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Nuclear Medicine in Musculoskeletal system

Introduction
Nuclear medicine is defined as a medical speciality which uses the nuclear properties of the matter to investigate physiology and anatomy, diagnose diseases, and to treat with unsealed sources of radionuclide

Introduction

Characteristic:

Used Radiation from Nuclear desintegration Physiologic process and change of function from the organ biochemistric process in celluler or moleculer levels. Non-invasif, sensitivity >>>, specificity <,

Introduction

A wide variety of musculoskeletal disorders can be investigated by nuclear medicine techniques, particularly through Bone scintigraphy/Bone Scan The principal conditions that can be imaged are : - metastatic bone disease - osteomyelitis - variety of benign conditions (fractures, avascular necrosis, inflammatories arthropathies, metabolic bone disease, etc).

Bone

scan is commonly performed with Tc99m-biphosphonates. Bone scanning is performed with the gamma camera. Bone scan is more sensitive than radiography in detecting skeletal disease.

Pathophysiology of Biphosphonate Uptake

The bone scan provides information that reflects skeletal metabolic activity. The mechanism involved in biphosphonate uptake is thought by chemiabsorption onto the calcium of hidroxyapatite in bone, i.e. the biphosphonate molecule is adsorbed onto the surface of bone. The major factors which affect this adsorption : - osteoblastic activity - skeletal vascularity.

The bone scan therefore reflects the metabolic reaction to a disease process. Because its ability to detect functional change, the bone scan can often be strongly positive, well before the structural X-ray changes occur.

The Normal Bone Scan

The most important : symmetry.

There should be uniform uptake, greater activity at sites of highest metabolic activity (joint margins) & areas rich in trabecular bone (the spinal vertebral bodies).
Biphosphonate not taken up by the skeleton is excreted via the urinary tract tracer is visualized in kidney & bladder. Uptake of bone scanning agents can also occur in soft tissues significant abnormalities.

Three-Phase Bone Scan

Provide additional valuable info regarding the vascularity of a lesion. This involves : o Initial dynamic flow study (1st phase) o A blood pool image (2nd phase) o Delayed static images (3rd phase) can be obtained between 2 & 4 hours. For the diagnosis of osteomyelitis, the three-phase bone scan is typically used.

Bone Scan in Malignancy

The detection of metastatic skeletal disease remains the most important indication for performing a bone scan. The common cancers that metastasise to the bone are those of the prostate, breast & lung.
The most characteristic feature of metastases is irregular focal lesions in a pattern that does not correspond to any single anatomical structure.

Bone Scan in Malignancy

In general, metastases must generate an osteoblastic response in order to be detected on the bone scan. Metastases can on occasion produce an area of decreased uptake (cold lesion) reflecting bone destruction & failure to stimulate a healing response. This is most often seen in myeloma or renal carcinoma.

Important variant to recognise : Superscan of malignancy extensive focal lesions. The renal images are not visualized due to less tracer is excreted via the renal tract. should be followed by more specific investigation directed to the site of abnormality.

Bone Scanning In The Management of Malignancy

For staging for a malignancy at presentation. Metastases may be present in an asymptomatic individual & even in patient with a suspected metastasis because of bone pain, more extensive disease may be found when the bone scan is undertaken.

Bone Scanning In The Management of Malignancy

The bone scan can be helpful in monitoring response to therapy. The use of the bone scan to assess the response to therapy is not always straightforward. Flare response : transient worsening of scan findings in response to treatment in the first few months after therapy.

Breast Cancer

An important part of staging in breast cancer patients. In early breast cancer, the pick-up rate of metastases is low, about 3% in stage II. However, bone scan has a useful role as a baseline study In more advances disease, at presentation the pick-up rate of metastases is high ( 28%). An abnormal bone scan carries a mean survival of 2-3 years, and is clearly of prognostic importance

Prostate Cancer Higher incidence of metastases (around 38% ) & increases in more advanced disease good case for bone scan in all patients for staging.
Prostate-specific antigen (PSA) is used to detect metastases. Although patients with an elevated PSA should have bone scan. It is common to find patients with normal PSA but who have skeletal metastase.

Lung

Cancer

Most patients with lung cancer have a poor prognostic at presentation. The bone scan important in such patients where surgery is considered to exclude skeletal metastase.

Primary Bone Tumours


A

wide variety of benign & malignant tumours can be investigated with bone scintigraphy. Of malignant tumours : osteosarcomas, Ewings tumours, & giant cell tumours usually show increased tracer uptake on both blood pool & delayed images.

Primary Bone Tumours

Among benign tumours, bone scan in most useful for detecting osteoid osteoma, as radiographs are commonly normal & the bone scan has a characteristic appearance Osteoblastomas & chondroblastomas also show increased activity on both blood pool & delayed images but have characteristic X-ray appearances.

Osteomyelitis

The use of bone scan for osteomyelitis has become an established routine procedure. Uptake in osteomyelitis is usually focal & present in all three phases. A bone scan will often show increased activity about 2 weeks before an X-ray becomes positive.

Metabolic Bone Disease

Increased uptake in axial skeleton Increased uptake in long bones Increased uptake in periarticular area Faint or absent kidney images Prominent calvaria and mandible Beading of costochondral junction Tie sternum

Avascular Necrosis
infarction complication of fracture Bone scan reduced uptake due to diminished blood supply.
Bony

Imaging infection/inflammation

Inflammation reaction of the body to any kind of injury Infection simply means contamination with microorganism

Radiopharmaceuticals for image infection

Non specific : Ga-67 citrate increased blood supply, vascular permeability and enhanced transudation Specific : specific processes of accumulation comprise a number of possible interaction between the radiopharmaceuticals and the target

Leucocytes : HMPAO, cytokines, interleukin-1, 2 and 8, platelet factors 4 Antibiotics : ciprofloxacin , peptides FDG-PET

Imaging with Tc99m-Ciprofloxacin (Infecton)

Introduction
Ciprofloxacin is an antibiotic with the property of binding to actively dividing bacteria. It binds to the DNA-gyrase enzyme. A study showed that it binds to a wide range of bacteria, particularly staphylococci appropriate for imaging infection.

Introduction
Imaging is undertaken at 1 hour & 4 hour after injection. In particular circumstances, a 24 hour imaging is essential.

Normal Features

Vascular, renal & urine activity are visible because infecton is renally excreted. Decrease of liver,spleen & blood pool activity with time. No bone marrow uptake the problem of bone marrow interference in the interpretation of inflammatory change does not arrise. Symmetrical uptake in bone epiphyses in growing children is a normal variant.

Clinical Advantages
The main indication : when there is a need to localise the site of bacterial infection, example : in patient with a fever of unknown origin. Its particular use in distinguishing active bacterial infection from inflammatory particularly in orthopaedic conditions : osteomyelitis, septic arthritis, evaluation of prostheses, vertebral abscess or infection in the sternum after coronary bypass surgery.

In the diabetic foot, is it skin & bone that is infected or skin alone ? In the knee, is it aseptic inflammation or septic arthritis ? In the hip prosthesis, does it have aseptic inflammation or is it infected ? It aids the management of patients with suspected or known bacterial infection, particularly with regard to key issue of when to stop antibiotic therapy.

Acute Inflammation Vs Active Infection


In

typical acute inflammatory joint due to rheumatoid or other arthropathy, the uptake at 1 h & 4 h is visible, but at 24 h it has faded not infected

Acute Inflammation Vs Active Infection

Infecton is a small molecule which rapidly diffuses in & out of sites of inflammation. It diffuses in rapidly because of the extra permeability of an inflammatory lesion. It diffuses out because there is no specific binding & as the blood level of infecton falls, so the level in the inflammation will fall.

Acute Inflammation Vs Active Infection

If there is specific binding, then Infecton will remain bound to that site because of the dividing bacteria.

As

well as its specificity for bacteria, there is a dynamic specificity, which helps to differentiate active bacterial infection from acute or active non-bacterial inflammation.

The

key to the success of this agent is not only that it binds to bacteria, but that it clears quickly from sites of noninfected inflammation 24 h image is essential.

References
1.

Maisey MN, Britton KE and Collier BD (1998). Clinical Nuclear Medicine. 3rd edition. Chapman & Hall Medical. London.

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