Use of radionuclides for the palliation of bone metastases

Pain palliation with bone-seeking radiopharmaceuticals is an effective and cost-effective management tool in patients with advanced cancer metastatic to bone. Strontium-89 ((89)Sr) (Metastron) and samarium-153 ((153)Sm) EDTMP (Lexidronam) are licensed for use in patients in the United States. Patients with a positive bone scan using technetium 99m methylene diphosphonate ((99m)Tc MDP) are eligible for treatment, and indications and contraindications for use are now well defined. The evidence in the literature now suggests that the radiopharmaceuticals can significantly reduce pain and analgesic requirements, can improve quality of life, can reduce lifetime radiotherapy requirements and management costs, and may slow the progression of painful metastatic lesions. Retreatment is safe and effective. Rhenium-186 ((186)Re) HEDP and Tin-117m diethylenetriaminepenta-acetic acid (DTPA) are in phase II/III trials to evaluate efficacy and compare efficacy with the licensed agents. Phosphorus-32 ((32)P) has been reassessed in two trials evaluating efficacy in comparison with (89)Sr and safety. Toxicity is reversible myelosuppression, which may be significant, and the treatments should not be given to patients with suspected disseminated intravascular coagulation.     

肺癌骨转移99mTc-MDP骨显像的临床价值及与CT、X-rays检查对比观察

目的　评价99mTc MDP骨显像诊断肺癌骨转移的临床价值。方法　 12 8例肺癌骨转移患者常规行99mTc MDP骨显像检查。 91例患者同时行骨显像、CT检查 :74例病变部位相符者同时行骨显像、X rays检查。分别对比观察99mTc MDP骨显像与CT、X rays诊断肺癌骨转移的阳性检出率 ,并分析相互之间产生差异的原因和机制。结果　全部病例中 ,99mTc MDP骨显像阳性检出率为 91.4% (117/12 8) ,假阳性率为 12 .0 % (16/13 3 ) ,假阴性率 8.5 9% (11/12 8) ;对比观察99mTc MDP骨显像与CT ,阳性检出率分别为 85 .7% (78/91)、2 9.7% (2 2 /74) ,(P <0 .0 1,已剔除部位不相符因素 ,但未剔除X线检查部位包括不全因素 )。结论　99mTc MDP骨显像诊断肺癌骨转移具有较高的临床价值 ,辅以CT、X rays检查可提高阳性诊断的准确性。     

Dual phase 99m‐technetium Sestamibi imaging with single photon emission computed tomography in primary hyperparathyroidism: Influence on surgery

The purposes of this study were to determine the positive and negative predictive values of 99m Technetium (^99mTc) Sestamibi dual phase imaging with single photon emission computed tomography (SPECT) for parathyroid adenomata or hyperplasia and the effect of preoperative localization on duration of surgery. We reviewed 33 adults (14 men, 19 women; mean age 53 years) with newly diagnosed primary hyperparathyroidism who underwent neck exploration. The duration of surgery for this cohort was compared with a group of historical controls (n = 53) who underwent surgery without preoperative SPECT. At surgery, there were 21 adenomata (including one carcinoma), 10 patients with hyperplasia and two with no pathology detected. The positive predictive values (PPV) for adenomata and hyperplasia were 95% and 100%, respectively. The negative predictive values (NPV) for these entities were 67% and 22%, respectively. The mean weight of adenomata detected was 3.4 g (range 0.2–17 g). Mean duration of surgery was 112.6 min as compared with 113 min in the historical controls (P = not significant). We conclude that ^99mTc Sestamibi dual phase imaging with SPECT has an excellent PPV for parathyroid adenomata and hyperplasia, but does not contribute to reduced duration of surgery in patients undergoing neck exploration for the first time. The NPV is low, suggesting that a negative result does not exclude an adenoma or hyperplasia.     

153Sm-EDTMP治疗多发性骨转移癌的疗效分析

目的：评价＾１５３Ｓｍ－ＥＤＴＭＰ对多发性骨转移癌的止痛效果及消作用。方法：首次静脉给药剂量为３７ＭＢｑ／ｋｇ。重复治疗剂量，结合患者病情、病灶数、血象等的情增减。３次为一个疗程，给药间隔平均６周。结果：１５６例骨转移患者，骨痛完全缓痛５２例（３３．３％），部分缓解８１例（５１．９％），无效２３例（２１．２％）。止痛有效率为８５．２％（１３３／１５６），７２例骨转移患者治疗后，病灶骨／全身骨放射睡     

Systemic radiopharmaceutical therapy of painful osteoblastic metastases

Bone pain from osteoblastic metastases can be ameliorated 40% to 80% of the time. Although we can predict nonresponders, we cannot predict responders; however, patients with a better performance scale may have a better chance of pain relief. Radiopharmaceuticals containing phosphorus 32, strontium 89, samarium 153, rhenium 186, and tin 117m are effective, but we do not know which is the most efficacious and the safest. Toxicity includes the flare phenomenon and mild to moderate pancytopenia, but disseminated intravascular coagulation can cause severe, life-threatening thrombocytopenia. This treatment may be repeated at about 9- to 12-week intervals, perhaps earlier with (153)Sm lexidronam, (186)Re etidronate, and (117m)Sn pentetate, with a success rate approaching that of the initial injection. The duration of action of pain reduction ranges from 2 weeks to many months. Tumorical effects are probably not the only mechanism of pain relief.     

Preliminary results of the use of Re-186-HEDP for palliation of pain in patients with metastatic bone disease

We evaluated the effectiveness of Re-186-HEDP in 25 patients with painful metastatic bone disease. Twenty-five patients with known prostatic (n = 19), non-small-cell lung cancer (n = 1) and breast cancer (n = 5) and multiple confirmed skeletal metastases were studied. All were taking analgesics daily (nonsteroidal antiinflammatory drugs/opiates). Re-186-HEDP (mean 35.2 mCi) was administered and patients were monitored for at least 50 days. In five patients, a repeat dose was administered 9 to 10 weeks later. The evaluation of the analgesic effect was based on a "pain diary" and by recording the use of analgesics. In 80% (20 of 25) of the patients, the effect was significant palliation, moderate in 3 patients (12%), and insignificant in 2 (8%). No significant myelotoxicity was observed. Transient pain flare was recorded in 8 of 25 patients. These results indicate that Re-186-HEDP can offer pain palliation in patients with painful bone metastases without being complicated by significant myelotoxicity.     

The potential use of 99mTc-MDP bone scans to plan high-activity 186Re-HEDP targeted therapy of bony metastases from prostate cancer

Patients with skeletal metastases from hormone-refractory prostate cancer have shown variable responses to high-activity therapy with (186)Re-HEDP and peripheral stem cell support. In this paper, we report on the use of a novel technique to compare sequential planar images acquired post-(186)Re-HEDP therapy administration with pretherapy diagnostic (99m)Tc-MDP scans, to evaluate the turnover of the radiopharmaceutical in normal and abnormal bone. It was found that the activity in normal (i.e., disease-free) segments of the spine demonstrates a faster effective decay than that of the metastases, with the latter showing only physical decay. This study showed, for the first time, a detailed correlation in the behavior of the (99m)Tc-MDP and (186)Re-HEDP images, encouraging the possibility of using the pretherapy 99mTc-MDP scan for estimations of absorbed doses to be delivered by prescribed activities of (186)Re-HEDP.     

99m Tc-tetrofosmin SPECT显像在鉴别乳腺包块良恶性病变中的价值

目的 :探讨99mTc tetrofosmin乳腺扫描在鉴别可扪及的乳腺包块良恶性病变中的价值。方法 :采用前瞻性同步盲法。 2 0 0 0年 6月～ 2 0 0 1年 1 2月在我院临床发现乳腺包块的 1 0 1例患者接受SPECT乳腺扫描 ,并与针吸细胞学检察 ,乳腺X片和乳房彩色多谱勒检查进行了对比。全部病例进行了手术 ,以术后病理结果为标准。以四格表进行评价分析。结果 :99mTc tetrofosmin在对可扪及的乳腺包块性质进行鉴别诊断时 ,特异性 84.0 % ,敏感性 86 .3 % ,准确性 85 .1 % ,阳性预测值 84.6 % ,阴性预测值 85 .7%。结论 :99mTc tetrofosmin在对可扪及的乳腺包块进行良恶性质的鉴别时 ,不失为一种方便且较为准确的方法     

21例多原发癌SPECT全身骨扫描显像的临床分析

目的：通过对21例多原发癌病人的SPECT全身骨扫描分析,了解骨转移病灶分布特点。方法：通过给病人注射^99mTc—MDP显像剂,2—3小时后,行全身SPECT骨扫描。结果：多原发癌病人尤其是与乳癌或肺癌合并的多原发癌病人,大部分发生多发性骨转移。结论：多原发癌病人,易发生多发性骨转移,常规行SPECT全身骨扫描是必要的。     

^89Sr治疗骨转移瘤后韧致辐射显像的临床应用

目的探讨应用韧致辐射原理显像，并监测放射性药物^89Sr治疗骨转移瘤后在患者体内的吸收分布情况及判断预后的可行性。方法经静脉注射放射性药物^89Sr的患者于治疗后1周进行韧致辐射显像．并与^89Sr治疗前所进行的^99mTc-亚甲基二膦酸盐（MDP）骨显像所得的图像进行对比。然后勾划感兴趣区（ROI）计算摄取最浓的病灶处和对侧或周围正常部位的放射性比值（T／NT比值）。并随访其疼痛缓解程度。结果89^Sr韧致辐射显像与^99mTc—MDP骨显像对照，所发现的病灶浓聚部位基本吻合。但与后者相比，^89Sr韧致辐射显像图像分辨率较差且解剖部位亦显示不佳，尤其是肋骨、小病灶处和^99mTc—MDP显像所示的放射性轻度浓聚灶。计算所得的T／NT比值约为3．13±1．03（1．24—5．81）。在后期随访中，^89Sr韧致辐射显像中T／NT比值较高的患者，其疼痛等症状缓解程度也较为明显。结论利用韧致辐射原理进行显像能够监测纯β发射体放射性核素^89Sr在患者体内的分布情况，并可以通过计算T／NT比值，再佐以患者疼痛的缓解程度可以初步判读预后情况。     

Detection of occult bone metastases of lung cancer with Fluorine‐18 fluorodeoxyglucose positron emission tomography

Accurate staging of cancer has a critical role in optimal patient management. Fluorine‐18 fluorodeoxyglucose positron emission tomography (FDG PET) is superior to CT in the detection of local and distant metastases in patients with non‐small cell lung cancer. Although Tc‐99 m methylene diphosphonate (MDP) bone scanning is well established in the evaluation of bone metastases, there are conflicting reports on the use of FDG PET in the evaluation of skeletal metastases. We report on a patient with locally advanced lung carcinoma in whom FDG PET accurately identified previously unsuspected widespread asymptomatic bone metastases (bone scan and X‐rays negative, confirmed on MRI). Assessment of glucose metabolism with FDG PET might represent a more powerful tool to detect bone metastases in lung cancer compared with conventional bone scans.     

Detecting mediastinal lymph node metastases in non-small-cell lung cancer using a combination of technetium-99m tetrofosmin chest single photon emission computed tomography and chest computed tomography

The staging of non-small-cell lung cancer (NSCLC) to detect mediastinal lymph node (MLN) metastases is very important for determining the therapeutic strategy.

Methods: Thirty-four patients with proven NSCLC were enrolled in this study. All patients underwent chest computed tomography (CT) and technetium-99m (Tc-99m) tetrofosmin chest single photon emission computed tomography (SPECT) preoperative staging. Mediastinal lymph node metastases were determined on the basis of postoperative pathologic findings to compare the diagnostic accuracy of chest CT with that of Tc-99m tetrofosmin chest SPECT.

Results: Tc-99m tetrofosmin chest SPECT showed a diagnostic accuracy rate of 85.3% in detecting MLN metastases. Chest CT had an accuracy rate of 73.5%. If either Tc-99m tetrofosmin chest SPECT or chest CT with positive findings was considered as positive findings, the sensitivity was 94.7%. If either Tc-99m tetrofosmin chest SPECT or chest CT with negative findings was considered as negative, the specificity was 93.3%.

Conclusion: Tc-99m tetrofosmin chest SPECT was more accurate than chest CT in detecting MLN metastases in NSCLC patients. In addition, the combined use of Tc-99m tetrofosmin chest SPECT and chest CT could significantly increase the sensitivity and specificity compared with the single use of either Tc-99m tetrofosmin chest SPECT or chest CT.     

Radiation exposure of hemophiliacs after radiosynoviorthesis with 186Re colloid

Very limited data are available in the literature on the doses of unwanted radiation that patients receive following treatment with radiosynoviorthesis (RSO). OBJECTIVE: The aim of this study was to assess the radiation exposure after RSO with (186)Re colloid in hemophiliacs. METHODS: This study involved 12 hemophiliacs who were treated for hemophilic joint disease with 14 RSOs by using (186)Re colloid. Whole-body scintigrams were performed 1, 6, and 24 hours and 3 and 7 days after RSO. Measurements, using a whole-body counter, were done immediately after scintigraphy, with the treated joint protected with a lead shield. The cumulative activity of (186)Re in the body and in the lymph nodes was calculated. The distribution of (186)Re in the body was determined by using the values for small colloids as proposed by the International Commission on Radiological Protection (ICRP) Publication 53. The computer code, OLINDA/EXM (Vanderbilt University, Nashville, TN), was used for the calculation of the internal dose. A constant distance of 1 m between the ankle joint and body organs, and of 0.33 m between the elbow or shoulder joint and body organs, was used to calculate the contribution of gamma radiation to the effective radiation dose. RESULTS: The mean effective dose received by hemophiliacs after RSO with (186)Re colloid was 28 +/- 9 microSv/MBq of the activity injected into the joint. The patients received 0.8-3.7 mSv (1.9 +/- 0.8 mSv) owing to the leakage of (186)Re from the treated joint and its retention in the body. The highest doses were established in the spleen (26.0 +/- 10.7 mGy), the liver (17.6 +/- 7.2 mGy), and red marrow (3.0 +/- 0.8 mGy). The contribution of gamma radiation to the effective dose was less than 0.1 mSv in RSO of the ankle, 0.4 mSv in the elbow, and 0.6 mSv in the shoulder-joint treatment. The activity of (186)Re in the regional lymph nodes was noted in 4 of the 14 treatments. In these cases, the estimated average dose received by individual lymph nodes was 14.7 +/- 1.9 Gy. CONCLUSIONS: RSO with (186)Re colloid is a safe treatment method. The effective dose received by patients after RSO by using (186)Re colloid is low, as are the radiation doses to the most exposed organs. If (186)Re is retained in the regional lymph nodes, the lymph node radiation dose would be high.     

(99M)Technetium-sestamibi scintimammography in non-palpable breast lesions found on screening X-ray mammography.

OBJECTIVE: The sensitivity and specificity of (99m)Tc-sestamibi scintimammography in patients with non-palpable breast lesions diagnosed by screening mammography and the value of (99m)Tc-sestamibi to detect axillary lymph node metastases was determined. METHODS: Between September 2000 and December 2003, 103 females with non-palpable breast lesions were included for further evaluation. X-ray mammography was repeated and 99mTc-sestamibi scintimammography performed within one-week. Anterior, and left and right lateral images were obtained. The scintimammography was analysed by 2 experienced observers who were blinded to the clinical, pathological, and radiological results. The sensitivity and specificity of scintimammography to diagnose non-palpable lesion(s), including the axillary regions, was compared with histopathology, clinical, and radiological follow up. RESULTS: Two patients (one non-small lung cancer and one non-Hodgkin's disease) were excluded. Both showed (99m)Tc-sestamibi avid lesions in the breast and axillary region. In the remaining 101 patients, 37 true positive (TP), 4 false positive (FP), 52 true negative (TN), and 8 false negative (FN) breast carcinomas were found. The specificity was 92.8%, sensitivity 82.2%, positive predictive value (PPV) 90.2%, and negative predictive value (NPV) 86.6%. (99m)Tc-sestamibi scintimammography showed axillary lesions in 5/15 (33%) patients with axillary lymph node metastasis. CONCLUSION: In patients with non-palpable lesions diagnosed by screening- X-ray-mammography, (99m)Tc-sestamibi scintimammography provided high specificity and PPV. Furthermore, (99m)Tc-sestamibi scintimammography detected 33% of patients with axillary lymph node metastases. Therefore, (99m)Tc-sestamibi scintimammography could be of incremental value in the surgical work-up of these patients.     

18F-FDG PET与99Tcm-MDP显像对肿瘤骨转移的诊断价值

  目的 探讨18F-FDG PET与99Tcm-MDP显像对肿瘤骨转移的诊断价值。方法 93例肿瘤患者2周内行18F-FDG PET和99Tcm-MDP显像，比较分析两种显像结果。结果 93例肿瘤患者PET和MDP诊断骨转移64例。64例骨转移患者中PET和MDP阳性43例，PET阳性而MDP阴性16例，PET阴性而MDP阳性5例。18F-FDG PET和99Tcm-MDP显像诊断骨转移的灵敏度分别为92.2 %，75.0 %（P＜0.05）；特异度分别为93.1 %，79.3 %（P＞0.05）；准确度分别为92.5 %，76.3 %（P＜0.01）。结论 18F-FDG PET诊断肿瘤骨转移的灵敏度和准确性显著高于99Tcm-MDP显像。18F-FDG PET对骨转移有一定的诊断价值。     

99mTc-MIBI显像在乳腺癌诊断中的应用

目的 :寻找有效和无创性诊断乳腺癌及腋窝淋巴结转移的方法。方法 :对 36例乳腺肿瘤患者进行了乳腺及其区域淋巴结 99m　Tc MIBI显像。全部肿瘤经病理证实。结果 :36例乳腺肿瘤中 14例为良性肿瘤 ,2 2例为乳腺癌 ,其中腋窝淋巴结转移者 13例。99mTc MIBI显像诊断乳腺肿瘤假阳性 1例 ,假阴性 4例 ,其灵敏度为 81 8% ,特异性为 92 6 % ,准确性为 86 1% ;99mTc MIBI显像诊断乳腺癌腋窝淋巴结转移假阴性 5例 ,未发现假阳性 ,其灵敏度为 10 0 % ,特异性为 6 1 5 % ,准确性为 77 3%。结论 :99m　Tc MIBI显像诊断乳腺恶性肿瘤灵敏度较高 ,是一种有效的无创性诊断方法 ,也有助于诊断乳腺癌腋窝淋巴结转移 ,但是其结果还不够理想 ,有待于进一步研究。     

Conventional MRI does not reliably distinguish radiation necrosis from tumor recurrence after stereotactic radiosurgery

Distinguishing radiation necrosis (RN) from tumor recurrence after stereotactic radiosurgery (SRS) for brain metastases is challenging. This study assesses the sensitivity (SN) and specificity (SP) of an MRI-based parameter, the "lesion quotient" (LQ), in characterizing tumor progression from RN. Records of patients treated with SRS for brain metastases between 01/01/1999 and 12/31/2009 and with histopathologic analysis of a subsequent contrast enhancing enlarging lesion at the treated site at a single institution were examined. The LQ, the ratio of maximal nodular cross sectional area on T2-weighted imaging to the corresponding maximal cross sectional area of T1-contrast enhancement, was calculated by a neuroradiologist blinded to the histopathological outcome. Cutoffs of <0.3, 0.3-0.6, and >0.6 have been previously suggested to have correlated with RN, mixed findings and tumor recurrence, respectively. These cutoff values were evaluated for SN, SP, positive predictive value (PPV) and negative predictive value (NPV). Logistic regression analysis evaluated for associated clinical factors. For the 51 patients evaluated, the SN, SP, PPV and NPV for identifying RN (LQ < 0.3) were 8, 91, 25 and 73 %, respectively. For the combination of recurrent tumor and RN (LQ 0.3-0.6) the SN, SP, PPV and NPV were 0, 64, 0 and 83 %. The SN, SP, PPV and NPV of the LQ for recurrent tumor (LQ > 0.6) were 59, 41, 62 and 39 %, respectively. Standard MRI techniques do not reliably discriminate between tumor progression and RN after treatment with SRS for brain metastases. Additional imaging modalities are warranted to aid in distinguishing between these diagnoses.     

18F-FDG符合线路显像在肺癌诊断以及疗效判断中的作用

目的探讨18F-脱氧葡萄糖(18F-FDG)符合线路显像在肺癌诊断及疗效判断中的应用。方法对病理检查证实的66例肺癌患者行18F-FDG符合线路显像,并与同期CT、MRI等影像检查结果进行对比分析。结果与其他常规显像方法相比,18F-FDG显像对肺癌诊断、分期及放疗、化疗疗效判断、手术后肿瘤残余、复发以及肺癌骨转移有一定的辅助诊断作用。结论18F-FDG显像是肺癌诊断、分期及疗效观察的重要手段之一,可及时发现手术后肿瘤残余和复发病灶。F-FDG显像与骨显像的联合应用将可提高肺癌骨转移的诊断灵敏度。     

Transient bone marrow oedema: A variant pattern of sacral insufficiency fractures

A 71-year-old woman presenting with severe low back pain was found to have a large oval area of increased sacral uptake on Tc-99m MDP scan, with corresponding T1-hypointense and T2-hyperintense areas on magnetic resonance (MR) images, highly suggestive of malignancy. Open biopsies showed only callus formation. The patient responded clinically to conservative measures, with twice-repeated follow-up Tc-99m MDP and MR scans documenting resolution of transient bone marrow oedema. We suggest that this form of marrow oedema represents a variant pattern of sacral insufficiency fractures.     

^18F—FDGPET显像与^99Tc^m-MDP全身骨显像诊断肿瘤骨转移价值的比较

目的评价^18F-脱氧葡萄糖（FDG）PET肿瘤显像与^99Tc^m-亚甲基二膦酸盐（MDP）全身骨显像诊断肿瘤骨转移价值。方法43例肿瘤患者,其中28例经其他检查或随访证实为骨转移,15例证实无骨转移。2周对患者内行^18F—FDGPET和^99Tc^m-MDP显像,比较分析两种显像结果。结果28例肿瘤骨转移患者中,^18F—FDG PET阳性26例,^99Tc^m-MDP阳性27例,灵敏度分别为92．9％（26／28）、96.4％（27／28）,差异无统计学意义（P〉0．05）。15例无骨转移患者中,PET阴性14例,MDP阴性8例,特异度分别为93．3％（14／15）、53．3％（8／15）,差异有统计学意义（P〈0．01）。两种方法检测骨转移的准确率分别为93．0％（40／43）、81．4％（35／43）,差异有统计学意义（P〈0．01）。结论^18F—FDGPET诊断肿瘤骨转移的灵敏度与^99Tc^m-MDP显像相近,但特异性和准确性均较高。对^99Tc^m-MDP骨显像阴性、单一病灶及可疑骨转移患者,进一步行^18F—FDG PET显像,可起到信息互补、明确诊断的作用。