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THE SKELETAL SYSTEM MUDr.Kateřina Táborská. Bone scintigraphy Bone physiology and skeletal anatomy balance osteogenesis bone resorption osteoblasts osteoclasts The response of bone to injury or disease ↓ reactive bone formation. Radiopharmaceuticals:

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slide1

THE SKELETAL SYSTEM

MUDr.Kateřina Táborská

slide2

Bone scintigraphy

Bone physiology and skeletal anatomy

balance

osteogenesis bone resorption

osteoblasts osteoclasts

The response of bone to injury or disease

reactive bone formation

slide3

Radiopharmaceuticals:

  • 99mTc – diphosphonates ( MDP –methylene diphosphonate)
  • Concentration predominantly in the mineral phase of bone (crystalline hydroxyapatite and amorphous calcium phosphate)
  • iv.
  • distributed via blood flow throughout the body
  • passively diffused into the extravascular and extracelular spaces
  • binding to the hydration shell around the bone crystal
  • unbound radiotracer clears from the plasma via urinary excretion
slide4

Uptake of RF depends on:

1. blood flow

flow must be present for delivery

increased blood flow increased deposition

2. metabolic bone activity

bony turnover

osteoblastic lesions growth centers

slide5

Patient preparation:

good hydration

to urinate immediately prior imaging

Contraindiaction:

pregnancy

slide6

Two types of bone scans:

Standart bone scan:

iv., imaging of the entire skeleton, 2-5 h

Three-phase bone scan:

1. Phase – angiographic

rapid sequence flow imagesof the area of interest(60 x 1 sec.)

2. Phase (blood pool, soft tissue uptake)

ten minut delayed static images

3. Phase (bone)

delayed images of the region in question, 2-5 h

bone spect improved sensitivity greater anatomic details
Bone SPECT – improved sensitivity greater anatomic details

I. 3D rekonstrukce II. tomographic slices

transaxiální

3D rekonstrukce

sagitální

koronální

slide13

Normal scan: axial and appendicular skeleton

Symetry, the bones with minimal soft-tissue activity

Both kidneys with mild activity, urinary bladder

slide14

Normal scan: children

increased uptake in growth centers

margins of growth plate clearly demarcated

slide15

Abnormal scan

Areas :

increased uptake95 - 98%

(fracture, osteomyelitis, neoplasia, arthritis)

decreased uptake

(lytic lesions, early necrosis)

slide16

Abnormal scan

superscan

Diffuse symetrical increased uptake

Lack of kidney activity

soft tissue or extra osseous uptake
Soft tissue or extra-osseous uptake

inflammation, calcification, muscle or tumor necrosis, myositis

neuroblastoma rhabdomyolysis

slide18

excretion via genitourinary tract

hydronephrosis

hydroureter

nefrocalcinosis

indications
INDICATIONS
  • metastatic disease
  • primary malignant bone tumors
  • benign primary tumors
  • osteomyelitis
  • fracture
  • avascular necrosis
  • metabolic bone disease
metastatic disease
METASTATIC DISEASE

Tumors most likely to metastasize to bone:

breast

prostate

lung

lymphoma

thyroid

renal

neuroblastoma

metastatic disease21
METASTATIC DISEASE

more sensitive than plain RTG, 30-50% of bone mineral must be lost before a lesion can be detected

surveying of the entire skeleton

slide22
Approximately 90% of metastases are multiple

initial staging

follow up

diffuse bone pain

laboratory findings (PSA)

Prostate cancer

slide23

METASTATIC DISEASE

flare fenomen

3-6 mo after chemotherapy, hormonal therapy

increased uptake in known lesions and even new foci may be seen because of a healing response

serial scanning

primary malignant bone tumors
PRIMARY MALIGNANT BONE TUMORS

Osteosarcoma

Ewing‘s sarcoma

3F bone scan

WB - skip lesions and metastatic foci

slide25
Osteosarcoma

19-year old man with pain of right knee, the initial staging

slide26
Ewing‘s sarcoma

17-year old man with pain of left knee, the initial staging

slide27
Osteosarcoma of left tibia

Persistent increased uptake at the treatment site 6-12 mo after therapy, compared with a postherapy baseline, is considered suspicious for local recurrence

21-year old man after chemotherapy and amputation

slide28

BENIGN PRIMARY TUMORS

usually normal uptake

bone cysts

bone islands

fibrous cortical defects

osteiod osteoma

negative scan virtually rules out

16-years old girl with aching pain, worse at night, relieved with aspirin and exercise at right

osteomyelitis
OSTEOMYELITIS

3-phase bone scintigraphy

flow – increased

blood pool – increased

delayed – increased

dif.dg. cellulitis – increased only flow and blood pool

high sensitive on unaffected bones

positive during 24-48 h

X-rays normal for first 10-14 days

slide30

1.phase 2.phase 3.phase

Osteomyelitis

(left calcaneous)

1.phase (curve from the region of interest - ROI)

slide31
multifocal osteomyelitis

13-year old girl with OM of left clavicule

slide32

1.phase

2.phase 3.phase

Myofasciitis of left thigh

1.phase

6-year old boy with pain of left thigh

fracture
FRACTURE

TRAUMATIC

will become positive within 24 h

90% normal by 2 years

tu pick up old fractures such as in spine

child abuse

STRESS

a) fatigue – caused by repeated abnormal stress on normal bone - runners

b) insufficiency – resulting from normal stress on abnormal bone (osteoporosis, postirradiation)

slide34
polytrauma

27-year old woman after car crash

slide35

Fracture of Th 8

13-year old boy after fall from tree

stress fracture of left tibia
Stress fracture of left tibia

pinhole collimator

ANT

anterior lateral

17-year old girl with painful left leg after training for an athletic event

avascular necrosis
AVASCULAR NECROSIS

Adults – as a result of fracture, metabolic disorder, steroids, hemolytic anemias, vasculitis

Children: Legg-Calve- Perthes disease

early: decreased activity

followed by increasing activity if subsequent revascularisation and healing occur

morbus perthes l sin
Morbus Perthes l. sin.

normal early phase

5-year old boy with hip pain

metabolic bone disease
METABOLIC BONE DISEASE

OSTEOPOROSIS

OSTEOMALACIA

HYPERPARATHYROIDISM (primary, secondary)

superscan or complication: pseudofracture,compresive fracture

PAGET‘S DISEASE

increased resorption of bone accompanied by increase in bone formation

newly formed bone is abnormally soft

increased uptake due to significant increase in blood flow

advantages
ADVANTAGES

high sensitivity

early changes

ability to survey the entire skeleton without added radiation (5 mSv)

disadvantages
DISADVANTAGES

lack of specificity

A specific diagnosis often can be made when the bone scan is correlated with other imaging (plain films, CT)