Prospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Radiol. Oct 28, 2021; 13(10): 344-353
Published online Oct 28, 2021. doi: 10.4329/wjr.v13.i10.344
Shoulder adhesive capsulitis in cancer patients undergoing positron emission tomography - computed tomography and the association with shoulder pain
Daichi Hayashi, Elaine Gould, Robert Shroyer, Eric van Staalduinen, Jie Yang, Musa Mufti, Mingqian Huang
Daichi Hayashi, Elaine Gould, Robert Shroyer, Eric van Staalduinen, Musa Mufti, Mingqian Huang, Department of Radiology, State University of New York at Stony Brook, Stony Brook, NY 11794, United States
Jie Yang, Department of Family, Population and Preventive Medicine, Stony Brook Medicine, Stony Brook, NY 11794, United States
Author contributions: Hayashi D, Gould E and Huang M designed the research study; Hayashi D, Gould E, Shroyer R, van Staalduinen E, Mufti M and Huang M performed the research including data collection and electronic medical record review; Gould E, Shroyer R and Huang M interpreted positron emission tomography - computed tomography images; Yang J performed the statistical analyses; Hayashi D analyzed results and wrote the manuscript; all authors have read, edited and approved the final manuscript.
Institutional review board statement: Our prospective study received Institutional Review Board approval at our institution (Protocol# 2015-3396-R2).
Clinical trial registration statement: Our study is not a clinical trial. Therefore, there is no Clinical Trial Registration Statement applicable to this submission.
Informed consent statement: Written informed consent was obtained from all patients.
Conflict-of-interest statement: All authors have nothing to disclose.
Data sharing statement: Patient data are not available for sharing for protection of patient confidentiality and anonymity. No additional data are available.
CONSORT 2010 statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Daichi Hayashi, MD, PhD, Associate Professor, Department of Radiology, State University of New York at Stony Brook, HSC Level 4, Room 120, Stony Brook, NY 11794, United States. daichi.hayashi@stonybrookmedicine.edu
Received: March 13, 2021
Peer-review started: March 13, 2021
First decision: July 31, 2021
Revised: August 3, 2021
Accepted: September 14, 2021
Article in press: September 14, 2021
Published online: October 28, 2021
Processing time: 226 Days and 21.7 Hours
Abstract
BACKGROUND

Adhesive capsulitis is a relatively common condition that can develop in cancer patients during treatment. Positron emission tomography - computed tomography (PET-CT) is routinely performed as a follow-up study in cancer patients after therapy. Being aware of PET-CT findings to suggest shoulder adhesive capsulitis may help to alert clinicians for the diagnosis of unsuspected shoulder capsulitis.

AIM

To assess the association of shoulder adhesive capsulitis with cancer/therapy type and symptoms in cancer patients undergoing PET-CT.

METHODS

Our prospective study received Institutional Review Board approval. Written informed consent was obtained from all patients, who answered a questionnaire regarding shoulder pain/stiffness at the time of PET-CT study, between March 2015 and April 2019. Patients with advanced glenohumeral arthrosis, metastatic disease or other mass in the shoulder, or shoulder arthroplasty were excluded. Patterns of shoulder capsule 18F-fluorodeoxyglucose (FDG) uptake were noted. Standard Uptake Value (SUV)max and SUVmean values were measured at rotator interval (RI) and deltoid muscle in bilateral shoulders. Normalized SUV (SUV of RI/SUV of deltoid muscle) was also calculated. We assessed if SUV values are different between symptomatic and asymptomatic patients in both shoulders. Covariates were age, gender, and therapy type (surgery, chemotherapy, radiation). Wilcoxon rank sum tests were used to compare unadjusted marginal differences for age, SUV measurements between symptomatic and asymptomatic patients. Multiple linear regression models were used to examine the relationship between right or left shoulder SUV measurements and symptom status, after adjusting for covariates. Statistical significance level was set at P < 0.05.

RESULTS

Of 252 patients initially enrolled for the study (mean age 66 years, 67 symptomatic), shoulder PET-CT data were obtained in 200 patients (52 were excluded due to exclusion criteria above). The most common cancer types were lymphoma (n = 61), lung (n = 54) and breast (n = 53). No significant difference was noted between symptomatic and asymptomatic patients in terms of age, gender, proportion of patients who had surgical therapy and radiation therapy. A proportion of patients who received chemotherapy was higher in patients who were asymptomatic in the right shoulder compared to those symptomatic in the right shoulder (65% vs 48%, P = 0.012). No such difference was seen for the left shoulder. In both shoulders, SUVmax and SUVmean were higher in symptomatic shoulders than asymptomatic shoulders (Left SUVmax 2.0 vs 1.6, SUVmean 1.6 vs 1.3, both P < 0.002; Right SUVmax 2.2 vs 1.8, SUVmean 1.8 vs 1.5, both P < 0.01). For lung cancer patients, bilateral RI SUVmax and SUVmean values were higher in symptomatic shoulders than asymptomatic shoulders. For other cancer patients, symptomatic patients had higher left RI SUVmax/mean than asymptomatic patients after adjustment.

CONCLUSION

In symptomatic patients metabolic activities in RI were higher than asymptomatic patients. Adhesive capsulitis should be considered in cancer patients with shoulder symptoms and positive FDG uptake in RI.

Keywords: Adhesive capsulitis; Positron emission tomography - computed tomography; Cancer; Shoulder; Pain; Imaging

Core Tip: Adhesive capsulitis is a relatively common condition that can develop in cancer patients during treatment. However, there has been relatively scant literature evidence on Positron emission tomography - computed tomography (PET-CT) findings specific to adhesive capsulitis. Our study showed that, in symptomatic cancer patients, metabolic activities in the rotator interval were higher than asymptomatic patients overall, and also specifically for lung cancer patients. Presence of adhesive capsulitis may explain shoulder pain or stiffness in cancer patients, which can be incidentally diagnosed on PET-CT. Demographic characteristics, treatment regimen, and cancer type did not appear to be an independent risk factor.