Bone scan

General View

• Bone disease can be investigated with bone

seeking radiopharmaceuticals .
Conventional diagnostic indices, such as
radiology, and serum enzyme measurements ,
are important but are often unreliable and
convey insufficient information. X-rays
remain normal many months after metastases
have shown up on a bone scan.
• Bone imaging is extremely sensitive
for the detection of infection or
malignancy involving any part of the
skeleton. It is the most appropriate
screening test for these conditions,
since scan abnormalities are present
long before structural defects develop
radiographically ( 3-6 month earlier ) .
• Bone scans are also accurate for
localizing lesions for biopsy ,
excision, or debridement. Stress
fractures can be diagnosed by bone
scan when radiographs are completely
normal.

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 Principle and Radiopharmaceuticals

• Bone,like other connective tissues , consists of

living cells and a predominant amount of
nonliving intercellular substance that is calcified .
It is a metabolically active tissue with large
amounts of nutrients being exchanged in the
blood supplying to bone. Thus the skeleton and
body fluids are in an equilibrium.
• The bone salt mineral (inorganic matter)
has the crystalline form of an apatite,and the
main anion constituent of bone is phosphorus
(as phosphate)
The accumulation of phosphate compounds
is related to the exchange of the phosphorus
groups onto the calcium of hydroxyapatite.
• The major radiopharmaceuticals used for bone
scans are the 99m Tc-complexed organic and
inorganic phosphate compounds, some with an
added hydroxyl group to increase crystal binding .
These includes (1) pyrophosphate(PYP) , which is
simply two phosphate molecules linked together;
(2) polyphosphate, a short chain of phosphate
groups; and (3) diphosphonate compounds that
have a P-C-P linkage binding replacing the P-
O-P found in phosphates.
• Recently 99mTc labeled diphosphonate
compound methylenediphosphonate (MDP)
is widely used in clinics. The accumulation
of tracer in bone is related to both
vascularity and rate of bone
production (osteoblast activity).
 Lesions with high regional
blood flow and metabolic activity
can uptake more tracer ,
such as trauma ,fracture ,
inflammatory diseases,metastasis
etc.

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Lesions with low regional blood
flow and metabolic activity
can uptake fewer tracer ,
such as bone infarction,some
necrotic lesion etc.

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 Indications for Bone Scanning
• The main indications for bone scanning at the
present time are:
• 1.Skeletal pain in patients with a history of
cancer and negative x-rays ;
• 2.In patients with x-rays suspicious but not
confirmatory of metastases ;
• 3.In excluding bony metastases in a patient
with cancer but no bone pain and a negative x-
ray skeletal survey;
 4.In patients with a known metastasis, since the
scan may reveal more widespread lesions than
were first suspected ;
5.For finding suitable sites for the biopsy of a
bony lesion;
6.For planning radiotherapy of bony tumors ;
7.For the evaluation of treatment of bony
tumors;
8. In patients with lymphoma and apparent
solitary myelomas where bony involvement
may be suspected ;
9. In patients in whom osteomyelitis is
suspected but the x-ray is negative;
10. Occasionally in fractures to assess if they
are recent or old, to diagnose small bone
fracture, e.g. scaphoid fracture ;
11. In the detection and assessment of joint
disease in various arthropathies and metabolic
bone diseases.

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 Scan Procedure
• Patient preparation:
• The patient for performing the procedure and
the details of the procedure itself should be
explained to the patient in advance .
• The patient does not need to be fasting for
this procedure. Patient should be encouraged
to drink fluids and to urinate as often as possible
during the waiting period because it will help
eliminate the tracer from the body that is not going
to the bones . before scanning the patient will be
asked to void just before scanning begins.
• The patient receives an intravenous
injection of a 99mtechnetium (99mTc)
phosphonate radiopharmaceutical [usually
methylenediphosphonate (MDP) ]. The
usual administered activity of 99mtc-labeled MDP
is 740 MBq- 1110mbq (20 to 30 mCi ).
 2-5 hours after the injection, whole
body and appropriate regional skeletal
images are acquired. An initial dynamic
flow study and/or early images may also be
acquired if osteomyelitis, osteonecrosis,
septic arthritis, or other inflammatory
disease is suspected. Three hours after
the injection, delayed static skeletal
images are acquired (3-phase technique).

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 Image Acquisition

• Routine delayed images are usually

obtained from 2 to 5hr after injection.
Additional delayed (6-24hr) images may
permit better evaluation of the pelvis if it was
obscured by bladder activity on the
routine delayed images..
 6- 24hr delayed imaging may be
particularly helpful in patients with
renal insufficiency and patients with
urinary retention. Whole body
scintigraphy can be accomplished
with multiple overlapping images or
continuous images obtained in
anterior and posterior views.

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 SPECT imaging is helpful to better
characterize the presence, location and
extent of disease. SPECT imaging should
be performed as recommended by the
camera manufacturer. Typical
acquisition an processing parameters
are 3600 circular orbit.
Normal whole bone scanning

• Normal Findings
homogeneous in axial
skeleton like
spinal,pelvis, vertebral
column etc. and
symmetric distribution
of activity throughout
all skeletal structures.
Normal whole bone scanning
Normal
whole
bone
scanning
There is no
hot spots and
cold spots
being found.
 Abnormal Radioactivity Distribution

• 1. Hot spots;
• 2. Cold spots ;
• 3. Hot spots without bone;
• 4. Super-bone scan;
• 5. Flare Phenomenon.
 Metastatic Bone Malignancies

• Bone scan is more sensitive than radiographs in

detecting skeletal metastases. This is probably
because about 50% of the bone mineral content
must be lost before a met is evident on a
radiograph.
• Multiple and randomly distributed hot sports in
the skeleton are characteristic of bony metastases ;
serial hot spots in the ribs are often the result of
multiple fracture. .
• About 90% of patients with skeletal metastases
present with multiple lesions. Nearly 80% of all
metastatic lesions are in the axial skeleton. In
patients with a known malignancy, 60 to 70%
of axial lesions are due to mets, whereas about
40 to 50% of lesions in the extremities or skull
are due to mets. A solitary rib lesion has about
a 10% probability of representing a met in a
patient with a known malignancy
• A single hot spot carries no diagnostic specificity
and may result from a variety of benign or
malignant conditions .
• a single lesion has about a 11% probability for
being a met in patients with known underlying
malignancy. The percentage increased to 35% when
2 new lesions were detected, and reached 100%
when 5 new lesions were identified .
Solitary Pubic Bone
Metastasis

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Widespread
metastatic
Prostate
Cancer

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Multiple bone metastases
lung cancer
Multiple bone metastases
 Primary Bone Malignancies: Extended Pattern

• The "Extended pattern" refers to increased

activity (usually mild to moderate) in adjacent
joints or along the entire ipsilateral extremity
in association with a primary tumor of a long
bone. This finding may be related to
generalized increased blood flow to the
extremity. It can lead to over-estimation of the
extent of the tumor by scintigraphy. It is also
called “ skip phenomenon” .
 Osteosarcoma:
The most common location for primary
osteosarcoma is about the knee , followed by
the proximal humerus . common sites for
metastases are the lungs and bones. Although
pulmonary mets can be detected in 20% to
40% of patients, skeletal mets are detected
in only 3% at the time of presentation.
Nonetheless, the presence of skeletal mets is
associated with a very poor prognosis and
will greatly alter treatment in these patients.
Primary Bone tumour Femoral Osteosarcoma

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 Primary bone
tumour
Femoral Osteosarcoma
skip lesion

tibias and femurs,

Primary bone tumour
ankle
 Vertebral Compression Fracture
• By 1year, about 60% of compression
fractures will normalize and 95% will
become normal by 3 years. When multiple
fractures are present in different stages of
healing , osteoporosis is the most likely
diagnosis . Some reasons may be bone
metastasis without primary tumor site being
seen. Multiple myeloma may occasionally
mimic this appearance.
Vertebral Compression Fracture
Breast Cancer Single Metastasis
 Super-bone
Scan
When pathology affects the entire
skeleton with general increase in bone
tumour, a corresponding general
increase of tracer concentration will
lead to the so-called super bone scan.
• This is due to, a higher bone-to-tissue and
a higher bone-to-blood ratio of tracer
distribution with a corresponding increase
in detail resolved on the scan. Super scan
can be found in patients with Hypertrophic
osteoarthropathy, diffuse metastatic
disease ,hyperparathyroidism and ,renal
osteodystrophy .

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 Metabolic Bone Disease:

Some metabolic bone disease can

be test with bone scan.These
include :
• Hyperparathyroidism;

• Renal osteodystrophy;

• Hypertrophic osteoarthropathy.
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术后三年
Hyperparathyroidism
Mask face
Renal osteodystrophy
• Whole-body bone
scintigraphy
demonstrates
diffusely increased
skeletal uptake,
minimal soft tissue
and renal uptake
and no bladder
activity. There are
no focal bony
lesions.
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 Hypertrophic
osteoarthropathy

• Woman with a
newly diagnosed
posterior right
upper lobe lung
mass, super scan
and linear
cortical uptake
of the
radiopharmaceut
ical in the lower
ditrack sign extremities
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 Diffused
Diffuse areas ofMetastatic
markedly
92-year
increased uptakeold
of man
the
with known
radioactivity are noted
metastatic
throughout the axial skeleton.
prostate skeleton is
The appendicular
carcinoma.
relatively spared withThe
the
patient
exception of thehad
proximal
aspect complaints of
of the right forearm.
diffuse bony
These findings are most
pain,
consistent most
with severe
widespread
in the
metastatic back.
disease.
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diffuse metastatic disease

78 year-old
male with
history of
prostate
cancer and
right arm
pain.

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 Pagets Disease

(1) Markedly increased activity is noted

throughout an expanded, deformed left lower
extremity. In addition, markedly increased
activity is noted in the third lumbar vertebrae
and in the manubrium.
(2) Moderately increased activity is noted in
the right knee, and shoulders bilaterally in a
pattern characteristic of degenerative
changes.
 Polyostotic fibrous dysplasia

multiple bilateral areas of abnormal

radiopharmaceutical uptake in the axial and
appendicular skeleton. Specifically, these
areas include the skull and both iliac wings,
proximal and mid femurs, and tibias. Linear
areas of decreased activity are seen in both
proximal femurs and traversing both femoral
necks.

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 Polyostotic
fibrous dysplasia
 Cold Spots

• Areas of reduced tracer concentration (cold

spts) are rare .They can occur mainly in
association with bone infarction or
predisposing pathology such as sickle-cell
aneamia .However, a bone infarct can show up
as hot spot reflecting the degree of bone
reaction around it . cold spots are most often
associated withy extraneous causes breast
prosthesis, bone nailing, hip prosthesis , earring
or necklaces, medals, etc.
Sternum and thoracic vertebra
radioactive sparseness

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 Hot Spots Without Bone

• Soft tissues,normal or involved

breast, pleural effusions , scars from
mastectomy surgery with or without
local recurrence, calcified myoma ,
dental abscess, root treatment
,myocardial infarction and sites of bone
biopsy may all lead to positive sites of
tracer concentration .
Soft Tissue Calcifying Without Bone

pelvis

bladder

Thigh
bone
Hot Spot Without Bone Lung Cancer
 Benign Bone Disease

The main areas of clinical application

are:
Early recognition of the pathological
process ; accurate assessment and
localization of the extent of the
disease;quantitative analysis of tracer
uptake and monitoring of the disease.
 Less often bone scanning is used as a test
for differential diagnosis,although in certain
areas it does offer valuable information : is
there avascular necrosis of the femoral
head;Is there evidence for graft healing,or
minor trauma to the skeleton,or fissure and
stress fractures etc.

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 Trauma

Fractures: general findings:

1) acute: (3-4 weeks)
There is increased flow and blood pool
activity with diffuse and somewhat poorly
defined increased delayed activity about the
fracture site which is wider than the fracture
line.
2) Subacute: (2-3 months)
Flow and blood pool abnormalities
diminish considerably and delayed
activity becomes more localized (focal at
the fracture site) and intense.
3) healing:
A gradual decline in activity occurs over
time with about 65% of exams normalizing
by 1 year, and 90% becoming normal by 2
years.

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58
 Occult Fracture

tibia
Metatarsal Fracture

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Avascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral Head
Avascular Necrosis
of the Femoral Head

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Rheumatoid arthritis

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 Flare Phenomenon

• The flare phenomenon reflects a favorable

response of bone metastases to treatment.
Patients are typically asymptomatic and plain
films generally show sclerosis of the lesions.
• The phenomenon is typically seen between
2 weeks to 3 months following therapy, but
can rarely be seen as late as 6 months after
treatment. In general, it is prudent to wait
about 3 months following completion of a
new therapeutic intervention prior to
repeating the bone scan.

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• The diagnosis of "flare" requires 2 criteria:
• Increased intensity and/or number of lesions on
bone scan (felt to be secondary to increased
osteoblastic activity associated with healing)
• Subsequent decrease uptake in these lesions on
repeat exam in 2-3 months.
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