettl C, Sweiss NJ, Lu Y. 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. 2017. The largest case series with same patient preparation protocol showed extra-thoracic sarcoid and CS occur with significant frequency, thus a PET/CT with field-of-view from the skull to upper thigh is necessary to the full extent of disease.
  48. 48.
    Gormsen LC, Haraldsen A, Kramer S, Dias AH, Kim WY, Borghammer P. A dual tracer (68)Ga-DOTANOC PET/CT and (18)F-FDG PET/CT pilot study for detection of cardiac sarcoidosis. EJNMMI Res. 2016;6(1):52.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Lapa C, Reiter T, Kircher M, Schirbel A, Werner RA, Pelzer T, et al. Somatostatin receptor based PET/CT in patients with the suspicion of cardiac sarcoidosis: an initial comparison to cardiac MRI. Oncotarget. 2016;7(47):77807–14.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Ohira H, Birnie DH, Pena E, Bernick J, Mc Ardle B, Leung E, et al. Comparison of (18)F-fluorodeoxyglucose positron emission tomography (FDG PET) and cardiac magnetic resonance (CMR) in corticosteroid-naive patients with conduction system disease due to cardiac sarcoidosis. Eur J Nucl Med Mol Imaging. 2016;43(2):259–69.PubMedGoogle Scholar
  51. 51.
    Dweck MR, Abgral R, Trivieri MG, Robson PM, Karakatsanis N, Mani V, et al. Hybrid magnetic resonance imaging and positron emission tomography with fluorodeoxyglucose to diagnose active cardiac sarcoidosis. JACC Cardiovasc Imaging. 2018;11(1):94–107.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Nuclear Medicine, Division of Diagnostic ImagingThe University of Texas MD Anderson Cancer CenterHoustonUSA

Personalised recommendations