18 F-FDG PET/CMR in cardiac sarcoidosis: A wild card in the deck?
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F-FDG PET/CMR in cardiac sarcoidosis: A wild card in the deck? Carmela Nappi, MD, PhD,a Andrea Ponsiglione, MD,a Massimo Imbriaco, MD,a and Alberto Cuocolo, MDa a
Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
Received Oct 17, 2020; accepted Oct 19, 2020 doi:10.1007/s12350-020-02427-3
See related article, https://doi.org/10.10 07/s12350-020-02359-y. Sarcoidosis is an inflammatory multi-system disorder of unknown origin, characterized by the formation of non-caseating granulomas.1 Although more than 90% of patients present with lung, heart, skin, and lymph nodes involvement, other organs and tissues can be also affected.2 Even if clinical manifestations of cardiac disease occur in less than 5% of cases, cardiac sarcoidosis (CS) is a potential life-threatening disease, due to ventricular arrhythmias.3 Thus, the identification of subclinical but active CS remains crucial. However, a gold standard assessment of the disease is still lacking. Identification of non-caseating granulomas by endomyocardial biopsy can definitively establish the final diagnosis of CS. Nevertheless, the high risk related to an invasive approach does not pay back in terms of sensitivity, due to the patchy involvement of the myocardium.4 A non-invasive advanced multi-imaging approach, including cardiac magnetic resonance imaging (CMR) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET), has been increasingly adopted.5-7 In particular, CMR provides a multidimensional assessment of left ventricular wall thickness, function, as well as tissue characterization.8 Late gadolinium enhancement (LGE) technique indeed allows the identification of myocardial injury in CS, usually occurring with a non-coronary distribution. However, LGE is not able to distinguish between active disease and chronic scar.9 Conversely, PET is optimally
Reprint requests: Alberto Cuocolo, MD, Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
suited to identify active macrophage-mediated inflammation using 18F-FDG.10 Nevertheless, even if myocardial physiological glucose uptake can be suppressed using dietary restrictions, this strategy may result ineffective potentially generating false-positive results.11 Recently, combined 18F-FDG PET/CMR has emerged as a promising tool either with truly hybrid systems or with sequential approaches using fusion postprocessing software.12-14 Among several benefits of a combined acquisition method, the potential to provide complementary information may overcome limitations of each stand-alone technique improving the overall single modalities performance. In the current issue of Journal of Nuclear Cardiology, Okune et al15 investigated the role of fusion PET/ CMR imaging for the identification of inflammatory phase in 74 patients with suspected CS. In particular, the Authors compared fusion 18F-FDG PET/CMR results with those obtained b
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