Phase Bone Scan Research Articles

99mTc-MDP Bone Scan Findings of Recurrent Langerhans Cell Histiocytosis in an Adult Involving Femur After Joint Replacement.

Langerhans cell histiocytosis (LCH) is a rare proliferative histiocytic disorder. It mainly occurs in children and is rare in adults. We reported 99mTc-MDP bone scan findings of recurrent LCH in an adult, which involved the right femur after right-side total hip arthroplasty. This case emphasizes that the possibility of LCH should be considered in osteolytic lesions in adults, especially after joint replacement. In addition, LCH should be included in the differential diagnosis of prosthetic joint pain and abnormal 3-phase bone scan after prosthesis arthroplasty.

99mTc-MDP 3-Phase Bone Imaging in 3 Cases of Pigmented Villonodular Synovitis.

Pigmented villonodular synovitis (PVNS) is a rare proliferative synovial benign disorder, which is characterized by villonodular hyperplasia of joints, tendon sheath, and synovium; invasion of adjacent tissue; and sometimes visible hemosiderin deposition. Studies regarding bone scan findings of PVNS were relatively limited. Here, we report our findings on 99mTc-MDP 3-phase bone scan with SPECT/CT images on delayed phase in 3 patients with joint PVNS.

Traditional Medicine- Related Pitfalls and Artifacts on Bone Scintigraphy

Three phase bone scan is performed routinely to identify bone and joint abnormalities in patients with suspected acute osteomyelitis with or without septic arthritis. However, abnormalities detected on bone scan may not always represent disease. We present two cases where the use of traditional medicine by the patients creates unusual pitfalls and artifacts. In addition it highlights the clinical relevance of SPECT-CT in differentiating uncommon artifacts.

Nuclear Medicine Scans in Total Joint Replacement.

A 3-phase bone scan is a potential first-line nuclear medicine study for pain after total joint arthroplasty (TJA) when there is concern for periprosthetic joint infection or aseptic loosening. In patients who have a positive bone scintigraphy result and suspected infection of the joint, but where aspiration or other studies are inconclusive, labeled leukocyte scintigraphy with bone marrow imaging may be of benefit. Magnetic resonance imaging (MRI), while not a nuclear medicine study, also shows promise and has the advantage of providing information about the soft tissues around a total joint replacement. Radiotracer uptake patterns in scintigraphy are affected by the prosthesis (total knee arthroplasty [TKA] versus total hip arthroplasty [THA]) and the use of cement. Nuclear medicine scans may be ordered 1 year postoperatively but may have positive findings that are due to normal physiologic bone remodeling. Nuclear studies may be falsely positive for up to 2 years after TJA. Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) (SPECT/CT), fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/CT, and MRI show promise; however, more studies are needed to better define their role in the diagnostic workup of pain after TJA.

SAT-385 A Normal FGF23 Does Not Preclude Tumor Induced Osteomalacia (TIO)

BACKGROUND: The phosphaturic, bone-derived hormone FGF23, mediates bone loss in TIO. Tumor resection typically results in skeletal healing and reversal of biochemical defects.Case: A 45-year-old Caucasian man with no past medical history presented with non-traumatic fractures of bilateral metatarsals. Over the subsequent 2 years, he sustained fragility stress fractures in bilateral femurs, eventually rendering him non-ambulatory; though he continued to work as a property manager in an office setting. History included 30 pack-years of smoking as well as osteochondrosarcoma in his mother. Labs showed a low phosphorus at 2.1 mg/dL [2.7–4.5], along with calcium 8.8 mg/dL [8.4–10.4], iPTH 48 pg/mL [12–88], and ALP of 155 [IU]/L [34–104]. 25-OH vitamin D and 1,25-(OH)2 vitamin D were 27 ng/mL [30–80] and 12 pg/mL [20–80], respectively. Free testosterone was 4.4 ng/mL [5–21] and LH 2.2 mIU/mL [3.0–10.0]. Other pituitary hormones and brain MRI were unremarkable.Vitamin D3, calcitriol, phosphate and testosterone were prescribed. Testosterone was discontinued 6 months later, after diagnosis with DVT/PE. Incidental rib fractures on CXR prompted a 3-phase 99Tc-MDP bone scan, revealing multiple sites of uptake: ribs, scapulae, sternum, thoracolumbar spine, sacrum, bilateral ankles and feet. DXA revealed T-scores of -2.8 in the spine and -1.9 in the femoral neck.Labs pointed to ongoing phosphate wasting, despite compliance with calcitriol 0.25 mcg, cholecalciferol 5000 IU and phosphorus 2250 mg in divided doses. Calculated TRP was 64% [>80%] and TmP/GFR 1.74 mg/dL [2.5–4.5], consistent with low phosphate reabsorption. Urine 24-hour calcium was 244.8 mg. Testing for causal mutations of hypophosphatemic rickets and osteogenesis imperfecta was negative. FGF23 was within the reference range at 138 RU/mL [LabCorp ELISA 44–215], interpreted as inappropriately normal given ongoing phosphate loss. This prompted a search for a suspected TIO locus.Two years after presentation, 18F-FDG-PET exhibited a hypermetabolic focus at the left suprapatellar recess. Biopsy was consistent with a mesenchymal tumor and chromogenic in situ hybridization (Mayo Clinic) was positive for FGF23 mRNA. After surgical resection of the 1.7 cm tumor, serum FGF23 declined to <50 RU/mL and was 90 RU/mL 3 weeks later [Mayo <180 RU/mL]. Calcitriol and phosphorus supplementation were discontinued. One year post-operatively phosphorus was 3.6 mg/dL [2.5–5.0], with a normal calcium, iPTH and 25-OH vitamin D. Lumbar spine T score improved to -1.0 (+46.43%).Conclusion: A high clinical index of suspicion is required for TIO in the setting of phosphaturic osteomalacia, particularly with a normal serum FGF23. Recently, similar microRNA profiles were noted in osteosarcomas and TIO1. This, along with our patient’s family history raises the question of a possible predisposition to skeletal neoplasms.1. Green et al. Bone Reports, 2017.

Contribution of a Three-Phase 99m Tc-HMDP Bone Scintigraphy Protocol Completed by SPECT-CT Scan in the Diagnosis and Management of Langerhans Cell Histiocytosis of Bones in an Adolescent

Langerhans Cell Histiocytosis (LCH) or Histiocytosis X is a rare disorder of the reticuloendothelial system due to the accumulation of Langerhans cells in the tissues, most often organized into granulomas. The bone is the most affected organ. It can be a single osteolytic lesion or a multi-systemic form with organ dysfunction. We report herein the case of a 15-yearold adolescent male with bone pain in the hip evolving for two months in whom the diagnosis of unifocal bone langerhansian Histiocytosis was confirmed by a triple phase bone scintigraphy supplemented by SPECT CT objectifying a single focus of the disease at the greater left trochanter of the femoral bone without any other pathological bone fixation clearly identifiable on the other parts of the skeleton. This clinical case allows us to clarify the key role of a triple phase bone scan supplemented by SPECT CT in the diagnosis and management of Langerhans Cell Histiocytosis of bone in our context.

Giant Abdominal Aortic Aneurysm in Bone Scan

Abdominal aortic aneurysm (AAA) may be incidentally detected in three-phased bone scintigraphy. AAA should be diagnosed prior to the development of symptoms to perform elective repair surgery. We present a rare case who presented with back pain and underwent a 3-phase bone scan with Tc-99m methylene diphosphonate, which revealed a giant AAA on blood-flow and blood-pool phases in addition to bone metastases. F-18-fluorodeoxyglucose positron emission tomography/computed tomography (CT) identified hypermetabolic liver, lung, and bone lesions, and CT component of the study confirmed the diagnosis of AAA with a maximum diameter of 92 mm. The initial two phases of a 3-phase bone scintigraphy are decisive to identify vascular pathologies that may be life-threatening, if left untreated.

Capillary Hemangioma as an Unusual Cause of Doughnut Sign on Bone Scan

A 28-year-old woman presented with a mass in her right leg, which, on plain radiograph, appeared as a lytic lesion in the mid-shaft of the tibia with cortical thinning but without periosteal reaction. Tc-MDP 3-phase bone scan demonstrated intense uptake in the periphery of the mass with a photopenic center, the so-called doughnut sign. Histopathology revealed a capillary hemangioma. This case demonstrates that the doughnut sign on bone scan can be caused by capillary hemangioma in addition to other reported bone pathologies, including aneurysmal bone cyst, giant cell tumor, and telangiectatic osteosarcoma.

Síndrome de dolor regional complejo

Complex regional pain syndrome (CRPS), formally known as reflex sympathetic dystrophy or Sudeck's syndrome, is a clinical situation with continuous, disproportionate pain occurring weeks or months after trauma or fracture. It is generally located in the distal areas of the limbs. The pain is accompanied by hyperalgesia and allodynia. Other manifestations are oedema, changes in local skin temperature and colouration, altered hair, nail and skin trophism, and changes in sweating. There can be motor manifestations in the more chronic phases, such as muscle weakness, essential tremor, myoclonus and dystonia. Diagnosis is principally clinical and the 2013 IASP criteria are useful. Complementary exploration is of little help, although 3-phase bone scan can confirm the diagnosis. The prognosis is uncertain; the condition generally resolves in the first 12 months. Response to treatment is variable and a multi-disciplinary approach is required with physical and occupational therapy, drugs, and in cases of poor outcome, an interventionist and psychological approach. Glucocorticoids, bisphosphonates and analgesics are effective in the primary stages. The recommended preventative measures include prompt mobilisation after fractures or trauma. Vitamin C also appears to reduce the frequency of CRPS.

Comparative Evaluation of the role of Scintimetric Characterization by Dr. V. Siva's Retention Ratio and the Triple Phase Bone Scan in the Skeletal Fracture Assessment

Aim: This prospective analysis of the findings of bone scans done for skeletal fracture assessment was undertaken to compare the findings of the Triple phase Bone scan and the Scintimetric Characterization by Dr.V.Siva’s retention ratio in the assessment and evaluation of the skeletal fracture. Materials and Method: In this total study population of 39, had 19 males and 20 females. The 3 phases were acquired immediately after the intra-venous injection of 25 mCi of Tc99m MDP in a dynamic fashion centering over the fracture site. The dual head gamma camera e-Cam was used. The static Skeletal phase image and the 4 h whole body bone scan images were acquired 4 h after injection. The images were processed, and the results were tabulated. The 24 h static Skeletal phase image was acquired the next day. The 4/24 h Dr.V.Siva’s retention ratios were calculated using the region ratio protocol and tabulated. Results: The 3phase bone scan analysis revealed that 18/39 46 % were of malignant nature and 21/39 54% were of benign or non-malignant causes. The Scintimetric Characterization of the malignant lesions by Dr.V.Siva’s retention ratio was 12.8 +/- 1.79 and that of the Non- malignant lesions was 5.8 +/- 2.41 indicating the gross difference between the two groups. The statistical analysis also confirmed the significant difference between the two groups. There was absolute concordance between the Triple phase bone scan findings and the Scintimetric Characterization by Dr.V.Siva’s retention ration in 30/39=77% of patients and the discordant between the two was noted in 9/39=23 % patients. Conclusion: It can be concluded that the Scintimetric Characterization of fracture site by Dr.V.Siva’s Retention ratio along with the Triple phase bone scan findings helps in the proper identification of the underlying pathological process in as high as 23% of the study.

Infective Endocarditis Presented with Septic Sacroiliitis

A 19-year-old girl presented to our hospital with right hip pain, fever, and weight loss for 4 weeks. Initial laboratory findingsshowed an elevated C-reactive protein (3.61 mg/L) and a positive rheumatoid factor. Arthritis on the both scaroiliac joints wasrevealed on three phase bone scan. She had treated with antibiotics for septic sacroiliitis. Penicillin susceptible Streptococcussanguinis was isolated from blood cultures. A transesophaseal echocardiography showed a vegetation on the mitral valve, whichconfirmed our diagnosis of infective endocarditis. She was treated with penicillin G and gentamicin with a total duration oftreatment of 4 weeks. This report showed a rare septic sacroiliitis complicated by infective endocarditis caused by viridansstreptococcus. Although, sacroilitis is an important component of inflammatory spondyloarthropathy, infective endocarditis wouldbe evaluated in case of a septic arthritis.

3-phase Technicium-99m bone scanning in patients with pain in the hip region after cemented total hip replacement: a multicentre series of 100 cases.

The aim of this study was to assess the benefit of a Technetium-99M (HDP) 3-phase bone scan (TPBS) as an additional diagnostic test in the evaluation of pain in the hip region following cemented total hip replacement (THR) surgery. A retrospective study over a 24-month period was performed comprising 100 patients investigated with a TPBS. Investigations were summarised and analysed, and were classified as entirely normal, possibly abnormal, and definitely abnormal. 45% (45) of TPBSs were reported as being entirely normal, 50% (50) as possibly abnormal, and 5% (5) as definitely abnormal. During the 24-month study period 230 revision THR procedures were performed at our institution; 10% (24) were investigated with TPBS and 90% (206) were not. 29% (7/24) of patients investigated with a TPBS that subsequently underwent revision THR surgery had an entirely normal preoperative TPBS. 84% (38) with an abnormal TPBS were managed conservatively. A TPBS had a sensitivity of 29% (95% confidence interval (CI), 13%-51%) and a specificity of 50% (95% CI, 38%-62%) in the detection of infection, or loosening with concurrent infection. A TPBS should only be considered following clinical evaluation, serological investigation, diagnostic imaging and microbiological analysis of fluid obtained from arthrocentesis by a specialist revision arthroplasty surgeon. A TPBS may be useful in the situation where abnormal serology is present, but where repeated joint aspirations samples are inconclusive.

Acute Osteomyelitis in the Hand Due to Dog Bite Injury: A Report of 3 Cases.

As many people keep small dogs as pets, dog bites are common injuries, accounting for approximately 80%–90% of all animal bite injuries. These injuries usually occur on the upper extremities, most commonly on the fingers. Most of these injuries appear as simple lacerations or abrasions of the skin. Common symptoms include inflammatory reactions of the soft tissue, such as pain, swelling, erythema, and cellulitis. However, the complications of small dog bites may include joint or cartilage injuries, including acute osteomyelitis. Once osteomyelitis develops, it is difficult to diagnose since it has a latency period of approximately 2 weeks. Plain radiography, magnetic resonance imaging, and 3-phase bone scans should be performed when acute osteomyelitis is suspected, and broad-spectrum empiric antibiotic treatment should be administered for approximately 8–12 weeks. We report 3 very rare cases of acute osteomyelitis that occurred after a dog bite injury.

Schwannoma of the femur: A rare case report

Schwannoma is a benign tumor derived from Schwann cells that cover myelinated nerve fibers (1). Among primary bone tumors, intraosseous schwannoma accounts for less than 0.2% (2). We are reporting a rare case of an 18-year-old female presented with swelling in the posterior right thigh. The patient was asymptomatic and this was incidentally discovered by her massage therapist. However, the swelling was gradually growing since then.The plain radiograph findings were suggestive of a benign bone tumor. MRI with gadolinium was performed for further evaluation but it demonstrated suspicious features as evidenced by the extra osseous enhancing soft tissue component. Three phase bone scan was done thereafter and it showed hyperemia with mild increased uptake of the lesion on the delayed phase. Osteosarcoma was suspected and chest CT was performed for staging purposes which turned out to be negative for metastasis.The lesion was biopsied under ultrasound guidance. The histologic features and the immunohistochemically profile were consistent with a benign schwannoma.The posterior thigh soft tissue mass was surgically resected with femur bone grafting. Recurrence of schwannoma should be considered but its malignant transformation is exceedingly rare and this can be discounted (3).

Rapid diagnosis of “Fatigue” stress fractures using bone scintigraphy: A practical approach

Stress fractures can broadly classified into “fatigue” or “insufficiency” fractures depending on baseline bone health and amount of physical activity. Of these fatigue stress fractures present with a classical history of increased physical activity in healthy bones followed by pain typically after a few weeks. Imaging modalities include plain radiographs, MRI, CT Scan, Bone Scintigraphy (Scan) and Ultrasound. We discuss a short case series and explore key points for all these modalities and propose a simple algorithm for rapid diagnosis of fatigue stress fractures involving three phase bone scan.

P2.02-005 A Rare Clinical Presentation Of EGFR-Mutant Non-Small Cell Lung Cancer With Oligo-Acrometastasis

44% of acrometastasis are originated from primary lung tumors and metastasis to digits is seen in 0.2% of patients with lung cancer. After clinical staging, amputation or radiotherapy are most often therapeutic options for pain palliation. We want to present an oligo-acrometastasis of fourth proximal phalanx of left hand from EGFR-mutant non-small cell lung cancer. A 58-year-old man was admitted with pain and swelling in fourth finger of his left hand (Figure 1A). Magnetic resonance imaging (MRI) of left upper extremity showed destruction by a soft tissue measuring about 30x17 mm on the distal part of fourth proximal phalanx of left hand (Figure 1B-C). Three phase bone scan with technetium-99m methylene diphosphonate (MDP) revealed increased radiotracer uptake in the fourth finger. Diffuse increased uptake is seen at the left wrist secondary to the old fracture and trauma in both blood pool and metabolic phases and hypertrophic osteoartropathy in both tibia (Figure1E-F). Computed thorax tomography (CTT) revealed a 25x21 mm lobulated contour lesion in the posterior segment of right lower lobe (Figure 1H). CT-guided biopsy was performed and pathological examination showed non-small cell lung carcinoma-not otherwise specified (NSCLC-NOS). A 24x27x24 mm mass with SUV-max value 9.85 in the right lower lobe, right tracheobronchial and right hilar lymphadenopathies 13 mm in diameter was detected (SUV-max: 7.51) on PET-CT. Patient was staged as T1bN2M1b with oligoacrometastasis. His finger was amputated from metacarpophalangeal level and surgery margin was negative for tumor. Pathological diagnosis was metastatic NSCLC-NOS harboring EGFR-21L858R mutation. After curative treatment of acrometastasis, concurrent chemo-radiotherapy was planned for primary lung cancer as a therapeutic approach. He is still under treatment. Oligometastatic disease by acral involvement in NSCLC is extremely rare. Curative treatment approach should be consider for both primary tumor and metastasis side.

Nuclear Medicine Imaging in Rheumatic Diseases

The rapid development of medical imaging technologies has greatly enhanced the utility of nuclear medicine imaging modalities over the last decade. Hybrid imaging technology merging computed tomography (CT) with single-photon emission computed tomography (SPECT) or positron emission tomography (PET) allows superimposing the physiologic data obtained by SPECT or PET on the detailed anatomy of CT, yielding a better understanding of the disease status and improving diagnostic performance. However, the conventional whole body bone scan and three phase bone scan still have their own distinct role as diagnostic imaging, reflecting the changes of bone metabolism in benign and malignant diseases, including rheumatic diseases. A review of each nuclear medicine imaging technique and clinical applications in various conditions of rheumatic diseases will be presented in this article. (J Rheum Dis 2017;24:4-13)

A large heterotopic ossification in a 25 years old laparotomy scar.

Heterotopic ossification (HO) is a benign condition when bone develops in tissues that do not usually ossify. The etiology is not fully understood but the condition can appear in variable locations, sizes and morphology in the body. We describe a large HO in a scar, discovered 25 years after a laparotomy of the upper abdomen. The calcification led to mechanical complaints and resection gave resolution of symptoms. HOs can be incidental findings on plain radiographs. CT-scan can show typical mature peripheral mineralization with central lucency. If symptomatic, resection must be performed after maturation. Maturation can be examined with activity-oriented imaging as 3-phase bone scan or SPECT-CT.

Is poststroke complex regional pain syndrome the combination of shoulder pain and soft tissue injury of the wrist?: A prospective observational study: STROBE of ultrasonographic findings in complex regional pain syndrome.

Patients with poststroke complex regional pain syndrome (CRPS) show different symptoms compared to other types of CRPS, as they usually complain of shoulder and wrist pain with the elbow relatively spared. It is thus also known by the term “shoulder-hand syndrome.”The aim of this study is to present a possible pathophysiology of poststroke CRPS through ultrasonographic observation of the affected wrist before and after steroid injection at the extensor digitorum communis (EDC) tendon in patients suspected with poststroke CRPS.Prospective evaluation and observation, the STROBE guideline checklist was used.Twenty-three patients diagnosed as poststroke CRPS in accordance to clinical criteria were enrolled. They had a Three Phase Bone Scan (TPBS) done and the cross-sectional area (CSA) of EDC tendon was measured by using ultrasonography. They were then injected with steroid at the EDC tendon. The CSA of EDC tendon, visual analogue scale (VAS), and degree of swelling of the wrist were followed up 1 week after the injection.TPBS was interpreted as normal for 4 patients, suspected CRPS for 10 patients, and CRPS for 9 patients. Ultrasonographic findings of the affected wrist included swelling of the EDC tendon. After the injection of steroid to the wrist, CSA and swelling of the affected wrist compared to that before the treatment was significantly decreased (P < 0.001). The VAS score declined significantly after the injection (P < 0.001).Our results suggest that the pathophysiology of poststroke CRPS might be the combination of frozen shoulder or rotator cuff tear of shoulder and soft tissue injury of the wrist caused by the hemiplegic nature of patients with stroke.

Nuclear medicine imaging of posttraumatic osteomyelitis.

IntroductionEarly recognition of a possible infection and therefore a prompt and accurate diagnostic strategy is essential for a successful treatment of posttraumatic osteomyelitis (PTO). However, at this moment there is no single routine test available that can detect osteomyelitis beyond doubt and the performed diagnostic tests mostly depend on personal experience, available techniques and financial aspects. Nuclear medicine techniques focus on imaging pathophysiological changes which usually precede anatomical changes. Together with recent development in hybrid camera systems, leading to better spatial resolution and quantification possibilities, this provides new opportunities and possibilities for nuclear medicine modalities to play an important role in diagnosing PTO.AimIn this overview paper the techniques and available literature results for PTO are discussed for the three most commonly used nuclear medicine techniques: the three phase bone scan (with SPECT-CT), white blood cell scintigraphy (also called leukocyte scan) with SPECT-CT and 18F-fluorodeoxyglucose (FDG)-PET/CT. Emphasis is on how these techniques are able to answer the diagnostic questions from the clinicians (trauma and orthopaedic surgeons) and which technique should be used to answer a specific question. Furthermore, three illustrative cases from clinical practice are described.