Bone and liver images in medullary carcinoma of the thyroid gland: concise communication

Thirty-four patients with surgically documented medullary carcinoma of the thyroid (MCT) and elevated serum calcitonin levels had Tc-99m phosphate bone and/or Tc-99m sulfur colloid liver images for suspected metastases. Liver images demonstrated metastatic lesions in nine of 32 patients (28%). Bone images were positive for metastases in eight of 30 patients (27%). Four of these eight abnormal bone studies detected only skeletal lesions, two demonstrated only extraosseous metastases, and two showed both kinds. Of 18 patients with both radionuclide bone studies and skeletal radiographs, four demonstrated skeletal metastases, and lesions were recognized on both examinations. This study demonstrates that radionuclide bone and liver images frequently detect metastatic lesions in patients with MCT and elevated serum calcitonin levels, and that some nonskeletal metastases in patients with this tumor display an unusual affinity for bone-seeking radiotracers.     

Radionuclide liver and bone scanning in the evaluation of patients with endometrial carcinoma

Staging bone scans or skeletal surveys were obtained of 97 patients with endometrial carcinoma. Of the 77 patients with Stage I or II disease, no metastases were identified at staging. Three patients in the entire series demonstrated bony metastases; all of these metastases were detectable by radionuclide bone scan and radiographic bone survey. Eighty-nine patients were examined with radionuclide liver/spleen scanning at the time of staging. Four of the 89 initial scans were interpreted as demonstrating hepatocellular disease, and all four patients had abnormal liver function studies. Only one patient demonstrated a possible hepatic metastasis at initial diagnosis. This patient also had abnormal liver function studies. Based on these results, bone surveys and radionuclide bone scans are not indicated as screening procedures in endometrial carcinoma. It is suggested that screening for liver metastases in patients with endometrial carcinoma is not warranted in patients with normal liver function studies.     

Intrathoracic manifestations of metastatic testicular seminoma: a comparison of chest radiographic and CT findings

The chest radiographs and CT scans of 200 patients with pure testicular seminoma were reviewed. The radiographs showed evidence of intrathoracic metastatic disease in 25 patients (12.5%). Of these, 17 had an abnormal mediastinal contour, seven had pulmonary metastases, five had pleural effusions, and two had discrete pleural masses. CT showed evidence of intrathoracic metastatic disease in 30 patients (15%). This included mediastinal nodal enlargement in 21, pulmonary metastases in 12, pleural effusions in six, and pleural masses in two. CT not only showed disease in five patients with normal chest radiographs, but also showed additional sites of disease in four other patients with abnormal chest radiographs. The results suggest that mediastinal nodal enlargement is the most common intrathoracic manifestation of metastatic testicular seminoma. CT is more accurate than chest radiography in the detection of metastatic seminoma in the chest and defines the extent of metastatic disease more precisely.     

An integrated approach to the evaluation of metastatic bone disease

The radionuclide bone scan is the most effective whole body screening test for bone metastases. Conventional radiography, although relatively insensitive to the presence of bone metastases, is the best modality for characterizing them once they are detected in radionuclide scans. When the radionuclide bone scan and appropriate correlative radiographs are analyzed and reported together, false-positive scan findings are reduced, and scan specificity is increased. Valuable information on response to treatment may be obtained by correlating the changes seen in radiographs and radionuclide bone scans. CT or MR imaging may be useful for evaluating suspicious radionuclide bone scan findings that cannot be explained radiographically, and may influence the decision regarding the need for biopsy. CT can also be used to monitor needle-biopsy procedures. The use of CT or MR imaging is helpful in determining the local extent of metastatic disease when planning palliative surgery or radiotherapy. Although a positive diagnosis by needle biopsy is considered definitive, a negative result must be suspect and may eventually necessitate open surgical biopsy. An algorithmic approach to the workup of a possible skeletal metastasis is illustrated in Figure 12.     

Transient osteoporosis: transient bone marrow edema?

Ten patients with debilitating hip or knee pain were examined with magnetic resonance (MR) imaging. All had conventional radiographs that were either normal or showed nonspecific osteopenia. Nine patients had bone scintigrams that showed focal increased radionuclide uptake in the region of the painful joint. In each case, MR images of the affected joint showed regional decreased signal intensity of the bone marrow on T1-weighted images and increased signal intensity on T2-weighted images. Biopsy results of four patients excluded ischemic necrosis and metastases. The symptoms resolved spontaneously in all cases. The ten patients were followed up for 12-36 months, and there were no recurrences. The authors believe that the findings on MR images represent a transient increase in bone marrow water content. The focal findings on scintigrams confirmed the periarticular distribution of the process and provided evidence of accompanying hyperemia and increased bone mineral metabolism. For lack of a better term and to emphasize the generic character of the condition, the authors termed this condition "the transient marrow edema syndrome."     

Radionuclide evaluation of skeletal metastases: Practical considerations

The indications for radionuclide bone scanning to evaluate possible metastatic disease are reviewed. The causes of false-positive and falsenegative interpretations are discussed and illustrated. Since breast cancer leads all malignant tumors in incidence of skeletal metastases found at autopsy, the efficacy of preoperative bone scans in patients with breast cancer is analyzed in detail. A routine preoperative bone scan for patients with Stage I breast cancer produces negligible immediate benefits, but may serve a useful purpose as a baseline to enhance the detection of subtle changes that could represent metastases in a subsequent scan. However, the clinical usefulness of this screening procedure for Stage I disease must be balanced with its cost. Clinical Stage II is a grey area and may include patients with large primary tumors and axillary nodal involvement, implying a greater chance for the occurrence of skeletal metastases and hence a significant yield in bone scans. Patients with clinical Stages III or IV disease have the greatest chance of harboring metastases and should have an extensive diagnostic evaluation including bone scans prior to definitive treatment. Selected radiographs of sites of abnormally increased radionuclide activity and an anteroposterior radiograph of the pelvis should be correlated with the scan to permit a single comprehensive diagnostic impression.Presented at the 11th Annual Meeting and Refresher Course of the International Skeletal Society, Philadelphia, Pennsylvania, USA, September 12–15, 1984     

Role of bone scanning in detection of subclinical bone metastasis in nasopharyngeal carcinoma

One hundred thirty-two new patients with nasopharyngeal carcinoma and no evidence of distant metastases were evaluated for bone metastases with bone scanning. Forty-four patients had abnormal hypercaptation. These abnormal findings were considered related to benign diseases in 39 patients after correlating clinical examinations and skeletal radiographs. The remaining five patients had positive bone scanning which was suggestive of bone metastasis. There were 13 patients who developed symptomatic bone metastases over a follow-up period of 0.2-41 months. In three of these, the bone metastases corresponded to the sites of abnormal hypercaptation in the initial positive bone scanning. In view of the low sensitivity and specificity of bone scanning in this setting, routine bone scanning for staging nasopharyngeal carcinoma is not recommended. But in the research setting, baseline scanning is useful to make subsequent scanning more valuable, and it reduces false-positive results.     

Regression of the radiological changes of Gaucher's disease following bone marrow transplantation

Seven children with Type I Gaucher's disease have been treated with bone marrow transplantation (BMT). One patient died from the complications of BMT. In five patients computed tomography (CT) of the femora showed initially high attenuation in the marrow, returning towards normal after successful BMT. One of these patients also showed clearing of pulmonary infiltrates following treatment. In the first patient in the series no pre-transplant CT measurements were carried out but plain radiographs have demonstrated a return to normal shape of her femora 21/2 years after BMT. It is hoped that CT of the marrow cavities may provide a simple, non-invasive method for monitoring progress following BMT.     

Swyer-James syndrome: CT findings in eight patients.

To determine the importance of chest CT findings in patients with Swyer-James syndrome (unilateral small lung with air trapping) and to compare these findings with those on chest radiographs and scintigrams, we reviewed the CT scans, chest radiographs, and scintigrams of eight patients with the syndrome. Radiographs showed unilateral hyperlucency in seven patients and bilateral asymmetric hyperlucency in one. CT showed that the hyperlucency was unilateral in only three and that hyperlucency in one. CT showed that the hyperlucency was unilateral in only three and that hyperlucent regions on radiographs contained patches of normal lung attenuation in five patients. Conversely, in four patients, CT also showed small hyperlucencies in regions considered normal on radiographs. These lucencies usually had poorly defined margins and irregular shapes (five patients), but sometimes were peripheral, wedge shaped, and sharply demarcated (two patients). CT also showed subtle abnormalities not visible on radionuclide scans in two patients. Air trapping in hyperlucent regions was confirmed by a lack of change in volume on expiratory CT scans in five cases. Bronchiectasis was found in only three patients. CT helps to exclude central bronchial obstruction, cysts, and vascular disease as causes of hyperlucency. By excluding central obstruction, CT may make bronchoscopy unnecessary in some patients. CT is more sensitive than radiographs and radionuclide scans in detecting hyperlucent regions and in showing their distribution. Our experience suggests that bronchiectasis is not a necessary component of the Swyer-James syndrome.     

Unsuspected sacral fractures: detection by radionuclide bone scanning

Unsuspected sacral fractures may present with confusing clinical, radiographic, and scintigraphic findings. Sacral fractures were diagnosed by radionuclide bone scans in 23 patients, most of whom were osteopenic and had only minor or no trauma. Symptoms usually consisted of low back pain, sometimes with radiculopathy, but some of the patients were asymptomatic and the fractures discovered coincidentally. Abnormalities on bone scanning consisted of increased uptake in the body of the sacrum and one or both sacral alae or only in a single sacral ala. A retrospective review showed abnormalities on radiographs in 11 of the 23 patients and in all four of the CT scans obtained, but the abnormalities were often overlooked or misinterpreted on the original reading. Bone biopsies of the sacrum, done in two patients to rule out metastatic disease, showed reactive bone formation consistent with fracture. Recognition of the characteristic scintigraphic patterns in sacral fractures and the frequency of these fractures in osteopenic patients can avoid mistaken diagnoses and unnecessary tests or treatment.     

Localization of 99mTc-HMDP in hepatic metastases from colonic carcinoma

To evaluate the significance and frequency of skeletal imaging agent localization in hepatic metastases from colonic carcinoma, scintigrams from 54 patients were retrospectively studied. Of 54 patients, 22 had hepatic metastases, and skeletal metastases were present in seven of 54. Six of the seven patients with skeletal metastases had concurrent hepatic deposits. Two patterns of bone agent localization in liver metastases occurred: diffuse and mild (10 patients) and ringlike in appearance (two patients). Twelve of the 22 patients had localization of skeletal imaging agent in hepatic metastases and extensive or large liver lesions. Concurrent serum calcium values for nine of 12 patients were reviewed; none had a high level of serum calcium. Among available plain films and /or CT scans of the abdomen for 21 of the 22 patients, only one patient with extensive colonic metastases had multiple calcifications shown on CT but not seen in plain films. The data indicate a high frequency of hepatic metastases in colon carcinoma (22/54, 40%) and a high frequency of skeletal imaging agent localization in the hepatic colonic metastases (12/22, 54.5%). Once skeletal metastases are observed, there are almost always hepatic metastases present (6/7). There was no relation between elevated serum calcium values and bone agent localization in hepatic deposits. The relation between skeletal imaging agent localization or radiographic calcifications and histopathology of colonic carcinoma was inconclusive. The presence of bone agent localization in a 99mTc hydroxymethylene diphosphonate (HMDP) bone study indicates colonic hepatic metastases that are substantially widespread and/or bulky.     

Pretherapeutic evaluation of bone matastases in patients with potentially curable breast cancer (author's transl)]

A pretherapeutic evaluation of skeletal metastases should be carried out in all patients with proven mammary cancer including early stages. The scintigraphy is more reliable for detecting bone metastases than the conventional roentgenological survey. We recommend to employ complementally skeletall scintigraphy and conventional X-ray survey in the search for bone tumors. Negative scintigraphical results do not require any supplementary research. In case of a pathological scan or skeletal pain, a target roentgneological examination should be carried out to differentiate between benign diseases and neoplatic lesions.     

Normal anatomic variant: scintigraphy of the ischiopubic synchondrosis

Radionuclide bone imaging in pediatric patients occasionally shows a focus of distinct localized increase of radiotracer uptake at the ischiopubic synchondrosis. Correlation of radionuclide bone images and conventional radiographs of this area in a group of pediatric patients demonstrates the positive bone scans to correlate with the period of beginning but incomplete fusion of the synchondrosis. This represents a normal phase of skeletal development that radiographically and scintigraphically may mimic disease and should not be confused with a focus of pathologic activity.     

Relative roles of radionuclide scanning and radiographic imaging in eosinophilic granuloma

Twenty-four skeletal lesions were studied in seven patients with eosinophilic granuloma by radiographic skeletal surveys and radionuclide bone imaging. The radiographs detected 22 (92%) of these lesions and missed only two, whereas the scintiscans identified only 16 (67%) of these lesions, and missed eight. Radiographic skeletal survey and radionuclide bone imaging are complementary procedures in detecting bone lesions in bone marrow disorders, including eosinophilic granuloma. Use of either method alone is fraught with the danger of missing bone lesions of eosinophilic granuloma.     

Early MR demonstration of spinal metastases in patients with normal radiographs and CT and radionuclide bone scans

Forty patients with known primary tumor and progressive back pain, suspected of having spinal metastatic disease, underwent magnetic resonance (MR) examinations of the thoracic and lumbosacral spine. Conventional radiographs and CT scans of the spine were all normal. The radionuclide bone scans were equivocal. In 21 patients focal or diffuse vertebral MR abnormalities were detected. In nine patients the lesions were hypointense on T1 sequence, and the same lesions were demonstrated poorly or not at all on T2 and proton density sequences. In eight other patients the bone marrow metastases presented with strong signal intensity on T2 and were poorly or not at all demonstrated on T1 and proton density sequences. In three patients with multiple myeloma, the signal intensity pattern of the vertebrae was diffusely heterogeneous, with alternating small foci of strong and weak signals (a mosaic-like pattern). Following the MR studies, needle biopsy confirmed the malignancy in the 21 patients who had shown abnormalities. No correlation between the type of primary tumor and the signal intensity of the vertebral metastases was shown. Possibly the mosaic pattern shown in three of the multiple myeloma patients represents a special case.     

Staging non-small cell lung cancer with whole-body PET.

PURPOSE: To compare the accuracies of whole-body 2-[fluorine 18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) and conventional imaging (thoracic computed tomography [CT], bone scintigraphy, and brain CT or magnetic resonance [MR] imaging) in staging bronchogenic carcinoma. MATERIALS AND METHODS: Within 20 months, 100 patients with newly diagnosed bronchogenic carcinoma underwent whole-body FDG PET and chest CT. Ninety of these patients underwent radionuclide bone scintigraphy, and 70 patients underwent brain CT or MR imaging. For each patient, all examinations were completed within 1 month. A radiologic stage was assigned by using PET and conventional imaging independently and was compared with the pathologic stage. The accuracy, sensitivity, specificity, and negative and positive predictive values were calculated. RESULTS: PET staging was accurate in 83 (83%) patients; conventional imaging staging was accurate in 65 (65%) patients (P < .005). Staging with mediastinal lymph nodes was correct by using PET in 67 (85%) patients and by using CT in 46 (58%) patients (P < .001). Nine (9%) patients had metastases demonstrated by using PET that were not found with conventional imaging, whereas 10 (10%) patients suspected of having metastases because of conventional imaging findings were correctly shown with PET to not have metastases. CONCLUSION: Whole-body PET was more accurate than thoracic CT, bone scintigraphy, and brain CT or MR imaging in staging bronchogenic carcinoma.     

Radiological manifestations of the skeleton, lungs and brain in Stueve-Wiedemann syndrome

A total of 25 patients with the rare skeletal dysplasia Stueve-Wiedemann syndrome (SWS) have been evaluated during the last 11 years. Of all patients with clinical suspicion of SWS, skeletal and chest radiographs were obtained for classification of the underlying skeletal dysplasia. In one case, CT was carried out for the first time for further investigation of the midface hypoplasia. Typical conventional radiological findings and CT features were analysed and compared with published data. Early diagnosis of SWS was made by correlating radiological and clinical findings. Follow-up radiological examinations of the skeleton and of the chest were carried out in six children surviving infancy for evaluation of progression. Clinically, they suffered from progressive orthopaedic problems, recurrent aspiration pneumonia and recurrent episodes of hyperthermia, as well as cutaneous infections. Radiologically progressive bowing of the long tubular bones and progressive metaphyseal decalcification were present on follow-up skeletal radiographs. Skeletal abnormalities in SWS are so characteristic that an early post-partum diagnosis can be made by correlation of typical clinical and radiological findings. Few cases survive infancy. First, these patients face progressive orthopaedic problems and respiratory infections.     

Small cell lung cancer: radionuclide bone scans for assessment of tumor extent and response

Radionuclide bone scans were performed before and during combination chemotherapy in 119 systematically staged patients with small cell carcinoma of the lung. Before therapy, 49 patients (41%) had positive scans. Scan positivity was significantly associated with the presence of metastatic tumor in the bone marrow, positive skeletal radiographs, and elevated serum alkaline phosphatase levels. Nonosseous distant metastases were significantly more likely to be detected as the number of areas of focal abnormalities on bone scan increased. The survival of patients with documented distant metastases in bone and nonosseous sites was significantly inferior to the survival of patients with limited disease, isolated osseous extensive disease, and extensive disease occurring only in nonbony sites. Of 36 patients with initially abnormal scans and tumor regression documented by other methods, scan findings improved in 24 (67%). In 26 (36%) of 72 scans in patients demonstrating disease progression in extraosseous sites, new areas of increased radionuclide uptake appeared. Improvement or worsening in follow-up scans was associated with nonbony tumor response or progression, respectively, 70% of the time. Serial bone scans provide reasonably accurate staging and prognostic information in patients with small cell lung cancer, although they are probably not sufficiently reliable to be used as the sole parameter in therapeutic decision-making.     

87例肺癌患者核素骨显像结果分析

目的：通过对87例肺癌患者放射性核素全身骨显像结果进行分析，探讨肺癌骨转移的特点和规律。方法：回顾性分析了经临床病理证实的87例肺癌患者的全身骨显像表现。结果：肺癌骨转移率为63．2％，发生骨转移最常见的部位为肋骨，其次为脊椎骨、盆骨、四肢骨、肩胛骨、颅骨和胸锁骨。在不同病理类型的肺癌中，腺癌和鳞癌较其它类型更易发生骨转移。结论：肺癌骨转移比较常见，所以肺癌患者应常规作全身核素骨扫描，以帮助临床制订正确的治疗方案。     

The role of bone scintigraphy in osteogenic sarcoma

Hospital records of 27 children with osteogenic sarcoma were reviewed in an effort to define the usefulness of skeletal scintigraphy in the initial evaluation and follow-up of their disease. Serial bone scans as well as plain radiographs, linear tomograms, and computed tomograms were evaluated for evidence of bone or lung metastases. Eighteen patients developed lung metastases and three developed bone metastases. Seven patients demonstrated uptake of tracer in lung metastases, however, the lesions were all easily identifiable by radiographic means. All bone metastases were detected by scintigraphy, in one instance prior to radiographic abnormality. In no cases were bone metastases known to occur in the absence of lung metastases. None of the bone scans performed for routine follow-up pruposes resulted in altered therapy for the patient. We propose that skeletal scintigraphy is useful in the initial metastatic work up of osteogenic sarcoma, and may be helpful in some patients with specific indications during their follow-up, but is less valuable when there is no clinical suspicion for bone metastases.