Isotope Bone Scan Research Articles

P075 What has parenteral iron got to do with rheumatology?

Abstract Background/Aims A 39 year-old female had been experiencing a six-month history of insidious onset migratory joint and bone pain, stiffness, malaise and over the last four months proximal muscle weakness. There had been partial relief with the use of non-steroidal anti-inflammatory medication. Past medical history included severe menorrhagia secondary to fibroids with a haemoglobin of 50g/dl on a handful of occasions, requiring x3 iron infusions (Ferric Carboxymaltose (FCM)1000mg) over a two year period. The last two infusions were provided three months apart. After each infusion, profound fatigue ensued. A blood test demonstrated an elevated ALP 301 (RR 30-130 U/L), reduced phosphate 0.48 (RR 0.8-1.5mmol/L) and mildly reduced 25OH vitamin D 44 (RR 50-140nmol/L). Corrected calcium was low-normal 2.29 (RR 2.2-2.6mmol/L) as was PTH 4.62 (RR 1.6-6.9pmol/L). A CTCAP excluded malignancy. Methods The patient had been treated with Cholecalciferol 1000iu and Dipyridamole 100mg daily with weekly blood test monitoring for six weeks prior to review in the metabolic bone clinic. Dipyridamole aided biochemical and symptomatic improvement. Further tests returned with an elevated FGF23 252 (RR 0-100 RU/ml), a normal Urine phosphate/Creatinine 1.6 and TmP/GFR ratio (suggesting the FGF23 effect on the kidney was not severe or its effects inhibited by Dipyridamole). ALP had reduced slightly to 269, PTH was elevated at 10.81 (RR 1.95-8.49micromol/L) and 1,25 Dihydroxy Vit D 182 (RR43-144 pmol/L). Results The patient was diagnosed with Parenteral iron triggered hypophosphatemia osteomalacia (6H-syndrome). A delayed diagnosis and referral resulted from unfamiliarity of side-effects of parenteral iron, especially Ferric Carboxymaltose, which has an alert on the GOV.UK website. The patient discontinued IV iron and was placed on oral Ferrous Gluconate 300mg daily. In retrospect, bone and joint pain was likely the result of enthesial pain and pseudofractures. In patients with diagnostic uncertainty, an isotope bone scan would be beneficial in assessing the extent of such pseudofractures. Hypophosphatemia is common following FCM (≥1/100 to < 1/10), and often self-limiting and asymptomatic. However, sustained hypophosphatemia (from recurrent infusions) can result in osteomalacia. Both anaemia and certain iron preparations can cause an elevation in FGF23 leading to increased urinary phosphate excretion. Dipyridamole has anti-phosphaturic effects by inhibiting FGF23. Conclusion It is advised in such patients to monitor serum phosphate levels at two- and five-weeks post infusion and to re-evaluate therapy with FCM in patients with persistent hypophosphatemia. It is common for symptoms, imaging, and biochemistry (FGF23 and ALP) to remain elevated/positive several months after diagnosis. This case highlights the need to ask about iron infusions in the drug history in patients presenting with hypophosphatemia and to be aware that musculoskeletal pain following iron infusions can be a sign of osteomalacia which will need investigating. Rarely, proximal muscle weakness can occur following the above iron preparation. Disclosure K.M. Achilleos: None. V. Rajagopal: None. C. Adams: None. G. Clunie: None.

Delayed and significant hypercalcaemia due to teriparatide therapy: a case report and review

IntroductionTransient hypercalcaemia due to teriparatide occurs in up to 11% of patients though delayed hypercalcaemia (> 24 h post injection) is rare. We report the case of a female who developed significant delayed hypercalcaemia after teriparatide treatment for osteoporosis and review other cases in the literature to date.Case reportA 72-year-old female on teriparatide for the treatment of osteoporosis was found to have hypercalcaemia (3.30 mmol/l) on routine testing approximately 3 months after starting therapy. Serum calcium pretreatment was normal at 2.39 mmol/l. She was admitted to the hospital for investigations which identified a serum 25-hydroxyvitamin D of 94 nmol/l, a low parathyroid hormone of 6.0 pg/ml, and normal test results for 1,25 dihydroxyvitamin D (115 pmol/l), parathyroid hormone-related peptide (< 1.4 pmol/ml), serum electrophoresis and angiotensin-converting enzyme (39 IU/l). CT abdomen, pelvis, and thorax revealed no evidence of malignancy and an isotope bone scan ruled out skeletal metastases. Serum calcium normalised (2.34 mmol/l) several days after stopping teriparatide and calcium supplements and administering intravenous fluid. On restarting teriparatide, delayed hypercalcaemia reoccurred and treatment was switched to denosumab.DiscussionDelayed moderate to severe hypercalcaemia (serum calcium > 3.0 mmol/l) due to teriparatide is rare but may lead to therapy withdrawal. The underlying predisposing risk factors remain unclear and highlight the importance of a routine serum calcium assessment on therapy.

A Case Report on Avascular Necrosis of Right Femoral Head in a 20-years Old Male

Avascular necrosis of the femoral head is a condition which causes cellular destruction of bone material due to interruption of blood supply. Necrosis is caused by inadequate blood supply, resulting in bone tissue destruction with collapsing of that segment. The disease usually occurs in young adults, and femoral head is one of the commonest sites. Avascular necrosis may be traumatic or non-traumatic and causes major musculoskeletal disability. Initially patients remain asymptomatic. In untreated cases the disease progresses and causes joint destruction, requiring surgical intervention and in later stages need total hip replacement. Plain X-ray, isotope bone scan and magnetic resonance imaging (MRI) play important role in making the diagnosis. MRI is highly accurate method for the diagnosis of avascular necrosis of the femoral head.

Single Dose vs. Fractionated High-Dose Rate Brachytherapy in Localized Prostate Cancer: Long Term Results

To evaluate long-term freedom from biochemical relapse (FFbR) and overall survival (OS) after single-dose high-dose-rate brachytherapy (HDR-BT) compared with 2 or 3 fraction schedules. HDR-BT, delivering 1 × 19 Gy or 1 × 20 Gy (A = 49), 2 × 13 Gy (B = 138) or 3 × 10.5 Gy (C = 106), was given to patients with intermediate or high-risk prostate cancer as their sole treatment. Patients were staged with pelvic MRI and isotope bone scan. Transperineal transrectal ultrasound guided implantation was followed by MRI based CTV definition based on GEC ESTRO guidelines. Biochemical relapse was assessed using the Phœnix definition (PSA nadir plus 2 µg/L). Patients were evaluated prospectively from 6 months after implant and bi-annually thereafter. Estimates of freedom from biochemical relapse, and overall survival (OS) were calculated using the Kaplan-Meier (K-M) method and the log-rank test to test for significance. Univariate and multivariate hazard ratios (HR) were obtained using Cox's proportional hazard model. For multivariate modelling a stepwise reduction method was used. Median follow-up was 123, 116 and 120 months (p = 0.4), (A, B, C, respectively). Neo-adjuvant and adjuvant androgen deprivation treatment was given to 80% of all patients, median duration was 9 months for A and 6 months for B and C. K-M estimates of FFbR, at 8 and 10 years, were 67% and 64% (Group A), 78% and 72% (Group B), and 80% and 76% (Group C). Differences in FFbR between dose groups was not significant (p = 0.2). Similarly, no significant difference was seen in OS. Eight and 10-year estimates were 81% and 75% (A), 85% and 74% (B), and 90% and 83% (C); p = 0.5. Hazard Ratios for risk of biochemical recurrence were significant for ADT administration (yes/no) and overall risk category, in multivariate analyses. Only the latter was significant in univariate analysis for risk of death, Gleason risk (low, intermediate, high), MRI tumor stage risk and overall risk category were significant in univariate analyses. Only tumor stage and Gleason risk were significant in multivariate analyses. Concerns around the efficacy of 19-20 Gy single dose HDR BT as monotherapy, based on early data, may have been unfounded. Long-term outcome data up to 10 years show no significant difference in PSA control and overall survival compared to 2 and 3 fractions of HDR-BT.

Neurological features of Paget’s disease of bone

Abstract: Paget’s disease of bone is a chronic focal disorder characterized by disorganized bone remodeling. It is usually asymptomatic and the diagnosis is made incidentally on the basis of other medical problem investigations. Head bones are frequently affected and may cause deformities due to overgrowth of bone leading to neurological manifestations such as headaches, dizziness, and deafness. Here, we describe a case of a 72-year-old woman who complained of headaches, back pain, tinnitus, and hearing loss. Clinical examination showed spinal deformities. Laboratory tests revealed elevated bone remodeling markers. Head computed tomography scan showed bone lesions suggesting Paget’s disease. Isotope bone scan revealed uptake in skull and thoracic spine. The patient was treated with zoledronic acid and analgesic with significant improvement of headaches and back pain and persistence of hearing loss.

E031 A rare case of diffuse osteosclerosis

Abstract Background/Aims Diffuse skeletal fluorosis is a common condition in countries with high content of fluoride in the ground water like India and China. Skeletal fluorosis in the UK is rare and presents with non-specific findings such as back pain, elevated ALP or bone sclerosis. We describe a case referred from haematology for investigation of osteosclerosis. Methods 74-year-old female presented to the emergency department on several occasions with recurrent abdominal pain, severe low back pain and swelling of her lower limbs. Her mobility had been reduced due to previous femoral nerve injury. Blood tests on admission showed mild macrocytic anaemia. Alkaline phosphatase, renal, liver function tests and electrolytes were within normal range. Furthermore, calcium, phosphate, vitamin D and parathyroid hormone levels were within normal limits. CT CAP was done and no obvious or sinister cause for abdominal pain was found. However, it showed diffuse bony sclerosis. Bone densitometry DXA scan results as follows: T-score of + 1.6 in the hip and +1.7 in the neck of femur, they were unable to scan the lumbar spine as the patient was unable to tolerate positioning for the scan. This confirmed relatively raised bone density for patient’s age despite having risk factors for osteoporosis like previous wrist fracture, strong family history of osteoporosis, early menopause following total hysterectomy at age 41, coeliac disease and multiple falls due to poor mobility. Results A bone marrow aspirate and trephine biopsy and immunophenotyping were carried out and did not demonstrate any evidence of myeloid or lymphoid neoplasm. The next line of investigations included an isotope bone scan and blood tests including serum tryptase, uric acid and fluoride levels. Fluoride level came back as 411 which is 8-times more than the normal value. Patient mentioned that she uses fluoride toothpaste and brushed her teeth at least 10-14 times/day. X-ray of the hands showed no evidence of periosteal reactions or sclerosis. We recommended that she use fluoride free toothpaste and referred her for a dental opinion. While there is no effective therapeutic agent to reduce fluoride levels, patient was encouraged to use fluoride free toothpaste and also consult with her dentist for further evaluation. Conclusion This case emphasises the need for a comprehensive history and maintaining a high index of suspicion of skeletal fluorosis when encountered with a patient with a high bone mineral density (BMD) score on the DXA scan or diffuse skeletal sclerosis. The increase in bone mineral density is thought to be related to fluoride’s enhanced osteoblastic activity. Disclosure S. Mohamed: None. A. Phillips: None. J. Thomas: None. D. Makkuni: None.

A Review on the Usage of Bone Single-Photon Emission Computed Tomography/Computed Tomography in Detecting Skeletal Metastases in the Post-COVID-19 Era: Is it Time to Ditch Planar and Single-Photon Emission Computed Tomography only Gamma Camera Systems?

Planar whole-body bone scanning (WBS) is widely used to evaluate skeletal lesions seen in cancer and noncancer cases. Frequently, degenerative, or other benign bony changes may give rise to indeterminate lesions that mimic bone metastases. In the post-COVID-19 era, there is an evolutionary phase that puts importance on global development and adaptability, which encompasses to include nuclear medicine practices worldwide. Single-photon emission computed tomography/computed tomography (SPECT/CT) can be used to improve the characterization of these lesions and help to resolve the diagnostic conundrum while reducing the need for patients to undergo multiple different examinations at various imaging departments. The fusion of SPECT and CT allows morphological characterization of functional abnormality detected by focal tracer uptake on planar scintigraphy, which provides a one-stop center imaging in nuclear medicine departments. The objective of this study was to review the diagnostic accuracy of SPECT/CT in diagnosing bone metastases in a variety of oncology and nononcology cases and to determine the feasibility of performing bone SPECT/CT in all suspected cancer cases, including cases of bone infection instead of planar imaging alone. The utilization of hybrid SPECT/CT in indeterminate bone lesions detected on planar WBS can significantly increase the diagnostic confidence and accuracy of image interpretation. Recognition of patterns of disease identified using hybrid imaging can improve the management of patients with potentially lower costs in the long term. Currently, hybrid SPECT/CT machines are becoming a norm in nuclear medicine departments, thus potentially making single planar application machines obsolete in the near future. We hypothesize that in the interest of providing a meaningful interpretation of isotope bone scans, the default protocol should involve the option of acquiring SPECT/CT images rather than relying on whole-body scans only. Departments choosing to upgrade existing equipment or those choosing to invest in only one gamma camera should proactively opt for hybrid SPECT/CT systems.

The role of radiotherapy in oligometastatic hormone-sensitive prostate cancer.

The aim of this article is to review the role of radiotherapy in the management of oligometastatic hormone-sensitive prostate cancer (HSPC). The M1|RT STAMPEDE trial showed a survival advantage to prostate radiotherapy in newly diagnosed oligometastatic HSPC. The combination of prostate radiotherapy with systemic treatment is now the recommended standard of care. Metastases-directed therapy (MDT) with stereotactic ablative radiotherapy (SABR) in the STOMP and ORIOLE trial reported excellent local control and a survival advantage in metachronous oligometastatic HSPC. Results were consistent with prostate cancer outcomes in the SABR-COMET trial and the NHS England Commissioning through Evaluation scheme (CtE). SABR in synchronous oligometastatic HSPC will be evaluated in a new comparison within the STAMPEDE trial. Current definition of oligometastatic HSPC is based on the number of metastatic lesions on conventional imaging (CT/MRI and Isotope bone scan). Novel imaging, such as PSMA PET/CT provide superior accuracy to conventional imaging. However, limited data exists on the role of novel imaging in determining subsequent clinical outcomes. Prostate radiotherapy improves survival and is standard of care with systemic treatment in newly diagnosed oligometastatic HSPC. The role of SABR in newly diagnosed oligometastatic HSPC is yet to be determined.

O15 Tumour-induced osteomalacia: a diagnostic challenge

Case report - IntroductionTumor-induced osteomalacia is a rare acquired metabolic bone disorder characterised by isolated renal phosphate wasting due to abnormal tumour production of fibroblast growth factor 23 (FGF23). Bloods show hypophosphatemia. However, given the lack of awareness of this disease, and the non-specific nature of the presenting symptoms, diagnosis is often delayed for years or even missed.With this case report, we want to shed light on this rare bone disorder and highlight the importance of not ignoring a low phosphate level.Case report - Case descriptionWe report the case of a 63-year-old gentleman who presented to us with a history of progressive bone pain, marked muscle weakness and fatigue. He had a persistently raised parathyroid hormone and very high alkaline phosphatase. Calcium was low normal, but vitamin D was normal. Phosphate was noted to be low and had been so since 6 years prior to being referred. X-ray pelvis showed sclerotic-looking iliac bones, but an isotope bone scan showed no evidence of metastatic disease.We referred him to our endocrinology colleagues to investigate for possible primary hyperparathyroidism. However, ultrasound scan of neck showed no abnormal parathyroid gland. PET and CT scan of the chest, abdomen and pelvis did not show any significant pathology. MIBI scan of parathyroid glands showed diffuse thyroid uptake. The SPECT-CT images showed a well-defined focal area of increased activity, posterior to the mid/lower pole of the right thyroid lobe, possibly indicative of hyperfunctioning parathyroid tissue. The radiologist questioned the possibility of renal osteodystrophy and resultant secondary hyperparathyroidism. However, there was no evidence for renal dysfunction with a creatinine of 80 umol/L.We referred this gentleman to the Oxfordshire Osteoporosis and Metabolic Bone Service. Bloods showed a raised P1NP. This was felt to be consistent with tumour-induced osteomalacia. Oversecretion of FGF23 was confirmed and DOTATATE scan revealed two areas of uptake: one in the right hip and one in the skull.Meanwhile, the patient had been started on Sandoz Phosphate and alfacalcidol, and his bone aches improved on this combination therapy.He had radio-ablation of the hip lesion this year and has now stopped all his medication. His fatigue and muscle strength has improved dramatically. The skull lesion is being monitored for now with yearly imaging and follow-up in the metabolic bone clinic.Case report - DiscussionTumour-induced or oncogenic osteomalacia is extremely rare. Symptoms include chronic muscle and bone pain, weakness, and fatigue and can result in fragility fractures due to osteomalacia. Lack of awareness of these clinical manifestations and relevance of low phosphate levels often leads to a diagnostic delay or misdiagnosis. As seen in our case, it took multiple investigations and almost 2 years before this gentleman had a confirmation of his diagnosis.The pathogenesis of tumour-induced osteomalacia involves tumour expression of fibroblast growth factor 23. This hormone inhibits reabsorption of phosphate in the proximal renal tubule and down-regulates renal conversion of 25-hydroxyvitamin D to its active form, 1,25-dihydroxyvitamin D. Replacing phosphate on its own paradoxically increases PTH levels. The metabolic abnormalities may be partially or completely corrected with phosphate supplementation and calcitriol. In our patient, his PTH levels remained elevated, but alkaline phosphatase improved, as did calcium and phosphate levels.Unlike many other causes of osteomalacia, tumour-induced osteomalacia is curable by resection of the offending tumour. However, finding the responsible FGF23-secreting tumour can be incredibly challenging. There is ongoing research into medical treatment for this condition, especially if the tumour is not found or is unresectable, or the patient is not a surgical candidate.Case report - Key learning pointsLow phosphate levels can be easily overseen, with significant consequences. This case emphasises the need to recognise hypophosphatemia and to look for its cause. Conversely, it also illustrates the need to investigate all patients with persistent musculoskeletal symptoms for hypophosphatemia.Our case underscores the importance of being aware of the rare condition of tumour-induced osteomalacia. This will enable early recognition and treatment of the metabolic abnormality, before the development of any deleterious effects of osteomalacia on the skeleton.

O13 A case of chronic recurrent multifocal osteomyelitis

O13 A case of chronic recurrent multifocal osteomyelitis

The Role of Positron Emission Tomography - Computed Tomography (PET - CT) Scan in the Assessment and Management of Carcinoma of the Prostate Gland: A Review and Update

Background: PET CT Scan has been used on numerous occasions in the assessment and management of various malignancies but it is only occasionally used in the assessment management of carcinoma of the prostate gland globally. There is the need to establish whether or not PET/CT scan is a useful imaging technique which should be used more often in the investigation of biochemical failure following treatment of carcinoma of prostate gland with curative intent Aim: To investigate the suggestion that PET/CT scan would be a useful and reliable imaging option for the investigation of biochemical recurrence resulting following the treatment of prostate cancer with curative intent by reviewing the literature relating to the use of PET / CT scan in carcinoma of the prostate gland. Method: Various internet data bases were searched including: Google, Google Scholar, Yahoo, and PUBMED. The search words that were used included: PET/CT Scan in carcinoma of the prostate, PET/CT scan in prostate cancer, PET/CT scan and prostate cancer, PET/CT scan and carcinoma of the prostate. Results: Fifty two manuscripts that have been published relating to the use of a form of PET/CT scan in relationship to investigation of carcinoma of the prostate gland were utilized to write the article. One of the articles published in Dutch was a review article. Another paper reported the use of PET CT scan in the diagnosis of Hurtle tumour (a benign tumour) in association with carcinoma of the prostate gland. The remaining manuscripts contained case reports and studies regarding the use of various types of PET/CT scan in the investigation of biochemical failure as well as in the treatment and follow-up of some cases of metastasis. On the whole almost all of the papers had confirmed the high sensitivity and high specificity of PET/CT scan in detecting localized and distant metastatic lesions in the scenario of slight elevations of serum PSA. There have been reports of PET/CT scan being able to detect localized and distant metastasis when conventional computed tomography scan and isotope bone scan failed to detect metastases. In one case when the serum PSA level was high isotope bone scan and CT scan failed to detect bone metastases but PET/CT scan detected bone metastases. Conclusions: PET/CT Scan is a very useful imaging modality that detects localized and distant metastases in biochemical recurrence of prostate cancer and this modality of imaging should be used more often from now onwards. CT scan would usually detect nodes/lesions that measure 1 cm or larger but PET/CT scan would detect smaller sized lesions at slightly raised levels of serum PSA. The detection of small localized metastasis at a slightly elevated serum PSA values would make it easier for the undertaking of a second-line treatment of curative intent in the form of salvage lymphadenectomy or salvage radiotherapy targeted at the lesion. Perhaps PET/CT scan should be the first-line imaging modality which should be used in investigating biochemical recurrence and this should be done when the serum PSA is slightly elevated.

P155. The utility of isotope bone scans in asymptomatic patients with advanced breast cancer

Aims: 15-20% of patients with stage T3/4 breast cancer present with metastatic disease. Hence whilst routine staging for early stage breast cancer and asymptomatic patients is not recommended we arrange both staging CT and Isotope bone scan (IBS) in the aforementioned high risk patients based on their tumour findings (T3-T4 cancers, node positive). We assessed whether CT scan alone can provide satisfactory staging data with omission of IBS.

P043 Fascinating phosphate: seek and you will find

Abstract Background/Aims A 62-year-old accountant was referred to the metabolic bone clinic with a 2 year history of thoracic back pain and a persistently raised ALP. There were no associated red flags for her back pain. She had a history of a gluteal lump, thought to be benign, for which she had declined excision. She has hypertension and had a previous navicular fracture. Medications included bendroflumethiazide and Adcal D3. She had restriction in neck movements and was tender to percussion in the thoracic spine. There was no proximal weakness or focal neurology. Systems and joint exam were unremarkable. Methods The case is discussed below. Results Salient abnormal results on presentation were a raised ALP of 207 and corrected calcium of 2.34. PTH was elevated at 8.2 (NR:1.6-6.9), Vitamin D 79 and a low phosphate of 0.34 (NR:0.8-1.50). Alkaline phosphatase isoenzymes showed the raised level came from bone. Protein and urine electrophoresis were normal. A bone density scan was normal, and a recent thoracic MRI showed only degenerative change. An isotope bone scan was requested and was reported to show increased activity in the nasal bone, maxilla and both orbits, raising the possibility of Paget’s disease. However, when reviewed in the Radiology meeting with a skull x-ray, the appearances were not felt to be in keeping with Paget’s. Despite physiotherapy, hydrotherapy, acupuncture and neuropathic medication the patient’s back pain continued. Her phosphate remained low and her calculated tubular reabsorption of phosphate from a 24h urine collection (TmP/GFR) was low at 0.42mmol/l (NR 0.80-1.35). She was started on phosphate replacement and calcitriol, and Adcal D3 was continued. The Fibroblast Growth Factor (FGF) 23 levels were sent and came back significantly elevated at 1380 (NR &amp;lt; 100). A 68Ga DOTA-TATE scan (whole body PET/CT scan), confirmed the right gluteal lump as the source of the FGF 23. The patient went on to have an excision biopsy and histology confirmed a mesenchymal tumour of the right buttock. Her phosphate replacement was gradually weaned, but on reducing the dose phosphate levels dropped and her symptoms returned. The repeat TmP/GFR was again low at 0.61, and FGF 23 levels were still raised at 204. A repeat 68Ga DOTA-TATE scan, 4 years after the first one, showed recurrence of the right gluteal lesion and a possible small lesion in the left gluteal muscle. She has been sent for further excision. Conclusion Tumour induced osteomalacia (TIO) is a rare condition and should be considered in cases of hypophosphataemia. Classical symptoms are proximal weakness and muscle and bone pain. They are typically associated with small benign tumours (most commonly mesenchymal tumours) which may be difficult to find. Excision is curative but if small amounts of tumour remain, relapses may occur. Disclosure J. Bakshi: None. C. Batten: None.

Paget’s Disease of the Bone: Patterns of Referral to Secondary Care Following Diagnosis on X-rays

Paget's disease of bone (PDB) is the second commonest metabolic bone disorder in the UK after osteoporosis and is both underdiagnosed and undertreated. PDB is often found incidentally on plain X-rays. There is effective treatment so identification of affected individuals is important. The aim was to conduct an audit to determine what proportion of individuals with X-ray evidence of PDB were referred to secondary care. A retrospective audit of X-rays reports in men and women over 55years of age was undertaken over 18months searching for the key word "Paget's." The images of possible cases were reviewed and the presence of PDB confirmed. The proportion already known to secondary care was determined and those that had had isotope bone scans and treatment. Data recorded included site of lesion, age, gender, level of total alkaline phosphatase (ALP) and complications. A total of 68,873 X-rays were screened and 43 cases found. Pelvic images had the highest proportion of positive findings at 0.2% and 65% of the cases. 74% had not been referred to secondary care. The mean age was 86.7years (range 65-95) and the ALP was elevated in 65% with a mean of 189u/L (range 47-804u/L). In 33 individuals, PDB had been recorded in the reports of previous X-rays. The rate of referral for specialist care remains low. The prevalence of the condition appears to be falling.

49. Giant cell arteritis and Takayasu arteritis: two sides of the same coin in an elderly female?

49. Giant cell arteritis and Takayasu arteritis: two sides of the same coin in an elderly female?

P080. The efficacy of systemic staging for detection of distant metastases in newly diagnosed breast cancer and its impact on patient management: two breast units review on practice

Introduction: Systemic staging for metastatic disease in newly diagnosed breast cancer is controversial; the detection yields is variable according to cancer stage and there is no consensus on which and how (CT +/- bone scan) patients should be staged. In two breast units in the West of Scotland, we routinely use CT (thorax, abdomen, pelvis) and isotope bone scan to stage women with ‘high risk’ cancers.

Awareness about risks of ionising radiation exposure in imaging investigations: a clinician survey

Purpose: To measure doctors’ knowledge of associated risks of exposure to computed tomography (CT) scans and other imaging procedures in a busy teaching hospital in England. Methods and materials: Doctors at the Royal Derby Hospital completed an online multiple-choice survey on their education and knowledge of the risks involved with exposure to ionising radiation. Results: Of 647 doctors contacted, 170 (26%) responded. Most respondents (65%) had received formal education on the risks of exposure to radiation. Almost all respondents identified that CT scans (98%) and chest X-rays (97%) involve ionising radiation. High proportions identified that isotope bone scans (84%) and positron emission tomography (PET) scans (81%), and very low proportions that magnetic resonance imaging (MRI) scans (8%) and ultrasound scans (4%), involve radiation. Lifetime cancer risk associated with a chest, abdomen and pelvis CT scan for a 20-year-old female was identified as approximately one in 30 (5%), one in 300 (the optimal response) (22%), one in 3000 (46%). The proportion underestimating risk as being either one in 30,000 or negligible was 27%. Conclusion: Over a third of respondents had received no formal education on the risks of exposure to ionising radiation, and over a quarter considered that the impact on lifetime cancer risk was either very small or negligible. As this is a potentially modifiable source of ionising radiation exposure, hospital doctors should receive regular mandatory education on the long-term risks of patient exposure to CT scans. This could promote consideration of alternative diagnostic strategies that avoid exposure to ionising radiation when possible.

MDP Bone Scintigraphy in Diagnosis of Polyostotic Fibrous Dysplasia- A Case Report on McCuneAlbright Syndrome

&lt;p&gt;&lt;span&gt;McCune-Albright syndrome (MAS) is an extremely rare disorder that classically affects the bones, skin and endocrine system. Classical features are fibrous dysplasia of bone, skin pigmentation and dysfunction of certain endocrine glands. Diagnosis of MAS is usually established on clinical grounds. Different imaging modalities help to confirm the fibrous dysplasia, among those radio iso-tope bone scan is an excellent tool for early diagnosis and evaluation of bony extension.&lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;span&gt;Bangladesh J. Nuclear Med. 19(1): 61-63, January 2016&lt;/span&gt;&lt;/p&gt;

The value of multimodality imaging in the investigation of a PSA recurrence after radical prostatectomy in the Irish hospital setting.

The diagnostic evaluation of a PSA recurrence after RP in the Irish hospital setting involves multimodality imaging with MRI, CT, and bone scanning, despite the low diagnostic yield from imaging at low PSA levels. We aim to investigate the value of multimodality imaging in PC patients after RP with a PSA recurrence. Forty-eight patients with a PSA recurrence after RP who underwent multimodality imaging were evaluated. Demographic data, postoperative PSA levels, and imaging studies performed at those levels were evaluated. Eight (21%) MRIs, 6 (33%) CTs, and 4 (9%) bone scans had PCa-specific findings. Three (12%) patients had a positive MRI with a PSA <1.0ng/ml, while 5 (56%) were positive at PSA ≥1.1ng/ml (p=0.05). Zero patient had a positive CT TAP at a PSA level <1.0ng/ml, while 5 (56%) were positive at levels ≥1.1ng/ml (p=0.03). Zero patient had a positive bone at PSA levels <1.0ng/ml, while 4 (27%) were positive at levels ≥1.1ng/ml (p=0.01). The diagnostic yield from multimodality imaging, and isotope bone scanning in particular, in PSA levels <1.0ng/ml, is low. There is a statistically significant increase in the frequency of positive findings on CT and bone scanning at PSA levels ≥1.1ng/ml. MRI alone is of investigative value at PSA <1.0ng/ml. The indication for CT, MRI, or isotope bone scanning should be carefully correlated with the clinical question and how it will affect further management.

A rare case of melorheostosis with oral mucosal lichen planus

A 36-yr-old male presented to the clinic with a 4-year history of painful swelling in the right distal forearm. No history of injury was reported. His X-ray showed focal cortical thickening involving the radial shaft, without soft tissue involvement (Fig. 1). MRI images confirmed the finding. Technetium-99 isotope bone scan revealed increased tracer uptake of the right distal radial/mid and proximal cortical bone. No associated abnormal soft tissue was reported. There was no scintigraphic evidence of primary bone malignancy or osseus metastasis. Oral mucosal lesions noted in the patient were identified as due to lichen planus infection.