SCINTIGRAPHY OF THE SKELETAL SYSTEM THE...
Transcript of SCINTIGRAPHY OF THE SKELETAL SYSTEM THE...
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SCINTIGRAPHY OF THE SKELETAL SYSTEMTHE “ BONE SCAN ”
By George N. Sfakianakis, M.D.Professor of Radiology and Pediatrics October 2009
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THE BONE SCAN
The premise
The bone scan is the most sensitive studyfor the detection of bone disease
which may be located anywhere in the body
and whether the patient has symptoms or not
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THE BONE SCAN
Can we always rely on the bone scan?
- A normal or negative bone scan excludes bone disease
[occasionally a negative bone scan may not exclude disease (some tumors)]
- An abnormal or positive bone scan shows bone disease
[a positive bone scan may be an old problem (old fractures)]
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The patient had persistent Pain 2 months after an Accident He had a negative work up (X-rays)
They suspected him a pretender to extract money from insuranceFinally they sent him for a Bone Scan
RIB FRACTURE from motor vehicle accident (MVA)
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99mTc-MDP or HEDP BONE SCAN in Children and Adults
INDICATIONS
• Malignant Tumors : Primary and Metastatic
• Benign Bone Tumors: Osteoid Osteoma
• Trauma: Occult Fractures, Domestic Violence/Abuse
• Infection: Osteomyelitis, Arthritis
• Metabolic diseases: Paget’s , Bone (Avascular) Necrosis
• Soft Tissue diseases: Myositis Ossificans• Unexplained bone Pain
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RADIOPHARMACEUTICALS FOR BONE SCAN(a“suitable for scintigraphy” radioisotope of Calcium does not exist )
CURRENTLY IN USE:
NEW DEVELOPMENTS:
Use PET/CT imaging with 18FNa (Sodium Fluoride) for bone scan
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BONE SCAN METHODOLOGY
99mTcMethylene (MDP) or Hydroxyethylene (HDP) Diphosphonate (20-30 mCi, adults 1-30 mCi children, based on weight)
Over 3-4 hrs MDP (HDP) is accumulated in the bones and in thelesions proportional to Blood Flow and to Osteoblastic Activity
Excretion of remainder in the urine and this Clears the background
Sufficient skeletal-to-soft tissue ratio at 3-4hr for Planar and Tomo
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BONE SCAN TECHNICAL ISSUES
Hydration and bladder emptying (catheterization if needed)
Sufficient waiting period post injection to clear BKG
Adequate renal function is needed, otherwise delay scanning
Immobilization (sedation) of the patient
Statistically Enough Counts 500kCts-1MCts (least 100kCts)
Total Body imaging (multifocality, referred pain)
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NORMAL BONE SCAN: The “Sweep”
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NORMAL BONE SCAN: Multiple “Spots”
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NORMAL BONE SCAN: AGE PATTERN
Child Young Adult
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Mature Adult Older overweight Person
NORMAL BONE SCAN: AGE PATTERN
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BONE SCAN PATHOPHYSIOLOGY (1)
Regional Hyperactivity may be due to:
a) Normal bone growth and remodeling
b) Increased Blood Flow (trauma, heterotopic ossification)
c) Reactive osteoblastic activity (active infections, tumors)
d) Reparative bone process (healing fractures, tumors, infections)
e) Hyper-metabolic activity (metabolic disorders)
They induce an increase in blood flow and osteoblastic activity,which enhance Ca / Phosphate local accretion into thehydroxyapatite matrix
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TYPICAL “HOT” SPOT BONE SCANSMETASTATIC PROSTATE CANCER FRACTURES
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BONE SCAN PATHOPHYSIOLOGY (2)
Exceptionally Some Lesions, although they destroy the bone,
they don’t generate Bone Reaction
This prevents osteoblastic reactivity and results in FN studies
Such non-active Lesions may appear as Cold Spots on the scans.
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Metastasis: “Cold” Lesion
Patient with Breast and Esophageal Cancer s/p Rad. Tx
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BONE SCAN PATHOPHYSIOLOGY (3)
Cold Spots may be caused by:
a) Malignant Tumors– Lung (2-4%)– Breast (5%)– Renal (10%)– Neuroblastomas (bone marrow mets)– Thyroid (most cases)– Multiple Myeloma (most cases)
b) Bone Abscesses (they are surrounded by activity)
c) Bone ischemia (AVN, sickle cell, etc.)
d) Hemangiomas (normal or decreased activity)
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Metastasis: “cold” Lesion Prostate Cancer
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BONE SCAN PATHOPHYSIOLOGY (4)
Some very aggressive Skeletal lesions
induce Bone Reaction around them = Hot Spots
and, centrally, they are Cold Spots on the scans
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Metastases: “HOT” and
“COLD” Lesions
Prostate Cancer
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BONE SCAN
IMAGING OPTIONS
1) Planar (3 hr) Total Body Study
a) with or without Tomographic Study (increases sensitivity)
b) or Pinhole Collimator (high resolution) views
2) Triple Phase Study (blood flow/blood pool/late phases)
(Differentiates Soft Tissues infection/inflammation from Skeletal lesions)
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TRIPLE PHASE BONE SCAN
(Differentiates Soft Tissues infection/inflammation from Skeletal lesions)
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TRIPLE PHASE BONE SCAN
NORMAL STUDY
35yo female with pain and a lytic lesion in left fibula
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TRIPLE PHASE BONE SCAN
CELLULITIS in a diabetic patient
flow blood pool
delayed
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TRIPLE PHASE BONE SCAN
ACUTE OSTEOMYELITIS in a diabetic patient
delayedblood pool
flow
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BONE SCAN TOMOGRAPHYSPECT
(Single Photon Emission Computed Tomography)
Increased Sensitivity in the lumbar spine by 20% to 50%
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BONE SCAN TOMOGRAPHYTHREE DETECTOR SPECT CAMERA
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INDICATIONS FOR BONE SPECT SCANS
1. Complex Bony Structures, such as skull and pelvis
2. Unexplained Bone Pain with normal planar studies
3. Precise Localization of a known abnormality
4. Improved Correlation with CT and MRI
5. Soft-Tissue v/s bony uptake (i.e., kidney from bone)
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NORMAL BONE SCAN STUDY
FLOW STUDY PLANAR IMAGES
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NORMAL BONE SCAN STUDY
TOMOGRAPHY SPECT
VOLUME/REPROJECTION SPECT
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Young patient with Back Pain
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THE VALUE OF SPECTSacroiliitis:
The planar image is normal The SPECT showed the lesion
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Patient with pain on the right side of the face
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THE VALUE OF SPECTTMJ Inflammation
PLANAR Negative(?)
A Normal SPECT study
SPECT Positive
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PINHOLE COLLIMATOR IMAGES
improves resolution of complex bony structures
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PINHOLE COLLIMATOR
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NORMAL PINHOLE OF THE HIPS
Hip pain; R/o aseptic necrosis
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QUALITY CONTROL
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RADIOISOTOPE INTERFERENCE
Patient with thyroid cancer, had treatment with RAI recently
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BARIUM ATTENUATION
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INTERPRETATION
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BONE SCAN
INTERPRETATION NEEDS INFORMATION
Why you need the Bone Scan?
Indication(s) for the study
Patient Profile, Diagnosis, Therapy
Patient history, symptoms, signs,
Findings on other studies
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BONE SCAN
INTERPRETATION: ISSUES TO ADDRESS
Reading of the Bone Scan issues:
Quality controlSkeletal lesions (multifocality, size, number, intensity )Need for SPECT and Volume Display Soft tissue abnormalitiesComparison with previous Bone Scans Correlation with Other imaging modalities Answer the questions asked by referring physician
“ Positive, Negative, Inconclusive”
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ACUTE OSTEOMYELITIS IN CHILDREN
THE BONE SCAN
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A 5 yo child with fever and swelling of the right knee
3 days duration
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On Admission On Admission
ACUTE OSTEOMYELITIS IN A CHILD
X-rays were nagative Two foci of osteomyelitis
15 days Later
Lytic lesion
The Bone Scan is more sensitive than Radiographs
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5 yo child with congenital ImmunodeficiencyRecent fever and blood culture positive
R/O Osteomyelitis
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Osteomyelitis of ribs
Normal epi/metaphysial activity
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Newborn from a HIV+ motherHas fever, leukocytosis and redness in the arm
R/O Osteomyelitis
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Osteomyelitis in a Newborn
Scalp Injection Site
A good quality bone scan is diagnostic of Osteomyelitis in the newborn despite publications claiming otherwise
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14mo with low back pain and recent history of otitis mediaEvaluate for Infection
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Diskitis of the Lumbar Spine
Notice that two lines of hyperactivity are present
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ACUTE OSTEOMYELITIS
TRIPLE PHASE BONE SCAN
Differentiates Soft tissue from skeletal lesionsThe Bone Scan is more sensitive than Radiographs
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58 yo Diabetic Lady with ulcer in the L tibiaR/O Osteomyelitis
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TRIPLE PHASE BONE SCAN
Acute Osteomyelitis in a Diabetic
Flow Blood pool Delayed
Osteomyelitis: The Delayed hyperactivity in the lesion is focal and of relatively equal or greater intensitythan the corresponding Early hyperactivity
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ACUTE OSTEOMYELITIS IN CHILDREN
THE CONTRIBUTION OF GALLIUM-67 SCAN
High Sensitivity for Acute and Chronic Lesions
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SEPTIC ARTHRITIS
BONE SCAN GALLIUMoverexposed
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ACUTE OSTEOMYELITIS
THE CONTRIBUTION OF LEUKOCYTE SCAN111In or 99mTc-HMPAO WBC SCAN
High Specificity for Acute Osteomyelitis
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INFECTION LOCALIZATION: OSTEOMYELITISBONE SCAN AND LABELED-WBC SCAN
Hand Auto-transplanted; r/o Osteomyelitis
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SERIAL BONE SCANS IN INFECTIONafter cessation of local inflammatory signs
In Serial Studies after effective treatment and no symptoms
Cellulitis: Bone Scan becomes Normal
Osteomyelitis: The Focal Hyperactivity persists long( repair of the damaged bone)
Arthritis: Non-specific diffuse activity in the region of thejoint remains for long (synnovial changes)
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EVOLUTION OF TREATED OSTEOMYELITISin a 6 year old boy
24 hours 1week
1month 2 months
6 months ant 6 months post
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SEPTIC ARTHRITIS
Arthritis: Non-specific diffuse activity in the region of thejoint remains for long (synnovial changes)
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99mTc-MDP or HEDP BONE SCAN in
TRAUMA (FRACTURES)
The Bone Scan is more Sensitive than Radiographs(hyperemia and osteoblastic activity v/s calcium loss)
Fractures appear earlier on bone scan and last longerand
It is easy to recognize them
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BONE SCAN TRAUMA - FRACTURES
TOTAL BODY PLANAR study (multifocality, referred pain)
SPECT for head, spine, pelvis, or if planar study negative
Accidents: MVA, Falls, Occupational, Osteporotic
Sports: Stress Fractures, Extension / Flexion Fractures,
Direct Injury to / Fractures of bones
Intentional: Child Abuse, Domestic Violence in Adults
Iatrogenic: Surgery, Resuscitation, Physical Therapy
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VISUALIZATION OF FRACTURES ON BONE SCAN
In non-osteoporotic patients, less than 65 y/o, 95% of fractures become visible on bone scanswithin 24 hours
In older patients, 95% of fractures are detectable on bone scan in 72 hours
The bone scan Remains positive for months to many years
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RIB FRACTURE from motor vehicle accident (MVA)
Persistent pain 2 months after MVA and negative work up
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Lung Cancer s/p resection of left Pancoast tumorR/O bone metastasis
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FRACTURES and TUMOR
Tumor InvolvementDegenerative Disease
Surgical Trauma: Sternotomy and Rib Fractures
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FRACTURES from Fall and Resuscitation
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99mTc-MDP or HEDP BONE SCAN in CHILD ABUSE
FRACTURES
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ROLE OF BONE SCAN IN EVALUATIONOF CASES SUSPECTED OF CHILD ABUSE
1. To detect recent fractures non detectable by radiography (3-5 days)
2. To detect old fractures in patients with burns and other findings suggesting abuse
The bone scan is more sensitive than radiographs because it detects increased osteoblastic activity and increased local blood pool
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99mTc-MDP or HEDP BONE
SCAN in CHILD
ABUSE
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A child is brought in the ER for “trauma from falling”
Cigarette burns raised suspicions of child abuse.
No acute fractures were present
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FRACTURES: CHILD ABUSEMultiple Fractures
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FRACTURES: SEVERE CHILD ABUSEMultiple Fractures
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SPORTS FRACTURES
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OCCULT FRACTURE:Triple Phase and Pin HoleBaseball player with pain in the hand and normal radiographs
3 HR PLANAR IMAGES
PIN HOLE IMAGE
Recent fracture of the HAMULUS OF THE HAMATE BONE
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Patient on Steroids for long timeNow with back pain following fall
Evaluate for fractures
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Left Ribs Fractures
Anything in the Spine?
Can you recommend anything more?
Compression Fractures of Spine: planar v/s SPECT
IATROGENIC FRACTURES
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COMPRESSION FRACTURES
Planar
Patient with a history of chiropractic maneuver
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BONE TUMORS
Primary benign and malignant
Metastatic bone tumors
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THE BONE SCAN
99mTc-Methylene (or Hydroxyethylene) Diphosphonate(MDP or HDP) 20-30 mCi, Imaging Total Body (or SPECT)
INDICATIONS IN ONCOLOGY
Primary Bone Tumors: Extend of tumor, multifocality,
metastases, recurrence
Skeletal Metastasis: The most sensitive, easily performed,
inexpensive total body imaging modality for early detection
and follow up of asymptomatic skeletal metastasis
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PRIMARY BONE TUMORS
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24 yo male with a painful lesion in the left calfX-rays showed a lucent lesion with peripheral reaction
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DIAGNOSIS: OSTEOID OSTEOMA
The flow study showed hyperemia
Central hyperactivityPeripheral fading
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OSTEOID OSTEOMA: PINHOLE COLLIMATOR
PIN HOLE COLLIMATOR PARALLEL HOLE COLLIMATOR
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21 yo with biopsy proven Osteosarcoma of the right proximal tibia
Evaluate for metastases
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OSTEOSARCOMA(osteoblastic=hot lesion)
EWING’S SARCOMA(cold lesion + bone reaction)
No bone metastasis present
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OSTEOSARCOMA
amputation
SINGLE FOCUS MULTIFOCAL (METASTATIC) LUNG METASTASIS
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OSTEOSARCOMA recurrent
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25 yo male with biopsy proven Ewing’s sarcoma
Evaluate for bone metastases
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After treatment Before treatment
EWING’S SARCOMA
(cold lesion + bone reaction)
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METASTATIC BONE TUMORS
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STRATIFICATION BY BONE SCAN
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Multiple Myeloma: “COLD” Lesion
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7yo boy with recurrent NeuroblastomaEvaluate for Bone metastasis
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METASTATIC NEUROBLASTOMA
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NEUROBLASTOMA METS AND RESOLUTION FOLLOWING THERAPY
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5 year old child with Neuroblastoma:Evaluation for bone metastasis
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BONE SCAN: SOFT TISSUE FINDINGSCALCIFIED TUMORS
NEUROBLASTOMA
Neuroblastoma with calcifications
Injection site
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Small Neuroblastoma Calcified
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59 yo Lady with Breast Tumor:R/O Bone Metastasis
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Calcified Liver Metastases
DJD
BONE SCAN:SOFT TISSUE FINDINGS:
CALCIFIED TUMORS
BREAST CANCERLIVER METASTASES
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Two females with history of Brest CancerEvaluation for bone metastasis
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METASTATIC BREAST CANCERDETERIORATION OF THE DISEASE
Early Disease Advanced Disease
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71 yo male with prostate cancer and PSA 250Evaluate for bone metastasis
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Body, head, proximal extremitiesfull with metastases
distal extremities spared(no metastases)
THE SUPERSCAN
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SUPERSCAN
Metastatic Prostate Cancer
Not Every Boneis hyperactive
In Metabolic DisordersEvery bone is hyperactive
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HYPERPARATHYROIDISM
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FOLLOW UP STUDIESMetastatic Prostate Cancer
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EFFECT OF THERAPY: TAMOXIFEN 6mo
Before Therapy
After 6mo Tamoxifen
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METASTATIC LUNG CANCER
Metastasis with Orthopedic Significance
62yo male with lung cancer
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METASTATIC BLADDER CANCER
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METASTASIS FROM
ESOPHAGEAL CANCER
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LYMPHOMA OF THE SKELETON
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FDG-PET/CT
Bone metastasis
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FDG-PET/CT
Bone metastasis 2 months later
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BONE SCAN
SOFT TISSUE FINDINGS
Often useful Information
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TRIPLE PHASE BONE SCAN
HETEROTOPIC OSSIFICATION
(MYOSITIS OSSIFICANS)
Occurs in Paraplegic or Quadriplegic patients soon after
rehabilitation therapy begins (may be related to muscle trauma).
Muscles develop inflammation which leads to new bone formation.
Clinically inflammatory findings appear around the joints and
Laboratory evidence of inflammation is found (increased ESR etc)
May be treated if confirmed early, otherwise needs surgery
The Bone Scan can establish the diagnosis early
(Increased Blood Flow and Blood Pool and delayed bone activity)
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TRIPLE PHASE BONE SCAN
HETEROTOPIC OSSIFICATION(MYOSITIS OSSIFICANS)
Phase 1:Increase in blood flow+pool onlyPhase 2Increase in blood flow+pool greater than in delayed activityPhase 3Increase in blood flow+pool equal to the delayed activityPhase 4Increase in blood flow+pool less than in delayed activityPhase 5Increase in delayed activity only
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Quadriplegic patient with evidence of soft tissue inflammatory reaction ( left hip and left shoulder)
Evaluate for Heterotopic Ossification
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HETEROTOPIC OSSIFICATION PHASE 3
Increased Delayed Activity
Increased Blood Flow and Blood Pool activity
Periodontal + Fractures
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HETEROTOPIC OSSIFICATION Phase 1R, 4 L
Quadriplegic with clinical inflammatory findings around the hips
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HETEROTOPIC OSSIFICATION Phase 4-5
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HETEROTOPIC OSSIFICATION in a Non-Paralyzed Patient
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HETEROTOPIC OSSIFICATION in a Non-Paralyzed Patient
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HETEROTOPIC OSSIFICATION in a Non-Paralyzed Patient
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12yo girl with “pelvic pain”, to evaluate for traumatic or inflammatory bone lesion: Triple bone study
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17 week Pregnancy
Placenta visualized
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Two patients for evaluation for metastatic bone disease
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Final Diagnosis: Kidney and Bladder Tumors
Pelvic Tumor (SOL)Renal Tumor (SOL)
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Patient with liver cancer.R/O bone metastasis
History of cirrhosis
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AscitesRenal Space
Occupying Lesion
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Back painR/O Osteomyelitis of the spine/pelvis
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Rib Fracture
Bowel Visualization (Sestamibi Previous Day)
Renal Transplant
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Breast CancerR/O metastatic bone disease
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Bowel Visualization / Free Tc-99m
Urine Contamination
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ARTERIAL INJECTION COMPRESSION OF PELVIC VEIN BY TUMOR
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SKELETAL BENIGN DISORDERS
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A 55 yo woman under evaluation for
Metastatic breast cancer.
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Hyperostosis Frontalis Interna
injection site
Degenerative Joint Disease
Urine Contamination
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PARS DEFECT (SPONDYLOLISTHESISand FRACTURE):
Is it centered behind the posterior margin of a vertebral body
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HIP PROSTHESIS: LOOSENING
Patient with metastatic bone tumors and painful left hip prosthesis
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BONE SCAN METABOLIC DISORDERS
Paget’s disease
Hypertrophic Pulmonary Osteoarthropathy
Hyperparathyroidism
Fibrous Dysplasia
Aseptic Necrosis
Sickle Cell Disease
Bone Marrow expansion
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55 yo male with history of Prostate CancerR/O bone metastasis
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Paget’s Disease of the left first RibDegenerative Joint Disease
of the cervical spine
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PAGET’S DISEASE AND PROSTATIC METASTASIS
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HYPERTROPHIC PULMONARY
OSTEOARTHROPATHY
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HYPERPARATHYROIDISM
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ACEPTIC NECROSIS OF THE HEAD OF FEMURLEGG PERTHS DISEASE
Patient is a 6yo boy with right hip pain for 2 weeks
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REFLEX SYMPATHETIC DYSTROPHY
History of trauma of the head and the left upper extremity
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25 yo patient with Sickle Cell DiseaseR/O Osteomyelitis of the left proximal tibia
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Sickle Cell Disease
Calcified Spleen
Bone Infarct
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Pain in the heels, left more than right:R/O Infection or fracture
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OSSIFYING TENDONITISTriple Phase and Multiple Views
No Increased blood flow or Blood Pool
Increased delayed activity
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FIBROUS DYSPLASIA
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Metastatic to Bones Lung CancerF/U bone scan S/P therapy
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RADIATION EFFECTPort included
Thoracic Spine, Ribs, Lung, Heart
Port on the lumbar spine
Multiple Bone Metastatic Foci
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BONE SCANNING: Metastasis
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BONE SCANNING: Metastasis
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METASTATIC LUNG CANCER: FDG-PET and BONE SCAN
surgery
Before therapy bone metastases show better
on the FDG-ΡΕΤ
THERAPY
Results of Therapy show better
on FDG-PET
46 yo with surgically removed carcinoma of the lung and lumbago
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18FNa-PET BONE SCANNING:
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18FNa-PET BONE SCAN v/s 99mTc-MDP-SPECT
Chronic stress to the spine: Additional information by 18F-PET
sagittalcoronalLR
18F-PET(50µCi/kg)
99mTc-MDP-SPECT
(50µCi/kg)
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18FNa-PET BONE SCAN v/s 99mTc-MDP-SPECT25 y.o. rower: stress to costovertebral junctions
coronal
T 9
T 9
L
18F-PET(50µCi/kg)
transverse
T 9
T 9L RR
99mTc-MDP-SPECT
(50µCi/kg)
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18FNa-PET BONE SCAN v/s 99mTc-MDP-SPECTVisual presentation of each lesion:
the same semi-quantitative grading was applied to both studies
51
22
49
14
83
52
0
95
0
10
20
30
40
50
60
70
80
90
100PET
SPECT
Lesionpoorvisible
Lesionnot
visible
Lesiongoodvisible
Lesionexcellent
visible
# of lesions