Nuclear Medicine Bone Scan Research Articles

Into the Unknown: Navigating Orbital Cellulitis to Reveal Retinal Metastasis of a Hidden Primary Tumor

Introduction
 This is a rare patient presentation of retinal metastasis with an unknown primary tumor. 
 
 Case Presentation
 A 65-year-old woman with a past medical history of left breast carcinoma stage 1 status post left mastectomy in 2014, iron deficiency anemia, anxiety, and depression presented to the emergency department with 1-2 weeks of worsening lower abdominal pain and left-sided chest pain. She also complained of right eye pain, blurry vision, and painful eye movement. Ocular examination demonstrated edema, mild proptosis, conjunctival chemosis, and conjunctival injection. Patient was started on bacitracin ointment and ceftriaxone due to concerns of orbital cellulitis. Ophthalmology was consulted, and their assessment was suggestive of bilateral metastatic neoplastic lesion in retina of both eyes, more pronounced in the right than the left eye. Left supraclavicular lymph node biopsy showed metastatic adenocarcinoma, likely of gastrointestinal or pancreaticobiliary primary. MRI brain was suspicious for calvarial metastatic disease, MRI abdomen showed multiple nodules in the liver suggesting metastases, and whole-body nuclear medicine bone scan suggested possible metastases in the hemithorax and bilateral femurs. After several goals of care discussions, the decision was made by the patient and her family to pursue comfort measures only and she was discharged home with home hospice and later passed away.
 
 Conclusion
 Retinal metastasis is a rare condition due to the absence of lymphatic system in the eye (1). The most common primary tumors to metastasize to the eye are from breast (47%), lung (21%), and the gastrointestinal tract (4%) (2). In some cases, patients may have no other symptoms (1). Thus, retinal metastasis is important to include in the differential diagnosis, especially for patients with a history of treated primary cancer.

SAT262 Bilateral Stress Fractures Of The Femur In A Patient With HIV On Long-term Tenofovir Disoproxil Fumarate And Short-term Alendronate

Abstract Disclosure: R.J. Mahatme: None. A.D. Lindsay: None. F.S. Mirza: None. Background: Tenofovir disoproxil fumarate (TDF) is a reverse transcriptase inhibitor used for HIV treatment, which has been documented to reduce bone mineral density through enhanced osteoclastic activity, reduced osteoblastic activity, disrupted calcium absorption and renal phosphate wasting. Prolonged use of TDF increases the risk of osteoporosis and fractures. Bisphosphonates (BP) are typically used to prevent osteoporotic fractures by inhibiting bone resorption. However, BP use for more than five years, and concomitant suppression of bone remodeling may be associated with an increased risk of subtrochanteric fractures. We report a case of unusual bilateral subtrochanteric stress fractures of the femur in a patient on long term TDF for HIV, who had taken alendronate for a very short duration. Clinical Case: A 56-year-old woman presented to orthopedics in 2017 with complaint of bilateral leg/hip pain associated with weight bearing. Past medical history was significant for HIV diagnosed in 1995, osteopenia diagnosed in 2015 and fibromyalgia. The patient had been taking TDF as part of HIV therapy since 1995 and had been started on alendronate 15 months prior for osteopenia. X-ray of the hips revealed diffuse osteopenia with areas of possible stress reaction/stress fracture at the proximal third of the right femur and in the subtrochanteric left femur. Nuclear medicine bone scan showed faint foci of increased uptake in the lateral subtrochanteric regions of both proximal femora and midshaft of the right femur suggesting insufficiency fractures. The report noted that these areas were present and unchanged compared to a prior bone scan from 2011. In view of significant discomfort and risk of progression to full fracture, she underwent prophylactic intramedullary nailing of the right femur and was referred to endocrine for bone health evaluation. Endocrine evaluation showed vitamin D insufficiency and suboptimal calcium intake which were both corrected. A call to the pharmacy revealed that she had only filled 3 prescriptions of alendronate even though she was initially prescribed alendronate a year and a half prior to her presentation. Alendronate and TDF were discontinued and tenofovir alafenamide (TAF) was added to her HIV regimen due to its less deleterious effects on the skeletal system. Patient did not report significant improvement in her leg pain after the intramedullary nailing and decided to maintain a conservative approach without intervention for the left femur stress fractures. Conclusion: This is an unusual presentation of bilateral stress fractures of the femur likely related to long term TDF therapy in a relatively young postmenopausal female who had taken alendronate for less than a year of cumulative dose. This case highlights the need to use medications that have less harmful effects on the bone in adults with HIV who are also at an increased risk for low bone density and fractures. Presentation: Saturday, June 17, 2023

The relation between prostate-specific antigen and whole-body bone scan result

The nuclear medicine bone scan is a versatile tool because of its high sensitivity for tumors, infection, and trauma, as well as its ability to image the entire skeleton at a reasonable cost, In this study we evaluate the correlation between the prostate-specific antigen number and bone scan result in patients that were diagnosed with prostate cancer. Method: Tc99m-MDP whole body bone scan was analyzed for 100 patients whose ages range between 66-92 years with a mean of 77 years, PSA level ranges from 0-100ng/ml,50% of bone scan result was normal and 50% of patient results had bone metastases. Results: The results show that there is no correlation between the PSA level of the patient and the bone scan result, and there is no correlation between the patient's ages and PSA levels. Conclusions: There was no correlation between PSA level and whole-body scan results in this study.

Presyncope and Ophthalmoparesis Due to Intracranial Erdheim-Chester Disease.

An 82-year-old female presented to the emergency department with presyncope and was found to be bradycardic with proptosis and ophthalmoparesis. MRI revealed an extra-axial enhancing mass compressing the medulla and bilateral enhancing retro-orbital masses. Imaging, including nuclear medicine bone scan, PET CT, and cardiac MRI raised the suspicion for a histiocytic neoplasm. These findings, along with a fibrohistiocytic infiltrate on bone biopsy and a BRAF V600E oncogenic mutation on plasma cell-free DNA confirmed a diagnosis of Erdheim-Chester disease. These enhancing masses invoke a broad differential, including a histiocytic or granulomatous process, fungal infection, amyloidosis, IgG4 disease, and lymphoma. Systematic laboratory, radiologic, pathology, and genetic testing yielded a diagnosis of this rare histiocytic disorder with frequent neurologic involvement.

Impact of choosing wisely on imaging in men with newly diagnosed prostate cancer.

Encouraging the appropriate use of staging imaging in patients with newly diagnosed prostate cancer remains a challenge. Assessing the effects of national efforts may help guide future initiatives in curtailing low-value care. The purpose of this study was to determine the impact of the Choosing Wisely campaign on imaging utilization among men with prostate cancer. Surveillance, Epidemiology, and End Results - Medicare data were used to complete a longitudinal population-based study of men diagnosed with prostate cancer from 2007 to 2015. An interrupted time series analysis evaluated the impact of the Choosing Wisely campaign on trends of imaging utilization. From 2007 to 2015 imaging utilization in low-risk patients decreased, with computed tomography (CT) usage declining from 45.0% to 34.4% (P<0.001) and nuclear medicine bone scan (NMBS) from 27.8% to 11.7% (P<0.001). Choosing Wisely likely contributed to an absolute reduction of 2.9% (P=0.03) in utilization of NMBS in the low-risk population. Imaging usage for all modalities increased in the high-risk population, but with 32.8% continuing to not receive guideline-supported imaging. In 2012, the Choosing Wisely campaign sought to decrease inappropriate staging imaging for men with low-risk prostate cancer and encourage stewardship of medical resources. Overall decreases in staging imaging trends suggest a move towards higher value care. However, this study found that the Choosing Wisely recommendations had a modest impact on utilization of NMBS, but not CT or PET scans. These results may help inform future efforts to promote guideline concordant imaging.

Evaluating the Downstream Revenues of a Self-Pay Bi-Parametric Prostate MRI Program

To quantify downstream healthcare utilization and revenue associated with a self-pay bi-parametric prostate MRI (bpMRI) program. Medical records of 592 patients who underwent bpMRI between August 2017 and March 2020 were examined for follow-up clinical activities. These include prostate biopsy, radical prostatectomy, external beam radiation therapy, brachytherapy, androgen deprivation therapy, CT Chest, Abdomen and Pelvis, PET/CT, MRI Pelvis, and Nuclear Medicine Bone Scans. The charges for each clinical activity were derived from the Medicare Physician Fee Schedule to conservatively estimate revenues. This patient population was further divided into four groups: Group A, patients who demonstrated an MRI lesion and underwent prostatectomy; Group B, patients who did not demonstrate lesion but underwent prostatectomy; Group C, patients who demonstrated lesion but did not undergo prostatectomy; and Group D, patients who neither demonstrated lesion nor underwent prostatectomy. Revenues for each group were categorized by Urology, Radiation Oncology and Radiology subspecialties. Conservative estimates yielded $520 of downstream revenue per patient who underwent bpMRI. Group A patients yielded 47% of total revenue ($1974 per patient). Group B patients, the smallest group, yielded $1828 per patient. Group C patients made up the largest group and grossed $398 per patient. Group D demonstrated the lowest per patient revenue of $179. Groups A and B yielded most relative revenue for Urology. Group C yielded most relative revenue for Radiation Oncology, and Group D yielded most relative revenue for Radiology. A self-pay bpMRI program has the potential to improve patient access to prostate cancer screening while remaining financial sustainable.

OA08 A case of Recalcitrant Psoriatic Disease- should new treatment strategies be considered?

Introduction/BackgroundDespite the advent of numerous biologic therapies and small molecular drugs targeting specific immune pathways, at least 40% of PsA patients exhibit poor response.Given the complexity and heterogeneity of signalling pathways resulting in synovio-entheseal disease in PsA; new treatment strategies must be evaluated to induce deep and sustainable clinical responses in all the phenotypic domains.In patients who do not achieve remission in all disease aspects on biologic monotherapy or combination of a biologic therapy with an oral synthetic agent; dual targeted anti-cytokines strategies or combined biologic with a targeted oral small molecule are a possible treatment option.Description/MethodA 40-year-old attended our rheumatology department in 2010 with peripheral synovitis, dactylitis and scalp psoriasis. A clinical diagnosis of PsA was made and she was commenced on combination methotrexate and sulphasalazine.In 2011, therapy was escalated to include etanercept and methotrexate due to persistent active disease clinically and on nuclear medicine bone scan.Between 2011 to 2015, sequential bDMARD switches including certolizumab, infliximab and adalimumab, failed to put the disease in remission.Due to loss of effect, adalimumab was switched to secukinumab in early 2016. A few months later, while on secukinumab, she developed new onset Crohn’s disease and required treatment change to ustekinumab.In August 2018 following a prolonged flare, ustekinumab was stopped and tofacitinib was started. The disease went in LDA until September 2020 when hospital admission for a severe PsA flare was required. She had dactylitis of 3 digits, a left temporomandibular joint effusion on ultrasound and elevated acute phase reactants. A treatment change to abatacept resulted in primary failure and abatacept was replaced with baricitinib.In March 2021, she attended clinic with new nail changes, dactylitis of 3 digits and a large left knee effusion. She underwent a diagnostic arthroscopy of the left knee and wash-out in May 2021 which showed a macroscopic synovitis score and vascularity score of 100% respectively. Synovial histology showed evidence of chronic synovitis with abundant plasma cells.Following the arthroscopy and careful discussion, it was decided to initiate combination therapy with adalimumab biosimilar and tofacitinib in June 2021. The patient was assessed at 2 months following starting combination therapy and a dramatic clinical and biochemical was noted. CRP had improved from 139.9mg/L to 6.3mg/L. She was mobilising without an aid for the first time in years. Both her psoriasis and Crohn’s disease were also well controlled.Discussion/ResultsWhile the outcomes of patients with psoriasis have dramatically improved with monoclonal antibody therapies targeting IL-23 and IL-17A; achieving a measurable low disease activity state such as minimal disease activity (MDA) for musculoskeletal manifestations of psoriatic disease is infrequent. Due to the heterogeneity of disease in PsA, multiple cellular pathways are involved in the pathogenesis resulting in recalcitrant disease in a subgroup of patients. These patients, like our case, exhibit poor response to the current therapeutic paradigm in PsA.In such patients, treating one disease domain, one type of cell or a single pathway at a time is unlikely to result in meaningful disease control and remission may be unachievable thus subjecting patients to sustained joint inflammation and damage seen in PsA. Very little data exist regarding the safety of dual immunomodulator therapies for concomitant psoriasis and psoriatic arthritis. Safety concerns such as infectious risks are important considerations with such strategies; however, the targeted second-generation anti-cytokine biologics and targeted JAK-I have exhibited improved safety profiles with regards to infections.In this case, following careful discussion with our patient, she felt that the prospect of possible reduction in her musculoskeletal symptoms outweighed the potential safety concerns.Multiple cases are reported in the literature regarding the use combined biologic strategies in psoriatic disease; the most common combination reported being anti-TNF therapy and ustekinumab with varying degrees of response. Prospective, high-quality studies are needed to identify safe and efficacious dual strategies in PsA to pinpoint dosages, sequence and frequency of therapies.Key learning points/ConclusionThis case truly highlights the heterogeneity and complexity that accompanies psoriatic disease and as such, modulating a single pathway may not be sufficient to address all the phenotypic domains (skin, synovium, entheses, and axial).While physicians are often, understandably, hesitant to prescribe combined immunomodulatory therapies due to concerns regarding potential complications, such strategies should be considered in debilitating cases of psoriatic disease who fail to respond to conventional treatment as they have the potential to foster deep and long-lasting remission.Our case highlights that a patient-centred approach with patient involvement in clinical decisions regarding their disease is required. With such strategies, patients and clinicians, both, should balance the potential associated risks particularly infectious risk.Further studies are required to better determine the efficacy and safety profile of combined immunomodulatory therapies in psoriatic disease.

Assessment of Patient and Staff Annual Effective Doses at a Nuclear Medicine Department during Bone Scans

The current research aims to assess the staff and patients’ effective doses during Nuclear medicine (NM) bone scans procedures. The administered activity was utilized to quantify the patients’ effective doses, while personnel’s effective doses were quantified using thermoluminescent detectors (TLD-100). The average administered activity was 650 (440 to 1440) MBq procedures using SPECT gamma camera system. The average annual staff effective dose (mSv) was estimated to be 2.3 (0.1 to 4.9). The typical patient’s effective dose was 4.9 (3.6 to 6.0) mSv per procedure. Staff exposure within the yearly effective dose limits. Patients’ exposure optimization is required based on patient weight. Estimating staff eye lens doses is suggested to confirm that the yearly effective radiation doses are within the safety range.

MP11-18 THE CONCORDANCE BETWEEN CONVENTIONAL COMPUTED TOMOGRAPHY AND NUCLEAR MEDICINE BONE SCINTIGRAPHY IN THE IDENTIFICATION OF PROSTATE CANCER METASTASES TO BONE

You have accessJournal of UrologyProstate Cancer: Staging (MP11)1 Sep 2021MP11-18 THE CONCORDANCE BETWEEN CONVENTIONAL COMPUTED TOMOGRAPHY AND NUCLEAR MEDICINE BONE SCINTIGRAPHY IN THE IDENTIFICATION OF PROSTATE CANCER METASTASES TO BONE Corey Weinstein, Benjamin Seiden, So Yeon Pak, Nikhil Karsala, Thy Vo, Natalie Sun, Yonatan Akivis, Akya Myrie, Jack Barnett, Sarah Shidid, Ashanda Esdaille, and Llewellyn Hyacinthe Corey WeinsteinCorey Weinstein More articles by this author , Benjamin SeidenBenjamin Seiden More articles by this author , So Yeon PakSo Yeon Pak More articles by this author , Nikhil KarsalaNikhil Karsala More articles by this author , Thy VoThy Vo More articles by this author , Natalie SunNatalie Sun More articles by this author , Yonatan AkivisYonatan Akivis More articles by this author , Akya MyrieAkya Myrie More articles by this author , Jack BarnettJack Barnett More articles by this author , Sarah ShididSarah Shidid More articles by this author , Ashanda EsdailleAshanda Esdaille More articles by this author , and Llewellyn HyacintheLlewellyn Hyacinthe More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001984.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The AUA/ASTRO/SUO 2017 Guidelines recommend the use of cross sectional imaging (CT or MRI) and Nuclear Medicine Bone Scan(NMBS) for staging high-risk localized prostate cancer (PCa). Studies have compared PET/CT with NMBS in identifying Osseous Metastasis (OM) in PCa, but data on the use of CT for this purpose is limited. We compared detection rates of OM between CT and NMBS in men receiving initial staging scans for PCa. METHODS: Patients who underwent NMBS and CT as part of the initial imaging workup for metastatic PCa at Kings County Hospital and Downstate Medical Center from 2014-2019 were identified through retrospective chart review. Exclusion criteria were patients with PCa and additional malignancy, undergoing imaging for recurrence, dual scans done ≥3 months apart, and those on androgen deprivation therapy. Presence of OM was determined by radiologic interpretation reports and confirmed with bone biopsy or clinical follow up. Cohen’s kappa(κ) was used to assess concordance. Sensitivity, specificity, positive and negative predictive values(PPV and NPV) were calculated. All analysis was conducted using IBM SPSS Statistic 27. RESULTS: 141 male patients with dual scans were included in this study. Table one shows patient characteristics. 123(87.2%) of our patients had concordant imaging results (κ=0.704). 18 (12.8%) had discordant findings. When stratified by concordant pairs, both CT and NMBS accurately diagnosed 88/92(95.7%) and 31/31(100%) non-metastatic and metastatic cases, respectively. Amongst the entire cohort, CT accurately diagnosed 97/104(93.3%) and 32/37(86.5%) non-metastatic and metastatic cases, respectively. NMBS accurately diagnosed 91/104(87.5%) and 36/37(97.3%) non-metastatic and metastatic cases, respectively. A NPV of 95.1% and a PPV of 91.9% were calculated for CT. CONCLUSIONS: Our study shows high concordance, good inter-rater reliability (κ=0.704), and comparable specificity and sensitivity between CT and NMBS in detecting OM in PCa. Potential benefits of CT as a singular staging tool for PCa also include soft tissue retroperitoneal staging, serendipitous detection of abdominal/pelvic pathology, reduced healthcare costs secondary to clinically redundant evaluations. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e186-e186 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Corey Weinstein More articles by this author Benjamin Seiden More articles by this author So Yeon Pak More articles by this author Nikhil Karsala More articles by this author Thy Vo More articles by this author Natalie Sun More articles by this author Yonatan Akivis More articles by this author Akya Myrie More articles by this author Jack Barnett More articles by this author Sarah Shidid More articles by this author Ashanda Esdaille More articles by this author Llewellyn Hyacinthe More articles by this author Expand All Advertisement Loading ...

Transthyretin cardiac amyloidosis: a review of the nuclear imaging findings with emphasis on the radiotracers mechanisms.

Cardiac amyloidosis is a protein deposition disease characterized by the infiltration of the myocardium and coronary arteries resulting in a progressive thickening of both ventricles, interatrial septum and atrioventricular valves, eventually leading to organ failure. It is a disease hard to diagnose, due to the lack of diagnostic investigations. However, development of new and more accurate examinations is undergoing. Endomyocardial biopsy is the gold standard investigation for this disease, but it has its limitations (invasive and not widely available). Other investigations may be able to detect the presence of cardiac amyloidosis but cannot specify the type involved. To that end, nuclear medicine through bone scanning offers a simple, non-invasive solution to detect, differentiate and diagnose transthyretin cardiac amyloidosis (ATTR) from other types of cardiac amyloidosis. In order to demonstrate the importance of bone scanning we will present a few methods of image processing based on literature and a personalized method, followed by a few important examples of positive cases. The aim of this review was to present the current methods of ATTR detection with emphasis on nuclear medicine bone scanning and its important place in the decision algorithm of the cardiologist for a personalized approach to this pathology.

Additional Magnetic Resonance or Nuclear Scintigraphy Imaging Influences Approach to Vertebral Augmentation: A Single Institution Experience.

Retrospective review. To ascertain impact of preprocedural magnetic resonance imaging (MRI) or nuclear medicine Tc99m-DMP scintigraphy on the treatment plan when compared with plain films and/or computed tomography prior to vertebral augmentation procedures. Over 1 million vertebral compression fractures (VCFs) occur in the United States annually with over 150,000 individuals hospitalized each year. Physical examination and history are essential to the workup of VCFs, but imaging remains necessary for confirming the diagnosis. VCFs can be imaged with various modalities and there is limited data on the comparative effectiveness of different imaging modalities. Six hundred fifty consecutive patients treated with vertebral augmentation at a single institution between May of 2013 and April of 2018 were reviewed. Preprocedure imaging of the spine obtained within 30 days prior to the procedure were reviewed. Preprocedure imaging results were cross-referenced against the levels treated by vertebral augmentation to determine whether there was a change in the levels treated after receiving an MRI or NM imaging study. Three hundred sixty-three patients had adequate imaging for inclusion. One hundred fifty-four of these 363 patients (42.4%) had an alteration of their treatment plan based upon the MR or NM imaging. Fewer vertebral levels were treated in 33, different levels were treated in 41, and more levels were treated in 80 patients. MRI or nuclear medicine bone scan imaging prior to vertebral augmentation altered the location and number of levels treated in a large percentage of patients, adding specificity to treatment over findings on radiographs or computed tomography alone. 3.

Five-year trends of bone scan and prostate-specific membrane antigen positron emission tomography utilization in prostate cancer: A retrospective review in a private centre.

In the last 5years, there has been a significant focus on the use of positron emission tomography (PET) for primary and secondary staging of prostate cancer. In this study, we aim to describe the trends of use between Gallium-68 prostate-specific membrane antigen ligand (Ga-68 PSMA) PET/computed tomography (PSMA PET/CT) and nuclear medicine bone scan (NMBS) for prostate cancer staging in the first institution in Australia to offer both modalities. We evaluated trends in prostate cancer staging/restaging imaging modalities at our facility between the time period January 2013-April 2018. Imaging logs were filtered to identify NMBS and PSMA PET/CT scans done within the time period for prostate cancer. Sub-analysis was undertaken (i) to investigate the number of patients who were imaged using both modalities, (ii) to compare the age of the patients in the NMBS group and the PSMA PET/CT group and (iii) to compare the use of PSMA PET/CT for pre-treatment staging compared to the detection of recurrence or metastatic disease (secondary staging). A total of 3144 examinations were performed in the time period reviewed, with 546 NMBS and 2598 PSMA PET/CT scans performed. In the 6months after PSMA PET/CT was introduced, there was a 45.7% decrease in the number of NMBS performed and 95.3% decrease across the duration of the study. In the PSMA PET/CT cohort, 1569 examinations were performed for pre-treatment staging and 1029 performed for secondary staging. There was a significant difference in the proportion of PSMA PET/CT conducted for pre-treatment staging compared with secondary staging when comparing the first and final 500 examinations (P<0.05). After the introduction of PSMA PET/CT there was a marked decline in the use of NMBS for prostate cancer staging. This finding is of note as it occurred before there was clinical data or guidelines supporting the use of PSMA PET/CT for prostate cancer imaging.

Abstract No. 57 - How often does advanced imaging change management prior to vertebral augmentation? A retrospective review of 292 cases

To examine the frequency with which a pre-procedural MRI or nuclear medicine bone scan alters the treatment plan when compared with plain films and/or CT prior to vertebral augmentation procedures. We retrospectively reviewed 292 vertebral augmentations (kyphoplasty or vertebroplasty) performed at a single hospital between May of 2013 and August of 2016. Preprocedure imaging of the spine obtained within the 30 days prior to the procedure (x-rays, CT, nuclear medicine bone scan, or MRI) was reviewed for each patient encounter. Pre-procedure imaging results were cross-referenced against the levels treated by vertebral augmentation to determine whether there was a change in the levels treated after receiving an advanced imaging study such as MRI or bone scan in addition to initial x-rays and/or CT. Patients were subdivided into 2 categories according to the combination of pre-procedure imaging received: Those who received x-rays and/or CT along with MRI and/or bone scan, and those who received only one category or the other. Of the 292 vertebral augmentations performed, 205 patients (69.9%) had a CT and/or x-ray of the affected spine followed by a more advanced study such as an MRI or bone scan to evaluate for acuity of fractures prior to their vertebral augmentation procedure. In patients that had both categories of studies, findings on MRI or bone scan changed the levels treated in 53.2% of the cases (109 out of 205 cases). MRI and/or bone scan findings correlated with x-ray and/or CT findings in only 46.8% of cases. MRI or nuclear medicine bone scan imaging prior to vertebral augmentation alters the location and number of levels treated in a large percentage of patients treated with vertebral augmentation, adding specificity to treatment over findings on plain film or CT alone. Therefore, patients who do not receive more advanced imaging to assess for the acuity of fractures may be incompletely treated, or treated unnecessarily.

Presumptive Late-Onset Ankylosing Spondylitis Simulating Osteoblastic Skeletal Metastasis in a Patient With a History of Prostate Carcinoma: A Diagnostic Challenge

ObjectiveThe purpose of this report is to present a presumptive case of ankylosing spondylitis with late stage progression that simulated osteoblastic metastasis in a patient with a history of prostate carcinoma. Clinical FeaturesA 67-year-old white man presented to a chiropractic clinic complaining of severe and worsening acute low back pain and right foot “numbness.” Further questioning also revealed a history of prostate carcinoma. Intervention and OutcomeImaging examination revealed a sclerotic pedicle and increased uptake of radiopharmaceutical on a nuclear medicine bone scan highly suggestive of osteoblastic skeletal metastasis. Further evaluation, however, revealed that the bone sclerosis was not the result of skeletal metastasis, but more consistent with a seronegative spondyloarthritis such as ankylosing spondylitis. ConclusionThis report describes a presumptive case of ankylosing spondylitis simulating skeletal metastasis in a patient with a past medical history of prostate cancer. This atypical presentation illustrates the inherent uncertainty of diagnosis and how that uncertainty can be challenging in clinical practice. It also reinforces that it is critical for healthcare providers to consider a wide spectrum of differential diagnoses to avoid misdiagnoses and inappropriate interventions.

Effect of prostate-specific membrane antigen positron emission tomography on the decision-making of radiation oncologists.

BackgroundPositron emission tomography (PET) imaging is routinely used in many cancer types, although is not yet a standard modality for prostate carcinoma. Prostate-specific membrane antigen (PSMA) PET is a promising new modality for staging prostate cancer, with recent studies showing potential advantages over traditional computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine bone scan imaging. However, the impact of PSMA PET on the decision-making of radiation oncologists and outcomes after radiotherapy is yet to be determined. Our aim was to determine the impact of PSMA PET on a radiation oncologist’s clinical practice.FindingsPatients in a radiation oncology clinic who underwent PSMA PET were prospectively recorded in an electronic oncology record. Patient demographics, outcomes of imaging, and impact on decision-making were evaluated.Fifty-four patients underwent PSMA PET between January and May 2015. The major reasons for undergoing PET included staging before definitive (14.8 %) or post-prostatectomy (33.3 %) radiotherapy, and investigation of PSA failures following definitive (16.7 %) or post-prostatectomy (33.3 %) radiotherapy. In 46.3 % of patients PSMA was positive after negative traditional imaging, in 9.3 % PSMA was positive after equivocal imaging, and in 13.0 % PSMA was negative after equivocal imaging. PSMA PET changed radiotherapy management in 46.3 % of cases, and hormone therapy in 33.3 % of patients, with an overall change in decision-making in 53.7 % of patients.ConclusionsPSMA PET has the potential to significantly alter the decision-making of radiation oncologists, and may become a valuable imaging tool in the future.

2:12 PM, Abstract No. 35 - Percutaneous vertebroplasty versus kyphoplasty: does managed care–directed therapy influence patient outcomes and costs?

The two most common methods for treating symptomatic vertebral body compression fractures are percutaneous vertebroplasty (PV) and kyphoplasty (KP). Controversy exists as to the optimal treatment method. However, there is no controversy as to the disparity with higher costs of KP over PV. Previous reports have failed to demonstrate efficacy of PV. This has lead to one major regional health insurance provider in our area to deny reimbursement for PV while continuing to approve KP. Here we review our experiences with PV and KP since the mandated implementation of KP by the insurance provider. Patients who presented with symptomatic compression fractures and MRI or spinal CT and nuclear medicine bone scan evidence of acute/subacute spinal compression fracture underwent percutaneous spinal interventions at our institution from December 1, 2012, through July 31, 2014, and were included in this retrospective analysis. KP was perfromed on some patients as required by their insurance provider. Baseline demographics, type of intervention, level treated, complications, outcomes, and repeat interventions were systematically reviewed. During the study time period, 120 [93(78%) VP and 27(22%) KP] patients underwent 198 [155(78%) VP and 43(22%) KP] procedures. There were no differences in baseline characteristics. Outcomes were similar in each group with no reported major adverse events. VAS pain scale was not statistically different between the two groups [pre 8.8 and 9.0 in KP and VP (p=0.7); post 4.7 and 4.3 in KP and VP (p=0.4)]. Longer rates of fluoroscopy time associated with KP was statistically significant [6.5 and 4.7 min in KP vs VP (P <0.001)]. Average Medicare reimbursement for a surgical center performing thoracic vertebroplasty in our area was approximately $2,100, while thoracic kyphoplasty was approximately $6,900. Although outcomes are similar between percutaneous vertebroplasty and kyphoplasty, kyphoplasty is associated with significantly higher rates of radiation exposure and drastically higher healthcare costs.

2:21 PM Abstract No. 36 - Clinical and imaging evaluation of targeted radiofrequency ablation (t-RFA) prior to cement augmentation of malignant spine lesions

Purpose: The two most common methods for treating symptomatic vertebral body compression fractures are percutaneous vertebroplasty (PV) and kyphoplasty (KP). Controversy exists as to the optimal treatment method. However, there is no controversy as to the disparity with higher costs of KP over PV. Previous reports have failed to demonstrate efficacy of PV. This has lead to one major regional health insurance provider in our area to deny reimbursement for PV while continuing to approve KP. Here we review our experiences with PV and KP since the mandated implementation of KP by the insurance provider. Materials and Methods: Patients who presented with symptomatic compression fractures and MRI or spinal CT and nuclear medicine bone scan evidence of acute/subacute spinal compression fracture underwent percutaneous spinal interventions at our institution from December 1, 2012, through July 31, 2014, and were included in this retrospective analysis. KP was perfromed on some patients as required by their insurance provider. Baseline demographics, type of intervention, level treated, complications, outcomes, and repeat interventions were systematically reviewed. Results: During the study time period, 120 [93(78%) VP and 27 (22%) KP] patients underwent 198 [155(78%) VP and 43(22%) KP] procedures. There were no differences in baseline characteristics. Outcomes were similar in each group with no reported major adverse events. VAS pain scale was not statistically different between the two groups [pre 8.8 and 9.0 in KP and VP (p1⁄40.7); post 4.7 and 4.3 in KP and VP (p1⁄40.4)]. Longer rates of fluoroscopy time associated with KP was statistically significant [6.5 and 4.7 min in KP vs VP (P o0.001)]. Average Medicare reimbursement for a surgical center performing thoracic vertebroplasty in our area was approximately $2,100, while thoracic kyphoplasty was approximately $6,900. Conclusion: Although outcomes are similar between percutaneous vertebroplasty and kyphoplasty, kyphoplasty is associated with significantly higher rates of radiation exposure and drastically higher healthcare costs.

Metastatic Hepatocellular Carcinoma Presenting as Bulky Lymphadenopathy Mimicking Lymphoma

Introduction: A 66-year-old Hispanic man with hepatitis C (HCV) cirrhosis presented to the emergency department with complaints of several weeks of epigastric/left upper quadrant abdominal pain, night sweats, and an 18-lb weight loss. Physical examination revealed no jaundice, no palpable lymphadenopathy, nor cutaneous stigmata of chronic liver disease. On abdominal examination, there was evidence of tender hepatomegaly with a fullness in the epigastrium and right upper quadrant. A CT scan revealed cirrhotic liver morphology with a 4-cm arterially-enhancing mass in segment 2 of the left hepatic lobe with delayed-phase washout, suspicious for a hepatocellular carcinoma (HCC). In addition, there was a confluent nodular mass in the gastrohepatic space measuring 6.5 x 5 cm with encasement of the celiac trunk, its branches, the portal venous confluence, and splenic vessels. A similar mass was seen in the retroperitoneum with encasement of the renal vessels. Mild ascites was noted with no evidence of portal vein thrombosis. Percutaneous biopsy of the hepatic mass revealed a moderately differentiated HCC. The patient’s alpha-fetoprotein (AFP) was 9.3. A CT scan of the chest and a nuclear medicine bone scan were negative for distant metastases. Due to the CT findings of bulky lymphadenopathy and associated “B symptoms” the patient underwent an endoscopic ultrasound (EUS) to rule out a concomitant lymphoma. The EUS confirmed the presence of widespread malignant-appearing abdominal adeopathy. Fine needle aspiration demonstrated carcinoma that was morphologically identical to the liver pathology, thus confirming a locally advanced metastatic HCC. There was no evidence of lymphoma on flow cytometry. The patient has since been treated with a combination of loco-regional transarterial chemoembolization of the primary hepatic HCC lesion and systemic sorafenib. Given his advanced disease, he was not deemed a suitable liver transplant candidate. Although lymph node metastases may be seen in HCC, the size and isolated extent of abdominal lymphadenopathy seen in this case were distinctly unusual and the presentation mimicked that of a lymphoma.

13. Septic Sacroilitis Mimicking an Inflammatory Spondyloarthropathy

Background: Post-partum back pain may herald the onset of an inflammatory arthritis or SpA. However, rarely a similar picture is seen with infection. Given that the treatment is immunosuppression vs antibiotics, correct diagnosis is extremely important. Methods: We present a lady with post-partum lower back pain and clinical and radiological features consistent with sacroiliitis who was found to have a multifocal septic arthritis. Results: A 40 year old woman presented 4 weeks post-partum with left hip and lower back pain. She had a healthy baby through a normal delivery after being induced at 40 weeks but had required an episiotomy. Approximately 12 h after delivery she developed left hip and lower back pain spreading to her left shoulder, wrist and hands with reduced range of movement. She then developed pain in her right shoulder, chest pain at the costochondral junctions and pain and swelling of her right knee. She reported ongoing vaginal bleeding since the birth of her child. Examination revealed a subtle swelling around the right sternoclavicular joint and second costochondral junction. Her lumbar spine was tender on movement and stressing her right sacroiliac joint provoked pain. Blood tests showed CRP 83, ESR >120, haemoglobin of 7.4, MCV 88, white cell count 5.6, neutrophils 4.4, lymphocytes 0.7 and platelets 283. MRI showed abnormal fluid signal within the right sternoclavicular joint space extending into the surrounding tissues, particularly the interclavicular recess and suprasternal notch and sub-chondral bony oedema. A large amount of abnormal fluid was present in the left sacroiliac joint extending into the surrounding tissues with pockets of fluid or pus within the paravertebral and left iliacus muscles and extensive bony oedema. A nuclear medicine bone scan showed marked uptake at the left sacroiliac joint and the right sternoclavicular joint. Synovial biopsies of her left sacroiliac and right sternoclavicular joints identified a fully sensitive Group B streptococcus. Due to penicillin allergy she was treated with i.v. ceftriaxone for 3 weeks, followed by 6 weeks of oral clindamycin. She had a good clinical response with resolution of the polyarthritis, back pain and inflammatory markers. ERPC showed retained products of conception that were evacuated. An MRI 6 months later showed a significant improvement of the inflammation previously seen. An echocardiogram was performed which excluded endocarditis. Conclusion: Recently there has been an increase in both the rates of adult native joint septic arthritis and Group B streptococcal disease in non-pregnant adults. Classically an acute monoarthritis, septic arthritis can present as oligoarthritis, or indeed sacroiliitis. Our patient’s multifocal Group B streptococcal septic arthritis was likely due to the retained products of conception as pre-natal screening had been negative. We highlight the importance of identifying such uncommon presentations in order to ensure correct treatment. Disclosure statement: The authors have declared no conflicts of interest.

The Paradox of Prevention—Bilateral Atypical Subtrochanteric Fractures due to Bisphosphonates in Osteogenesis Imperfecta

A 64-year-old woman with osteogenesis imperfecta type 4 was commenced on iv bisphosphonates after a low-trauma fracture of her ankle. After having received pamidronate for 3 years and zoledronic acid for 2 years, she complained of a 10-month history of right lateral thigh and groin pain. She was able to bear weight with only minimal discomfort, and there was no limitation of movement. Plain radiographs demonstrated an incomplete subtrochanteric fracture of the lateral cortex of the right femur (Figure 1A) and a similar finding at the mid-diaphysis on the left (Figure 1B). Nuclear medicine bone scanning with single photon emission computed tomography (CT) combined with CT revealed intense uptake in the regions corresponding to those identified on the plain x-rays (Figure 1, C and D). Further bisphosphonate treatment was withheld. Teriparatide, a bone anabolic agent, was commenced to promote fracture healing. Osteogenesis imperfecta is typically associated with frequent fractures in childhood and adolescence, but, with age-associated decline in bone density, patients may enter a second period of heightened fracture risk. Our patient had a genetic predisposition to fractures and was treated with bisphosphonates to ameliorate fracture risk (1, 2). Paradoxically, in this case, such treatment is linked to the evolution of bilateral incomplete subtrochanteric fractures (3, 4). Even in patients with unequivocally increased fracture risk (such as in osteogenesis imperfecta), close clinical scrutiny and follow-up are required when using iv bisphosphonates to provide individualized treatment. Careful and sequential reassessments of risks and benefits must be made when managing all patients with bisphosphonates.