Preparation Methods For Decreasing Uptake Of 18F-FDG By Myocardium,Brown Adipose Tissue, And Muscle Before Pet/ct Scanning And The Clinical Significance Of PET/CT In Non-mycosis Fungoides/S(?)zary Syndrome,Primary Cutaneous Lymphoma

Part I Preparation methods for decreasing uptake of 18F-FDG by myocardium,brown adipose tissue,and muscle before PET/CT scanningObjectiveDiscussion The effect of low-carbohydrate high-fat protein on dietary intake of 18F-FDG in myocardial,brown fat and muscle.Materials and methods1.Case collection and dietary allocationPatients who met the inclusion criteria from January 2010 to April 2015 in the Guangdong Provincial People’s Hospital were included in the study’s low carbohydrate,high fat,protein diet group:（1）no history of renal disease and diabetes in patients;older than 18 years of age;（2）PET/CT examination of all patients 24 hours before exercise;（3）before the survey by the questionnaire,the patient is good to obey the diet requirements,2 meals before the meal using low-carbohydrate,high fat,protein diet,4 to,hours after meal 18F-FDG PET/CT scan.Meet the above criteria were 126 cases.In order to reduce the possible factors such as weather,temperature and other factors,fasting control group of 126 patients in each case were based on each case of the diet group time selected in the diet group of patients with the same day,the inspection time difference（2）24 hours before PET/CT examination in all patients,and（2）all patients who were not included in the fasting group were included in the control group at the same time as the following inclusion criteria:（1）no history of diabetes and nephropathy;Exercise;（3）patients with fasting for at least 12 hours or more,a total of 126 cases.The following recipes were suggested for the two meals before 18F-FDG injection（4～5 hours after meals）Food requirements of the patients who were checked before 12 noon:Dinner before examination:Fish/meat（beef,pork）/Fried eggs/scrambled eggs;tea/clear water（no sugar or milk;no rice or pasta）Breakfast on examination day:Fried eggs/scrambled eggs/tea eggs;tea/clear water（no sugar or milk of above,Can’t eat rice or pasta）Food requirements of the patients who were checked after 12 noon:Breakfast on examination day:Fried eggs/scrambled eggs/tea eggs;tea/clear water（without sugar or milk;rice or noodles were forbidden）Lunch on examination day:Fish/meat（beef,pork）/Fried eggs/scrambled eggs;tea/clear water（without sugar or milk;rice or noodles were forbidden）2.18F FDG PET/CT scan2.1.18F-FDG)-based PET central RDS111 cyclotron（US Jing Qi Co.,Ltd.）production,the drug by the radiochemical（18F-FDG）,the production of 18-fluoro-fluorodeoxyglucose（18F-FDG）Pure,sterile,no heat,no endotoxin and other strict testing qualified.2.2.Check before the preparation of patients with morning blood glucose control are 4.0～8.Ommol/L.In the course of the inspection,the ambient temperature remains warm,so that patients feel warm,to avoid the cold stimulation of patients.The whole body and brain three-dimensional PET/CT scintigraphy were performed by intravenous injection of 18F-FDG and resting for 60 ± 5min in 3.7～7.4MBq/kg body weight.The imaging range was perineum to head.2.3.PET/CT imaging method The Sensation Biograph Somatom 16 HR PET/CT machine（Siemens,Germany）was used.Patients were supine,the first body imaging imaging in the brain,were first low-dose attenuation correction CT（CT attenuation correction,CTAC）scan and then the same range of PET scan.Body imaging range for the nasopharynx to the upper thigh.CTAC scan parameters of 120 kV voltage,current 50mA s,pitch 1.25,collimation 1.5,reconstruction layer thickness 5.0 mm,layer spacing 5.0 mm.PET scan for 7-9 beds,13.1cm per bed,each bed collection 3min.Visualization Zhu Huanzhe emptying the bladder,check Zhu Huanzhe calm breathing;skull imaging head slightly backward,ranging from the skull to the foramen magnum,the collection time of 5 min.2.4 CT scan of the body and brain diagnostic grade CT scan parameters with reference to each site.Intravenous injection of non-ionic contrast agent iohexol（General Electric Company）,the concentration of 300mgl/ml,dose of 1.0～1.5ml/kg,injection flow rate of 3.0 ml/s,using a high pressure syringe（Ulrich XD2001）.3.Image analysisVisual assessment of the degree of uptake grading criteria:evaluation of diet and fasting methods on myocardial,brown fat and muscle uptake of FDG effects,we use the visual evaluation method,by two experienced nuclear medicine doctors in the patient is not clear which group group,The degree of uptake of 18F-FDG by myocardial,brown fat and muscle uptake was divided into 0,1,2,3 and 4 grades.Myocardial grading was as follows:Grade 0 was negligible myocardial uptake,a level of mild myocardial uptake,uptake or less close to the degree of liver uptake,2 for the myocardial uptake FDG for moderate but uneven,3 For the uptake of myocardium was significantly uniform uptake of FDG.BAT grading is as follows:0 for brown fat is not developed,a brown fat very light uptake of FDG,the degree of intake below or close to the liver,2 brown fat moderate intake of FDG,the degree of uptake close to the liver The degree of uptake,grade 3,was very visibly developed for brown fat.Muscle grading is as follows:0 for the negligible muscle uptake,1 for the muscle light intake of FDG,muscle intake below or close to the degree of liver uptake,2 for moderate muscle uptake FDG,uptake higher than the liver Of the degree of uptake,3 for the muscle is very obvious uptake of FDG.The left ventricular endocardial background for the blood background,the ROI as much as possible in the absence of lesions outlined in the left ventricular cavity,if the left ventricle is occupied by lesions,still ROI outlined in the right ventricle without disease,followed by 1 Aorta,to calculate the Blood SUVmax and Blood SUVmean.While the ROI as much as possible in the absence of lesions outlined in the liver,calculate the Liver SUVmax and Liver SUVmean for the liver background.4.Statistical analysisThere were no statistically significant differences in the uptake of myocardium,brown fat and muscle between the diet group and the fasting group using SPSS software using two independent sample nonparametric tests（Mann-Whitney U test）P<0.05,the difference was statistically significant).Spearman correlation coefficient was used to analyze the correlation between FDG uptake of myocardium,brown fat and muscle in all patients.（SUVmax,blood SUVmax,SUVmax,SUVmean）between fasting and fasting groups were analyzed statistically.Results:There were no statistically significant differences between the fasting group and the fasting group in different parameters（age,sex,body mass index,blood sugar,FDG dose,SUVmax,difference.ResultThere were no significant differences in age,sex,BMI,blood glucose,and FDG dose between fasting groups.Blood SUVmax and SUVmean between the two groups were statistically significant,fasting blood group higher than the fasting group.Liver SUVmax and SUVmean between the two groups were not statistically significant.The degree of FDG uptake of myocardium,brown fat and muscle was statistically different between the two groups.There was a significant positive correlation between the degree of uptake of myocardium,brown fat and muscle in all patients.Conclusion1.Low-carbohydrate high-fat protein allows the preparation of pre-imaging method is a high preparation method,can effectively inhibit myocardial,brown fat and muscle uptake of FDG.2.This preparation method to inhibit myocardial imaging at the same time,can inhibit brown fat and muscle development,the degree of uptake between the three are positively correlated.Part II Preliminary evaluation of 18F-FDG PET/CT imaging in the diagnosis and primary staging of primary cutaneous lymphoma of non-mycosis fungoides/Sezary syndromeObjectiveTo evaluate the value of PET/CT in the diagnosis of primary cutaneous lymphoma of non-mycosis fungoides/Sezary syndrome.Materials and Methods1.Patient informationThe patients who met the inclusion criteria from June 2007 to September 2014 in Guangdong General Hospital were included in this study:（1）clinical or general imaging examination of suspected primary skin lymphoma patients;（2）skin lesions in the end of the study Confirmed by surgery or biopsy;（3）lymph nodes,other parts of the lesion（in addition to the skin and lymph nodes）by surgical or biopsy pathology confirmed;or clinically confirmed lymphoma infiltration（PET/CT found in other lymph nodes and other parts of the disease,chemotherapy After review of PET/CT lesions found to shrink or disappear）;（4）complete clinical data.There were 18 patients（7 males and 11 females,aged 13-85 years,median 36.5 years）,13 cases of primary cutaneous T-cell lymphoma,4 cases of primary cutaneous B-cell lymphoma,Primary skin precursor tumor in 1 case.1 case of primary skin lesions in patients with surgical excision,but without other treatment,the remaining patients were PET/CT before untreated.2.FDG-PET/CT scanSensation Biograph Somatom 16 HR PET/CT（Siemens,Germany）was used in all patients.All patients were given a low-carbohydrate high-fat protein diet before PET/CT,and a PET/CT examination within 4-5 hours after the second meal.Patients were asked to rest in a quiet room after injection of 3.7-7.4 MBq/kg（0.15-0.2 mCi/kg）of 18F-FDG.PET/CT scans were performed within 60 ± 5 minutes after injection.3.Image analysis（SUVmax/SUVmax/SUVmax/SUVmax/SUVmax）of the cutaneous SUVmax and SUVmax of the skin were measured with the skin background（skin lesion adjacent to the normal skin）as the reference.PET/CT criteria for the diagnosis of skin lesions SUVmax for lesions higher than the adjacent normal skin of the background SUVmax,combined with CT scan and enhanced features;diagnosis of lymph node infiltration of lymph node lesions SUVmax greater than 2.5 positive,combined with CT scan and Enhanced features;skin and other organs outside the lymph node infiltration for lesions of the SUVmax is greater than the background of the organ is positive,combined with CT scan and enhanced features.4.Data analysisAccording to the final pathological results,sensitivity,specificity,accuracy and positive predictive value of CT,PET/CT diagnosis of primary skin lesions,CT,PET/CT diagnosis of lymph nodes and other lesions（skin and lymph node）Values and negative predictive values.Result1.PET/CT findingsThe SUVmax of the skin primary lesion was 1.4～17.4,the median was 4.5,the SUVmax lesion/background was 1.2（4.8/0.4）₂7（5.4/0.2）and the median was 15（4.5/0.3）.The SUVmax of lymph node lesions was 2.1 to 22.6 with a median of 5.0.SUVmax was 1.3 to 13.2 with a median of 4.6 in the skin and other extranodal lesions.2.CT and PET/CT fusion images in the diagnosis of primary cutaneous lymphoma of non-mycosis fungoides/Sezary syndrome,respectively18 patients with primary skin lesions in 7 cases（including 1 case of postoperative）,11 cases of multiple.CT missed 3 cases,2 cases of subcutaneous panniculitis-like T-cell lymphoma,1 case of extranodal NK/T cell lymphoma（nasal）;PET/CT were positive.CT and PET/CT diagnosis of primary skin lesions were 82.4%（14/17）,100%（17/17）,PET/CT compared with CT,the diagnostic sensitivity than CT alone.18 cases of lymph node involvement in 9 cases occurred only in the surrounding lymph nodes in 2 cases,only the center of lymph nodes in 1 case,occurred in the surrounding and central parts of 6 cases.1 case of false positive CT,4 cases of false negative;PET/CT showed false negative in 1 case,dermal cell plasma-like dendritic cell tumor patients,inguinal invasive lymph node diameter less than 1.5cm,SUVmaxThe diagnostic sensitivity,specificity,accuracy,positive predictive value and negative predictive value of CT and PET/CT in diagnosis of lymph node lesions were 55.6%（5/9）,88.9%（8/9）/8）,83.3%（5/6）,66.7%（8/12）;88.9%（8/9）,100%（9/9）,94.4%（17/18）,100%),90.0%（9/10）.5 cases occurred in addition to skin and lymph nodes other organs infiltration,only occurred in 4 cases of bone infiltration occurred simultaneously with bone and muscle infiltration in 1 case.CT false negative in 3 cases,PET false negative in 1 case.1 case of bone infiltration CT no morphological changes at the same time no FDG metabolic abnormalities were missed,1 case of bone infiltration CT was negative,PET/CT was positive.1 patient had both bone and muscle infiltration,CT were no abnormalities,missed diagnosis,PET/CT showed a significant increase in FDG uptake.The diagnostic sensitivity,specificity,accuracy,positive predictive value and negative predictive value of CT and PET/CT were 40.0%（2/5）,100%（13/13）,83.3%80%（4/5）,100%（13/13）,94.4%（17/18）,100%（15/18）,100%（2/2）,81.3%（13/16）3/3),92.9%（13/14）.Conclusion18F-FDG PET/CT reflects the pathophysiological changes of SUVmax or SUVmax lesion/background value according to 18F-FDG PET/CT.The pathological features of the primary cutaneous lymphoma of non-mycosis-like granuloma/Sezary syndrome are different.Combined with high-resolution CT provides morphological information for non-mycosis fungoides/Sezary syndrome,primary cutaneous lymphoma with high diagnostic and early stage value for the clinical to provide a new means of inspection.Part Ⅱ Predictive Survival Value of 18F-FDG PET/CT in Primary Cutaneous Lymphoma of non-mycosis fungoides/Sezary syndrome before TreatmentObjectiveTo evaluate the value of PET/CT in predicting the progression or mortality of primary cutaneous lymphoma of non-mycosis fungoides/Sezary syndrome.Materials and Methods1.Patient information（1）clinical or general imaging examination of suspected primary skin lymphoma patients of non-mycosis fungoides/Sezary syndrome;（2）the skin lesions in the end（1）the clinical manifestations of patients with primary cutaneous lymphoma;（3）through PET/CT,CT or MR close follow-up;（4）complete clinical data.Meet the above criteria were 30 cases.2.FDG-PET/CT scanSensation Biograph Somatom 16 HR PET/CT（Siemens,Germany）was used in all patients.All patients were given a low-carbohydrate high-fat protein diet for two meals before PET/CT.PET/CT was performed within 4-5 hours after the second meal.The patient’s blood glucose level was measured prior to 18F-FDG injection.The following PET/CT examinations should be performed only if the patient’s blood glucose level is between 4.0 and 8.0 mmol/L（72.0-144.0 mg/dL）.Patients were asked to rest in a quiet room after injection of 3.7-7.4 MBq/kg（0.15-0.2 mCi/kg）of 18F-FDG.PET/CT scans were performed within 60 士 5 minutes after injection.Check the process of the control of the environment temperature,so that patients with insulation,to avoid cold stimulation,especially in winter and spring,so that patients in the PET center to wear warm way,the general temperature maintained at 22 °～25°,60 minutes before the break When patients covered with blankets.Check before the introduction of the inspection process,such as psychological comfort to avoid the subjects nervous,reduce sympathetic stimulation,reduce the occurrence of brown fat imaging probability.3.Data analysis and statistical methodsThe following clinical information was collected and analyzed:SUVmax,age,type of lymphoma（inertia,invasion）,morphology and extent of skin lesions,location of skin lesion,treatment,presence of B symptom,serum dehydrogenase Lactate dehydrogenase（LDH）,β-microglobulin,ECOG PS,International Prognostic Index（IPI）,lymph node infiltration,presence of bone metastasis,extranodal location and survival time.Progression-free survival（PFS）is defined as the time from initial diagnosis to disease progression,relapse,death from any cause,or final follow-up.Statistical analysis was performed using SPSS software.The optimal cutoff value of SUVmax was calculated using the ROC curve to predict the death or progression of cutaneous lymphoma.Survival stage using Kaplan-Meier method,compared with the log rank test.The relationship between prognostic factors at diagnosis and PFS was analyzed using the Cox regression model.Results1.Survival analysisKaplan-Meier analysis showed that the progression-free survival of 30 patients was 24.592 ± 4.507,95%confidence interval（15.759,33.425）.2.Survival analysis of different treatment methodsThirteen patients in 30 patients were treated with general therapy and 17 patients received intensive treatment.Cox regression analysis showed a statistically significant difference in PFS between the two groups.Patients with intensive therapy had a longer PFS than the usual regimen,p = 0.021 and Exp（B）= 11.157.Survival analysis of different therapeutic effects in the early stage of treatmentAccording to the modified IWC evaluation criteria,6 of 30 patients achieved CR criteria（20%）,5 patients achieved PR criteria（16.7%）,7 patients achieved SD criteria（23.3%）,12 patients PD,Representing 40%.Kaplan-Meier analysis showed that the progression-free survival was 24.592±4.507 and the 95%confidence interval（15.759,33.425）in 30 patients,65.833 ± 7.455 in 95%confidence interval（51.221,80.445）PFS was 27.200±4.641,95%confidence interval（18.103,36.297）;PFS of SD patients was 17.786 ± 3.201,95%confidence interval（11.511,24.060）;PFS of PD patients was 6.833 ± 1.766,95%confidence interval（3.372,10.295）.There were significant differences in PFS among the four groups.Log Rank（Mantel-Cox）,Breslow（Generalized Wilcoxon）and Tarone-Ware all showed p =0.000.4.SUVmax predict ROC curve of death or progression in patients with primary cutaneous lymphoma of non-mycosis fungoides/Sezary syndrome;Survival analysis of SUVmax positive and negative patientsThe ROC curve showed that the SUVmax cut-off was 8.6,the sensitivity was 61.5%,the specificity was 94.1%,the area under the curve was 0.783,p = 0.009,the SUVmax>8.6 was defined as positive and the SUVmax<8.6 was defined as negative.PFS was significantly higher in SUVmax-negative patients than in SUVmax-positive patients.Log Rank（Mantel-Cox）p = 0.021,Breslow（Generalized Wilcoxon）p ＝0.042,Tarone-Ware p = 0.030.PFS of SUVmax-negative patients was 28.326 ± 5.290,95%confidence interval（17.958,38.694）,PFS of SUVmax-positive patients was 9.714 ± 3.010,95%confidence interval（3.815,15.614）.Cox regression showed that PFS of patients with SUVmax positive and negative primary cutaneous lymphoma of non-mycosis fungoides/Sezary syndrome was statistically different.SUVmax negative patients had longer PFS than SUVmax positive patients,p = 0.028 and Exp（B）= 6.188.5.The correlation between SUVmax and therapeutic effectSpearman correlation analysis showed that there was a significant correlation between SUVmax and therapeutic effect（CR,PR,SD,PD）,p = 0.021,the higher the SUVmax,the worse the therapeutic effect.6.Analysis of prognostic factorsCOX analysis showed that SUVmax,skin lesion area（focal,extensive）,skin lesion（torso,limbs）,treatment,B symptoms,ECOG score and lymph node infiltration were prognostic factors.SUVmax p = 0.028,Exp（B）= 6.188,SUVmax positive in patients with PFS worse than SUVmax negative patients.P = 0.21,Exp（B）=13.709,PFS of patients with extensive skin lesions was worse than that of focal skin lesions.P = 0.002,Exp（B）= 39.940.Skin lesions occurred in the extremities or in the limbs and trunk of patients with PFS worse than the skin lesions occurred in the trunk of the patients.Treatment,see above.B symptoms of P = 0.029,Exp（B）=8.281,B symptoms of patients with PFS worse than patients without B symptoms.ECOG score p = 0.038,Exp（B）= 6.491,and patients with high ECOG scores had worse PFS than those with low ECOG scores.Lymph node infiltration p = 0.001,Exp（B）= 38.428,the prognosis of patients with lymph node infiltration worse than no lymph node infiltration in patients.LDH level（p = 0.267）,β-microglobulin（p =0.545）,age（p = 0.720）,inertia/invasiveness（p = 0.402）,lesion morphology（patch,nodule）IPI score（p = 0.886）,with or without bone infiltration（p = 0.081）,and extranodal involvement（p = 0.073）were not associated with prognostic PFS（p>0.05）.ConclusionBefore treatment,PET/CT has a strong prognostic value of the prognosis of primary cutaneous lymphoma of non-mycosis fungoides/Sezary syndrome in patients with progression and death.Patients with positive SUVmax before treatment had a shorter PFS than patients with negative SUVmax.