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. 2021 Mar;48(3):777-785.
doi: 10.1007/s00259-020-05027-y. Epub 2020 Sep 9.

Increased incidence of interstitial pneumonia detected on [18F]-FDG-PET/CT in asymptomatic cancer patients during COVID-19 pandemic in Lombardy: a casualty or COVID-19 infection?

Lucia Setti  1 , Manuela Bonacina  1 , Roberta Meroni  2 , Margarita Kirienko  3 , Francesca Galli  4 , Serena Camilla Dalto  5 , Paola Anna Erba  6 , Emilio Bombardieri  7
Affiliations

Increased incidence of interstitial pneumonia detected on [18F]-FDG-PET/CT in asymptomatic cancer patients during COVID-19 pandemic in Lombardy: a casualty or COVID-19 infection?

Lucia Setti et al. Eur J Nucl Med Mol Imaging. 2021 Mar.

Abstract

Purpose: The study aimed to compare the incidence of interstitial pneumonia on [18F]-FDG PET/CT scans between two 6-month periods: (a) the COVID-19 pandemic peak and (b) control period. Secondly, we compared the incidence of interstitial pneumonia on [18F]-FDG PET/CT and epidemiological data from the regional registry of COVID-19 cases. Additionally, imaging findings and the intensity of [18F]-FDG PET/CT uptake in terms of maximum standardized uptake value (SUVmax) were compared.

Methods: We retrospectively analyzed [18F]-FDG PET/CT scans performed in cancer patients referred to nuclear medicine of Humanitas Gavazzeni in Bergamo from December 2019 to May 2020 and from December 2018 to May 2019. The per month incidence of interstitial pneumonia at imaging and the epidemiological data were assessed. To evaluate the differences between the two symmetric groups (period of COVID-19 pandemic and control), the stratified Cochran-Mantel-Haenszel test was used. Chi-square test or Fisher's exact test and t test or Wilcoxon test were performed to compare the distributions of categorical and continuous variables, respectively.

Results: Overall, 1298 patients were included in the study. The two cohorts-COVID-19 pandemic (n = 575) and control (n = 723)-did not statistically differ in terms of age, disease, or scan indication (p > 0.05). Signs of interstitial pneumonia were observed in 24 (4.2%) and 14 patients (1.9%) in the COVID-19 period and the control period, respectively, with a statistically significant difference (p = 0.013). The level of statistical significance improved further when the period from January to May was considered, with a peak in March (7/83 patients, 8.4% vs 3/134 patients, 2.2%, p = 0.001). The curve of interstitial pneumonia diagnosis overlapped with the COVID-19 incidence in the area of Lombardy (Spearman correlation index was equal to 1). Imaging data did not differ among the two cohorts.

Conclusions: Significant increase of interstitial lung alterations at [18F]-FDG PET/CT has been demonstrated during the COVID-19 pandemic. Additionally, the incidence curve of imaging abnormalities resulted in resembling the epidemiological data of the general population. These data support the rationale to adopt [18F]-FDG PET/CT as sentinel modality to identify suspicious COVID-19 cases to be referred for additional confirmatory testing. Nuclear medicine physicians and staff should continue active surveillance of interstitial pneumonia findings, especially when new infection peak is expected.

Keywords: COVID-19; Ground-glass opacities; Interstitial pneumonia; Lung consolidations; SARS-CoV-2; [18F]-FDG-PET/CT.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Patient selection flowchart
Fig. 2
Fig. 2
Interstitial pneumonia detected in the periods December 2018–May 2019 and December 2019–May 2020. Stratified CMH test and Cochran–Mantel–Haenszel test stratified by PET/CT month. 95%CI, 95% confidence interval
Fig. 3
Fig. 3
Comparison between [18F]FDG PET/CT suggestive for COVID-19 interstitial pneumonia and cases of COVID-19 confirmed in the area of Bergamo
Fig. 4
Fig. 4
A 75-year-old patient, affected by breast cancer, who performed the [18F]FDG PET/CT for treatment response in COVID-19-free period. CT (a) (CT axial view) and [18F]FDG PET (b) (fused PET/CT axial view) were suggestive for interstitial pneumonia. The image shows moderate FDG uptake (SUVmax 3.4) at peripheral ground-glass opacities in lower lung lobes
Fig. 5
Fig. 5
A 76-year-old patient, affected by breast cancer, who performed the [18F]FDG PET/CT for staging/restaging in COVID-19 period (April). CT (a) (CT axial view) and [18F]FDG PET (b) (fused PET/CT axial view) were suggestive for interstitial pneumonia. A subsequent PCR test confirmed COVID-19. The images show moderate FDG uptake (SUVmax 2.3) at peripheral ground-glass opacities in lower lung lobes
See this image and copyright information in PMC

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