Gratitude fo everuthing

1. Bone Scan/ Bone Marrow
SUMAN S
MSc MIT
191142007

2. Content
• Introduction
• Anatomy
• Indications and contraindications
• Patient preparation
• Radio pharmacy
• Equipment's
• Procedure
• Post procedure care
• Artefacts
• Bone Marrow

3. Definition
• A bone scan is a test that detects areas of increased or decreased bone
activity by injecting a certain radiopharmaceutical commonly technetium-
99m–labeled methylene diphosphonate (MDP).

4. Anatomy

5. Indications:
• Oncology
• Orthopedics
• Others

6. Oncology
• Primary Bone tumors
• Skeletal Metastases
• Extension of soft tissue
• Treatment Response Evaluation

7. Orthopedics:
• Trauma
• Fractures
• Infectious bone diseases
• Prosthesis evaluation

8. Others:
• Metabolic bone disease
• Paget’s disease
• Un-explained bone pain

9. Contradictions:
• Pregnancy
• Breastfeeding
• The scanning should not be performed immediately after or during
radiotherapy, chemotherapy, after endoscopic examinations,
operations, or biopsies.
• Patient who recently(24-48 hours) had Tc based nuclear medicine
scan.
• Patient who has recently ingested contrast medium.

10. Patient Preparation:
• Verify doctor’s order & explain the procedure.
• Take proper patient history.
• Patient should remove any attenuating material from ROI.
• Hydrate the patient well and urinate often before imaging.
• Instruct patient to remain motionless for duration of imaging.

11. Equipment
• Camera- Large field of view
• Collimator- Low energy, high resolution, or low energy, all purpose
• Computer setup
Flow
• Static imaging- Extreme 200000-300000 counts
• Whole body sweep- check length of patient, usually -10-14 cm/min
• SPECT- Circular or non circular,360 degrees, 64 stops, 20-25 sec/stop; ROI
centered.

12. Radiopharmacy:
99mTc
• Half life(t1/2) : 6 hrs.
• Energies : 140 keV
Radiopharmaceutical:
• MDP (Methylene diphosphonate)
• HDP or HMDP (Hydroxy methylene diphosphonate)

13. Radiopharmaceutical preparation:
• Tc-99m MDP can be prepared from a simple kit.
• Technetium-99m, in the form of sodium pertechnetate (NaTcO4), is obtained
from a molybdenum-99 generator and injected into a vial containing methylene
diphosphonate, stabilizers, and stannous ion.
• Stannous tin acts as a reducing agent which allows the technetium-99m to form a
chelate bond with the methylene diphosphonate carrier molecule.

14. QUALITY CONTROL:
• No O2 in kit.
• Use within 4 hrs.
DOSE RANGE:
• Adult : 20 – 30 mCi (740 – 1110 MBq)
• Pediatrics : 250–300 µCi/kg (9 – 11 MBq / kg)

15. Method of administration:
• I.V, with saline flush.
• Flow requires good bolus injection.

16. Uptake
• After intravenous injection,Tc-99m MDP rapidly distributes
into the extracellular fluid and is quickly taken up into the
bone.
• Tc-99m MDP accumulates primarily in relation to osteogenic
activity levels
• Activity is much higher in areas of active bone formation
compared with mature bone.
• Approximately 50% of the dose is localized to the bone with
the remainder excreted by the kidneys.

17. • The peak bone uptake occurs approximately 1 hour after injection, highest
target-to-background ratios are seen after 6–12 hours
• This must be balanced with the relatively short 6-hour half-life of Tc-99m
and patient convenience.
• Therefore, images are typically taken 2–4 hours after injection.

18. Procedure:
• Instruct the patient to empty the bladder and check for anything that can cause
artifact and attenuation.
• Remove cardiac monitors from FOV.
• Note location of pacemaker, colostomy bags etc.
• For whole body scan, position patient supine, arms at side , with knee pillow and
foot band.
• The injection site should be chosen to avoid any suspected pathology.

20. • Tc 99m HDP bone scan before rescue
therapy with vitamin D (left) showed
increased uptake of radionuclide
tracer in ribs and left sacroiliac joint.
• After rescue therapy (right), scan
showed no appreciable uptake at any
site

21. Images
Three-phase: Obtain flow and immediate blood pool. Position ROI in
camera view.
• Inject radiotracer; start pictures after slight delay to capture the flow
into ROI (watch for first sign of “blush” in persistence scope. It takes a
little longer for feet or elderly patients).
• Obtain immediate blood pool image after flow (~200,000–500,000
counts).
• For extremities, obtain at least immediate blood pool image of ROI;
also may take images including nearest joint and laterals/medials.

22. • For reflex sympathetic dystrophy (RSD), obtain flow to wrists, then
bilateral statics for hands to shoulders. If hands or wrists need to be
flowed, consider a foot vein injection.
• Obtain statics: 2–4 hours after injection, 24-hour delays (fourth phase)
uncommon but can be requested.
• Limited: ROI same as immediate blood pool.
• Axial: Acquire anterior/posterior, laterals, obliques.

23. • Extremities: Anterior/posterior, proximal and distal joints, legs—add
laterals and medial. If knees are ROI, take laterals and medial with
knees at 90° angle.
• With flow: Obtain images the same as acquired with flow. Be sure to
include ROI, images to closest proximal joint, and laterals/medial
(especially with lower extremities).
• For reflex sympathetic dystrophy, obtain images up to shoulder.
• For carpal tunnel syndrome and all hand and wrist flows, obtain
images up to elbow.

24. Other common static images: Right and left posterior obliques, right and
left anterior obliques, tail on detector (TOD), tail in air (TIA),
laterals/medials, frog leg, plantar, palmar, vertex, etc.
• Whole body statics: 2–4 hours after injection.
• Anterior: Pelvis, femur, knees, tibia/fibula, feet, abdomen, thorax, right
shoulder, left shoulder, head.
• Posterior: Pelvis, abdomen, thorax arms down/arms up to move
scapula, head

25. Whole body sweep, single and dual head cameras: 2–4 hours after
injection. Low energy, high resolution collimator(s). Matrix set for 256
× 1025 × 16 or greater, time set for 20–30 minutes (10–20 cm/min), 24-
hour delays if ordered.
• If anything is visualized that cannot be easily identified or the position
assessed, add static oblique and lateral views, particularly with an
outpatient.

26. Post procedure care:
• Patient should drink water more and should void frequently to reduce
radiation dose to the bladder wall.

27. Artifacts:
• Patient movement or rotation may distort view.
• Imaging began too soon or with patient not hydrating adequately before imaging
may show excessive activity in soft tissue.
• Urine contamination.

28. Hot spots and cold spots

29. Bone Marrow

30. Bone marrow is a dynamic tissue compartment in the
cavity of bones. In adults, haematopoietic cells are
produced by the bone marrow cells in the large bones that
account for 2–5% of an adult’s weight
Non-invasive imaging techniques have been used for
visualization of the functional activity of the bone marrow
compartment.

31. Imaging with radiolabelled compounds may allow
different bone marrow disorders to be distinguished.
These imaging techniques, almost all of which use
radionuclide-labelled tracers, such as:
99mTc-nanocolloid
99mTc-sulphur colloid

32. Indications:
• Evaluation of the degree of radiotherapy effect on bone marrow
• Location of the optimal site for bone marrow biopsy
• Diagnosing and staging of hematological bone marrow disorders
• Detection of bone marrow metastases
• Evaluation of bone marrow transplantation

33. Preparation and precautions
• No tests that use barium for at least 48 hours prior to a bone marrow
scan.
• Patient may eat and drink as usual
• Patient should bring a list of His/her medications
• Patients of childbearing age should review the pregnancy and
breastfeeding guidelines

34. Radiopharmaceutical:
• Tc-99m labelled colloid
• 8 mCi, is given.
Scanning time:
• Imaging takes about 40 minutes and occurs about 60-90
minutes after injection

35. IMAGING TECHNIQUES:
• Bone marrow imaging using radionuclides may be divided into two
categories:
 Imaging the reticuloendothelial system (RES)
 Imaging erythroid compartment

36. RETICULO ENDOTHELIAL SYSTEM (RES)
• The RES can be easily imaged using radiolabeled colloids
• Colloids are small particles that remain suspended in an appropriate
medium.
• After intravenous injection, they are phagocytosed by macrophages
and distributed throughout the body in the RES.

37. Imaging the erythroid bone marrow (‘the red
cells’)
• The erythropoietic part of the bone marrow can be imaged
with the PET tracer 52Fe.
• Iron is incorporated into the hemoglobin of erythrocytes.
• 52Fe is a cyclotron-produced positron-emitting isotope with
a half-life of 8.2 h

38. Reference
• Nuclear Medicine Technology procedures and quick
reference
-By Pete Shackett
• Radionuclide imaging of bone marrow disorders
By Ali Agool & Andor W. J. M. Glaudemans

39. THANK YOU