Abstract
Objective:
This study aimed to evaluate fluorine-18 fludeoxyglucose positron emission tomography-CT (18F-FDG PET-CT) for the diagnosis, targeted biopsy and therapy of relapsing polychondritis (RP).
Methods:
The literature pertaining to the use of 18F-FDG PET-CT in patients with RP was retrieved from the Cochrane Library, PubMed, Excerpta Medica Database (EMBASE), China National Knowledge Infrastructure (CNKI) and Wanfang databases until July 2015. Clinical characteristics, auxiliary examination results, chest CT findings, tracheoscopy and biopsy findings, high metabolic activity lesions, maximum standardized uptake values, 18F-FDG PET-CT-guided biopsy site, pathologic results of biopsy samples and alteration in high 18F-FDG-uptake lesions after treatment were retrospectively analysed.
Results:
18 publications with 26 cases were enrolled. The five most common symptoms of patients with RP diagnosed with 18F-FDG PET-CT were cough, fever, chest tightness, sore throat and arthralgia. Of the 26 patients, 23 patients had multiple and symmetric cartilage lesions with high metabolic activity, revealed by 18F-FDG PET-CT. The disease mainly affected organs such as the bronchus, trachea, throat, costicartilage and auricle. The maximum standardized uptake values ranged from 1.93 to 13.03 (mean, 4.94). 18F-FDG PET-CT revealed that patients with RP with tracheal and bronchial involvement had a close correlation with cough (χ2 = 6.80, p = 0.006). 18F-FDG PET-CT showed a significantly higher positive biopsy rate compared with bronchoscopy (χ2 = 12.91, p < 0.001) for targeted lesions with high metabolic activity. Post-treatment re-examinations with 18F-FDG PET-CT showed obvious subsidence or complete disappearance of high 18F-FDG-uptake lesions in 13 cases, showing highly consistent symptom improvements.
Conclusion:
18F-FDG PET-CT is likely to become a valuable imaging tool in the diagnosis and treatment of RP.
Advances in knowledge:
The presence of symmetrically distributed high FDG-uptake lesions may be a criterion for the diagnosis of RP. 18F-FDG PET-CT is useful for targeting biopsy sites, which remarkably increase the positive biopsy rate. Therefore, 18F-FDG PET-CT may be of great value in the diagnosis and treatment of RP.
INTRODUCTION
Relapsing polychondritis (RP) is a multisystem inflammatory disease characterized by recurrent episodes of inflammation in the cartilage and connective tissues at multiple sites of the body. Its aetiology remains unknown; however, the disease is often associated with autoimmune disorders.1,2 Although RP is a rare disorder, it has various types of clinical manifestations, which involve multiple systems. In addition, there are no specific detection methods available, resulting in difficult early diagnosis of RP. With unavailable early diagnosis, timely and effective therapy is not possible, thereby leading to the development of severe complications in late stages such as respiratory failure and subsequent death.3
Fluorine-18 fludeoxyglucose positron emission tomography-CT (18F-FDG PET-CT) has been widely used in the diagnosis and therapeutic evaluation of tumours, nervous system diseases and cardiovascular disorders.4–6 Recently, case reports have described the use of 18F-FDG PET-CT for the diagnosis and treatment of RP, making it a vital tool in RP management.7 This study was, therefore, designed to retrospectively analyse the literature pertaining to the use of 18F-FDG PET-CT in the diagnosis and treatment of RP.
METHODS AND MATERIALS
Literature search and data collection
Publications regarding the use of 18F-FDG PET-CT in patients with RP were retrieved from the Cochrane Library, PubMed, Excerpta Medica Database (EMBASE), China National Knowledge Infrastructure (CNKI) and Wanfang databases, until July 2015, using the terms “relapsing polychondritis”, “RP”, “positron emission tomography-computed tomography”, “PET-CT” and “PET/CT”. Duplicated references were excluded. Patients' age, gender, nationality, clinical characteristics, auxiliary examination results, bronchoscopical signs of airway, chest CT findings, 18F-FDG PET-CT-guided biopsy, lesions with high metabolic activity on 18F-FDG PET-CT images prior to treatment and their maximum standardized uptake values (SUVmax), alterations in high metabolic activity lesions on 18F-FDG PET-CT images post treatment, treatment regimen and year of publication were extracted from each study for retrospective analysis. The present retrospective study was approved by the Ethics Committee of The First Affiliated Hospital of Soochow University, and the patient information was anonymized and de-identified prior to analysis.
Statistical analysis
All statistical analyses were performed using the SPSS® statistical software v. 18.0 (IBM Corp., New York, NY). Differences in proportions were assessed by χ2 test. p < 0.05 was considered statistically significant.
RESULTS
Characteristics of the screened studies
A total of 18 eligible publications were retrieved,8–25 which involved 26 patients with RP. Four articles were published between 2007 and 2010, four articles in 2012, two articles in 2013, six articles in 2014 and two articles in 2015. Most cases reported were from Europe and Asia. The patients included 17 males and 9 females, with a male to female ratio of 17 : 9. Their average age was 54.5 years. The detailed clinical characteristics of these patients are summarized in Table 1.
Table 1.
Clinical data of patients with relapsing polychondritis
| Patient's number (N) | Study | Age/sex | Symptomsa | ESR (mm h−1) | CRP (mg l−1) | Other examinations of the blood | Chest CT |
|---|---|---|---|---|---|---|---|
| N1 | Nishiyama et al;8 Japan | 47/M | 1, 2, 3, 4 | NR | 14.13 | Negative | Thickening of the tracheal and bronchial walls |
| N2 | De Geeter and Vandecasteele;9 Belgium | 67/M | 1, 2, 3, 5 | 130 | 20 | WBC, LDH and ANCA, increased; ANA, negative | NR |
| N3 | Yokoyama et al;10 Japan | 60/M | 1, 2, 3, 6 | NR | 11.59 | WBC, IL-2 receptor and anti-CII Ab, increased; tumour marker, ANCA, negative | Thickening of the tracheal and bronchial walls |
| N4 | Sato et al;11 Japan | 59/F | 1, 2, 4, 5, 7, 8 | 77 | 5.16 | ANCA and other laboratory examinations of the blood, negative | Thickening of the tracheal and bronchial walls and narrowing of airway, with swelling of multiple lymph nodes |
| N5 | Cassone et al;12 Italy | 77/M | 3, 5, 8, 9, 10, 11, 12 | 120 | 9.77 | NR | Inflammatory tissue filling the tympanic cavity and left mastoid |
| N6 | Czepczyński et al;13 Poland | 57/M | 1, 6 | 118 | 180 | Negative | Thickening of the tracheal walls |
| N7 | Blanc-Caille et al;14 France | 55/F | 1, 3 | NR | 200 | Negative | Thickening of the tracheal and bronchial walls and narrowing of airway |
| N8 | Honne et al;16 Japan | 50/F | 2, 3, 5, 7 | NR | 4.29 | ANA, RF and ANCA, negative; anti-CII Ab, positive | Thickening of the tracheal walls and narrowing of bronchus |
| N9 | Yamashita et al;18 Japan | 79/F | 3, 4, 8, 10, 11, 12, 13 | 20 | 4 | NR | Thickening of the tracheobronchial wall |
| N10 | Yamashita et al;18 Japan | 61/M | 1, 4, 6, 10, 11, 14 | 93 | 28.2 | NR | Swelling of the cervical lymph node |
| N11 | Yamashita et al;18 Japan | 74/F | 7, 8, 12 | 122 | 114 | anti-CII Ab, positive | Sinusitis |
| N12 | Yamashita et al;18 Japan | 66/M | 1, 2, 3, 6 | NR | 91.1 | NR | Thickening of the tracheobronchial wall and swelling of the mediastinal lymph node |
| N13 | Yamashita et al;18 Japan | 44/F | 2, 3, 5 | NR | 5 | NR | Thickening of the tracheobronchial wall |
| N14 | Deng et al15 and Wang et al;19 China | 37/M | 1, 2, 7 | 100 | 220 | Negative | Thickening and narrowing of the trachea and main bronchus |
| N15 | Wang et al;19 China | 38/M | 2, 15 | 115 | 106.9 | Negative | Thickening and narrowing of trachea and main bronchus |
| N16 | Wang et al;19 China | 55/M | 1, 2 | 10 | 0.3 | Negative | Calcification of the trachea |
| N17 | Wang et al;19 China | 66/F | 2, 3 | 105 | 53.6 | Negative | Normal |
| N18 | Wang et al;19 China | 41/M | 2, 3 | 120 | 264.1 | Negative | Thickening and narrowing of the trachea and main bronchus |
| N19 | Wang et al;19 China | 55/M | 2 | 112 | 234.1 | Negative | Thickening and narrowing of the trachea and main bronchus |
| N20 | Mahida, et al;20 UK | 39/M | 2, 3, 5, 6 | 114 | 121 | Plt, increased; other laboratory examinations of the blood, negative | Thickening of the tracheal wall and swelling of mediastinal lymph node |
| N21 | Sugrue et al;21 UK | 51/M | 7, 11 | 25 | 28 | NR | Normal |
| N22 | Bayer et al;22 France | 37/F | 1, 2, 3, 7, 12, 16, 17 | NR | 247 | NR | Normal |
| N23 | Chen et al17 and Lei et al;23 China | 42/M | 1, 2, 8 | 124 | 14.89 | Plt and Fer, increased; other laboratory examinations of the blood, negative | Normal |
| N24 | Lei et al;23 China | 51/M | 1, 2 | 57 | 15.06 | WBC, Plt and Fer, increased; other laboratory examinations of the blood, negative | Increased lung markings and enlarged mediastinal lymph nodes |
| N25 | Ikeda et al;24 Japan | 40/F | 1, 2, 8, 11, 12, 15, | Increase | Increase | anti-CII Ab, increased; ANCA, negative | Stenosis in the trachea and bilateral bronchus |
| N26 | Hagiya et al;25 Japan | 68/M | 2 | NR | NR | anti-CII Ab, increased | Thickening of the tracheal wall |
1, fever; 2, cough; 3, chest tightness; 4, hoarseness; 5, sore throat; 6, weight loss; 7, arthralgia; 8, hearing loss; 9, headache; 10, conjunctivitis; 11, swelling and redness of the auricle; 12, swelling and redness of the nasal bridge; 13, dizziness; 14, shoulder pain; 15, chest pain; 16, alopecia; 17, dermatitis.
ANA, antinuclear antibody; ANCA, anti-neutrophil cytoplasmic antibody; anti-CII Ab, antitype II collagen antibody; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; F, female; Fer, ferritin; IL-2, interleukin 2; LDH, lactic dehydrogenase; M, male; N, patient's number; NR, no record; Plt, platelet; RF, rheumatoid factor; WBC, white blood cell.
Major clinical manifestations
The major clinical manifestations of patients with RP included cough, fever, chest tightness, sore throat, arthralgia, weight loss, hearing loss, hoarseness, conjunctivitis, swelling and redness of the auricle, swelling and redness of the nasal bridge, headache, dizziness, shoulder pain, chest pain, alopecia and dermatitis. The five most common clinical symptoms were cough (19/26), fever (14/26), chest tightness (12/26), sore throat (6/26) and arthralgia (6/26) (Table 1).
Major results of auxiliary examinations
The auxiliary examinations described in the 18 studies mainly included erythrocyte sedimentation rate detection, C-reactive protein level assessment, pulmonary function test and bronchoscopy. Elevated C-reactive protein levels were found in 76% (19/25) of patients, and increased erythrocyte sedimentation rate was detected in 94.4% (17/18) of patients. Chest CT scans displayed thickening of the tracheal and/or bronchial wall in 64.0% (16/25) of subjects, while ventilation dysfunction was detected in 90.0% (9/10) of patients. In addition, five and two patients had elevated levels of antitype II collagen antibody and ferritin, respectively. However, no patient had systemic lupus erythematosus, antineutrophil cytoplasmic antibody, rheumatoid factor or a tumour marker (Table 1).
Major imaging characteristics of 18F-FDG PET-CT in patients with RP
Of the 26 patients with RP described in the screened studies, 18F-FDG PET-CT images displayed high FDG uptake in the following 15 sites: bronchus, trachea, throat, costicartilage, auricle, lymph nodes, shoulder joint, wrist joint, nasal cartilage, elbow joint, sinus and paranasal sinus, auditory canal, sternum, annular cartilage and aorta. The five most commonly affected sites were the bronchus (18/26), trachea (17/26), throat (14/26), costicartilage (12/26) and auricle (6/26). Among the 26 patients, 3 patients had only a single affected organ. For the remaining 23 (88.5%) patients, the cartilaginous tissue and joint in 2 or more sites were affected: 2 sites, 4 cases; 3 sites, 5 patients; 4 sites, 7 subjects; 5 sites, 6 cases; and 6 sites, 1 individual. The lesions with high metabolic activity appeared symmetrical on 18F-FDG PET-CT scans. In addition, SUVmax was estimated in 20 patients of the 26 patients, and a mean value of 4.94 (range, 1.93–13.03) was obtained (Table 2). The presence of symmetrically distributed high FDG-uptake lesions at 2 or more cartilages displayed by 18F-FDG PET-CT highly suggests the diagnosis of RP.
Table 2.
The positron emission tomography-CT (PET-CT) imaging characteristics and PET-CT-guided biopsy of patients with relapsing polychondritis
| Patient’s number (N) | Uptake focuses of PET-CT (before treatment)a | SUVmax | Uptake focuses of PET-CT (after treatment) | Bronchoscopy and biopsy results | PET-CT-guided biopsy sites and results |
|---|---|---|---|---|---|
| N1 | 18, 19, 20, 21 | 6.25 | No | Oedema in the main bronchus and hypertrophy of the carina; positive | Tracheal mucous membrane; positive |
| N2 | 18, 19, 22, 23 | NR | 9 months; mostly disappeared | NR | Costicartilage; positive |
| N3 | 18, 23 | NR | After therapy; eliminated | NR | Aurical cartilage; positive |
| N4 | 18, 19, 22, 23, 24 | 6.41 | 6 months; disappeared | NR | Undone |
| N5 | 24, 25, 26 | NR | 13 months; disappeared | NR | Undone |
| N6 | 20, 22, 23, 27, 28 | 4.5 | No | NR | Undone |
| N7 | 18, 19, 23 | 4.5 | 1 and 8 months; disappeared in both follow-up scans | Oedema in the main bronchus; negative | Undone |
| N8 | 18, 19 | NR | No | NR | Undone |
| N9 | 22, 23, 26, 30 | 3.38 | No | NR | Undone |
| N10 | 21, 24, 26, 31 | 6.44 | No | NR | Undone |
| N11 | 19, 20, 21, 23, 27, 32 | 13.03 | 1.5 months; disappeared | NR | Nasal cartilage; positive |
| N12 | 18, 19, 21, 23, 32 | 4.75 | No | NR | Laryngeal cartilage; positive |
| N13 | 19 | 1.93 | No | NR | Undone |
| N14 | 18, 19, 22, 23, 29 | 5.8 | 5 months; decreased | Oedema in the main bronchus and hypertrophy of the carina; negative | Costicartilage; positive |
| N15 | 18, 19, 22, 23, 29 | 4 | 3 months; decreased | Oedema in the main bronchus and hypertrophy of the carina; negative | Aurical cartilage; positive |
| N16 | 22, 23, 26, 29 | 4.8 | 2.5 and 9 months; decreased in both follow-up scans | Oedema in the main bronchus and hypertrophy of the carina; negative | Costicartilage; positive |
| N17 | 23 | 3.6 | No | Oedema in the main bronchus and hypertrophy of the carina; negative | Aurical cartilage; positive |
| N18 | 18, 19, 22, 24, 26 | 5 | 3 months; decreased | Oedema in the main bronchus and hypertrophy of the carina; negative | Aurical cartilage; positive |
| N19 | 18, 19, 26 | 4.2 | 4 months; decreased | Oedema in the main bronchus and hypertrophy of the carina; negative | Aurical cartilage; positive |
| N20 | 18, 19, 23, 24 | NR | No | Widespread inflammation of the bronchus and trachea with expiratory collapse; negative | Lymph node, trachea, tonsil; negative |
| N21 | 31 | 2.3 | 36 months, increased | NR | Aurical cartilage; (before PET-CT) |
| N22 | 18, 19, 22, 23 | 4.1 | No | NR | Undone |
| N23 | 18, 19, 22 | 3.73 | No | Congestion and oedema in the main bronchus and trachea; (guided by PET-CT, positive) | Tracheal rings; positive |
| N24 | 18, 19, 22 | 5.04 | No | Congestion and oedema in the main bronchus and trachea; (guided by PET-CT, positive) | Tracheal rings and lymph nodes; positive |
| N25 | 18, 19, 22 | 5.0 | 14 months; disappeared | Diffuse mucosal swelling and stenosis; (undone) | Auricular cartilage and costicartilage; positive |
| N26 | 18, 19 | NR | 6 months; disappeared | Stenosis; (undone) | Undone |
18, trachea; 19, bronchus; 20, wrist joint; 21, shoulder joint; 22, costicartilage; 23, throat; 24, lymph nodes; 25, auditory canal; 25, auricle; 27, elbow joint; 28, sternum; 29, nose; 30, annular cartilage; 31, aorta; 32, sinus and paranasal sinus.
N, patient's number; NR, no record; SUVmax, maximum standardized uptake value.
Correlation between lesions with high metabolic activity and clinical symptoms
We further analysed the frequent symptoms and lesions with high metabolic activity in patients with RP diagnosed with 18F-FDG PET-CT. Of the 19 patients with cough, 89.5% (17/19) patients had high FDG uptake at the bronchus and/or trachea, as revealed by 18F-FDG PET-CT. Conversely, among the 19 patients showing high FDG uptake at the bronchus and/or trachea on 18F-FDG PET-CT scans, 89.5% (17/19) patients were coughing. These findings demonstrated a strong correlation between cough and high FDG-uptake lesions at the bronchus and/or trachea on 18F-FDG PET-CT scans (χ2 = 6.80, p = 0.006) (Table 3).
Table 3.
The correlation between PET-CT lesions and clinical symptoms
| Cough | Uptake at bronchus and/or trachea |
χ2 value | p-value | |
|---|---|---|---|---|
| Yes | No | |||
| Yes | 17 | 2 | 6.80 | 0.006 |
| No | 2 | 5 | ||
18F-FDG PET-CT facilitates targeted guiding to the biopsy site
Of the 26 patients with RP, 16 patients underwent biopsy; the sites mainly included the aurical cartilage, costicartilage, tracheal mucous membrane, nasal cartilage, laryngeal cartilage and tracheal rings. Among these 16 cases, 15 cases received targeted biopsy of the lesions with high metabolic activity according to the imaging findings of 18F-FDG PET-CT scans. Interestingly, positive results were obtained in 14 of 15 individuals, with a success rate of 93.3%. In addition, no severe complications occurred as a result of 18F-FDG PET-CT. The remaining nine patients underwent tracheoscopy-guided biopsy of the bronchial mucosa, and success was achieved only in one case, with a positive rate of 11.1%. These data indicated a significantly higher positive rate for 18F-FDG PET-CT-targeted biopsy compared with tracheoscopy-guided biopsy (χ2 = 12.91, p < 0.001) (Table 4).
Table 4.
PET-CT facilitates better targeted guidance to the biopsy compared with bronchoscopy
| Biopsy | Positive | Negative | χ2 value | p-value |
|---|---|---|---|---|
| PET-CT-guided biopsy | 14 | 1 | 12.91 | <0.001 |
| Bronchoscopy biopsy | 1 | 8 |
18F-FDG PET-CT is useful in assessing the therapeutic efficacy in RP
Of the 26 patients with RP reported, 25 patients had described treatment protocols, and the major drugs were hormones and immunosuppressants. In addition, an airway stent and non-invasive positive pressure ventilation were employed in two cases with RP. Post-treatment re-examinations with 18F-FDG PET-CT revealed a reduction in number or complete disappearance of the lesions with high metabolic activity in 13 of 14 patients compared with the situation before treatment; the SUVmax values of lesions with high metabolic activity all decreased remarkably or returned to normal, consistent with improved clinical symptoms and laboratory examination results. No SUVmax reduction was seen in one case, as revealed by post-treatment examination with 18F-FDG PET-CT. However, the patient's symptoms and laboratory examination data returned to normal following treatment with an increased dose of the drug. The first re-examination with 18F-FDG PET-CT was performed 1–36 months post treatment with a mean time to re-examination of 6.6 months. Three cases underwent two 18F-FDG PET-CT re-examinations individually, and all showed improvements in the lesions with high metabolic activity following the integrated therapy (Table 2).
DISCUSSION
RP is a recurrent, degenerative, inflammatory disease of the cartilaginous tissue, which is characterized by the involvement of organs such as the ears, nose, throat, trachea, eyes, joints and heart valves, and connective tissues like blood vessels. It is difficult to comprehensively assess the affected site and therapeutic efficacy in patients with RP using conventional approaches. 18F-FDG PET-CT plays an important role in the diagnosis and assessment of therapeutic efficacy in tumours,4 and its potential diagnostic and therapeutic values have been reported for inflammatory disorders.26,27
However, studies assessing 18F-FDG PET-CT in the diagnosis and treatment of RP are scarce. The present study retrospectively analysed the publications describing the application of 18F-FDG PET-CT in the diagnosis and therapy of patients with RP until July 2015. A total of 18 articles reporting 26 patients were screened.8–25 Most patients with RP (88.5%) had symmetric and multiple high FDG-uptake lesions at the cartilage and joint as shown via 18F-FDG PET-CT scans. The most frequently affected sites included the bronchus (18/26), trachea (17/26), throat (14/26), costicartilage (12/26) and auricle (6/26). The mean SUVmax of the lesions with high metabolic activity was 4.94. Two or more symmetrically distributed cartilages or joints with high FDG-uptake lesions highly indicated the diagnosis of RP. Therefore, it is recommended to revise Damiani's diagnostic criteria28 for RP. Based on our opinions, individuals who meet one of the following four criteria may be diagnosed with RP: (1) meeting three or more of the six current parameters: (a) relapsing chondritis of both ears, (b) non-invasive polychondritis, (c) chondritis of the nose, (d) inflammation of the eyes, (e) respiratory chondritis involving the throat and/or tracheal cartilage and (f) invasion of the cochlea and/or ear vestibules); (2) positive for at least one parameter, together with histological confirmation (cartilage biopsy); (3) development of chondritis at two or more anatomical sites, and effective treatment with glucocorticoid or dapsone; and (4) 18F-FDG PET-CT scan displays symmetrically distributed high FDG-uptake lesions in two or more cartilages or joints. Such a revision should not only decrease the number of biopsies and biopsy-induced complications,29,30 but also help avoid the use of hormones and immunosuppressants for therapy and the development of treatment-associated adverse events to the utmost extent.31,32
We analysed the correlation between the affected lesions displayed by 18F-FDG PET-CT and patients' clinical symptoms. Of the patients with RP with cough, the bronchus and/or trachea were involved in 89.5% (17/19) patients as revealed by 18F-FDG PET-CT scans, while 89.5% (17/19) of patients with RP with involvement of the bronchus and trachea on 18F-FDG PET-CT images were coughing. These results demonstrated a close correlation between the bronchus and trachea involvement and cough in patients with RP. To the best of our knowledge, we did not find a case report on the increased SUVmax in the trachea and bronchia in the chronic cough disease, such as chronic obstructive pulmonary disease, asthma, interstitial lung disease and tuberculosis. Our findings suggest that atypical patients with RP with cough, without involvement of the ears and/or nose, may be definitely diagnosed through biopsy of the airway and tracheal cartilages with transbronchial needle aspiration in the absence of 18F-FDG PET-CT scan.23
Of the 26 patients described in 18 studies, 14 patients received 18F-FDG PET-CT scans before and after treatment. Following treatment, all clinical symptoms and some laboratory parameters improved remarkably or returned to normal, and post-treatment re-examinations with 18F-FDG PET-CT revealed partial or complete disappearance of pre-treatment lesions with high metabolic activity, in agreement with improved clinical symptoms and laboratory examination data. This finding suggests that 18F-FDG PET-CT may be used to evaluate the therapeutic efficacy in RP with relatively higher objectivity.
Among the 26 patients with RP, 16 patients received biopsy, including 15 patients who underwent targeted biopsy of the lesions with high metabolic activity according to the 18F-FDG PET-CT data. Satisfactory biopsy specimens were obtained, with a positive rate of 93.3%, and no severe complications were observed. The remaining nine patients received tracheoscopy, and tracheal mucosa oedema was seen. Biopsy of bronchial mucosa was successful in one case, with a positive biopsy rate of 11.1%, indicating that targeted biopsy of the lesions with high metabolic activity according to 18F-FDG PET-CT scan may remarkably improve the diagnosis of RP. The affected sites of patients with RP can be comprehensively assessed based on the lesions with high metabolic activity present at multiple sites displayed by 18F-FDG PET-CT, which provides new insights into the diagnosis of RP. In addition, the best option for biopsy sites can be chosen according to the doctors' experience, technical conditions and patient's health status. This would not only achieve satisfactory pathologic results, but also avoid the development of severe complications to the greatest extent.
This study has some limitations. Few cases were included in this retrospective analysis, and each patient had incomplete medical records. Therefore, selection bias cannot be excluded. One study showed that PET-CT could reduce the treatment cost of patients with head and neck cancer without apparent clinical side effects.33 It remains elusive whether PET-CT reduces the treatment cost of patients with RP. Further large-scale, prospective clinical trials are required to determine this surmise and to validate the findings presented here.
CONCLUSION
In summary, the presence of symmetrically distributed high FDG-uptake lesions, at two or more cartilages displayed by 18F-FDG PET-CT, may be a criterion for the diagnosis of RP. 18F-FDG PET-CT reveals that most patients with RP with cough have involvement of the airway, and there is a positive correlation between cough and airway involvement in patients with RP. In addition, 18F-FDG PET-CT is useful for targeting biopsy sites, which remarkably improves the positive biopsy rate, providing a possibility for an appropriate choice of biopsy sites. The results of the present study demonstrate that 18F-FDG PET-CT has the potential to become an imaging approach for objectively and comprehensively evaluating the therapeutic efficacy in RP. Therefore, 18F-FDG PET-CT may be of great value in the diagnosis and therapeutic evaluation of RP.
Acknowledgments
ACKNOWLEDGMENTS
We thank Zhi-de Hu (Department of Laboratory Medicine, General Hospital of Jinan Military Command Region) for help with the statistical analysis and Hong-wei Yao (Department of Environmental Medicine, University of Rochester) for editing this article.
Contributor Information
Wei Lei, Email: leiwei1978@163.com.
Hui Zeng, Email: 20135232051@stu.suda.edu.cn.
Da-xiong Zeng, Email: darxzeng@126.com.
Bin Zhang, Email: zbnuclmd@126.com.
Ye-han Zhu, Email: zhuyehansz@sina.com.
Jun-hong Jiang, Email: jiang20001969@163.com.
Jian-an Huang, Email: huangjianansdfyy@163.com.
FUNDING
This work was supported by the youth science and technology project of Suzhou City (number: KJXW2012001), clinical key speciality project of China and National Natural Science Foundation of China (number: 81300026).
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