Muscular injury in a child diagnosed by 99mTc-MDP bone scan

An 11-year-old boy had bone scanning to rule out an osscous lesion of the right arm. He presented progressive pain and hard swelling of the right arm. His past medical history and general physical examination were unremarkable. He trained for karate. The scan demonstrated considerable muscular uptake in both arms. CPK and CPK MB levels were both abnormally high, suggesting muscle injury. After a 10-day rest period the bone scan returned to normal.     

Muscular injury in a child diagnosed by 99mTc-MDP bone scan

An 11-year-old boy had bone scanning to rule out an osseous lesion of the right arm. He presented progressive pain and hard swelling of the right arm. His past medical history and general physical examination were unremarkable. He trained for karate. The scan demonstrated considerable muscular uptake in both arms. CPK and CPK MB levels were both abnormally high, suggesting muscle injury. After a 10-day rest period the bone scan returned to normal.     

Quantitative assessment of 99mTc-MDP scans in investigation of diffuse alterations in bone

Whereas bone scanning is usually employed to detect focal alterations, it is usually difficult to diagnose diffuse pathological involvement of the skeleton. Using 99mTc labelled MDP, 505 scans obtained from 342 patients were analysed quantitatively. Count rate densities in femoral regions of interest were determined and compared with adjacent soft tissue radioactivity in the thigh by computing ratios. The assessed regions of the femur were visually normal, with neither focal radionuclide uptake nor patchy alterations. Scans showing abnormal nuclide accumulation in soft tissue sites of the thigh (42% of all scans) were selected and assessed separately. A control group of normal patients was formed including those who had no clinical evidence of bone diseases and who had normal laboratory findings such as alkaline phosphatase. While individual femur to soft tissue ratios of the normal group did not exceed the maximum of 2.00 (x₅₀=1.55), in most cancer patients considerably higher ratios were computed, some cases reaching 5 and more. These results do not establish this as a method to exclude diffuse bone lesions. However they can suggest such scans to be pathological by higher ratios than those obtained from the normal group. This statement is limited to adult patients over 20 years of age.     

99MTc-MDP全身骨显像对骨转移瘤的诊断价值

目的：探讨^99mTc-MDP全身骨显像对骨转移瘤的诊断价值。方法：对300例肿瘤患者静脉注射^99mTc-MDP 15～20mci行SPECT全身骨显像，并对结果进行比较。结果：阳性结果为121例，阳性率为40．3％，其中的75例与X线检查对照，骨显像阳性而X线阴性者12例。结论：SPECT全身骨显像对骨转移瘤早期诊断治疗，预后的观察具有一定的临床价值。     

The value of a baseline bone scan in patients with newly diagnosed prostate cancer.

PURPOSE: This study evaluated the role of bone scans in managing newly diagnosed, untreated prostate cancer. METHODS: Two hundred seventy consecutive staging bone scans in patients (mean age, 69 years) with newly diagnosed prostate cancer who had serum prostate-specific antigen (PSA) determinations and biopsies between January 1995 and October 1997 were evaluated retrospectively. RESULTS: The bone scans were positive for metastatic bone disease in 24 patients and negative in 246. Serum PSA levels, the number of positive biopsy cores, the extent of tumor in the prostate gland, and Gleason scores were all significantly correlated with scintigraphic bone metastases (P < 0.0001 for each). Of the 177 patients with PSA levels less than 10 ng/ml, three had bone metastases. Bone metastases were found in 2 of 34 patients with PSA levels of 10.1 to 20 ng/ml, in 3 of 29 patients with PSA values of 20.1 to 50 ng/ml, and in 16 of 30 patients with PSA levels greater than 50.1 ng/ml. Only one patient had a bone metastasis when the prostate cancer involved fewer than 2 biopsy cores (1 of 135) or when disease was confined to one lobe (1 of 131), but the incidence increased significantly when the malignancy involved three or more biopsy cores (20 of 114) or disease was present in both prostate lobes (20 of 118). Four of 160 patients with Gleason scores less than 6 had bone metastases, whereas 20 of 110 patients with Gleason scores greater than 7 had bone metastases. CONCLUSIONS: The likelihood of bone metastases is low in patients with newly diagnosed, untreated prostate cancer when the initial PSA level was less than 10 ng/ml, the number of positive biopsy cores was less than 2, tumor was confined to one lobe, or the Gleason score was less than 6. However, none of these criteria can be used to exclude metastatic bone disease. A baseline bone scan is an important staging procedure and should be obtained to provide maximum data for clinical management of the disease.     

Correlation of 99mTc-sestamibi uptake with blood-pool and osseous phase 99mTc-MDP uptake in malignant bone and soft-tissue tumours

Technetium-99m-sestamibi (99mTc-MIBI) imaging is a well-established modality in oncologic investigations. The current study aimed to investigate whether any relationship could be found between 99mTc-MIBI uptake and local perfusion in malignant bone and soft-tissue tumours. It also aimed to compare 99mTc-MIBI images with those of technetium-99m-methylene diphosphonate (99mTc-MDP) bone scintigraphy with regard to the activity distribution pattern, intensity and lesion extension. The study group included 24 patients with various bone and soft-tissue tumours. Three-phase bone scintigraphy and 99mTc-MIBI studies were performed within the same week before any surgical and therapeutic intervention. Images were evaluated visually and quantitatively using regions of interest (ROIs) over the lesion and adjacent normal tissue. The 99mTc-MIBI study was positive with varying degrees of uptake (range, 1.4-5.3). The mean 99mTc-MIBI uptake and 99mTc-MDP blood-pool and osseous phase activity ratios were 2.5 +/- 0.5, 2.8 +/- 1.0 and 5.5 +/- 4.0, respectively. The correlation between the 99mTc-MIBI uptake and blood-pool ratios was 0.70 (P<0.05). While activity distribution patterns were in agreement in 99mTc-MIBI and blood-pool images in the majority of cases, 99mTc-MIBI better delineated tumour viability and extension in five cases. In conclusion, 99mTc-MIBI accumulation shows a reasonable correlation with blood-pool uptake assuming the presence of multifactorial mechanisms in addition to local hyperaemia. Better delineation of tumour outlines and cellular activity seems to be an advantage of 99mTc-MIBI scintigraphy which may be helpful in the evaluation of musculoskeletal tumours.     

Changing the referral criteria for bone scan in newly diagnosed prostate cancer patients

Objectives

The aim of this study was to correlate the prostate-specific antigen (PSA) level and Gleason score with staging bone scan result in patients with a new diagnosis of prostate cancer in order to establish the feasibility of implementing the European Association Urology guidelines, which state that a bone scan may not be indicated when PSA <20 in well–moderately differentiated tumours.

Methods

We identified 633 patients retrospectively and 186 patients prospectively with a new diagnosis of prostate cancer undergoing a staging bone scan between March 2005 and January 2010. Patients were excluded if there was no Gleason score available or if the PSA level was checked over 3 months prior to bone scan. Bone scan results were analysed with respect to age, PSA level and Gleason score. In the case of an equivocal result, subsequent imaging was taken into consideration or the initial bone scan was re-reviewed. In persistently equivocal cases, all relevant imaging was assessed by a blinded panel of radiologists to allow a final decision to be made.

Results

Of 672 patients aged 39–93 years (median 71 years), who fulfilled the inclusion criteria, 54 (8%) had evidence of bony metastases. PSA level and Gleason score were both independent predictors of bone scan positivity and their predictive value was additive p<0.01. None of the 357 patients with a PSA level of <20 and a Gleason score of <8 had a positive bone scan.

Conclusion

Staging bone scans in newly diagnosed prostate cancer patients with a PSA level of <20 and a Gleason score of <8 can be safely omitted, with these criteria having a negative predictive value of 100% in our series.Prostate cancer is currently the most common malignancy diagnosed in men in the UK [1] and bone is the second most common site of metastasis [2]. Bone metastases are present in up to 14% of patients at presentation [3] and in 80–85% of those who die of the disease [4], and they therefore affect morbidity, reflect prognosis and significantly influence decisions with regard to patient management.Sensitivity of planar bone scan for the detection of bone metastases is 72–77% in adults [5,6] and is currently the investigation of choice. However, it lacks diagnostic specificity, with indeterminate results often prompting the need for further imaging.Prostate-specific antigen (PSA) level is an established prognostic marker that correlates with bone scan positivity, and various studies demonstrate a low risk of a positive bone scan in newly diagnosed patients with a low PSA level [3,4,7-13]. Gleason score is also of important prognostic significance and has been shown to be an independent predictor of bone scan results on multivariate analysis [4,7,12,14]. There is still a lack of consensus, however, on the referral criteria for bone scan in low-risk patients, with different authors supporting various cut-off levels of PSA, with some including Gleason score and clinical stage. The European Association of Urology (EAU) guidelines, updated in March 2009, recommend that staging bone scan may not be indicated in patients with a PSA level of <20 with moderately to well-differentiated tumours in the absence of bony symptoms [15], while the American Urological Association and American Joint Committee on Cancer (AJCC) both recommend that staging bone scan is indicated in patients with a Gleason score of >7 or a PSA level of >20 prior to treatment [14].Despite this, there remains a large demand for isotope bone scanning in patients with a new diagnosis of prostate cancer regardless of risk stratification based on these prognostic tools.The purpose of the current study was to correlate PSA levels and Gleason scores with bone scan results in patients with newly diagnosed prostate cancer, with the aim of identifying a subgroup of patients who did not require staging bone scan, and assess the feasibility and safety of implementing EAU guidelines.     

Bladder diverticulum simulating a pelvic metastasis on a Tc-99m HDP bone scan

Carcinoma of the prostate was diagnosed in a 74-year-old man. A Tc-99m HDP bone scan was performed as part of the initial staging process. The findings on the bone scan were normal except for an area of increased tracer uptake projected over the left sacroiliac joint, which was seen best on the anterior view. When this was investigated further, the findings of a plain radiograph were inconclusive. Computed tomography showed a large diverticulum projecting from the left side of the bladder; the tracer retained within this diverticulum had produced the findings on the bone scan.     

Combined endorectal and phased-array MRI in the prediction of pelvic lymph node metastasis in prostate cancer

OBJECTIVE: The objectives of our study were to evaluate the accuracy of combined endorectal and phased-array MRI in detecting pelvic lymph node metastasis (LNM) in patients with prostate cancer and to determine whether radiologists' predictions of LNM improve with the incorporation of Partin nomogram or MRI findings (or both) regarding extracapsular extension or seminal vesicle invasion. SUBJECTS AND METHODS: Between May 1999 and September 2003, 411 consecutive patients with clinically localized prostate cancer underwent MRI before surgery. Serum prostate-specific antigen (PSA) level, Gleason grade, clinical stage, greatest percentage of cancer and percentage of positive cores in all biopsy cores, presence of perineural invasion on biopsy, and likelihood of LNM based on the Partin tables (2001 version) were recorded. MRI studies were interpreted prospectively, but the risks of LNM, extracapsular extension, and seminal vesicle invasion were scored retrospectively on the basis of the MRI reports. Surgical pathology constituted the standard of reference. The accuracy of LNM prediction was assessed using areas under receiver operating characteristic curves (AUCs) and univariate and multivariate logistic regression analyses. For multivariate models, the jackknife method was used for bias correction. A p value below 0.05 denoted statistical significance. RESULTS: At surgical pathology, LNM was present in 22 (5%) of 411 patients. MRI was an independent statistically significant predictor of LNM (p = 0.002), with positive and negative predictive values of 50% and 96.36%, respectively. On multivariate analysis, prediction of lymph node status using the model that included all MRI variables (extracapsular extension, seminal vesicle invasion, and LNM) along with the Partin nomogram results had a significantly greater AUC than the univariate model that included only MRI LNM findings (AUC = 0.892 vs 0.633, respectively; p < 0.01). CONCLUSION: Incorporation of the Partin nomogram results and MRI findings regarding both extracapsular extension and seminal vesicle invasion improves the MR prediction of LNM in patients with prostate cancer.     

PI-RADS version 2: Preoperative role in the detection of normal-sized pelvic lymph node metastasis in prostate cancer

ObjectivesTo analyze whether Prostate Imaging Reporting and Data System (PI-RADSv2) scores are associated with a risk of normal-sized pelvic lymph node metastasis (PLNM) in prostate cancer (PCa).Materials and methodsA consecutive series of 221 patients who underwent magnetic resonance imaging and radical prostatectomy with pelvic lymph node dissection (PLND) for PCa were retrospectively analyzed under the approval of institutional review board in our institution. No patients had enlarged (≥0.8 cm in short-axis diameter) lymph nodes. Clinical parameters [prostate-specific antigen (PSA), greatest percentage of biopsy core, and percentage of positive cores], and PI-RADSv2 score from two independent readers were analyzed with multivariate logistic regression and receiver operating-characteristic curve for PLNM. Diagnostic performance of PI-RADSv2 and Briganti nomogram was compared. Weighted kappa was investigated regarding PI-RADSv2 scoring.ResultsNormal-sized PLNM was found in 9.5% (21/221) of patients. In multivariate analysis, PI-RADSv2 (reader 1, p = 0.009; reader 2, p = 0.026) and PSA (reader 1, p = 0.008; reader 2, p = 0.037) were predictive of normal-sized PLNM. Threshold of PI-RADSv2 was a score of 5, where PI-RADSv2 was associated with high sensitivity (reader 1, 95.2% [20/21]; reader 2, 90.5% [19/21]) and negative predictive value (reader 1, 99.2% [124/125]; reader 2, 98.6% [136/138]). However, diagnostic performance of PI-RADSv2 (AUC = 0.786–0.788) was significantly lower than that of Briganti nomogram (AUC = 0.890) for normal-sized PLNM (p < 0.05). The inter-reader agreement was excellent for PI-RADSv2 of 5 or not (weighted kappa = 0.804).ConclusionPI-RADSv2 scores may be associated with the risk of normal-sized PLNM in PCa.     

Reduced hemithoracic uptake on 99mTc-MDP bone scintigraphy: an underrecognized sign of massive pleural effusion--a case report

The uptake of (99m)Tc-methylene diphosphonate (MDP) in malignant pleural effusions and, rarely, in nonmalignant pleural effusions has been well documented in the literature. Although the exact mechanism of uptake in these conditions remains unclear, there have been attempts to use the bone scintigraphic features of pleural effusion to predict sensitivity and specificity for malignancy based on pleural fluid cytology. It has been suggested that activity in the chest increases with an increase in effusion volume. We report here, however, a case of malignant pleural effusion, that showed reduced hemithoracic activity in contrast to the expected increased activity. Our experience highlights the need for an open and inquisitive mind to avoid diagnostic pitfalls when confronted with a bone scintigram showing reduced uptake unilaterally or bilaterally in the chest.     

Tc-99m hexamethylpropylene-amine oxine (HM-PAO) uptake in a bone metastasis

Uptake of Tc-99m Hexamethylpropylene-amine Oxine (HM-PAO) was seen in bone metastases from carcinoma of the lung. The uptake was prominent when compared to Tc-99m MDP, I-123 IMP, and Ga-67 citrate. Brain imaging with Tc-99m HM-PAO and N-isopropyl-p-[I-123] iodoamphetamine (IMP) is now frequently performed. Uptake of these agents has been reported in brain tumors and melanomas. In this report, uptake of Tc-99m HM-PAO in a metastatic lesion in bone is discussed.     

Comparison of diagnostic ability between 99mTc-MDP bone scan and 18F-FDG PET/CT for bone metastasis in patients with small cell lung cancer

Objective

The aim of this study was to compare the diagnostic ability of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) with that of ^99mTc-methylene diphosphonate (^99mTc-MDP) bone scan for bone metastasis in staging patients with small cell lung cancer (SCLC).

Methods

Ninety-five patients with SCLC who underwent both ¹⁸F-FDG PET/CT and ^99mTc-MDP bone scan for initial staging work-up were retrospectively enrolled. All ¹⁸F-FDG PET/CT and bone scan images were visually assessed. Bone metastasis was confirmed by histopathological results and all available clinical information.

Results

Of 95 patients with SCLC, metastatic bone lesions were found in 30 patients, and 84 metastatic lesions were evaluated on a lesion-basis analysis. The sensitivity of ¹⁸F-FDG PET/CT was 100?% on a per-patient basis and 87?% on a per-lesion basis, and there was no false-positive lesion on PET/CT images. In contrast, the sensitivity of the bone scan was 37?% on a per-patient basis and 29?% on a per-lesion basis. The bone scan showed 11 false-positive lesions. The bone scan detected two metastatic lesions that were not detected by PET/CT, which were outside the region scanned by PET/CT. On follow-up bone scan, 21 lesions that were not detected by the initial bone scan but were detected by PET/CT were newly detected.

Conclusions

In patients with SCLC, ¹⁸F-FDG PET/CT showed higher detection rate of bone metastasis than ^99mTc-MDP bone scan. Thus, ¹⁸F-FDG PET/CT can replace bone scan in staging patients with SCLC.     

99mTc(V)-DMSA and99mTc-MDP uptake and no67Ga-citrate uptake in a case of primary pulmonary leiomyosarcoma

Tumor scintigraphy with 67Ga-citrate, 99mTc(V)-DMSA and 99mTc-MDP were performed on a patient with rare primary pulmonary leiomyosarcoma. While 67Ga-citrate accumulation to the tumor was not recognized, 99mTc(V)-DMSA and 99mTc-MDP scintigraphy showed relatively intense localization of the tracers in the lesion, and were very useful in suggesting the characteristics of the tumor.