Keywords:Bone scintigraphy - PDF document

Keywords:Bone scintigraphy – Tumour imaging – Pro-mation about bone scintigraphy in oncology. Theseto another and from one medical institution to another.medicine physicians and is intended to offer assistance inbe obtained from bone scintigraphy. The corresponding(breast, prostate, lung, head and neck cancer, etc.). Phos-Tc and are used Under the auspices of the Oncology Committee of the EuropeanAssociation of Nuclear Medicine. versity, Tübingen, Germany), Bauer R. (Klinik fur Nucklear-burg, Germany), Mather S.J. (Department of Nuclear Medicine,St. Bartholomew’s Hospital, London, UK), Merrick M.V. (Depart-ment of Nuclear Medicine, Western General Hospital, Edinburgh,per lo Studio e la Cura dei Turmo, Milano, Italy), Tarolo G.L. (Di-van Rick P.P. (Department of Nuclear Medicine, Academisch EmilioBombardieri (IstitutoNazionaleperloStudioelaCuradeiTumori, Milano, Italye-mail:mednuc@istitutotumori.mi.itEmilioBombardieri, CumaliAktolun, RichardP.Baum, AngelikaBishof-Delaloye, JohnBuscombeJeanFrançoisChatal, LorenzoMaffioli, RoyMoncayo, LucMortelmans, SvenN.ReskeIstituto Nazionale per lo Studio e la Cura dei Tumori, Milano, ItalyUniversity of Kocaeli, TurkeyPET Center, Bad Berka, GermanyCHUV, Lausanne, Switzerland©EANM2003 a)Limited bone scintigraphy or spot views (planar im-b)Whole-body bone scintigraphy (planar images of thec)SPET (tomographic image of a portion of the skeleton)d)Multiphase bone scintigraphy (immediate and delayedwhen there is diagnostic uncertainty. Multiphase boneusually indicated in oncology.and the effectiveness of therapy by showing the sequentialchanges in tracer uptake. Bone scintigraphy offers the ad-–Primary tumours (e.g. Ewing’s sarcoma, osteosarcoma)–Staging, evaluation of response to therapy and follow-–Secondary tumours (metastases)Sr, Sm-EDTMP, teoblastic activity. For this reason, bone scan images also–Osteomyelitis–Perthes’ disease, avascular necrosis–Metabolic disorders (Paget’s disease, osteoporosis)–Arthropathies–Fibrous dysplasia and other rare congenital conditions–Stress fractures, shin splints–Loose or infected joint prosthesis–Low back pain, sacro-iliitis–Reflex sympathetic syndrome–Any other bone injuries–Pregnancy (suspected or confirmed). In the case of a–Breast-feeding should be discontinued and milk ex-pressed and discarded when possible for 24h (and atleast for 4h) post radiopharmaceutical administra-Patient preparationPre-injectionof bone scintigraphy, especially:–Relevant history, including type of suspected or–Relevant history of fractures, trauma, osteomyelitis,–Current symptoms, physical findings–Results of previous bone scintigraphy or other recentrecommended that every effort be made to obtain hard–Results of other imaging studies such as conventionalradiography, CT, MRI (as with previous scintigraphicexaminations, it is recommended that every effort be–History of therapy that could affect bone scintigraphy(e.g. antibiotics, steroids, chemotherapy, radiationtherapy, diphosphonates, iron therapy)European Journal of Nuclear Medicine and Molecular Imaging Vol. 30, No. 1, January 2003 –Orthopaedic and non-orthopaedic surgery affecting–Relevant laboratory results (e.g. PSA for patients with–Presence of urinary tract abnormalities–Possible contraindications to hydrationThe radiopharmaceutical (MDP, HMDP, HDP, etc.)pean Atomic Energy Community Treaty, and in particu-the European Union (Directive 97/43/EURATOM).This Directive supplements Directive 96/29/EURAT-groups of standard-sized patients and for broadly de-Tc-diphosphonate should be considered only as acountry, nuclear medicine physicians should respect theDRLs and the rules set out by local law.phy by a single i.v. injection should be 500MBq(300–740MBq) (8–20mCi). The organ which receivesthe largest radiation dose is bone (see table of adsorbedgiven by the EANM Paediatric Task Group. In children aminimum activity of 40MBq is necessary in order to ob-tain images of sufficient quality. Practitioners could bePatients should drink a large amount of fluids duringthe 24h after radiopharmaceutical administration.Tc-phosphonatesthird in calcium phosphate. Two major factors controlflow and extraction efficiency, which in turn depend oncapillary permeability, acid-base balance, parathyroidtion is reached 1h after injection and the level remainspractically constant up to 72h. The blood clearance ofneys is reached after approximately 20min. Within 1h,bound complex has undergone glomerular filtration andwithin 6h, 60%. The quantity of phosphonates eliminat-life of phosphonates is 26h.The estimated adsorbed radiation dose to various organsTc-la-belled phosphates and phosphonates is given inTable1.1.99mTc] diphosphonates.diphosphonate (MDP), hydroxymethylene diphospho-European Journal of Nuclear Medicine and Molecular Imaging Vol. 30, No. 1, January 2003 PreparationTc-labelled diphosphonates are prepared by additionc-labelled diphosphonates are prepared by addition99mTc]pertechnetate,ing to the manufacturer’s instructions.Quality controlion chamber. Radiochemical purity may be confirmedTc-MDP 0.0, reduced hydro-Tc 0.0, Tc-pertechnetate 1.0; mobile phase IITc-MDP 1.0, re-Tc 0.0, Tc-pertechnetate 1.0.)Labelling ef�ficiency should be 95%.Special precautionsused within 6h of preparation.performed, according to the rules of each country, asstated in the Council Directive 97/43/EURATOM.–Single- or double-headed gamma camera equippedwith a low-energy, high-resolution collimator–Energy window: 10% energy window (±5%) centredRoutine images are usually obtained between 2 and 5hafter injection. Later (6–24h) delayed images result in ahigher target-to-background ratio and may permit betteractivity on the routine (2–5h) images. Six- to 24-h de-with renal insufficiency or peripheral circulatory disor-500,000 to 1 million counts depending on the field ofview (FOV) of the gamma camera. The larger the FOV,the larger the number of total counts required to giveskeleton. Moreover, the presence of physiologically highEuropean Journal of Nuclear Medicine and Molecular Imaging Vol. 30, No. 1, January 2003Table1.(mGy/MBq), for various organs in healthy subjects following theTc-labelled phosphates and phosphonates OrganAdult15 year olds5 year olds Adrenals0.00210.00270.0058Bladder0.0480.0600.073Bone surfaces0.0630.0820.22Brain0.00170.00210.0043Breast0.000710.000890.0022Colon0.00270.00340.0061Gallbladder0.00140.00190.0042Heart0.00120.00160.0034Kidneys0.00730.00880.018Liver0.00120.00160.0036Lungs0.00130.00160.0036Muscles0.00190.00230.0044Oesophagus0.00100.00130.0030Ovaries0.00360.00460.0070Pancreas0.00160.00200.0045Red marrow0.00920.0100.033Skin0.00100.00130.0029Small intestine0.00230.00290.0053Spleen0.00140.00180.0045Stomach0.00120.00150.0035Testes0.00240.00330.0058Thymus0.00100.00130.0030Thyroid0.00130.00160.0035Uterus0.00630.00760.011Remaining organ0.00190.00230.0045Effective dose (mSv/MBq)0.00570.00700.014 count density organs (typically the kidneys) may hamperfor the same time as the first view. Spot images may beFilms of scintigrams photographed with different intensi-posterior whole-body images obtained 2–5h after injec-the gamma camera manufacturer. Typical acquisition andera are 360°circular orbit, 60–120 steps, 64er matrix, and 10–40s/stop. An equivalent total numbertion images of a specific area are necessary. Approxi-verging collimator may also be used to improve resolu-gential and special views may be obtained if necessary.The pelvis can be difficult to evaluate when there isoverlying bladder activity. In patients with pelvic symp-–Repeat images immediately after voiding.–Sitting-on detector (caudal) or oblique views.–Lateral views.–24-h delayed images.–SPET acquisition. Single or multiple rapid (5–10minbladder. Bladder artefacts are exaggerated in the plane–Image immediately following catheterisation of thebladder. (Note: Bladder catheterisation should be re-In the case of SPET, one should take into account thedifferent types of gamma camera and software available:be adopted in order to optimise the imaging quality.–The bone scan is very sensitive for localisation oflow. It must be interpreted in the light of all availableinformation, especially patient history, physical ex-–Symmetry in the representation of right and left sides–Both increases and decreases in tracer uptake have to beassessed; abnormalities can be either focal or diffuse.–Increased (decreased) tracer activity in the bone, com-(decreased) osteoblastic activity.–Differential diagnosis can sometimes be based on the–Focal decrease without adjacent increase in tracer up-artefact or absence of bone, e.g. due to surgical resec-–Decreases in the intensity of tracer uptake and in the–Increases in the intensity of tracer uptake and in thereflect a flare response to therapy.European Journal of Nuclear Medicine and Molecular Imaging Vol. 30, No. 1, January 2003 –Normal structures should be noted: kidneys and blad-der. Tracer uptake in the kidney can be focal or diffuse.–Generalised increased soft tissue uptake compared–A generalised decreased soft tissue uptake comparedactivity and route), a summary of patient history, all cor-1.The procedure (whole body, SPET if applicable, ra-diopharmaceutical, injected activity, delayed images,2.Findings. Abnormal tracer uptake (increased, de-3.Comparative data (correlation with other diagnostic4.Interpretation. A clear diagnosis should be given iftion of the study limitations. Further, more definitivedifferential diagnosis is broad.–Patient movement–Greater than necessary collimator-to-patient distance–Imaging too soon after injection, before the radiophar-–Injection artefacts–Radiopharmaceutical degradation–Urine contamination or a urinary diversion reservoir–Prosthetic implants, radiographic contrast materials or–Homogeneously increased bony activity (e.g. “super-–Restraint artefacts caused by soft-tissue compression–Prior administration of a higher energy radionuclideTc radiopharmaceuticalwhich accumulates in an organ that could obscure or–Significant findings outside the area of interest may–Changing bladder activity during SPET of the pelvic–Purely lytic lesions–Pubic lesions obscured by underlying bladder activity–Renal failureTc-phosphonate bone scintigraphy in theraphy is indicated in symptomatic patients. However, itis unproven whether bone scintigraphy is cost-effectiveTc-phosphonate bone scintig-its current role in spite of the emerging high diagnosticaccuracy of PET.dures with high quality. These general recommendationsmay be different than the spectrum usually seen in aor one medical facility to another. For these reasons,European Journal of Nuclear Medicine and Molecular Imaging Vol. 30, No. 1, January 2003 1.Bares R. Skeletal scintigraphy in breast cancer management.2.Beauchamp CP. Errors and pitfalls in the diagnosis and treat-Orthop Clin North Am3.Brown ML, Collier BD, Fogelman I. Bone scintigraphy: part I.4.Brown ML, O’Connor MK, Hung JC, et al. Technical aspectsof bone scintigraphy.5.Cameron PJ, Klemp PF, Martindale AA, Turner JH. Prospec-tigraphy.6.Collier BD, Fogelman I, Brown ML. Bone scintigraphy: part7.Collier BD, Fogelman I, Rosenthall L, eds.New York: Mosby, 1996.8.Cook GJ, Fogelman I. Skeletal metastases from breast cancer:9.Cook GJ, Fogelman I. 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