Basic knowledge about Nuclear medicine and Bone scan for first year radiology residents.

2. Prepared by:
DR.WASEEM AYUB
RESIDENT RADIOLOGY

3. INTRODUCTION TO NUCLEAR
MEDICINE
• Nuclear medicine investigations differ from
most other imaging modalities in that
diagnostic tests primarily show the
physiological function of the system being
investigated as opposed to traditional
anatomical imaging such as CT or MRI.

4. • Nuclear medicine imaging studies are
generally more organ or tissue specific (e.g.:
lungs scan, heart scan, bone scan, brain
scan, etc.) than those in conventional
radiology imaging, which focus on a
particular section of the body (e.g.: chest X-
ray, abdomen/pelvis CT scan, head CT scan,
etc.)

5. • In addition, there are nuclear medicine
studies that allow imaging of the whole
body based on certain cellular receptors or
functions.

6. Examples are
• Bone scan
• Renal scan (DTPA, DMSA)
• Thyroid scan
• Lung scan (V/Q scan)
• Whole body PET scan or PET/CT scans
• Gallium scans,
• Indium white blood cell scans,
• MIBG and octreotide scans etc

7. Gamma camera dual headed

8. • INTRODUCTION:
A technique used in nuclear medicine in which
bone specific agents (phosphonates) are injected
intravenously and followed with the help of
gamma camera to detect their
metabolism(functional imaging) which alters with
the diseased states of bone.
Methylene diphosphonate (MDP) and
hydroxymethylene diphosphonate (HMDP) are
the most commonly used agents; both agents
resist in vivo hydrolysis by alkaline phosphatase.

9. INDICATIONS
• Detection of metastases
• Staging of malignancies
• Detection of osteomyelitis
• Detection of radiographically occult fractures
• Determine multiplicity of lesions
(e.g., fibrous dysplasia, Paget disease)
• Diagnosis of reflex sympathetic dystrophy

10. TECHNIQUE
1. Inject 740 MBq 99m Techentium Methylene Di
Phosphonate Intravenously.
2. Take image 2 to 4 hours later.
3. May have to wait longer before imaging patients with
renal insufficiency to allow for soft tissue clearance
4. Have patient urinate immediately before imaging to
decrease bladder activity.
5. Two image acquisition formats:
• Whole-body single pass (lower resolution)
• Spot views (longer time of acquisition, better resolution)

11. AREAS OF NORMAL UPTAKE
Adults
• Locally increased activity may be a normal variant:
• Patchy uptake in the skull may be normal.
• Common location for degenerative changes (usually at both
sides of a joint)
• Sternoclavicular joint, manubriosternal joint
• Lower cervical and lumbar spine (usually at concavity of
scoliosis)
• Knees, ankles,wrists,1st carpometacarpal joint,Tendon
insertions Regions of constant stress Geometric overlap of
bones (ribs)
• Normal,secondary uptake of the label: Nasopharynx ,
Kidneys, Soft tissues

13. Anterior (left) and posterior (right)
whole-body bone scintigrams obtained
in an adult
Findings
Normal symmetric uptake in both
shoulders,sternoclavicular joints,
areas of overlapping of bones
such as ribs and iliac blades,
nasopharynx, kidneys and urinary
bladder

14. Older patients
• The older the patient, the
higher the proportion of
poor quality scans.

15. Children
• Intensive accumulation in growth
plates
Findings:
Normal child showing uptake in
growth plates

17. NOTE:
Findings that are always abnormal:
• Strikingly asymmetrical changes
• Very hot spots
Findings
Extensive osseous metastases from
lung carcinoma. Anterior (left) and
posterior (right) whole-body bone
scintigrams show multiple, randomly
distributed foci of abnormal radiotracer
uptake. The foci vary in size and
intensity.

19. OSTEOMYELITIS
DEFINITION:
Osteomyelitis is simply infection involving bone.
An invading organism may attack bone by direct
invasion from an infected wound, or from an
infected joint, or it may gain access by
haematogenous spread from distant foci, usually
in the skin. Haematogenous osteomyelitis
usually occurs during the period of growth, but
all ages may be affected and cases are even
found in old age.

20. Osteomyelitis is commonly evaluated with a 3-phase
bone scan:
Flow (“flow images”),
Immediate static (“blood pool image”), and
Delayed static images (metabolic image).
Increased activity on flow images suggests hyperemia,
often present in inflammation and stress fractures.

21. Pearls
• Bone scan allows detection of
osteomyelitis much earlier (24 to 72 hours
after onset) than plain radiographs (7 to 14
days).
• Bone scan is sensitive but nonspecific for
osteomyelitis.

22. OSTEOMYELITIS (CONTD)

23. PERFUSION
OSTEOMYELITIS (CONTD)

24. BLOOD POOL
OSTEOMYELITIS (CONTD)

25. If first and 2nd phases are positive (hyperemia)
with normal third phase, diagnosis would be
cellulitis.
In acute osteomyelitis all 3-phases are positive
(hyperemia and osteoblastic process in the bone).
OSTEOMYELITIS (CONTD)

26. DELAYED
OSTEOMYELITIS (CONTD)
FINDINGS:
INCREASED UPTAKE IN ALL THREE PHASES
SUGGESTIVE OF OSTEOMYELITIS

27. Osteomyelitis. Dynamic (left), blood pool (center), and bone (right)
images from a three-phase bone scan demonstrate focal
hyperperfusion, focal hyperemia, and foci of increased bone uptake,
respectively, in the right great toe.

30. CASE 1
EXPLAIN THE FINDINGS???

31. FINDINGS
Bone metastases from gastric carcinoma.
Anterior (left) and posterior (right) whole-
body scintigrams show diffuse, irregularly
increased activity throughout the
appendicular and axial skeleton. There is
minimal soft-tissue activity and virtually no
renal or bladder activity. This pattern is
indicative of diffuse bone metastases and
is often referred to as a
superscan.

32. CASE 2
EXPLAIN THE FINDINGS???

33. FINDINGS
Renal osteodystrophy and secondary
hyperparathyroidism. Anterior (left) and
posterior (right) whole-body scintigrams
demonstrate uniformly increased activity
throughout the skeleton that is especially
intense in the calvaria. These images
show the superscan pattern associated
with
metabolic bone
disease

34. CASE 3
FOLLOW UP SCANS WITH 3 MONTHS INTERVAL
SHOWING DISEASES PROGRESSION OR
REGRESSION?????

36. Bone metastasis from breast carcinoma. Scintigram from the initial bone study (left)
demonstrates numerous foci of increased activity. On a scintigram obtained 3 months
later (center), the abnormalities are more intense, and new abnormalities have become
evident. On a third scintigram obtained yet 3 months later (right), many lesions have
resolved, and those that remain have decreased in intensity. No new abnormalities have
appeared. The changes present on the second study (center) reflect a response to
treatment and the flare phenomenon, not disease progression.

37. CASE 4
An 83-year-old patient who complained
of left hip pain after a fall.

38. An 83-year-old patient who complained
of left hip pain after a fall.
(a) Radiograph demonstrates no fracture.

39. (b) Anterior (left) and posterior (right) radionuclide bone scans demonstrate
foci of increased activity in the left femoral neck, a finding that is consistent
with trauma.

40. Fracture of the femur in (c) Computed tomographic (CT) scan helps confirm the presence
of a left femoral neck fracture (arrow).

41. CASE 5
COMMENT ON
UPTAKE PATTERN IN
LOWER LUMBAR
VERTEBRAE.
????METASTASIS OR
NOT

42. FINDINGS
Posterior planar scintigram
shows bilateral foci of
increased activity in a lower
lumbar vertebra. tomograms
help confirm that this increased
activity is confined to the
posterior elements, sparing the
pedicles, and therefore does
not represent metastatic
disease.

43. CASE 6
WHERE IS
ABNORMALITY OR
METASTASIS???

44. Scintigram shows a
bone metastasis in a
lower lumbar
vertebra (arrow) as
an area of decreased
rather than increased
activity.

45. CASE 7: FINDINGS AND DIAGNOSIS????

46. Plantar fasciitis. Radionuclide scans demonstrate foci of
increased activity on the plantar surface of the right calcaneus
(arrow), where the plantar fascia attaches to the calcaneal
tuberosity.

47. CASE 8
FINDINGS AND DIAGNOSIS???
SPOT DIAGNOSIS

48. Paget disease. Whole-body
scintigram demonstrates increased
radiotracer accumulation in the
proximal right femur and in the
deformed and enlarged tibias.

49. CASE 9
FINDINGS AND
DIAGNOSIS???
STRAIGHT FORWARD!!!

50. Anterior (left) and posterior
(right) whole-body
scintigrams obtained in a
patient who fell
demonstrate multiple foci
of increased radiotracer
uptake. The linearly
distributed rib foci and H-
shaped sacral activity
indicate trauma as the
cause of these foci. The
increased activity in the
right proximal humerus is
due to a fracture.

51. LAST CASE
FINDINGS AND
DIAGNOSIS???
VERY DIFFUCULT!!!

52. Anterior (left) and posterior
(right) whole-body bone
scintigrams obtained in a
child demonstrate
NORMAL
anatomy. Note the increased
activity in the physes of the
long bones and in the
hematopoietically active
facial bones.