Bone Scintigraphy
Department of Nuclear Medicine
Dr. Pei-Shan Wu
Radiopharmaceuticals
 Sr-85: high radiation absorbed dose, poor
imaging characteristics, and delayed imaging
time (5~7 da...
Technique
1. Patient preparation and follow-up
 be well hydrated
 void immediately before study
 remove metal objects
2...
Normal bone scan
1. Areas with normally increased activity include:
acromioclavicular joints, sternoclavicular joints,
sca...
Abnormal bone scans
A. Metastatic disease
 Tumors most likely to metastasize to bone include:
breast, lung, prostate, lym...
Abnormal bone scans
B. Primary malignant bone tumors
 Osteogenic sarcoma, chondrosarcoma,
Ewing’s sarcoma
C. Benign prima...
Abnormal bone scans
E. Fracture
1. Traumatic fracture
 positive within 24 hours
 2/3 return to normal by 1 year
 child ...
Abnormal bone scans
2. Stress fractures
 Fatigue fracture: caused by repeated abnormal stress
on normal bone
_fusiform, l...
Abnormal bone scans
F. Metabolic bone disease
1. Osteoporosis: normal or decreased uptake
2. Osteomalacia:
_vitamin D defi...
Abnormal bone scans
4. Hyperparathyroidism
a. Primary: caused by hyperplasia or tumor of
parathyroids
 50~80% normal bone...
Abnormal bone scans
G. Avascular necrosis
 result of: fracture, metabolic disorder, fat
embolization, steroids, hemolytic...
Abnormal bone scans
H. Heterotopic ossification
_associated with paraplegia and quadriplegia
_increased activity in soft t...
Radionuclide inflammation
scan and tumor scan
Department of Nuclear Medicine
Dr. Pei-Shan Wu
Application of Radionuclide Imaging
in Infection
 Radionuclide imaging for detection of infection
–Ga-67 scan
–Tc-99m (V)...
Gallium-67
Cyclotron produced
Half-life: 78 hrs
Biological behavior: similar to ferric ion
Binding to iron-binding mol...
Gallium-67 scan: Mechanism
 Not thoroughly understood
 Ga-67 citrate binds to transferrin in the blood
=> transported to...
Ga-67 scan: Technique
 Dose:
–Inflammation: 3-5 mCi
–Tumor: 5-10 mCi
 Imaging time:
–48-72 hr to 1 week
–Inflammation: 2...
Ga-67 scan: Normal distribution
 Liver: greatest Ga-67 uptake
 Other: Spleen, nasopharynx, lacrimal and
salivary glands,...
Ga-67 scan: image interpretation
Abnormal uptake:
≥ liver or spleen  abscess
= liver  clinical important inflammation...
Ga-67 scan: Advantages
Whole body survey
Sensitive for detection of all
inflammatory process whether or not
they are dis...
Ga-67 scan: Disadvantages
Time delay between injection and imaging
Poor spatial definition of anatomically
discrete lesi...
Tc-99m (V) DMSA scan
 A tumor scan: e.g. medullary carcinoma of
thyroid, soft tissue tumor
 Mechanism:
–unknown
–hypothe...
Tc-99m (V) DMSA scan:
Advantages
Good availability
High resolution
Low price
Low radiation dose
Preparation technique...
Tc-99m (V) DMSA scan:
Disadvantages
GU tract infection
Infection vs tumor
Chronic infection
Further study
Scintigraphic diagnosis of
osteomyelitis
 ESR: Sensitive, but nonspecific
 Blood culture: 40% negative
 X-ray
–First im...
Three-phase bone scan:
Osteomyelitis
 Blood flow study: Imaging at 3-5 sec intervals
throughout the 1st-2nd minutes after...
Ga-67 scan: Osteomyelitis
 Positive:
 within 24-48 hr of symptomatic onset
 Return to baseline quickly following succes...
Neonatal osteomyelitis
Diffuse nature, propensity for
complications, paucity of associated
signs => whole body image
Thr...
Scintigraphic diagnosis of painful
prosthesis
 Three-phase bone scan
–Focally increased uptake: loosening
–Diffuse, unifo...
Infection in immunosuppressed
patients
Diffuse pulmonary uptake
PCP
 CXR: bilateral diffuse infiltrate from hilum to
pe...
Infection in immunosuppressed
patients
CMV
 Low-grade diffuse lung uptake, perihilar
 Maybe with ocular(retinitis), adr...
Infection in immunosuppressed
patients
 Focal pulmonary uptake
 Bacterial pneumonia: a lobar like, without nodal and
par...
AIDS: Radionuclide Studies
Ga-67 scan:
–Infection, Tumor (lymphoma)
Thallium-201 scan:
–tumor (Kaposi’s sarcoma, lymphom...
AIDS: Ga-67 scan and Tl-201 scan
Kaposi’s sarcoma:
–Ga-67: (-), Tl-201: (+)
Infection:
–Ga-67: (+), Tl-201: (-)
Lymphom...
Overview of Tumor Scintigraphy
 Organ-specific tumor
imaging radionuclides
–Cold spot: Thyroid scan,
Liver scan
–Hot spot...
Ga-67 scan
Mechanism of tumor localization
Adequate blood supply
Vascular premeability
Specific tumor-associated trans...
Ga-67 scan – image interpretation
 Salivary gland uptake is noted after C/T or R/T
 Faint symmetrical hilar uptake may b...
Ga-67 scan – tumor detectability
Histology: high grade
Lesion size
Location: superficial > deep
Tumor detection: lymph...
Tl-201 Chloride tumor scan
Thallium-201: a potassium analog
Factors determining tumor cell uptake:
Blood flow
Tumor vi...
Tl-201 Chloride tumor scan
- Clinical application
 Brain tumor
 Correlated with gliomas grade
 Post-op or post-R/T recu...
Tl-201 Chloride tumor scan
- Clinical application
Thyroid cancer
Advantage
 Continue thyroid hormone
 Localized thyroi...
Tc-99m sestamibi
A lipophilic cationic complex
Factors determining tumor cell uptake:
Blood flow
Tumor viability
Tumo...
Tc-99m sestamibi
Localized in liver, kidney, heart and
skeletal muscle
Difficult imaging:
Sub-diaphragmatic tumor  liv...
Tc-99m sestamibi
- Clinical application
 Breast cancer
 Sensitivity 85%, specificity 81%
 Higher in palpable, lower for...
F-18 FDG tumor imaging
 F-18 FDG:
 F-18 FDG enters the metabolic cycle like glucose,
but it is trapped in the tissue in ...
Lymphoscintigraphy
 Clinical applications of lymphoscintigraphy
 Distinguish lymphatic from venous edema,
myxedema, lipe...
Lymphoscintigraphy
Methodology
Radiotracers : colloidal gold(198Au), Tc-
99m labeled tracers (antimony sulfide
colloid, ...
Sentinel lymph node detection and
imaging
 Lymphatic effluent of a tumor drains initially to
one or two lymph nodes befor...
Sentinel lymph node detection and
imaging
 If the sentinel node is negative for tumor, then
other nodes are not likely to...
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Radionuclide imaging in bone, inflammation and oncology 吳佩珊醫師

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Radionuclide imaging in bone, inflammation and oncology 吳佩珊醫師

  1. 1. Bone Scintigraphy Department of Nuclear Medicine Dr. Pei-Shan Wu
  2. 2. Radiopharmaceuticals  Sr-85: high radiation absorbed dose, poor imaging characteristics, and delayed imaging time (5~7 days)  Sr-87m: Low target-to-background ratios  Fluorine 18: positron emission  Tc-99m MDP: 140 KeV, 6-hour half-life  distributed rapidly throughout the extracellular fluid space  rapid uptake in bone  clearance from the body via the kidneys  the skeleton-to-background tissue ratio improves with time
  3. 3. Technique 1. Patient preparation and follow-up  be well hydrated  void immediately before study  remove metal objects 2. Dosage and route of administration  20 mCi (740MBq) Tc-99m MDP  intravenous injection  adjust dosage for pediatric patients, minimum 2 mCi 3. Time of imaging  2~4 hr after tracer administration 4. Images: three-phase, whole body, SPECT
  4. 4. Normal bone scan 1. Areas with normally increased activity include: acromioclavicular joints, sternoclavicular joints, scapular tips, costochondral junctions, sacroiliac joints, lower neck, sternum, renal pelves and bladder 2. Pediatric patients: growth centers and cranial sutures 3. Pitfalls - Patient rotation - Urine retained in calyx may overlie lower rib - Urine contamination - Belt buckles, earrings, necklaces, and the like frequently create cold defects - Recent dental procedures - Radiopharmaceutical problems: breakdown of tag leading to free pertechnetate causes activity in thyroid and GI tract
  5. 5. Abnormal bone scans A. Metastatic disease  Tumors most likely to metastasize to bone include: breast, lung, prostate, lymphoma, thyroid, renal and neuroblastoma  Tumors in which falsely normal bone scan can be expected include: multiple myeloma, some anaplastic tumors, and pure lytic lesions  Location of metastases: axial skeleton – 80%, skull – 10%, long bones – 10%  Super scan: diffuse symmetrical increased uptake _ tumors frequently causing super scan: prostate, breast, lung bladder and lymphoma _ nontumor causes of super scan: hyperparathyroidism, osteomalacia, Paget’s disease, and fibrous dysplasia
  6. 6. Abnormal bone scans B. Primary malignant bone tumors  Osteogenic sarcoma, chondrosarcoma, Ewing’s sarcoma C. Benign primary tumors  Osteoid osteoma, bone islands, bone cysts, fibrous cortical defects, and others D. Osteomyelitis and septic arthritis
  7. 7. Abnormal bone scans E. Fracture 1. Traumatic fracture  positive within 24 hours  2/3 return to normal by 1 year  child abuse : _will not detect old, healed fx _difficult to evaluate around metaphyseal/epiphyseal region _may miss some skull fractures
  8. 8. Abnormal bone scans 2. Stress fractures  Fatigue fracture: caused by repeated abnormal stress on normal bone _fusiform, longitudinal shape, most often involving posterior tibial cortex _focal, less than 1/5 length of tibia _common located in junction of middle and distal third of tibia  Insufficiency fracture: resulting from normal stress on abnormal bone _seen in such diseases as: osteoporosis, osteomalacia, paget’s disease, fibrous dysplasia, and status postirradiation
  9. 9. Abnormal bone scans F. Metabolic bone disease 1. Osteoporosis: normal or decreased uptake 2. Osteomalacia: _vitamin D deficiency _results in failure of bone matrix to calcify _generalized increased skeletal uptake 3. Paget’s disease _increased uptake in bone scan _distribution of lesions: pelvis (70~80%), lumbar- thoracic vertebrae, femur, skull, scapula, tibia, and humerus
  10. 10. Abnormal bone scans 4. Hyperparathyroidism a. Primary: caused by hyperplasia or tumor of parathyroids  50~80% normal bone scan  abnormal uptake at: calvarium, mandible, acromioclavicular joint, sternum, lateral humeral epicondyles and hands  soft-tissue calcification in: lungs, stomach, kidneys, heart and periarticular b. Secondary: associated with chronic renal failure  usually have abnormal bone scan  super scan  focal abnormalities
  11. 11. Abnormal bone scans G. Avascular necrosis  result of: fracture, metabolic disorder, fat embolization, steroids, hemolytic anemia, and vasculitis  plain film is normal in early stage (6 months)  bone scan: normal for first 48 hr  decreased activity  increased activity  develop degenerative joint disease (increased uptake in the acetabulum)  Legg-Calve-Perthes disease: afftects boys aged 4~8 years
  12. 12. Abnormal bone scans H. Heterotopic ossification _associated with paraplegia and quadriplegia _increased activity in soft tissue I. Arthritides 1. Degenerative joint disease - most common locations: hands, feet, hips, knees, SI joints and shoulders 2. Rheumatoid arthritis - symmetrical increased uptake: hands feet, knees and cervical spine
  13. 13. Radionuclide inflammation scan and tumor scan Department of Nuclear Medicine Dr. Pei-Shan Wu
  14. 14. Application of Radionuclide Imaging in Infection  Radionuclide imaging for detection of infection –Ga-67 scan –Tc-99m (V) DMSA scan –Tc-99m HMPAO labeled WBC scan –Tc-99m labeled IgG scan  Utility in specific diseases –Osteomyelitis –Painful prosthesis –AIDS
  15. 15. Gallium-67 Cyclotron produced Half-life: 78 hrs Biological behavior: similar to ferric ion Binding to iron-binding molecules, including transferrin, lactoferrin, ferritin, siderophores
  16. 16. Gallium-67 scan: Mechanism  Not thoroughly understood  Ga-67 citrate binds to transferrin in the blood => transported to site of inflammation/infection  Localization depends on a number of factors –Adequate blood supply –Increased vascular permeability –Leaking into areas inflammation/infection  Ga-67 can be used in leukopenic, immunocompromised patients  Within 12-24 hours: Ga-67 firmly bound within lesion
  17. 17. Ga-67 scan: Technique  Dose: –Inflammation: 3-5 mCi –Tumor: 5-10 mCi  Imaging time: –48-72 hr to 1 week –Inflammation: 24 hr; Earlier images: high background: false- negative  Imaging parameters: –Energy: 93, 185, 296 keV peaks –Total body scan, focal view, SEPCT –Medium energy collimator –Bowel activity: bowel preparation
  18. 18. Ga-67 scan: Normal distribution  Liver: greatest Ga-67 uptake  Other: Spleen, nasopharynx, lacrimal and salivary glands, bone marrow, scrotum, testes  First 24 hours: kidneys, bladder - 48-72 hours: kidneys: only faintly visualized  After 24 hours, biological clearance through bowel  Breast uptake: variable, woman’s hormonal cycle  Thymus: children
  19. 19. Ga-67 scan: image interpretation Abnormal uptake: ≥ liver or spleen  abscess = liver  clinical important inflammation < bone marrow  low-level inflammation No difference in sensitivity fro acute or chronic infection Less sensitivity in tuberculosis, fungal infection
  20. 20. Ga-67 scan: Advantages Whole body survey Sensitive for detection of all inflammatory process whether or not they are discretely defined anatomically For detecting source of sepsis Leukopenic, immunocompromised patients Tumor detection
  21. 21. Ga-67 scan: Disadvantages Time delay between injection and imaging Poor spatial definition of anatomically discrete lesions Potential misinterpretation as a result of gallium uptake in adjacent organ (e.g. liver) Bowel activity Infection vs tumor
  22. 22. Tc-99m (V) DMSA scan  A tumor scan: e.g. medullary carcinoma of thyroid, soft tissue tumor  Mechanism: –unknown –hypothesis: resemble phosphate ion distribution  Biodistribution: Cardiovascular system, kidneys  Technique –20 mCi Tc-99m (V) DMSA iv injection –Imaging: 4 hr post-injection
  23. 23. Tc-99m (V) DMSA scan: Advantages Good availability High resolution Low price Low radiation dose Preparation technique: Easy Imaging: 4 hr post-injection
  24. 24. Tc-99m (V) DMSA scan: Disadvantages GU tract infection Infection vs tumor Chronic infection Further study
  25. 25. Scintigraphic diagnosis of osteomyelitis  ESR: Sensitive, but nonspecific  Blood culture: 40% negative  X-ray –First imaging study –Not detectable until 10-21 days after onset of symptoms  Scintigraphic methods –Three-phase bone scan –Ga-67 scan –Tc-99m (V) DMSA scan –WBC scan –IgG scan
  26. 26. Three-phase bone scan: Osteomyelitis  Blood flow study: Imaging at 3-5 sec intervals throughout the 1st-2nd minutes after radiotracer administration Blood pooling study: Obtain 5-20 min after injection Delayed scan: 2-4 hr post-injection  DD osteomyelitis and cellulitis  Cellulitis: diffuse hyperemia, delayed: negative  Osteomyelitis: focal hyperemia, delayed: positive  Positive: –24-48 hr after onset of symptoms –Remain positive for months after resolution  Sensitivity: 90-100%, specificity: 75-90%
  27. 27. Ga-67 scan: Osteomyelitis  Positive:  within 24-48 hr of symptomatic onset  Return to baseline quickly following successful treatment  Sensitivity: 80-90%, specificity: 70%  Sequential bone and gallium scans  Positive: Ga-67 uptake is incongruent with the bone scan  Negative: low-trade uptake  Equivocal: intense congruent uptake
  28. 28. Neonatal osteomyelitis Diffuse nature, propensity for complications, paucity of associated signs => whole body image Three-phase bone scan: –22-68% falsely normal or cold defects –Resolution –Cold lesion: subperiosteal abscess Bone scan: negative, clinically suspected => Ga-67 scan
  29. 29. Scintigraphic diagnosis of painful prosthesis  Three-phase bone scan –Focally increased uptake: loosening –Diffuse, uniformly distribution: infection –Not very specific  Ga-67 scan –Differential between pure mechanical loosening and infection  Sequential bone-gallium imaging –Incongruent image: Ga uptake exceed Tc-99m MDP bone radiotracer uptake (spatial, intensity of uptake) –sensitivity: 70%, specificity: 90%, Accuracy: 80%
  30. 30. Infection in immunosuppressed patients Diffuse pulmonary uptake PCP  CXR: bilateral diffuse infiltrate from hilum to peripheral  Ga-67: diffuse bilateral pulmonary uptake without nodal or parotid uptake (often before CXR)  Severe in CXR but decreased uptake in Ga-67  deficient immune response  poor prognosis
  31. 31. Infection in immunosuppressed patients CMV  Low-grade diffuse lung uptake, perihilar  Maybe with ocular(retinitis), adrenal, renal uptake, persistent colon uptake(diarrhea) Lymphoid interstitial pneumonia  Low-grade diffuse lung uptake, without nodal uptake, and symmetrically increased parotid uptake
  32. 32. Infection in immunosuppressed patients  Focal pulmonary uptake  Bacterial pneumonia: a lobar like, without nodal and parotid uptake  Actinomyces, Nocardia and Aspergillus: multiple sites of focal accumulation, frequently with local bone invasion  Nodal uptake  Mycobacterium avium-intracellulare (MAI), tuberculosis, cryptococcal, HSV infection and lymphadenitis, lymphoma  MAI: 25~50% of AIDS, patchy lung uptake with hilar and nonhilar nodal uptake
  33. 33. AIDS: Radionuclide Studies Ga-67 scan: –Infection, Tumor (lymphoma) Thallium-201 scan: –tumor (Kaposi’s sarcoma, lymphoma) Tc-99m HMPAO brain SPECT: –Dementia
  34. 34. AIDS: Ga-67 scan and Tl-201 scan Kaposi’s sarcoma: –Ga-67: (-), Tl-201: (+) Infection: –Ga-67: (+), Tl-201: (-) Lymphoma: –Ga-67: (+), Tl-201: (+)
  35. 35. Overview of Tumor Scintigraphy  Organ-specific tumor imaging radionuclides –Cold spot: Thyroid scan, Liver scan –Hot spot: Bone scan, conventional brain scan  Non-specific tumor imaging radionuclides –Ga-67 –Tl-201 –Tc-99m sestamibi –Tc-99m (V) DMSA –PET (F-18 FDG)  Tumor-type specific radionuclides –Thyroid cancer: I-131 –Adrenal tumors: I-131 MIBG or NP-59 –Hepatocyte origin tumors: Tc-99m DISIDA –Hemangioma: Tc-99m RBC
  36. 36. Ga-67 scan Mechanism of tumor localization Adequate blood supply Vascular premeability Specific tumor-associated transferrin receptor Tumor metabolism
  37. 37. Ga-67 scan – image interpretation  Salivary gland uptake is noted after C/T or R/T  Faint symmetrical hilar uptake may be seen normally and is common after C/T  Faint or absent liver uptake:  Extensive tumor metastases  Hepatic failure  C/T (vincristine) given within 24 hrs of Ga-67 injected  Iron overload
  38. 38. Ga-67 scan – tumor detectability Histology: high grade Lesion size Location: superficial > deep Tumor detection: lymphoma, HCC, soft tissue sarcoma, melanoma, lung cancer, head and neck tumors
  39. 39. Tl-201 Chloride tumor scan Thallium-201: a potassium analog Factors determining tumor cell uptake: Blood flow Tumor viability Tumor type Sodium-potassium ATPase system Cotransport system Calcium ion channel system Clearance by kidney, half-life: 73 hrs
  40. 40. Tl-201 Chloride tumor scan - Clinical application  Brain tumor  Correlated with gliomas grade  Post-op or post-R/T recurrent  Therapeutic effectiveness  In AIDS p’t: D.D. lymphoma and toxoplasmosis  Bone and soft tissue tumor  Correlation between Tl-201 uptake and response to C/T  Lack of Tl-201 uptake  tumor necrosis
  41. 41. Tl-201 Chloride tumor scan - Clinical application Thyroid cancer Advantage  Continue thyroid hormone  Localized thyroid ca (when I-131 negative, but TG elevated) Disadvantage  Not specific  Not predict the potential therapeutic effectiveness Kaposi’s sarcoma: Ga(-), Tl(+)
  42. 42. Tc-99m sestamibi A lipophilic cationic complex Factors determining tumor cell uptake: Blood flow Tumor viability Tumor type Lipophilic cation Large negative transmembrane potential
  43. 43. Tc-99m sestamibi Localized in liver, kidney, heart and skeletal muscle Difficult imaging: Sub-diaphragmatic tumor  liver uptake and urinary clearance Brain tumor  choroid plexus uptake
  44. 44. Tc-99m sestamibi - Clinical application  Breast cancer  Sensitivity 85%, specificity 81%  Higher in palpable, lower for lesion < 1cm  Fibroadenoma is commonest false positive  Diffuse uptake is nonspecific and usually not malignancy  Useful in  Non-diagnostic mammogram  Dense breast or anatomical changed  Fibrocystic disease
  45. 45. F-18 FDG tumor imaging  F-18 FDG:  F-18 FDG enters the metabolic cycle like glucose, but it is trapped in the tissue in the form of F-18 FDG-6-phosphate without further metabolism  Increased glycolysis associated with malignancy  Excreted by kidney  Clinical: lung cancer, colorectal cancer, lymphoma, breast cancer etc.
  46. 46. Lymphoscintigraphy  Clinical applications of lymphoscintigraphy  Distinguish lymphatic from venous edema, myxedema, lipedema, or other etiology  Assess pathways of lymphatic drainage  Identify sentinel nodes in patients with melanoma, breast, or genitourinary cancer  Identify patients at high risk for development of lymphedema after axillary lymph node dissection  Quantify lymphatic flow
  47. 47. Lymphoscintigraphy Methodology Radiotracers : colloidal gold(198Au), Tc- 99m labeled tracers (antimony sulfide colloid, sulfur colloid, albumin colloid, HSA) Tracer: injected into the tumor or surrounding tissue to identify the nodes receiving the lymphatic drainage of that tumor: subcutaneous, Intradermal, and Subfascial Injection
  48. 48. Sentinel lymph node detection and imaging  Lymphatic effluent of a tumor drains initially to one or two lymph nodes before other nodes receive the tumoral drainage  Sentinel node develops lymphatic metastases before other nodes  Careful examination of the sentinel node can be a more accurate predictor of regional nodal metastases than examination of adjacent nodes even if they are located in the same drainage basin as the sentinel node
  49. 49. Sentinel lymph node detection and imaging  If the sentinel node is negative for tumor, then other nodes are not likely to contain metastases, and the patient can be spared the unnecessary morbidity and expense of a more extensive node dissection  To localize the proximal or initial portion of the lymphatic chain, efferent from the tumor, for subsequent surgical excision and histologic diagnosis

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