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Intensity of [sup.18]F-FDG PET Uptake in Culture-Negative and Culture-Positive Cases of Chronic Osteomyelitis.

1. Introduction

Osteomyelitis, especially its less common hematogenous forms, is a remarkably difficult diagnostic problem. Based on recent meta-analyses [1-3], fluorodeoxyglucose positron emission tomography ([sup.18]F-FDG PET) is the most sensitive radiographic technique for detecting chronic osteomyelitis and it has a greater specificity than leukocyte scintigraphy, bone scintigraphy, or magnetic resonance imaging. [sup.18]F-FDG PET is less accurate in the diagnosis of periprosthetic joint infections [4]. One of the contributing factors may be the virulence of the causative bone pathogen and the severity of the subsequent infection [5], which appear to contribute to the intensity of local [sup.18]F-FDG uptake in infected tissues. In a standardized animal model, localized subacute/chronic osteomyelitis caused by S. epidermidis has been characterized by a low [sup.18]F-FDG uptake [6], while acute suppurative osteomyelitis caused by S. aureus results in a high uptake [7, 8].

The definitive diagnosis of osteomyelitis is made by culturing the pathogen from the site of infection. Unfortunately, biopsy cultures are not infrequently negative emphasizing the importance of both histologic and microbiologic samples of tissue samples [9]. In children, the rate of culture-negative osteomyelitis has been reported to be up to 47% [10]. The rate of negative cultures in histologically proven cases of osteomyelitis obtained from imaging-guided bone biopsies (excluding spine biopsies) was even higher (66%) [11]. In recent studies of vertebral osteomyelitis, the negative culture rate of image-guided biopsy was also high (68-70%) [12, 13]. The factors that predict positive or negative culture results are largely unknown [11, 14]. One reason is inappropriate culture conditions. Technical errors of biopsies and starting of antibiotic treatment before biopsy may also affect culture results. There are cases in which even repeated open biopsies fail to recover the underlying pathogen. Sequestra of chronic osteomyelitis are known to be covered by metabolically quiescent bacteria within adherent biofilms [15] and it has been suggested that false-negative infections are due to viable but nonculturable biofilm organisms [14].

Based on this knowledge, certain cases of culture-negative, histologically low-grade osteomyelitis may represent clinical conditions with an inherent difference in metabolic activity compared with culture-positive cases. We assumed that [sup.18]F-FDG PET could potentially detect such a difference, because intracellular accumulation of the tracer reflects metabolic rate of cells at sites of infection and inflammation [16]. Thus, the purpose of this study was to determine whether the level of [sup.18]F-FDG uptake differs in culture-negative and culture-positive cases of histologically and/or microbiologically proven osteomyelitis.

2. Methods

2.1. Patients. A part of this study has been published in a Ph.D. work [17]. The patient population represents 40 consecutive orthopaedic patients who had [sup.18]F-FDG PET in a five-year period (ending December 2004) with minimum 4-year follow-up data as an adjunct imaging modality for evaluation of a clinically suspected bone infection. The suspicion of bone infection was based on clinical symptoms, laboratory findings, and results of other imaging modalities. The study cases were retrieved from the hospital database based on the reference number of the PET imaging. The clinical charts of the patients were retrospectively reviewed. There was no contact with patients, and according to the national law the study did not require approval of the ethical aboard. The investigation was approved by the hospital administration and was conducted in accordance with the principles of Declaration of Helsinki.

Fourteen of the original 40 patients were excluded from the current analysis. Seven cases were excluded because no histopathologic or microbiologic verification of the diagnosis was made. Five cases were excluded because [sup.18]F-FDG PET was applied only to evaluate of antimicrobial treatment response. Two additional cases were excluded because the primary indication for PET imaging was not suspected infection.

Twenty-six (65%) of the 40 patients had definite histopathologic and/or microbiologic diagnosis based on the examination of samples (Table 1). Biopsy samples were obtained during neurosurgical decompression of the spinal canal, during an open biopsy performed by an orthopaedic surgeon, or by CT/MRI guided needle biopsy performed by a musculoskeletal radiologist. The definite diagnosis was osteomyelitis in 16 patients (62%), soft tissue infection in four patients (15%), and spinal implant infections in two patients (8%). The histologic diagnoses for the four remaining cases were plasmacytoma, osteoblastoma, transient bone marrow oedema, and degenerative sternoclavicular osteoarthritis.

A microbiologic culture was considered positive, if any relevant organism grew based on the judgment of a microbiologist. Of the 16 cases with proven osteomyelitis, eight (50%) had positive cultures and seven (44%) had negative cultures (Table 2). One patient with low-grade sacral osteomyelitis (case #4) had no cultures done of the biopsy specimen. The culture-negative cases were predominantly rare forms of hematogenous osteomyelitis, including two indolent Brodie's abscesses, two cases of recurrent chronic osteomyelitis of the femur, one case of chronic osteomyelitis of the medial clavicle (possible synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome), and two cases of vertebral osteomyelitis (Table 2).

None of the patients with negative cultures had antibiotic therapy before sampling (Table 2). Three patients with negative cultures had repeated biopsies because of failures in recovering the pathogen (Table 2). Three other patients with culture-negative osteomyelitis had multiple tissue samples taken at surgery (laminectomy) or during open biopsies. Only one case of culture-negative vertebral osteomyelitis was based on a single procedure of CT-guided biopsy. Routine microbiologic analysis of bone specimens included extended culture times and specific cultures for the diagnosis of tuberculosis, if indicated. Molecular diagnostic technology of polymerase chain reactions (PCRs) was applied in four patients with repeated biopsies (in three culture-negative patients and one culture-positive patient). None of universal PCRs were positive.

There were three patients with a past history of a skeletal infection with fever in both groups (culture-negative cases #2, #5, and #30 and culture-positive cases #6, #16, and #40). Two of these cases had history of osteomyelitis treatment as a child. One additional culture-positive case (case #8) had been hospitalized for an unexplained skeletal pain as a 15-year-old. The current diagnostic studies were most commonly started due to local pain or night aching. None of the patients had fever or draining sinus as a sign of acute exacerbation of chronic osteomyelitis. Pain had lasted [less than or equal to] one month in six patients and for 3-12 months in the remaining 10 patients. Aside from pain, one patient had recognized a local resistance (case #3). One patient was symptomless (case #8). One patient (case #20) suffered from radiating back pain for a month and developed acute paraparesis before spinal decompression.

Patient groups of culture-negative and culture-positive osteomyelitis both had normal or slightly elevated blood levels of C-reactive protein (median 6 mg/L, range 1-73 mg/L, respective to median 6 mg/L, range 1-49 mg/L). All patients with culture-negative osteomyelitis, except one, had slightly elevated erythrocyte sedimentation rate (median 18 mm/hour, range 7-27 mm/hour). There was a trend for higher erythrocyte sedimentation rate (median 28 mm/hour, range 2-82 mm/hour) in culture-positive cases.

2.2. [sup.18]F-FDG PET. [sup.18]F-FDG PET imaging was performed as an adjunct part of routine work-up in the differential diagnostics of osteomyelitis. The clinical reviewers of the PET images had access to all patient charts, including the results of conventional imaging modalities. Based on the interpretation of the reviewers, the result of [sup.18]F-FDG PET was recorded as true positive or false negative (Table 3). The patients were instructed to fast for 6 hours prior to PET. [sup.18]F-FDG PET imaging was performed with an Advance PET scanner (General Electric Medical Systems, Milwaukee, WI, USA) operated in 2-dimensional mode (high resolution). The scanner had 18 rings of bismuth germanate detectors, and the axial length of the imaging field of view (FOV) was 152 mm. Whole body acquisition was started 60 minutes after the injection of [sup.18]F-FDG (5 minutes per bed position). The mean dose of intravenous bolus injection of [sup.18]F-FDG was 297 MBq (SD 71 MBq; range, 160-384 MBq). A standard transmission scan for attenuation correction was obtained after the emission imaging using two rod sources containing germanium-68. All 35 transaxial image slices were reconstructed with an ordered subsets expectation maximization algorithm (OSEM) and the central 200 mm-diameter transaxial FOV and 128 x 128 matrix leading to pixel size 1.56 x 1.56 mm were used. Random counts and dead time were corrected by the system and scatter correction was incorporated into the reconstruction algorithm. Quantitative analysis of the [sup.18]F-FDG uptake was performed on standardized circular regions of interest (ROIs, diameter of 15 mm) at the site of visually detected increased tracer accumulation from background using transaxial slices. Tracer accumulation was reported as the standardized uptake value (SUV), which was calculated as the radioactivity of the ROI divided by the relative injected dose expressed per patient's body weight. Both [SUV.sub.mean], representing the average uptake on the selected ROI, and the maximum SUV value ([SUV.sub.max]), representing the highest pixel uptake in the ROI, were analyzed. In addition, [SUV.sub.ratio], that is, the ratio between the site of suspected infection and the ROI of the corresponding healthy anatomic site, was calculated for [SUV.sub.mean] and [SUV.sub.max] [7,18].

2.3. MRI, Bone Scintigraphy, and Infection Scans. The decision to perform other imaging modalities (MRI, threephase bone scintigraphy, infection scan with labeled leukocytes or antigranulocyte antibodies, and occasionally CT) (Table 3) was based on the judgment of clinical indications in each case. The three-phase bone scintigraphy (bone scan) was performed with [sup.99m]Tc-HDP or DPD (mean dose 670 MBq). Infection scans were performed using either [sup.99m]Tc-white blood cell scanning (HMPAO, Ceretec, GE Healthcare, Amersham Place, United Kingdom, mean dose 209 MBq) or [sup.99m]Tc-antigranulocyte scintigraphy (LeukoScan[R], Immunomedics GmbH, Darmstadt, Germany, mean dose 1000 MBq) technique. Based on the interpretation of the clinical reviewers, the results were recorded as true positive or false negative (Table 3).

2.4. Statistical Analysis. Data are expressed as mean [+ or -] standard deviation (SD). Nonparametric Mann-Whitney U test was applied in the comparison of [SUV.sub.mean] and [SUV.sub.max] values between patients with culture-positive and culture-negative osteomyelitis. p < 0.05 was considered significant. All statistical analyses were performed using IBM SPSS Statistics software (International Business Machines Corp., Armonk, New York, USA).

3. Results

[SUV.sub.mean] values of culture-negative (mean [+ or -] SD, 2.07 [+ or -] 0.74) and culture-positive cases of chronic osteomyelitis (2.18 [+ or -] 1.31) did not differ significantly. The [SUV.sub.max] values of culture-negative (2.81 [+ or -] 0.96) and culture-positive cases (3.73 [+ or -] 1.70) neither showed significant intergroup differences (Figure 1).

There was a clear visual difference in the uptake of [sup.18]F-FDG at the infection site and at the corresponding ROI of the contralateral healthy bone (Figure 2). Both in culture-negative and culture-positive cases, the calculations of [SUV.sub.ratio] confirmed high mean values for [SUV.sub.mean] (7.65 versus 4.98, resp.) and for [SUV.sub.max] (6.51 versus 6.84, resp.) (Figure 1).

The patients with histologically and/or microbiologically proven osteomyelitis (n = 16) were all correctly interpreted as true positive in the routine clinical reading of [sup.18]F-FDG PET images (Table 3). Four patients (25%) out of 16 (cases #4, #7, #20, and #40) had false-negative MRI or labeled leukocyte scintigraphy (Table 3). In the retrospective view, in these cases [sup.18]F-FDG PET brought a significant diagnostic help compared with the results of other imaging modalities.

Among the whole group of patients (n = 26) (Table 1), [sup.18]F-FDG PET gave no false-negative cases and three false positive cases. The three false positive cases were due to periarticular soft tissue infections (cases #12 and #33) and vertebral plasmacytoma (case #26).

4. Discussion

The present retrospective analysis was focused on the diagnostic imaging and microbiologic challenges in a special subgroup of patients with predominantly rare forms of hematogenous chronic osteomyelitis, including four cases of Brodie's abscesses. The rate of positive cultures was 47%, which is similar to the reported rates of 30%-42% in previous studies on imaging-guided biopsies with combined histologic and microbiologic evaluation [9, 11-13]. Thus, our patient population resembles the previously published series and was subsequently appropriate for evaluation of [sup.18]F-FDG PET imaging in the characterization of culture-negative cases. The culture-negative cases may be incorrectly described as negative because the infecting microbe(s) may be nonculturable [14]. If true, we assumed that culture-negative cases might have a lower metabolic activity than culture-positive cases measured by [sup.18]F-FDG PET imaging. Against our hypothesis, there was no relationship between the level of [sup.18]F-FDG PET uptake and the presence of positive or negative bacterial cultures among these patients with histologically and/or microbiologically proven chronic osteomyelitis.

Reflecting the rarity of the cases, it is evident that a multicenter prospective study is needed to get definitive answers to the open questions. Previously Wu and coworkers [11] have already paid attention to the small number of requests for imaging-guided core bone biopsies for suspected osteomyelitis. They found that two large US centers had only 3-7 such cases per year. The number of cases enrolled in our study closely resembles the experience of Wu and coworkers. Twenty-six patients, who had [sup.18]F-FDG PET imaging for suspected osteomyelitis and underwent the necessary microbiologic and/or histologic examinations of biopsies during a five-year period, represented about 5 referred cases per year in our university hospital district of about 800.000 inhabitants. Most of these cases were primarily scrutinized by the sarcoma treatment group for exclusion of a bone tumor. Overall, it is important to emphasize two facts. First, the majority of osteomyelitis patients (like posttraumatic cases) have an undisputed clinical history with clear-cut laboratory/radiographic data suggesting osteomyelitis and do not require advanced noninvasive differential diagnostics like [sup.18]F-FDG PET imaging and a histologic proof of the diagnosis. Secondly, the microbiologic isolation of the causative bone pathogen(s) yields positive results in most cases (78%) of posttraumatic osteomyelitis [19] and, for example, virtually in all cases with recurrent infection of open tibial fractures [20]. As shown in the previous studies [9,11-13] and in the current study, the situation is different in subgroups of patients who are referred to [sup.18]F-FDG PET imaging and/or imaging-guided biopsy for suspected chronic osteomyelitis.

Based on previous studies, a negative [sup.18]F-FDG PET scan can virtually rule out chronic osteomyelitis [18]. The high accuracy of [sup.18]F-FDG PET for excluding chronic osteomyelitis may be related to the high uptake of [sup.18]F-FDG by activated macrophages, which are among the predominant cells in chronic infections [16]. The false positive case of vertebral plasmacytoma demonstrates the inability of [sup.18]F-FDG PET imaging in the differentiation of chronic osteomyelitis and a malignant bone tumor. Both of these conditions result in the high accumulation of [sup.18]F-FDG and may even share the macrophage-related mechanism of the tracer uptake. [sup.18]F-FDG accumulates not only in tumor cells, but also in macrophages and newly formed granulation tissues, which are infiltrating the marginal areas of tumor necrosis [21].

This study had limitations. Data of the small patient population were retrospectively extracted from medical records of a single university hospital. There were no definite indications for the use of [sup.18]F-FDG PET imaging in the diagnostic armamentarium of suspected osteomyelitis. Thus, seven of the original 40 patients had PET imaging but never had definite histopathologic or microbiologic verification of the diagnosis probably due to mild symptoms and negative imaging results. The execution of other imaging modalities was not determined but was solely based on the clinical judgment. As a result, imaging studies were not performed in a constant manner for the comparison with [sup.18]F-FDG PET imaging and the variation could affect the interpretation of [sup.18]F-FDG PET images. We cannot exclude occasional errors in the sampling of the biopsies as well as in the performance of microbiologic analyses. However, a special attention had been placed to repeat biopsies in culture-negative cases minimizing the risk of errors in surgical sampling. In addition, the microbiologic culture techniques were based on the notion that detection of low-virulent slow-growing bacteria requires extended culture times. Molecular assays, such as polymerase chain reaction (PCR), have been developed to aid in bacterial detection and identification [22, 23]. These techniques were applied, but not in all culture-negative cases. The applied PET imaging technique was constant in all patients and the clinical follow-up time of all patients was long enough, but as a result the imaging was not performed with the current models of PET scanners with a low-dose or full-dose diagnostic CT, which provide means to acquire more precise anatomic and physiologic data improving foremost specificity but also sensitivity [24, 25]. This technical limitation seemed to have only a minor impact, because the interpretation of the PET images of both culture-positive and culture-negative cases was unquestionable and showed high [SUV.sub.ratio] values. Only the two false positive cases due to periarticular soft tissue infections could have been avoided by using [sup.18]F-FDG PET/CT, because it provides exact anatomic localization of [sup.18]F-FDG uptake. As a potential technical limitation, a standard circular ROI (15 mm in diameter) was applied in the SUV analyses of FDG tracer accumulation. Certainly, the infected bone regions varied in size and most of them were larger than the selected ROI. The small diameter of the ROI carried a risk for partial-volume effect (PVE) meaning that the apparent pixel values in PET images were influenced by the surrounding high pixel values [26]. If the measured [SUV.sub.mean] values were under the possible influence of PVE, the current analysis included also the comparison of [SUV.sub.max] values based on the maximum uptake of [sup.18]F-FDG in a single pixel (size of 1.56 x 1.56 mm).

5. Conclusion

We conclude that there is no relationship between the level of [sup.18]F-FDG PET uptake and the presence of positive or negative bacterial cultures in patients with histologically proven osteomyelitis. The result favors the concept that culture-negative cases are false-negative infections due to nonculturable microbes. Thus, [sup.18]F-FDG PET may help to confirm the presence of active infection in patients with culture-negative low-grade osteomyelitis and guide their appropriate treatment.

https://doi.org/10.1155/2017/9754293

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Acknowledgments

This research was financially supported by the Sigrid Juselius Foundation.

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Petteri Lankinen, (1) Marko Seppanen, (2) Kimmo Mattila, (3) Markku Kallajoki, (4) Juhani Knuuti, (2) and Hannu T. Aro (1)

(1) Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Turku University Hospital, University of Turku, Turku, Finland

(2) Turku PET Centre, Turku University Hospital, Turku, Finland

(3) Medical Imaging Centre of Southwest Finland, Turku University Hospital, University of Turku, Turku, Finland

(4) Department of Pathology, Turku University Hospital, Turku, Finland

Correspondence should be addressed to Hannu T. Aro; hannu.aro@utu.fi

Received 22 June 2017; Accepted 7 September 2017; Published 11 October 2017

Academic Editor: Cristina Nanni

Caption: Figure 1: Comparison of [SUV.sub.mean] (a), [SUV.sub.max] (b), [SUV.sub.mean] ratio (c), and [SUV.sub.max] ratio (d) values measured in [sup.18]F-FDG PET imaging of osteomyelitis patients. The differences between culture-negative (n = 7) and culture-positive (n = 8) cases were not statistically significant. Box plots are showing median, 1st and 3rd quartiles, minimum and maximum values, and outliers (white circles and asterisks).

Caption: Figure 2: A 25-year-old man with an indolent Brodie's abscess in the proximal tibia (case #8). The patient had been hospitalized for knee pain 10 years earlier, but no specific diagnosis was made. He now suffered a sports related ACL ligament rupture of his left knee. As an incidental finding, anterior-posterior and lateral radiographs (a) showed cystic lesion with surrounding sclerosis in the proximal tibia. Coronal and transaxial MR-images (b) demonstrated a 2 cm sclerotic osseous lesion with contrast medium enhancement and oedema of the surrounding tissues. Coronal and transaxial [sup.18]F-FDG PET images (c) showed an increased local uptake of the tracer. Compared with the corresponding ROI of the contralateral tibia, [SUV.sub.mean] ratio was 10.1 and [SUV.sub.max] ratio 20.51. The lesion was correctly characterized with infection scintigraphy with labeled antibody fragments (LeukoScan) (d) and three-phase bone scintigraphy (e). Based on percutaneous biopsy samples taken under fluoroscopy, the final histological diagnosis was Brodie's abscess and the microbiologic culture revealed S. aureus as the causative pathogen.

Table 1: PET/imaged patients with definite histopathologic and/or
microbiologic diagnosis (n = 26).

Case #   Age/sex     Anatomic location      Implant

1         64/F     Sternoclavicular joint     No
2         21/M             Femur              No
3         59/F        Medial clavicle         No
4         61/F             Sacrum             No
5         60/F             Femur              No
6         17/F            Humerus             No
7         70/M             Pelvis             No
8         25/M             Tibia              No
9         67/F         Lumbar region          Yes
12        21/F           Hip region           No
13        59/M         Thoracic spine         No
15        59/M           Symphysis            No
16        52/F             Tibia              No
18        18/M         Thoracic spine         Yes
20        73/F         Thoracic spine         No
25        68/M            Sternum             No
26        73/F         Thoracic spine         No
27        19/M             Femur              No
29        73/F          Lumbar spine          No
30        17/F             Tibia              No
32        73/F          Elbow region          No
33        22/F          Ankle region          No
34        19/F             Tibia              Yes
36        42/M          Lumbar spine          No
39        28/M             Femur              No
40        42/M             Radius             No

Case #   Analysis of biopsy sample   Microbiologic
                                        culture

1         Histology, microbiology      Negative
2         Histology, microbiology      Negative
3         Histology, microbiology      Negative
4                Histology             Not done
5         Histology, microbiology      Negative
6         Histology, microbiology      Positive
7         Histology, microbiology      Positive
8         Histology, microbiology      Positive
9              Microbiology            Positive
12        Histology, microbiology      Positive
13        Histology, microbiology      Negative
15        Histology, microbiology      Positive
16             Microbiology            Positive
18             Microbiology            Positive
20        Histology, microbiology      Negative
25        Histology, microbiology      Positive
26        Histology, microbiology      Negative
27        Histology, microbiology      Negative
29        Histology, microbiology      Positive
30        Histology, microbiology      Negative
32             Microbiology            Positive
33        Histology, microbiology      Negative
34        Histology, microbiology      Positive
36        Histology, microbiology      Negative
39        Histology, microbiology      Negative
40        Histology, microbiology      Positive

Case #          Definite diagnosis

1                 Osteoarthritis
2                Brodie's abscess
3             Chronic osteomyelitis
4             Chronic osteomyelitis
5        Recurrent chronic osteomyelitis
6        Recurrent chronic osteomyelitis
7             Chronic osteomyelitis
8                Brodie's abscess
9            Spinal implant infection
12            Soft tissue infection
13           Vertebral osteomyelitis
15         Postoperative osteomyelitis
16          Recurrent Brodie's abscess
18           Spinal implant infection
20           Vertebral osteomyelitis
25            Soft tissue infection
26                 Plasmacytoma
27       Recurrent chronic osteomyelitis
29           Vertebral osteomyelitis
30               Brodie's abscess
32            Soft tissue infection
33            Soft tissue infection
34         Postoperative osteomyelitis
36         Transient bone marrow oedema
39                Osteoblastoma
40            Chronic osteomyelitis

Table 2: Patients with histologically and/or microbiologically proven
osteomyelitis (n = 16).

Case   Age/sex               Definite diagnosis

6       17/F     Recurrent chronic osteomyelitis of humerus
7       70/M           Chronic osteomyelitis of pelvis

8       25/M              Brodies abscess of tibia
15      59/M      Postoperative osteomyelitis of symphysis
16      52/F         Recurrent Brodies abscess of tibia
29      73/F               Vertebral osteomyelitis
34      19/F        Postoperative osteomyelitis of tibia
40      42/M           Chronic osteomyelitis of radius

2       21/M              Brodies abscess of femur
3       59/F      Chronic osteomyelitis of medial clavicle
5       60/F      Recurrent chronic osteomyelitis of femur
13      59/M               Vertebral osteomyelitis
20      73/F               Vertebral osteomyelitis
27      19/M      Recurrent chronic osteomyelitis of femur
30      17/F              Brodies abscess of tibia
4       61/F           Chronic osteomyelitis of sacrum

Case         Microbiologic culture

6      Coagulase-negative Staphylococcus
7        P. aeruginosa, Enterococcus,
                 S. epidermidis
8                  S. aureus
15               S. epidermidis
16                 S. aureus
29               S. epidermidis
34               S. epidermidis
40              Bacillus species

2                   Negative
3                   Negative
5                   Negative
13                  Negative
20                  Negative
27                  Negative
30                  Negative
4                   Not done

Case                Method of biopsy                  Antimicrobial
                                                      therapy before
                                                          biopsy

6                      Open biopsy                          No
7                      Open biopsy                   Yes, interrupted
                                                      before biopsy
8        Percutaneous biopsy under fluoroscopy              No
15                  MRI-guided biopsy                       No
16                     Open biopsy                          No
29              Biopsy during laminectomy                   No
34        Open biopsy and removal of bone screw             No
40     MRI-guided biopsy and repeated open biopsy    Yes, interrupted
                                                      before biopsy

2          Repeated open and CT-guided biopsy               No
3                      Open biopsy                          No
5                      Open biopsy                          No
13              Biopsy during laminectomy                   No
20                  CT-guided biopsy                        No
27         Repeated MRI-guided and open biopsy              No
30             MRI-guided and open biopsy                   No
4                   CT-guided biopsy                        No

Case   Antimicrobial
       therapy started
         before PET

6            No
7            Yes

8            No
15           No
16           No
29           Yes
34           No
40           No

2            No
3            No
5            No
13           Yes
20           No
27           Yes
30           No
4            No

Table 3: Results of [sup.18]F-FDG PET and additional imaging
modalities in patients with proven osteomyelitis (n = 16).

Case #    Microbiologic     PET   MRI   Bone   Infection   CT
             culture                    scan     scan

6        Culture-positive   TP    TP     TP       --       --
7        Culture-positive   TP    FN     TP       FN       --
8        Culture-positive   TP    TP     TP       TP       TP
15       Culture-positive   TP    TP     TP       --       TP
16       Culture-positive   TP    TP     TP       TP       TP
29       Culture-positive   TP    TP     TP       TP       --
34       Culture-positive   TP    --     --       TP       FN
40       Culture-positive   TP    TP     TP       FN       --

2        Culture-negative   TP    TP     TP       TP       --
3        Culture-negative   TP    --     TP       --       FN
5        Culture-negative   TP    TP     TP       TP       --
13       Culture-negative   TP    TP     --       --       --
20       Culture-negative   TP    FN     TP       TP       TP
27       Culture-negative   TP    TP     --       --       --
30       Culture-negative   TP    TP     TP       TP       --
4            Not done       TP    FN     TP       TP       FN

Case #                 SUV

         [SUV.sub.mean]   [SUV.sub.max]

6             1.19             1.98
7             3.93             5.53
8             0.99             2.86
15            4.62             7.59
16            0.90             2.81
29            2.54             4.11
34            1.72             2.59
40            1.55             2.37

2             0.74             1.16
3             1.95             2.50
5             2.34             2.79
13            3.08             4.43
20            1.80             3.05
27            1.96             2.91
30            2.60             2.86
4             2.57             2.80

Case #           [SUV.sub.ratio]

         [SUV.sub.mean]   [SUV.sub.max]

6             2.25             2.89
7             5.44             4.78
8             10.1            20.51
15            3.79             5.56
16            3.60             4.36
29            2.42             2.83
34            9.72            11.28
40            2.48             2.47

2             4.90             2.57
3             2.30             2.14
5            16.10            14.28
13            3.47             3.61
20            2.12             2.77
27           11.44            12.47
30           13.20             7.72
4             1.36             1.89

PET = positron emission tomography; MRI = magnetic resonance imaging;
Bone scan = three-phase bone scintigraphy; Infection scan = labeled
leukocyte scintigraphy; CT = computerized tomography; TP = true
positive; FN = false negative; -- = not done.
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Title Annotation:Research Article
Author:Lankinen, Petteri; Seppanen, Marko; Mattila, Kimmo; Kallajoki, Markku; Knuuti, Juhani; Aro, Hannu T.
Publication:Contrast Media & Molecular Imaging
Article Type:Report
Date:Jan 1, 2017
Words:5387
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