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18F-FDG PET/CT for diagnosing infectious complications in patients with severe neutropenia after intensive chemotherapy for haematological malignancy or stem cell transplantation

Vos FJ, Donnelly JP, Oyen WJ, Kullberg BJ, Bleeker-Rovers CP, Blijlevens NM - Eur. J. Nucl. Med. Mol. Imaging (2011)

Bottom Line: Pathological FDG uptake was found in 26 of 28 cases despite peripheral neutrophil counts less than 0.1 × 10(-9)/l in 26 patients: in the digestive tract in 18 cases, around the tract of the central venous catheter (CVC) in 9 and in the lungs in 7 cases.FDG uptake in the CVC tract was associated with coagulase-negative staphylococcal bacteraemia (p < 0.001) and deep venous thrombosis (p = 0.002).Pulmonary FDG uptake was associated with the presence of invasive fungal disease (p = 0.04). (18)F-FDG PET/CT scanning during chemotherapy-induced febrile neutropenia and increased CRP is able to detect localized foci of infection and inflammation despite the absence of circulating neutrophils.

Affiliation: Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. f.vos@aig.umcn.nl

ABSTRACT

Purpose: Between 30 and 50% of febrile neutropenic episodes are accounted for by infection. C-reactive protein (CRP) is a nonspecific parameter for infection and inflammation but might be employed as a trigger for diagnosis. The aim of the study was to evaluate whether (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT can be used to detect inflammatory foci in neutropenic patients with elevated CRP and whether it helps to direct treatment.

Methods: Twenty-eight consecutive patients with neutropenia as a result of intensive chemotherapy for haematological malignancies or myeloablative therapy for haematopoietic stem cell transplantation were prospectively included. (18)F-FDG PET/CT was added to the regular diagnostic workup once the CRP level rose above 50 mg/l.

Results: Pathological FDG uptake was found in 26 of 28 cases despite peripheral neutrophil counts less than 0.1 × 10(-9)/l in 26 patients: in the digestive tract in 18 cases, around the tract of the central venous catheter (CVC) in 9 and in the lungs in 7 cases. FDG uptake in the CVC tract was associated with coagulase-negative staphylococcal bacteraemia (p < 0.001) and deep venous thrombosis (p = 0.002). The number of patients having Streptococcus mitis bacteraemia appeared to be higher in patients with grade 3 oesophageal FDG uptake (p = 0.08). Pulmonary FDG uptake was associated with the presence of invasive fungal disease (p = 0.04).

Conclusion: (18)F-FDG PET/CT scanning during chemotherapy-induced febrile neutropenia and increased CRP is able to detect localized foci of infection and inflammation despite the absence of circulating neutrophils. Besides its potential role in detecting CVC-related infection during febrile neutropenia, the high negative predictive value of (18)F-FDG PET/CT is important for avoiding unnecessary diagnostic tests and therapy.

18F-FDG PET/CT images of patient 1 during severe right side abdominal pain, diarrhoea and signs of local peritonitis on physical examination, showing grade 3 FDG uptake in the entire colonic wall
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Fig4: 18F-FDG PET/CT images of patient 1 during severe right side abdominal pain, diarrhoea and signs of local peritonitis on physical examination, showing grade 3 FDG uptake in the entire colonic wall

Mentions: FDG uptake grade 2 or more was found in the digestive tract, irrespective of the localization, in 24 of 28 (86%) cases. Citrulline levels were known in 20 of 28 patients (see Table 1). In two of the four patients in whom no pathological FDG uptake was found in the digestive tract citrulline levels were measured and below 10 μmol/l. FDG uptake grade 2 or more in the oesophagus and colon were not concomitant (p = 1.0). Grade 3 FDG uptake in the wall of the oesophagus was seen in 11 cases. Endoscopy was not performed in these patients. Of these 11 patients, 7 (64%) had retrosternal complaints consistent with oesophagitis (Fig. 3). Only one of the patients with retrosternal complaints did have Streptococcus mitis bacteraemia. On the other hand there appeared to be an association between Streptococcus mitis bacteraemia and grade 3 oesophageal FDG uptake (p = 0.08), as five of seven patients with Streptococcus mitis bacteraemia did have grade 3 FDG uptake in the oesophagus (Table 2). Grade 3 FDG uptake in the wall of the colon was found in 13 cases, but there was no correlation with Streptococcus mitis bacteraemia (p = 0.2). Four patients had severe abdominal complaints consistent with typhlitis and grade 3 colonic FDG uptake was found in each case (Fig. 4).Fig. 3

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18F-FDG PET/CT for diagnosing infectious complications in patients with severe neutropenia after intensive chemotherapy for haematological malignancy or stem cell transplantation

Vos FJ, Donnelly JP, Oyen WJ, Kullberg BJ, Bleeker-Rovers CP, Blijlevens NM - Eur. J. Nucl. Med. Mol. Imaging (2011)

18F-FDG PET/CT images of patient 1 during severe right side abdominal pain, diarrhoea and signs of local peritonitis on physical examination, showing grade 3 FDG uptake in the entire colonic wall
© Copyright Policy
Fig4: 18F-FDG PET/CT images of patient 1 during severe right side abdominal pain, diarrhoea and signs of local peritonitis on physical examination, showing grade 3 FDG uptake in the entire colonic wall
Mentions: FDG uptake grade 2 or more was found in the digestive tract, irrespective of the localization, in 24 of 28 (86%) cases. Citrulline levels were known in 20 of 28 patients (see Table 1). In two of the four patients in whom no pathological FDG uptake was found in the digestive tract citrulline levels were measured and below 10 μmol/l. FDG uptake grade 2 or more in the oesophagus and colon were not concomitant (p = 1.0). Grade 3 FDG uptake in the wall of the oesophagus was seen in 11 cases. Endoscopy was not performed in these patients. Of these 11 patients, 7 (64%) had retrosternal complaints consistent with oesophagitis (Fig. 3). Only one of the patients with retrosternal complaints did have Streptococcus mitis bacteraemia. On the other hand there appeared to be an association between Streptococcus mitis bacteraemia and grade 3 oesophageal FDG uptake (p = 0.08), as five of seven patients with Streptococcus mitis bacteraemia did have grade 3 FDG uptake in the oesophagus (Table 2). Grade 3 FDG uptake in the wall of the colon was found in 13 cases, but there was no correlation with Streptococcus mitis bacteraemia (p = 0.2). Four patients had severe abdominal complaints consistent with typhlitis and grade 3 colonic FDG uptake was found in each case (Fig. 4).Fig. 3

Bottom Line: Pathological FDG uptake was found in 26 of 28 cases despite peripheral neutrophil counts less than 0.1 × 10(-9)/l in 26 patients: in the digestive tract in 18 cases, around the tract of the central venous catheter (CVC) in 9 and in the lungs in 7 cases.FDG uptake in the CVC tract was associated with coagulase-negative staphylococcal bacteraemia (p < 0.001) and deep venous thrombosis (p = 0.002).Pulmonary FDG uptake was associated with the presence of invasive fungal disease (p = 0.04). (18)F-FDG PET/CT scanning during chemotherapy-induced febrile neutropenia and increased CRP is able to detect localized foci of infection and inflammation despite the absence of circulating neutrophils.

Affiliation: Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. f.vos@aig.umcn.nl

ABSTRACT

Purpose: Between 30 and 50% of febrile neutropenic episodes are accounted for by infection. C-reactive protein (CRP) is a nonspecific parameter for infection and inflammation but might be employed as a trigger for diagnosis. The aim of the study was to evaluate whether (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT can be used to detect inflammatory foci in neutropenic patients with elevated CRP and whether it helps to direct treatment.

Methods: Twenty-eight consecutive patients with neutropenia as a result of intensive chemotherapy for haematological malignancies or myeloablative therapy for haematopoietic stem cell transplantation were prospectively included. (18)F-FDG PET/CT was added to the regular diagnostic workup once the CRP level rose above 50 mg/l.

Results: Pathological FDG uptake was found in 26 of 28 cases despite peripheral neutrophil counts less than 0.1 × 10(-9)/l in 26 patients: in the digestive tract in 18 cases, around the tract of the central venous catheter (CVC) in 9 and in the lungs in 7 cases. FDG uptake in the CVC tract was associated with coagulase-negative staphylococcal bacteraemia (p < 0.001) and deep venous thrombosis (p = 0.002). The number of patients having Streptococcus mitis bacteraemia appeared to be higher in patients with grade 3 oesophageal FDG uptake (p = 0.08). Pulmonary FDG uptake was associated with the presence of invasive fungal disease (p = 0.04).

Conclusion: (18)F-FDG PET/CT scanning during chemotherapy-induced febrile neutropenia and increased CRP is able to detect localized foci of infection and inflammation despite the absence of circulating neutrophils. Besides its potential role in detecting CVC-related infection during febrile neutropenia, the high negative predictive value of (18)F-FDG PET/CT is important for avoiding unnecessary diagnostic tests and therapy.

View Similar Images In: Results  - Collection
View Article: PubMed Central -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=3227801&rFormat=json&query=null&req=5