Bone Radiopharmaceuticals
Radiopharmaceuticals:
1. Because The Skeleton Is Such A Large Structure Composed
Of Bones Of Varying Shapes, Sizes, & Thicknesses &
2. & Very High Target/Non Target Ratio Is Desired.
Patient Preparation :
1. Explain The Reason For The Delay Between Bone Tracer
Administration And Imaging.
2. Administer 20-30 mCi (740-1,100MBg) Of Tc99m Labelled
Compounds Intravenously. If A Flow Study Is Needed,
Position The Patient Under Scintillation Camera Before Tracer
Adminstration.
3. The Patient Should Be Well Hydrated
& Drink 2 Or More 8 Oz Glasses Of Water
Prior To The Procedure (After The Injection)
1. Hydration Helps Rid The Body Of The
Radiopharmaceutical Through The Kidneys
Giving Better Target / Non-Target Ratios
2. Lowers The Radiation Dose To The Patient
B. The Patient Should Void Frequently.
C. Frequent Voiding Decreased Bladder Radiation Dose.
D. The Patient Should Void Just Prior To Imaging.
1. The Bladder Must Be As Small As Possible
On The Image
2. Increased Bladder Activity Could Obscure
Any Pelvic Pathology
E. Voiding Particularly In Incontinent Patients May
Result In Contamination Of The Patient’s Skin Or Clothing.
This May Obsure The Underlying Pathology Or Mimic A Lesion
On The Images. Removal Of All Contaminated Clothing
May Be Necessary
F. Urine Contamination :
1. The Most Common Cause Of A Hot Spot Artifact.
2. Decontaminate The Patient And Image Patient Again
G. Remove Densities: Ie: Jewelry, Coins Etc
A. Cold Spots
.
Concerns With Bone Scans: Technical Considerations
A. Artifacts:
1. Extravasation Of The Tracer At The Injection Site
2. Urinary Contamination: Especially
A. Children
B. Incontinent Patients
Protect Equipment And Check Garments And
Linens Before Imaging Begins
3. Attenuating Materials: Could Cause a Photopenic Area
On The Images
A. Jewelry
B. Belt Buckles
C. Levy Jeans
D. Removable Prostheses
E. EKG Leads
F. False Teeth
G. Metal Joints In Patients
B. Close Attention To Precise Patient Positioning Is Essential.
1. Contralateral Sides Of Bony Structures (Eg Iliac Crests,
Shoulder Joints Must Be Positioned At The Same Angle
And At the Same Distance From The Detector
2. Failure To Do So May Cause One Side To Appear
To Have A Greater Tracer Concentration Than The Other Side
Assymmetry Of Contralateral Sides May Be Falsely Interpreted
As An Abnormality
C. An Unexpected Pattern Of Tracer Distribution May Indicate:
1. Improper Preparation Of The RP
& Can Degrade The Image
D. Excess Free Pertechnetate Appears As Tracer Concentration
In The Thyroid Gland, Salivary Glands &The Stomach.
E. Liver Uptake Or Increased Soft Tissue & Kidney Uptake
Can Also Be Indicators Of RP Problems
Imaging:
1. Imaging Can Begin 2 Hours After Tracer Administration
2. Ascertain That The Patient Has Voided Before Proceeding With
The Imaging.
3. Set Camera Controls( Photopeak Energy, Percentage Windows)
4. Place The Patient In A Supine Or Prone Position Whichever Is
Better Tolerated. The Supine Position Is Preferred.
5. The Patient–Detector Distance Should Be Minimized For
Each View.
6. Use The Spot Image Technique, Whole Body Technique
& SPECT To Acquire The Data
Blood Flow Dynamic Hot (In Bone) Hot (In Soft Tissue)
Blood Pool Static Hot (In Bone) Hot (In Soft Tissue)
Note:
LOCALIZED CAUSES:
A. Overlying Attenuation Artifacts:
1. Pacemakers
2. Barium
B. Instrumentation Artifacts
C. Radiation Therapy
D. Localized Vascular Compromise Includes:
1. Infarction
2. Early Aseptic Necrosis
3. Marrow Involvement By Tumor
E. Early Osteomyelitis
F. Osseous Metastases: From
1. Cancers
A. Neuroblastoma
B. Renal Carcinoma
C. Thyroid Carcinoma
D. Anaplastic Tumors (Eg Reticulum Cell Sarcoma)
G. Cysts
GENERALIZED CAUSES :
A. Inadequate Amounts Of Radiopharmaceutical
B. Old Age
C. Chemotherapy
Sclerotic Lesions:
1. Require 50% Greater Density Than Soft Tissue
Or Buildup of Calcification In An Area To Visualize
(See) It On An X-Ray.
Lytic Lesions:
1. Need Greater Than 50% Less Density Than Adjacent
To Visualize (See) It On X-Ray.
1. Bone Fracture :
A. Causes Increased Blood Flow
B. Causes An Osteoblastic Response
C. Here One Is Repairing & Laying Down
Bone Matrix-Hydroxyapatite To Which The
Radiopharmaceutical Attaches.
D. Therefore: Focal Hot Spots In Multiple Adjacent Ribs
On Bone Scan
Long Hot Lesions Running Along The Length
Of A Rib Are Usually Not Fractures.
2. Tumors:
A. Primary Bone Cancer Tumors
1. Some Bone Cancers:
A. Osteoblastic Response:
B. A Hot Spot
2. Other Bone Cancers:
A. Osteoclastic Response
B. Cold Spot
C. Why? One Is Removing Bone Matrix
& Hydroxyapatite ; Therefore Decreased
Radiopharmaceutical Present In Bone
B. Metastatic Cancer To Bone:
A. An Osteoblastic Response
B. Hot Spot
C. Random Distribution
D. Analysis:
1. Metastatic Cancer Cells Lodge In Bone
& Grow. The Bone In This Area Is Being
Destroyed .
2. Therefore Normal Bone Tries To Repair
The Bone Damage.
3. Therefore: An Osteoblastic Response Occusr
At The Metastatic Site
C. Metastatic Lesions To Bone : An Osteoclastic Response:
A. That Cause A Cold Spot (Photopenic Areas)
B. Causes:
1. Renal Cell Carcinoma
2. Lung Carcinoma
3. Thyroid Cancer
4. Breast Cancer
INTENSE:
Fibrous Dysplasia
Giant Cell Tumor
Aneurysmal Bone Cyst
Osteoblastoma
Osteoid Osteoma
MODERATE:
Adamantinoma
Chondroblastoma
Enchodroma
MILD TO MODERTE:
Fibrous Cortical Defect
Bone Island
Cortical Desmoid
Non-Ossifying Fibroma
Osteoma
COLD:
Bone Cysts Without Fractures
VARIABLE:
Hemangioma Of Bone
Multiple Hereditary Exostosis
3. Metabolic Bone Disorders :
A. Disorders of Normal Bone Metabolism
1. Inflow & Ouflow Of Minerals
B. Osteoblastic Response/ Hot Spot
1. Paget Disease
2. Osteomalacia
3. Rickets
A. An Inflow Of Minerals & Calcium
B. Laying Down Bone Matrix
9. Loosening Of Prostheses:
A. A Hot Spot: Activity At The Tip & Near The
The Lesser Trochanter: Most Frequent Site
A. The Prosthetic Device: Appears As A Cold Spot
B. Infected Prosthesis: Infection At The Site:
1. Hot Lesions All Along The Length of the Shaft
On Bone Scan Possible
C. Wear & Tear Of Normal Bone Bone Repair
1. Hot Spot On Bone Scan
D. Postoperative Activity Around A Cemented Prosthesis
Can Normally Persist For 6 Months To 1 Year
E. Activity Around A Non-Cemented Prosthesis
Can Normally Persist For 2-3 Years.
.
Bone Inflammatory Disease (Osteomyelitis)
Vs
Soft Tissue Inflammatory Disease (Cellulitis)
Blood Flow Dynamic Hot (On Bone) Hot (On Soft Tissue)
Blood Pool Static Hot (On Bone) Hot (On Soft Tissue)
Static Delayed Images Hot (On Bone) Normal (On Soft Tissue)
NOTE:
1. Cellulitis: Tends To Visualize As More Widely Diffuse
4. Shin Splints:
A. Blood Flow Dynamic Study: Normal
(Angiographic Study)
B. Blood Pool Static Images: Normal
C. Static Delayed Images: Hot In The Posterioromedial
Aspects Of The Tibia
: Insertion Of The Soleus Muscle
Analysis of Three Phase Bone Study:
1. First Study:
1. Blood Flow Dynamic Study Over The Localized Area
Of Bone Under Study For 60 Seconds.
2. Blood Pool Static Study:
1. Is A Regular Static Image Performed Right After
Dynamic Blood Flow Study.
2. Take Two : 2-3 Minute Static Images
3. Visualizes The Blood Into Arteries, Capillaries, Veins
Then RP Leaves The Blood & Enters The Soft Tissue
4. Blood Pool Image Looks At “RP” In Vascularity & ECF
Space Compartment .
5. Therefore There Is Both:
A. Increased Blood Flow
B. Edema
3. Delayed Images
1. Wait For The PIV Time And Then Perform Imaging
(PIV Time= 2 Hours) Therefore First Delay Imnage
At 2 Hours
Or
2. Image After The PIV Time
Delay Image After 24 Hours
Teaching Point:
Imaging Can Occur Longer Than The Normal PIV Time
Even 24, 48, 72 Hour Delay Images After Injection
What Can One Do: Decrease Statistical Accuracy From 1 Million Counts to
500K Counts
Ga67 & 111In: Have Longer Half Lives For Delayed Imaging
On Three Phase Bone Imaging
Some Bone Scans Viewed In Class:
1. Flair Response:
A. In A Patient Undergoing Chemotherapy
The Chemotherapy Kills The Metastatic Tumor Cells.
B. Normal Bone Starts To Repair Itself Osteoblastic Response
C. Therefore Hot Spots On Bone Scan Because Chemotherapy Is
Sucessful & The Bone Is Undergoing Repair Osteoblastic
Response Hot Spots On Bone Scan
D. Most Phenomenon Seen Within 1-3 Months Of Recent
Chemotherapy Completion
2. Bone Scan
A. Showing A Obstructed Left Ureter & Kidney :
1. Hot Left Ureter & Kidney
3. Plantar Views:
A. View Looking Posteriorly
B. Patient’s Right Foot On Right Side
C. Patient’s Left Foot On Left Side
Three Phase Bone Study
1. Osteomyelitis:
A. Focal Increased Uptake In Medullary Canal
Of Bones
B. Three Or Four Phase Study
C. Early Disease: Variations:
1. Cold Spot: Due To Ischemia Of The Vasculature
D. Late Disease:
1. Cold Spot : Abscess With Necrotic Center
E. Sensitivty : High For Osteomyelitis = 90%
On 3 Phase or 4 Phase Study
F. Mosre Sensitive Than An X-Ray
G. Specificity: Not Very Specific For Osteomyelitis
H. Typical Findings: Osteomyelitis
1. Phase 1: Positive
2. Phase 2: Positive
3. Phase 3: Positive
I. Typical Findings : Cellulitis: Soft Tissue Infection
1. Phase 1: Positive
2. Phase 2: Positive
3. Phase 3: Negative
J. Couple 3 Phase Study With 24 Hour Delay Image
1. Compare Target/ Background Activity
In 24 Hour Delay and 4 Hour Delay Image
The Ratio Should Increase In The 24 Hour Delay
K. Couple Study With Gallium 68 Study & Indium 111 WBC Study
1. Allows Increased Specificit
L. Comparison Of A 3 Phase Bone Study With Gallium Study
COMMON CAUSES:
Artifactual : After A Tc99m Sulfur Colloid Study
(Diffuse Activity)
Apparent Causes: Due To Abdominal Wall Or Rib Uptake
(Focal Activity)
Metastatic Carcinoma:
1. Colon
2. Breast
3. Ovary
4. Squamous Cell Of The Esophagus
5. Oat Cell Lung Carcinoma
6. Malignant Melanoma
UNCOMMON CAUSES:
Diffuse Hepatic Necrosis (Diffuse Activity)
Elevated Serum Aluminum +3 (Diffuse Activity)
RARE CAUSES:
Cholangiocarcinoma (Focal Activity)
Improper Preparation Of Radiopharmaceutical
Causing Colloidal Formation (Diffuse Activity)
Amyloidosis ( Diffuse Activity)
Hepatoma
FOCAL:
Common:
Urinary Tract Obstruction
Uncommon:
Calcifying Metastases : Breast Cancer
Poorly Differentiated Lymphoma
Radiation To The Kidneys
Rare:
Renal Carcinoma
Renal Metastases :From Lung Carcinoma
DIFFUSE:
Common Causes:
Urinary Tract Obstruction
Idiopathic
Uncommon Causes:
Metatstatic Calcification
Malignancies: Transitional Cell Carcinoma Of The Bladder
Malignant Melanoma
Hyperparathyroidism
Chemotherapy: Cyclophosphamide, Vincristine Doxorubicin
Thalassemia Major
RARE:
Multiple Myeloma
Crossed Renal Ectopia
Renal Vein Thrombosis
Iron Overload
Administration Of Sodium Diatrizoate After Tc99m Phosphate Injection
Paroxysmal Nocturnal Hemoglobinuria
Acute Pyelonephritis
Clinical Applications Of Bone Imaging
1. Malignant Bone Tumors:
A. Osteogenic Sarcoma:
1. Depends On:
A. Vascularity
B. Aggressiveness Of The Tumor
C. The Amount Of Neoplastic & Reactive Bone Production
2. Increased Activity Is Usually Intense &
Often Patchy With Photopenic Areas.
3. MRI May Provide More Exact Information
Regarding Tumor Extent, Especially The Soft Tissues
4. Follow-up Bone Scans Are now Recommended
Due To Advances In Chemotherapy.
5. Now About 20 % Of Patients Develop Osseous Metastases
Before Pulmonary Metastases.
6. In Interpretation Of Follow–Up Scans:
A. Care Must Be Taken Not Mistake
Post Amputation Changes At The Amputation Site.
7. Soft Tissue Metastases May Also Be Seen:
A. Pulmonary and Hepatic Metastases:
1.With Foci Of Extra-Skeletal Increased Activity
8. 40-50% Of Patients Develop Osseous Metastases
Within 2 Years of Presentation.
B. Ewing’s Sarcoma:
1. Occurs Primarily In The Pelvis Or Femur.
2. Intense & Homogenous Activity
3. High Vascular Tumors
4. May Mimic Osteomyelitis On A 3 Phase Bone Study
5. Osseous Metastases: 11% Of Patients
6. 40-50% Of Patients Develop Osseous Metastases
Within 2 Years Of Presentation.
7. Follow-Up Bone Scans Are Recommended
2. Benign Osseous Tumors:
A. Intense Activity On Delayed Images Include:
1. Osteoblastomas
2. Osteoid Osteomas
3. Chondroblastomas
4. Giant Cell Tumors
B. Hot Or Warm:
1. Enchondromas
C. Intermediatee Activity:
1. Chondroblastomas
D. Normal Intensity Or Warm Intensity:
1. Fibrous Cortical Defects
2. Non-Ossifying Fibromas
E. Increased Activity And Usually
Cannot Be Distinquished From Normal Bone
1. Bone Islands
2. Hemangiomas Of Bone
3. Cortical Desmoid Tumors
F. Cold Defects With A Warm Rim:
1. Bone Cysts
G. Single Or Multiple Areas Of Increased Activity
1. Fibrous Dysplasia
H. Multifocal & Metastatic Disease Presentation:
1. Polyostotic Fibrous Dysplasia
2. Paget’s Disease
2. Soft Tissue Uptake: Extraosseous Activity On A Bone Scan
A. Generalized:
1. Poor Radiopharmaceutical Preparation
2. Renal Failure
B. Localized:
1. Injection Sites
2. Normal Kidneys
3. Obstructed Kidneys Or Ureters
4. Urine Contamination
5. Tissue Infarction: Brain, Heart, Rhabdomyolysis, Spleen
6. Myositis Ossificans
7. Polymyositis
8. Pulmonary or Stomach Calcification
(Hyperparathyroidism)
9. Vascular Calcification
10. Hematoma
11. Breast Uptake Due To Steroids
12. Sites Of Iron Injections: (Chronic Iron Overload)
13. Sites Of Calcium Extravasation
14. Kidney Chemotherapy
15. Radiation Treatment Portals
16. Metastatic Calcification
17. Dystrophic Calcification: Due To Trauma Around Joints
18, Calcific Tendinitis
19. Free Pertechnetate (Stomach, Thyroid, SweatGlands)
20. Amyloidosis, Sarcoidosis
21. Soft Tissue Tumors:
Breast, Ovary( Mucinous Tumors)
Colon Cancer, Neuoblastoomas, Endometrial Carcinoma
Uterine Fibroids (Leiomyomas), GI Lymphoma,
Hepatic Metastases, Meningiomas, Lung Carcinomas
22. Malignant Ascites Or Malignant Effusions
23, Renal Failure: Stomach, Lungs &KIdneys
24. Breast Activity:
A. Menstruating Women
B. Mastitis
C. Breast Carcinomas
D. Trauma
E. Other Conditions
25. Persistent Increased Kidney Parenchymal Activity:
A. Radiation Treatments
B. Chemotherapy
C. Hyperparathyroidism
D. Amyloidosis
E. Sarcoidosis
3. Rheumatoid Arthritis:
A. Types:
1. Adult Form
2. Still’s Disease: Childood Form
B. Periods Of Remission & Exacerbation
C. Acute Phase:
1. Increase Uptake Of MDP In The Joint Space
And Along The Bone Surfaces Of A Joint
D. Rheumatoid Arthritis Is Often Positive In A Radionuclide Study
But Is Often Less Impressive On X-Rays
E. During RA Exacerbation Periods: An 111In WBC
Study Correlates With Pain & Joint Swelling
Therefore Intense Inflammation Is Present
DJD:
1. Bone Scans More Sensitive Than A Plain X-Ray
For Osteoarthritis.
5. Aseptic Arthritis:
A. Juxta-Articular Increased Activity On
A 99m Tc Disphosphonate Bone Scan
1 Day 95 80
3 Days 100 95
1 Week 100 98
----------------------------------------------------------------------------
Vertebrae 59 90 97 7
Long Bones 64 91 97 6
Ribs 79 93 100 5
8. Osteoporosis:
A. Often Multiple Fractures & Widespread Effects On Bone
B. A Greater Abnormality On Plain Radiograph (X-Rays)
Than Bone Scans
19. Diskitis;
A. Usually Occurs in Children
B. Increased Activity Of Adjacent Contiguous
Lumbar Vertebral Bodies, Often Adjacent
End Plates On Bone Scan
C. Radiographs: May Show A Narrowed Disk Space
20. Pseudoarthrosis:
A. A False Joint
B. Poor Alignment Leads To
Osteoblastic Activity And Cold Area
23. Hyperparathyroidism:
A. Symmetrically Generalized Increased Uptake
B. Site Possible: Sternum, Ribs, Skulls Mandible
C. A High Bone/Soft Tissue Ratio
D. Hyperparathyroidism &Renal Osteodystrophy
May Produce A Superscan With Diffusely
Increased Activity Throughout The Skeleton
Including The Mandible, Skull & Long Bones
& Relatively Diminished OR Absent Renal Activity
E. This May Be Accompanied By Metastatic Calcification
As Increased Activity In The Thyroid Gland, Lungs
& Stomach & Kidneys.
F. When Brown Tumors Are Present, Focal Areas Of
Increased Activity In The Skeleton May Be Seen.
24. Osteomalacia:
A. Softening Of The Bones in Adults.
B. Increased In Periarticular Regions:
1. Wrists, Feet, Hands, Long Bones, Calvarium
C. Bone/ Soft Ratio Is Almost As High As Paget Disease
1. Types:
A. Primary
1. Age Related Disorder
2. Decreased Mass Bone Mass
3. Increased Susceptibility To Fractures
4. Subtypes:
A. Type 1: Post Menopausal Osteoporosis
1. Estrogen Deprivation
B. Type 2: Senile Osteoporosis
5. Dual Photon (DPA) & Dual X-Ray Absorptiometry
(DEXA) Has Replaced Bone Radionuclide Methods
For Determination Of Bone Mineralaztion
B. Secondary Forms:
1. Hyperparathyroidism
2. Osteomalacia
3. Multiple Myeloma
4. Diffuse Metastastic Disease
5. Glucocorticoid Therapy
6. Intrinsic Excess
A. Procedure:
1. A Radionuclide Bone Scan Should Be Performed
Before Therapy To Ensure That There Will Be Uptake
Of The Therapeutic Radiopharmaceutical.
B. Rx:
1. Metastron: Strontium 89 Chloride
A. A Beta Emitter
B. T ½ = 50.5 Days
C. Maximum Range of Beta Emission
In Tissue= 8 mm
D. Metastases With An Blastic Response
Have A Significantly Moe Concentration
& Longer Retention Than Does Normal
Bone.
E, Excretion = Via The Urinary Tract
F. Dose = 40-60 uCi/Kg Up To 4 mCi
Via Slow IV Injection Using
A Shielding Syringe
G. Side Effects
1. Depression Of Bone Marrow
A. Should Not Be Used If WBC Count
Is < 2400/uL
B. Should Not Be Used If Platelet Count
Is < 60,000 uL.
2. Other Radiopharmaceuticals:
A. Rhenium 186 (186 Re) Hydroxyethylene
Diphosphonate (HEDP Or Etidronate)
1. T ½ = 90 Hours ( Physical Half Life)
2. Allows For A Large Radiation Dose
To Be Delivered In A Relatively Short Time
3. A Beta Emitter & A Gamma Emitter
Which Allows Imaging
4. Approved In Europe Only