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Annotation
POSITRON EMISSION TOMOGRAPHY AND THE ORTHOPAEDIC
SURGEON
M. A. Smith,
M. J. O’Doherty
Orthopaedic surgeons have embraced a variety of imaging
techniques over the last decade. CT and MRI have
improved the anatomical definition of abnormalities and
radionucleide imaging the functional definition of disease.
Progress continues in trying to define the sites of disease
and the nature of its activity using magnetic resonance
1-3
spectroscopy (MRS) and positron emission tomography
4-8
(PET). It was therefore surprising that a recent paper by
9
Cheng and Thompson made no mention of PET.
PET allows the visualisation of the metabolic activity of
disease. In orthopaedic surgery it is of most help in the
diagnosis of malignant tumours and their recurrence, the
staging of tumours and the monitoring of their response to
therapy, and in the diagnosis of osteomyelitis.
The positron-emitting tracers may be used to define
18
glucose metabolism ( F-fluorodeoxyglucose (FDG)), ami11
11
no-acid uptake ( C-methionine; C-tyrosine), DNA turno18
ver ( F-fluoro methyl thymidine (FLT)), tissue hypoxia
18
18
( F-fluoromisonidazole) and possible bone turnover ( Ffluoride). Tumours and infection show increased uptake of
FDG which can therefore be used in both circumstances.
Primary malignant tumours presenting to the orthopaedic
surgeon are either of bone or the connective tissues, i.e.,
sarcoma of bone or soft tissue. These are rare and should be
dealt with at centres where there is a multidisciplinary team
10
available to provide the necessary expertise which should
include imaging facilities to give accurate localisation and
characterisation of the primary tumour. FDG imaging of
soft-tissue sarcomas can distinguish high-grade from low4,8,11
grade tumours and benign lesions,
although the separation of low-grade from benign lesions is not possible.
Metabolic imaging with FDG combined with MRI may be
useful in directing the surgeon to the most malignant area
M. A. Smith, FRCS, Consultant Orthopaedic Surgeon
St Thomas’ Soft Tissue Tumour Unit, Department of Orthopaedics, Guy’s
Hospital, St Thomas’ Street, London SE1 9RT, UK.
M. J. O’Doherty, Senior Lecturer in Radiological Sciences
Guy’s and St Thomas’ Clinical PET Centre, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK.
©2000 British Editorial Society of Bone and Joint Surgery
0301-620X/00/310819 $2.00
J Bone Joint Surg [Br] 2000;82-B:324-5..
324
within a large heterogeneous mass. Biopsy should be
undertaken in conjunction with, or preferably by, the orthopaedic surgeon who will eventually carry out the definitive
10
procedure. A combination of imaging techniques may be
used, first to define the most abnormal site by MRI/CT with
FDG PET and then to carry out the biopsy using CT for
guidance. The biopsy is a crucial step in the management of
soft-tissue and bone sarcomas, particularly with the increasing use of adjuvant therapies before definitive surgery. Any
information which helps the surgeon to take the most
appropriate sample of the tissue is essential in order to
make an accurate diagnosis and to prevent
12
complications.
FDG PET is useful in the localisation of distant and
multisystem disease in patients with soft-tissue sarcomas or
sarcomas of bone. The localisation of metastases from softtissue sarcoma in the lung, however, is not as sensitive as
7
that with CT, although metastases from osteosarcoma are
13
readily visualised. The combination of an initial wholebody FDG PET scan with a local scan of the tumour, CT of
the chest and MRI of the primary lesion is probably the
optimum initial appraisal to provide more precise evaluation of the primary tumour and lead to more accurate
staging.
Definition of the primary tumour with a number of
14
radiotracers will allow the determination of blood flow,
11
15
the turnover of DNA using C-thymidine or possibly
16,17
FLT, the turnover of amino acids,
hypoxia of the
tumour and the glucose metabolism. This will enable metabolic staging of the tumour to be done which may have a
predictive value equal to or surpassing histological techniques, although this is as yet unproven. These tracers will
also provide information to direct and monitor the response
6,13
to neoadjuvant therapy,
and to allow the assessment of
its delivery. An interesting study assessing the value of
neoadjuvant therapy before and after treatment in osteosarcomas has shown that the FDG response after such
regimes has helped to identify those tumours which have
had a suitable response before operation, and may therefore
13
influence further surgical procedures. Although the best
strategies for imaging still need to be established for these
11
various groups of tumours, multicentre trials should
include PET in order to confirm its role.
Another area of potential use of FDG PET is in the
THE JOURNAL OF BONE AND JOINT SURGERY
ANNOTATION
18
localisation of infection within bone. Sugawara et al have
shown in a small number of patients that FDG accumulated
in areas affected with chronic osteomyelitis, although one
false-negative result was noted among six patients. Guhl19
mann et al explored the use of FDG PET in 51 patients
with suspected osteomyelitis, of whom 28 had the infection
and 23 did not. This study compared the use of bone
scanning and antigranulocyte antibody imaging with FDG
PET, and showed that FDG had an accuracy in the peripheral skeleton of 96% and in the central skeleton of approximately 96%, compared with 89% and 76%, respectively,
for the antigranulocyte antibody imaging. The use of FDG
has the potential advantage of a single-step procedure with
imaging one hour after the injection, rapid loss of radioactivity from the patient and a radiation dose comparable to
the leucocyte imaging techniques. The advent of dualcoincidence PET imaging or C-PET will make the use of
these techniques practicable in conventional Departments
of Nuclear Medicine.
The introduction of expensive technology must be carefully assessed. Savings in cost seem to be the most important factor by which management issues are judged, but the
issues of quality and cost-effectiveness should be the major
concern in the care of patients. PET has been shown to be
cost-effective in the management of lung cancer by reducing morbidity from unnecessary operative intervention and
allowing better selection of patients for definitive sur20,21
Although PET has been used clinically for only
gery.
ten years it is becoming increasingly valuable to the orthopaedic surgeon. FDG PET should be used in the assessment
of tumours and included in prospective studies of their
surgical management and their response to neoadjuvant
therapies. The potential use in infection is that no cell
labelling is required, rapid imaging is achievable and the
radiation dose is reasonable compared with that of leucocyte imaging.
New techniques in medicine are often slow to be used,
but the clinical application of PET has come of age. Further
work needs to be undertaken to allow its optimum
utilisation.
References
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