Bone Imaging:

The Indications Of Bone Imaging:

1. Staging Of Malignant Disease
A. Screening Of Patients With Primary Tumors Know To
Known To Readily Metastasize To Bone
1. Prostate Cancer
2. Lung Carcinoma
3. Breast Carcinoma
2. Evaluation Of Response To Therapy
3. Localization Of Biopsy Sites
4. Evaluation & Detection Of Primary Bone Neoplasms:
1. Osteogenic Sarcoma
2. Ewing’s Sarcoma
3. Chondroblastoma, Chondrosarcoma
4. Enchondroma
5. Osteoid Osteoma
6. Fibrous Dysplasia
5. Detection Of Metastatic Bone Disease
6. Detection Of Skeletal Inflammatory Disease Vs Infection:
1. Osteomyelitis ( Infection Of Bone) Vs
2. Cellulitis ( Infection Of Soft Tissue)
7. Detection Of Soft Tissues Metastases & Extraosseous Calcification
8. Determination Of Bone Viability When Blood Supply
Is In Question:
1. Bone Infarction Vs
2. Avascular Necrosis
8. Prosthetic Joint Evaluation:
1. Loosening
2. Infection
9. Evaluation Of Skeletal Pain Of Unknown Cause
10. Diagnosis Of Metabolic Bone Disease
1. Paget’s Disease
2. Rickets
3. Osteomalacia
4. Osteoporosis
 11. Evaluation Of Fractures: Detection Of Occult Fractures
1. Fractures: Diffuse To Assess By Radiographs:
A. Stress Fractures (Occult Fractures)
B. Fractures Of Complex Structures
C. Hairline Fractures
D. Possible Fractures In Battered Children
2. Hip & Knee Replacements
12. Detection Of Bone Growth In Children:
1. The Epiphyseal Regions Of Bone (Example)
13. Evaluation Of Bone Pain In Patients With
Normal Or Equivocal Radiographs
14. Evaluation Of The Significance Of An Incidental
Skeletal Finding On A Radiograph

Bone Radiopharmaceuticals

1. Earliest Applications Of Bone Radiopharmaceuticals: 32 P & 45 Ca:

1. The Observation Of Bone Structure and Function
2. A Pure Beta Emitter
3. Lacked Clinical Application Due To Lack Of
Gamma Emission
B. 1960s: 85 Sr: A Calcium Analog
1. With The Introduction Of The Rectilinear Scanner
2. T ½=65 Days
3. Produces Gamma Emission
4. Energy= 513 KeV
5. Rapid Accumulation In Bone
6. 2-7 Days Were Needed Between Injection Time & Scan
7. Dose= 100 uCi
8. Limited To Patients With Malignancy
C. 87m Sr:
1. T ½= 2.9 hours
2. Dose= 1-4 uCi
3. Scans Performed 2-3 Hours After Injection
4. A Generator Produced Isotope
5. Parent Product Is 87-Yttrium
6. Very Expensive
D. Late 1960s-1970s: 18 F Hydroxyl Analogs
1. Acceptable Radiation Dose
2. Higher Quality Scans Than 87mSr
3. Rapid Blood Clearance
4. High Ratio of Bone / Soft Tissue
5. Disadvantages:
A. Expensive To Manufacture &
Deliver To Large Numbers Of Hospitals
At Large Distances.
E. 1971 : Subramanian Discovered 99mTc Phosphate Complexes:
1. An Ideal Characteristic For The Anger Camera
2. Short Half Life
3. Ability to Image With High Information
Density
F. First Commercially Available Agents: 99m Tc Polyphosphates:
1. Chain Lengths Approximately 40-55 Phosphates
2. Leads To Formation Of A Radiocolloid In The Bloodstream
Causing Hepatic Localization
3. Bone Imaging Time : ~ 4 Hours
4. PIV Time= 4.5 Hours
G. Further Development Led To Pyrophosphates:
1. PIV Time= 3 Hours
H. Currently Used Diphosphonates: PIV Time= 1.5- 2 Hours
1. Examples:
A. Methylene Diphosphonates (MDP): Tc99m Medronate
B. Ethylenehydroxydiphosphonate (EDP):
C. Hydroxymethylenediphosphonate (HDP):Tc99m Oxidronate
2. Blood Clearances of MDP & HDP In
The Initial 3-4 Hours After Administration
Is Very Similar To 18 F-FDG.
3. MDP (Medronate) Has A Faster Blood Clearance
Than Other Labelled Phosphate Compounds.
4. HDP Has A Greater Uptake
5. MDP & HDP Labelled With 99mTc
A. Provide A Better Bone Image
Because Blood & Tissue Concentrations
Have A Higher Target To Tissue Ratio.
6. MDP & HDP Are Comparable Quality
Imaging Agents
 7. Approximately 50% Of The Administered
Tracer Is Concentrated In Bone Tissue
8. The Other 50% Of The Tracer Is Excreted
Through The Kidneys
6. Mechanism of Accumulation:
A. Related Both To
1. Vascularity: Blood Flow
A. Blood Flow Is Required To Bring The RP
To Bone
B. Increases Blood Supply To An Area
Of Bone Which Results In A Blood Pool Image
With Increased Activity Immediately
After RP Administration
2. Rate Of Bone Production Or Remodelling
A. Bone Remodelling : Is Process By Which
Bone Is Constantly Being Detroyed Or Replaced
With New Bone Throughout Life.
B. Localization of Bone Imaging Agents Is Related
To Exchange Of Ions In Bone Colloid: Via:
1. Heterionic Exchange: The Process
Of Exchange of An Ion Native To Bone
For A Labeled Bone Seeking Ion/ Plus
2. Chemisorption With Hydroxyapatite In
Bone Matrix.
I. These Tc Labeled Diphosphonate Compounds Require
1. Lower Quantities Of Activity To Be Administered
2. With Resultant Lower Radiation Doses
3. A Monoenergetic Gamma Ray Emission = 140 Kev
& Lack Of Particulate Radiation Makes It A Well Suited
RP For The Scintillation Camera.
4. Dose = 20-30 mCi In Adults: (740MBq To 1.11GBq)
250-300 uCi/ Kg In Children (9-11MBq/Kg)
With A Minimum Of 0.5-1.0 mCi In Children (20-40 MBq)
5. Very Low Cost
 J. Tc99m Based Diphosphonate Radiopharmaceuticals:
1. Show Resistance To Hydrolysis
2. Rapid Renal Excretion
3. High Target/Non Target Ratio In 2-3 Hours After
After Injection
A. With 50-60% Of Activity Localizing In Bone
B. 40-50% Activity Cleared By The Kidney
4. Factors That Impair Renal Function Increase Soft
Tissue Activity Which Reduces The Quality Of A
Bone Scan.
5. Maximal Skeletal Uptake: About 5 Hours
6. Biologic Half-Life Tbiol = 24 Hours

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.

The Following Characteristics Of The Radiopharmaceutical

Agents Are Archieved By:
1. High % Of Radiopharmaceutical Uptake In The Bone
2. Rapid Radiopharmaceutical Uptake Into Bone
3. Rapid Blood Clearance Of The Radiopharmaceutical
From The Blood By The Excretory Organ Which Are
Kidneys
(This Is Reason We See The Kidneys On The Bone
Image)
Patient History: Should Include:
1. Patient’s Diagnosis
2. Recent Injuries & Or Surgeries
3. Previous Injuries To Bone
4. Medications (Certain Medications
May Alter Tracer Distribution
5. Location, Duration And Frequency Of Pain
(If Patient Is Experiencing Bone Pain)
6. Serum Alkaline Phosphatase Levels
7. Prostate–Specfic Antigen Levels In Patients
With Prostate Cancer And Chemotherapy And Radiotherapy
That May Affect The Results.

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

Imaging Techniques In Bone Imaging:

A. Spot View Technique
1. Visualizes A Particular Region Of The Skeleton
2. Only Performed For CertainViews.
3. Perform Equal Time Counting To Obtain Uniform Count
Density For Different Spot Vies Of The Body
4. 10-30 Separate Images May Be Required
To Image the Entire Skeleton
5. A Medium Or High Resolution , Parallel-Hole Or
Diverging Collimator Can Be Used.
6. An Anterior Or Posterior View Of the Chest
Is Imaged For A Pre-Set Number Of Counts
7. 500-1000,000 Counts Are Recommended
8. All Subsequent Images Are Collected For The Same
Time Interval.
9. Therefore, The Density Of One Image Can Be Compared
With That Of Another
10. Multiple Spot Films Of Particular Regions Are
Obtained As Dictated By:
A. Patient History B. Symptoms
B. Whole Body Imaging
1. Whole Body Imaging Sweep Areas
Across The Table
2. One To Three Passes Are Required
To Cover The Width Of the Patient’s Body
Depending On The Size Of Field Of View
And The Collimator Used
3. Requires 20-30 Minutes For Whole
Body Sweep.
4. Total Counts=25 Million Counts
The Technique :
5. A Low Energy, High Resolution Or Ultrahigh
Resolution Parallel Hole Collimator.
6. Counts Should Be A Minimum Of 1000K Per View.
For Whole Body Imaging With 256 X 256 X 216 Or Greater
Matrix.
7. Spot Images Should Have A 128 X 128 X 16 Or
256 X 256 X 16 Matrix
8. The Scanning Speed Should Be Adjusted So Routine
Anterior & Posterior Whole Body Delayed Images Contain
1.5 Million Counts.
9. Routine Views Should Include: Anterior & Posterior
Views Plus A Lateral Skull Image.
A. Patient Positioning: Can Be Supine,Prone Or Sitting
B. Photopeak Selection Should Be 140KeV With A 20% Window
C. Dosimetry In Rad/ mCi Of Administered Activity: Should Be
1. Effective Dose: 0.02
2. Bone Surface: 0.23
C. SPECT Imaging:
1. Is Useful For Imaging Limited Areas Of The Skeleton
Where Bony Structures Are Superimposed One On Another.
2. These Areas Include:
A. The Knees
B. Hips
C. Lumbar Spine
D. Facial Bones
3. Use A Low Energy, All Purpose, Parallel Hole Collimator
Recommended.
4. Minimize Patient-Detector Distance
5. This Distance Will Vary, Depending On The Area Of
The Body Being Imaged, Because The Detector Must Be Able
To Rotate Around The Patient Unimpeded For 360 Degrees
Image Findings:

1. RP Is Normally Taken Up Symmetrically

Throughout The Skeleton.
2. Areas Of Normally Increased Activity Include:
A. The Sacroiliac Joints
B. Anterior Iliac Crests
C. Sternum
D. Nasopharyngeal Area
E. The Shoulder Joints
F. Spine
3. Children: Have Increased Tracer Concentration
At:
A. Epiphyseal Plates Of Long Bones
B. Costochondral Junctions
Due To Increased Bone Production
4. The Elderly Have Overall Decreased Skeletal Uptake
Than Younger People.
5. Activity In The Kidney Is Usually Less Than Bone Activity
But The Kidney Activty Can Vary And May Indicate
Certain Types Of Renal Disease
6. Tracer Accumulation Can Also Occur In Normal Breast Tissue
As Well In Certain Breast Diseases
Diagnosis of Cellulitis From Osteomyelitis:
A. Requires:
1. A Blood Flow Dynamic Study Of 30 Frames
A. With A 64 X 64 X 16 Or Greater Matrix
B. At 1-3 Seconds / Frame
2. A 3-5 Minute Blood Pool Static Image
A. 128 X 128 X 16 Or Greater Matrix
B. 200-3000K Counts Per Image
Within 10 Minutes of Injection
Over The Region Of Interest
2. Delayed Static Images Are Taken:
A. At 3-4 Hours Later
B. 24 Hours Delayed Images May Be Necessary
C. 48 Hour Delayed Images May Be Necessary

Visualizations Patterns In General:

Osteomyelitis Cellulitis

Blood Flow Dynamic Hot (In Bone) Hot (In Soft Tissue)

Blood Pool Static Hot (In Bone) Hot (In Soft Tissue)

Delayed Static Images Hot (In Bone) Normal ( In Bone&

Tissue)

Note:

1. Cellulitis: Tends To Visualize As Widely A Diffuse Area Of

Visualization
(Looking Like It Is In Bone & Soft Tissue Areas)
2. Ostemyelitis: Tends To Visualize As More Focal In Bone Visualization
Normal Scans:
A. In Children : In The Areas Of Growth In
The Epiphysis Show Intense Radionuclide Accumulation.
B. In Adults: The Older The Adult The Higher The Proportion
Of Poor Quality Scans Are Obtained.
C. There Usually is Good Skull Visualization.
D. Focal Maxillary & Mandibular Alveolar Ridge Activity
Is Often Seen In Adults Due To Dental Disease
E. It Is Common To See Focal Areas Of Increased Activity
Through Lower Cervical Spine Secondary To Degenerative
Changes (Osteoarthritic Changes) Or Lordosis.
F. On Anterior Views:
1. Look For Bladder Activity
2. Look For Displacement Of The Bladder
G. On Posterior Views:
1. The Thoracic Vertebrae Show Degenerative Changes Often
In The Elderly
2. The Sacroiliac Joints Are Often Pronounced
H. Assymmetric Osseous Activity Should Be
Viewed With Suspicion.
I. Look For The Presence & Location Of Renal Activity:
1. Focal Space Occupying Lesions Produce A
Photopenic Defect Especially In The Renal Cortex.
2. Displacement of The Kidneys May Also Be Present
J. If UTIs Are Suspected :
1. Kidney Views Should Be Repeated After Patient
Ambulation To Distinquish Obstruction Vs.
Position Related Collecting System Activity
Extravasation:

When Giving IV Injections Even The Slightest

Extravasation At The Injection Site Can Cause A Focus OF
Markedly Increased Soft Tissue Activity.(A Focal Spot)
&
The Glove Phenomenon
A. Is Inadvertent Arterial Radiopharmaceutical Injection
& It Localized Areas Of Soft Tissue Activity In The
Extremity Distal To The Site of Injection May be Seen/
Initial Accumulation of Technetium Based Radiopharmaceuticals
In Bone Is:
1. Primarily Related To Vascularity Or Blood Supply.
2. Other Factors Play A Role:
A. Capillary Permeability
B. Local Acid Base Relations
C. Fluid Pressure Within The Bone
D. Hormones
E. Vitamins
F. Quantity Of Mineralized Bone
G. Bone Turnover

Mechanism Of Localization of Bone Imaging Agents:

The Process Of Agents Accumulating In Bone Is

Not Completely Understood. It Is Believed To Be A
Combination Of The Following Factors:

1. Blood Flow To Bone & The ECF In Canaliculi

& Lacunae

2. Heterionic Exchange Or Chemisorption With

Hydroxyapatite In Bone Matrix
Causes Of A Cold Lesions (Spot) On A Bone Scan:

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

Warm Spots Needed To Be Evaluated Where The

Radiopharmaceutical Localizes Outside The Bone Such As:
A. Myocardial Infarction
B. Cerebral Infarction
C. Some Soft Tissue Infections
D. Healing Trauma Or Wounds
E. Inflammatory Diseases Of Heart & Muscle
All Of These Diseases Can Have Increased Calcium
Deposition At These Soft Tissue Locations.
Summary:
1. Hot Spots On A Bone Scan:
A. Increased Vascularity
1. More Radiopharmaceutical In Bone
B. Increased Osteoblastic Response
1. Increased Bone Deposition Or Remodeling
2. Increased In-Flow Of Minerals
Which Leads To Increased Heterionic Exchange
Or Chemisorption Due To More Hydroxyapatite Present

2. Cold Spots On A Bone Scan:

A. Decreased Or No Vascularity: Poor Perfusion
Of An Area Of Bone
1. Little of No Radiopharmaceutical In Bone
The ECF In Canaliculi & Lacuane
B. Increased Osteoclastic Response
1. Increased In Bone Destruction Or Dissolution
2. Increased Outflow Of Minerals
Which Leads To Decreased Heterionic Exchange
Or Chemisorption Due To Less Hydroxyapatite Crystals.
C. Overlying Attenuating Material
D. Gamma Camera Dysfunction
1. Poor Photomultipier Tube

SPECT Is Useful For Localization In:

A. Vertebral Bodies
B. Disk Spaces
C. Posterior Elements.

1. The Transverse SPECT Images Resemble CT Sections/

2. The Coronal & Sagittal SPECT Images Are Analogous

To AP & Lateral Radiographic Tomograms/
SPECT/CT:
1. Uses:
A. Bone Infection: Osteomyelitis
Conflicting Examinations & Medications:

1. Increased Renal Uptake By:

Amphotericin B
Aluminum Antacids
Iron Preparations
Aluminum 3- Ions In Preparation
Radiation Therapy
Recent Radiographic Contrast Medium
Sodium Diatrizoate
Dextrose
Gentamycin
Chemotherapy Agents: Particularly:
A. Vincristine
B. Doxorubicin
C. Cyclophophosphamide

2. Increased Breast Uptake:

Gynecomastia Producing Drugs
Digitalis
Estrogens
Cimetidine
Spironolactone
Diethylstilbestrol (DES)

3. Increased Gastric Uptake:

Isotretinoin

4. Increased Liver Uptake:

Aluminum Antacids
Iron Preparations
Aluminum 3- Ions In Preparation
Excess Sn+2 Ions In Preparation
Recent Radiographic Contrast
Sodium Diatrizoate
Alkaline pH
5. Increased Splenic Uptake:
Phenytoin
Aluminum Preparations

6. Excessive Blood Pool Activity:

Aluminum Preparations
Iron Dextran
Too Few Sn+2 Ions In Preparation

7. Focal Soft Tissue Or Muscle Uptake:

Result From
Iron Dextran Injections
Calcium Gluconate Injections
Heparin Injections
Meperidine Injections
Radiography:
1. Based On Density Of Tissues.
2. Use Of Barium: Increase Contrast and Visualize The GI Tract
3. Use Of Iodine: Visualization Of Blood Vessels

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.

Increased Blood Flow = An Osteoblastic Response

Decreased Blood Flow = An Osteoclastic Response

One Can See Pathologies Of Bone Earlier On

A Nuclear Medicine Study Than X-Ray.
Bone Pathology & Physiologic Action:

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

Typical Activity Of Benign Bone Tumors On

Bone Scans:

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

C. Other Metabolic Bone Disorders:

1. Osteoclastic Response
Outflow Of Minerals & Calcium
D. Osteoporosis: Normal Pathologic Response
4. Infections: Osteomyelitis: Hot Spot
A. Increased Blood Flow: Brings In WBCs
B. Osteoblastic Response Of Bone :
1. To Repair Microorganism Damage To Bone
C. Hot Spot On Bone Scan
5. Bone Infarction: Cold Spot
A. Thrombus Or Embolus Blocks Blood Flow
B. Therefore: No Blood Flow Downstream Of TheThrombus
C. Therefore:No Radiopharmaceutical Reaches The Bone
D. A Cold Spot on Bone Scan Appears
6. Joints: Hot Spots
A. Always Give Hotter Images Than Normal Bone
B. Why: Always Moving Your Joints: Joints Always In Motion
C. Therefore: There Is Always A Little Damage And Little Repair
7. Children & Teenagers: Hot Spots/ Osteoblastic Resposnse
A. Growing Bones
B. Epiphyseal Plates Are Growing/ Bones Are Growing
C. Osteoblasts Laying Down More Bone
D. Hot Spots on Bone Scan
8. Radiation Therapy To A Given Area Of Bone:
1. Multiple Sequential Cold Lesions Of Vertebral Bodies (Example)
A. RT Kills The Bone Tumor Cells In A Given Area
B. Therefore RT Inactivates That Bone Area
C. Gives Multiple Sequential Cold Lesions On Bone Scan

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.

10. Causes Of Focal Soft Tissue Activity On A Bone Scan:

A. A Process That Produces Bone:
1. Metastatic Osteosarcoma
B. Calcified Soft Tissue:
1. Colon Cancer
2. Ovarian Cancer
3. Breast Cancer
C. Dystrophic Calcification:
1. Infarction
2. Myosisits OSsifcans
3. Tumoral Calinosis
4. Dermatomyositis
5. Polymyositis
12. Focal Liver Activity On A Bone Scan:
1. Metastatic Disease: From
1. Colon Cancer
2. Breast Cancer
3. Ovarian Cancer
4. Lung Cancer

13. Diffuse Liver Activity On A Bone Scan:

A. Causes:
1. Hepatic Necrosis
2. Radiopharmacetical Problem

14. Diffuse Splenic Activity On A Bone Scan:

A. Splenic Infarction:
1. Sickle Cell Anemia

15. Difuse Renal Parenchymal Activity On A Bone Scan:

A. Chemotherapy
1. Especially With Bone Metastases

.
 Bone Inflammatory Disease (Osteomyelitis)
Vs
Soft Tissue Inflammatory Disease (Cellulitis)

Visualization Patterns Osteomyelitis 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

2. Osteomyelitis: Tends To Visual As More Focal in Bone Visualization.

3. Other Causes Of Three Phase Positive Bone Scan:

A. Acute Fractures
B. Ewing’s Sarcoma
C. Reflex Sympathetic Activity

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

You Will Need Increased Time Of Imaging To Obtain

Statistical Accuracy With Tc99m Based Radiopharmaceuticals

IE: Four Times As Much Time Is Required For Imaging

For Four Half Lives Of Tc99m RP

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

A. If There Is Generalized Increased Activity Around A Hip

Prosthesis Especially The Shank (The Stem) It May Be
Indicative Of Osteomyelitis

1. If There Is A Question Of Infection:

A Gallium Scan May Be Useful Because
A Normal Scan Effectively Excludes Osteomyelitis
As The Cause Of Symptoms.

2. If The Gallium & 99m Tc Diphosphonate Distiributions

Are Spatially Incongruent Or If They Are Spatially
Congruent But Gallium Activity Exceeds The
Technetium Activity, Osteomyelitis Should Be Considered.

3. If The Gallium & Technetium Images Are Partially

Congruent & Equal In Intensity, The Study Is Considered
Equivocal.

4. An Infected Joint Replacement Is More Specifically

Diagnosed By Comparing An 111 In Or 99mTc
Labelled WBC Image With a 99mTc Cooloid Bone
Marrrow Scan

5. When There Is Periprosthetic Leukocyte Accumulation

Without Corresponding Marrow Activity On The Colloid
Images : The Study Is Positive For Infection
2. Differential Diagnosis Of Osteomyelitis
On A 3 Phase Bone Scan:
A. Osteoarthritis
B. Recent Acute Fracture
C. Stress Fractures
D. Neuropathic Joints
E. Gout
F. Charcot Joint
G. Osteotomy
H. Reflex Sympathetic Dystrophy
I. Orthopedic Implants

3. Other Entities Which Can Be 3 Phase Bone Scan Positive:

A. Paget Disease
B. Bone Tumors
C. Recent Fractures

3. 24 Hour Delay Images:

A. Increase The Sensitivity & Specificity Of The Study.
B. Look For An Increase Target/ Background Radioactivity

Hepatic Uptake of Tc99m Phosphate Compounds:

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

Increased Uptake Of Tc99 Labelled Bone Imaging

Agents In The Kidneys:

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

4. Degenerative Joint Disease:

A. Older Populations
B. Moderate To Increased Semi Focal Uptake Seen
On Both Central & Peripheral Joints:
Shoulders, Spine, Hips & Knees
C. Uptake Is Less Intense Than Rheumatoid Arthritis
D. If Very Intense, There Is Very Focal
Uptake: R/O Primary Or Secondary Tumors
DD:
Rheumatoid Arthritis:
1. More Joint Space Uptake &
2. More Uptake Along Bones Of The Joint

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

6. Septic Arthritis: 3 Phase Bone Scan Almost Always Seen As

A. Increased Blood Flow Dynamic Activity
B. Increased Blood Pool Static Activity
C. Increased Delayed Static Images
Usually Can Be Differentiated From Osteomyelitis
By The Presence Of Diffusely Increased Bone Activity
On Both Sides Of The Joint

7. Trauma & Fractures

A. Bone Scan Appearance After A Fracture
May Be Divided Into:
1. Acute Phase
2. Subacute Phase
3. Healing Phase
B. The Acute Phase:
1. Usually Lasts From 3-4 Days &
2. Demonstrates A Generalized Diffuse Increase
In Activity Around The Fracture Site.
C. The Subacute Phase:
1. Last For 2-3 Weeks
2. With Activity More Localized & Intense
D. The Healing Phase:
1. May Occur Over A Much Longer Time Period &
2. Is Accompanied By A Gradual Decline In Intensity
Of Radiotracer Activity.
E. Post Fractures:
1. Most Fractures Show An Early Increase In Activity
As A Result Of Hyperemia & Inflammation.
2. Repair Begins Within a Few Hours
& Reaches A Maximum In 2-3 Weeks
3. Elderly Adult:
A. A Later Onset Of Uptake
B. Bring The Patient Back For Another Study In A Week
4. The Location Of The Fracture Determines The Time
Of Appearance Of Increased Activity On The Bone Scan
 5. In The First 3 Days:
A. Only 30 % Of Pelvic & Spinal Fractures
Show Increased Activity
6. Virtually All Recent Fractures In The Axial
Skeleton & Long Bones Can Be Seen By 14 Days.
7. Skull Fractures Constitute A Major Exception
A. They May Not Show Any Increase In Activity
On A Bone Scan.
8. Rib Fractures Almost Always Show Intense
Activity & Can Be Recognized Often By Their Location
In Consecutive Ribs: Generally Speaking
9. Single Rib Fractures Are Often Difficult To
Distinquish From A Metastasis
A. But Eliciting A Trauma History From
The Patient May Be Helpful.
B. Rib Fractures Present As Punctate
Foci Of Increased Activity.
C. Neoplastic Lesions Frequently Have
A More Linear Distribution Following The
Long Axis Of The Ribs
10. About 3 Days: Are Needed To Reliably
Detect A Hip Fracture In The Elderly
On A Bone Scan.
11. Therefore Many Clinicians Prefer To Order
An MRI Scan & Do Prompt Surgery
Rather Than Leave An Elderly Patient In Bed
& Wait For A Bone Scan.
F. Return Of A Bone Scan To Normal
After A Fracture Or Surgical Trauma Is Variable.
A. Fractures Or Even Craniotomy Defects In Older
Patients May Be Visible On Bone Scans For Several
Years.
B. Few Fractures Of Weight Bearing Bones Return To
A Normal Bone Scan Appearance Within
5 Months, Whereas About 90% Are Normal In 3 Years.
C. More Intense & Prolonged Uptake Has Been Demonstrated:
In Fractures With :
1. Open Reduction Was Peformed Or
2. A Fixation Device Is Applied
 D. Fracture Can Be Positive 50-60 Years Later:
Why? Site Of Remodeling May Be Present.

E. Factors Which Advance The Timetable Of Healing Include:

1. Poor Approximation Of Fracture Ends
2. Underlying Bone Abnormalities May Be Present:
1. Osteoporosis
2. Bone Tumor
3. Osteogenesis Imperfecta
----------------------------------------------------------------------------

Time After Fracture At Which A Bone

Scan Becomes Abnormal:

Time After Fx % Abnormal

Patients < 65 Yrs All Patients

1 Day 95 80
3 Days 100 95
1 Week 100 98

----------------------------------------------------------------------------

Time After Fx At Which A Bone

Scan Returns To Normal:

Fracture Site % Normal Minimum Time To

Return To Normal (Mo)

1Yr 2Yr 3Yr

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

9. Shin Splints: Medial Tibial Stress Syndrome

A. A Three Phase Bone Study Is Performed
B. Normal Blood Flow Image
C. Normal Blood Pool Images
D. Usually The Third Phase Bone Scan Is Positive
E. Delay 3 Hour Images: There Is Increased Activity
In A Linear Distribution Of the Posteromedial
Tibial Shafts

10. Stress Fractures:

A. Occurs Often In
1. The Femoral Neck
2. Wrist
3. Scaphoid Bone
4. Vertebrae
B. Often Difficult To Visualize On
Plain X-ray Radiographs
C. Often These Fractures Are Not
Visualized For 7-10 Days :
1. Why ? By Which Time Interval
Decalcification Becomes Apparent
Radiographically Around The Fracture Site
2. However, Radionuclide Bone Scans
Are Frequently Positive At The Time
Of Clinical Presentation & Offer
A Means Of Early Diagnosis & Treatment
D. On A 3 Phase Bone Study:
1. Increased Activty On Blood Flow
2. Increased Blood Pool Activity
3. Tend To Be More Focal or Fusiform On Delayed Images
E. In Conclusion:
1. Bone Scans : An Excellent Means Of Diagnosis
Of Either Fatigue Or Insufficiency Stress Fractures.
11. Insufficiency-Type Stress Fractures
A. Usually Occur :
1. In The Pelvis
2. Around The Knees
B. An Occur Due To Osteoporosis

12. Battered Children Fractures:

A. Characteristic Rib And Thoracic Spine
Fractures Are A Strong Indication
Of Physical Abuse

13. Elderly Patients

A. Bone Scans May Not Show A Fracture
For Several Days.
B. However Effectively Excludes Occult Fracture
C. SPECT Scans May Occasionally May be Useful
For Demonstration Of Occult Fractures In The Spine.
D. SPECT Imaging of The Spine May Be Helpful
For Detection Of Pseudoarthrosis.
B. Pronounced Increase In Uptake More Than 1 Year
After Fusion is Highly Indicative Of Motion
In A Failed Spinal Fusion

14. Entities Which May Be Distinquished From

Other Entities Which May Be 3 Phase Bone Scan Positive:
1. Plantar Fascitis
2. Achilles Tendinitis
3. Bunyons
4. Retrocalcalcaneal Bursitis

15. Bone Contusion:

A. A Blow To The Chest
B. Osteoblastic Activity
16. Avascular Necrosis:
A. Causes:
1. Trauma
2. Steroid Administration
3. Vascular Diseases
B. Femoral Head & Neck
C. Without Sepsis
D Without Blood Supply
E. 25-40% Of All Fractures
F. Avascualarity = Cold Area on Flow
& Blood Pool Image Of A 3 Phase Bone Scan
G. Cold Area Surrounded By Increased Uptake On Delayed
Images On A 3-Phase Bone Scan Are Seen
H. Relative Decreased Activity In The Femoral Head
Suggest Avascularity.
I. Either Dipshosphonate Or S Colloid Imaging Can Be
Used.
J. SPECT Imaging:
1. Increased Ability To Evalaute
Avascular Necrosis
K. Rx: Replacement of Femoral Head & Neck

17. Hip Replacement:

A. Complications
1. Loosening
2. Infection

B. Types OF Hip Replacement:

1. Total Hip Replacement
A. An Acetabulum & Femoral Head Prosthesis
2. Austin Moore Prosthesis

C. Loosening Of A Hip Replacement:

1. Three Point Sign: Increased Uptake At
Pivot Points: Due To Increased Osteoblastic Activity
 D. Infections Of A Hip Replacement:
1. Use a 3 Phase Bone Scan
2. Linear Spot Along The Shaft Of The Prosthesis

E. Porous Coated Prosthesis:

1. Increased Uptake At Tip Normally

F. Indirect Stress Effects:

1. Changing Gait & Weight Bearing
2. Paralytic Efffects Are A Long Term Effect

Normal Leg Will Show Increased Uptake

Because The Patient Change His Center Of Gravity

G. Damage To Arteries Supplying Specific Bone:

1. Early Diffusely Decreased Uptake In Bone
As Vascularity Increased So Also Did
Osteoblastic Activy

H. May Need Gallium Scanning To Evaluate Loosening

Of Hip Replacement.

18. DD Of Increased Uptake In Bone:

1. Adaptation To A Prosthesis:
A. Trauma To Stump In The Prosthesis
2. Biopsy Sites
3. Bone Harvesting For Laminectomy
4. Bone Spinal Fusion
5. Bone Marrow Aspirate Sites
6. Tooth Extraction

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

21. Radiation Injury To Bone:

A. Multiple Factors Determine The Bone Scan Findings
After Radiation Treatment:
1. Cumulative Amount Of Radiation
2. Fractionation Of Dose
3. Length Of Time After Therapy
B. Immediate Period After Radiation
Increased Uptake
C. After Fractionated Doses Of 4000-5000 Rad
(40-50Gy) To Bone There Is Decrease In
Localized Vascular Patency To Bone In The
Area Of Treatment Within The First Month.
D. The Vascularity May Return To Near Normal
In About 6 Months Is The Reduced Again
Due To Endothelial Proliferation & Arteriolar
Narrowing.
E. An Abrupt Geometric Decrease Osseous Activity
Should Raise The Suspicion Of Skeletal Trauma
Due To Radiation Therapy.
22. Paget’s Disease:
A. Unknown Etiology
B. Assymmetric Increased Uptake Due To Greatly
Increased Regional Blood Flow
C. There Is Notable Expansion Or Enlargement Of Bone
D. The Disease Is Polyostotic In 70-80% Of The Cases
The Most Common Sites: Upper Femur, Skull,
Spine, Pelvis, Ribs
E. Uptake In Serial Bone Scans One Sees Improvement
& Less Uptake On Bone Scans.
F. When The Lesions Are Intense :
a. This Is The Period Of Most Pain
G. It Has The Highest Bone/ Soft Tissue Uptake Ratios
Of Any Metabolic Bone Disease.
H. Sarcomatous Degeneration Occurs In 1 % Of The
Cases.
I. Later The Malignant Area May Appear Photopenic.
J. In 111WBC Study Or Sulfur Colloid Study
Used To Analyze The Bone Marrow :
1. There Is Decreased Uptake In The Bone Marrow
While Bone Scan Shows Increased Uptake
In Paget Disease

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

25. Dialysis & Renal Failure:

A. Increased Bone Uptake
B. High Bone/ Soft Tissue Ratios
C. Extraosseous Localizations Such As:
Head, Lungs, Kidneys, Skeletal Muscle

26. Diabetic Osteoarthopathy:

A. Diabetes Mellitus
B. Generalized Increased Bone Uptake
C. Sites: Distal Lower Extremities: Feet
D. Indicates Susceptibility To Fractures
E. Patient Develops Charcot Joints.

27. Charcot Joints: Three Phase Bone Scan Positive

A. Involves Nerve Destruction In Diabetes Mellitus
B. Diabetic Effects In Blood Supply
C. Trauma Will Precipitate It Such As:
1. Everyday Walking Will Cause Microtrauma
D. There Is Breakdown& Remodeling
E. The Tarsals And The Metatarsal Bones Usually Affected

28. Pulmonary Hypertrophic Osteoarthropathy:

A. Bilateral Symmetric Uptake In Long Bones
1. Especially The Tibia
B. An Oxygenation Problem
C. Seen In Cardio-Pulmonary Disorders
D. Seen In Lung Cancer Pateints
29. Abnormal WBC Accumulation In Bone:
A. Osteomyelitis
B. Periostitis
C. Acute Arthrides
D. Healing Fractures
E. Heterotopic Ossifcation
F. Compacted Bone Marrow From Prostheses
G. Paget Disease
H. Neolasms
Osteochondromas
Primary Tumors OF Bone
I. Large Osteophytes
J. Sesamoid Bones With Marrow
K. Areas Of Expanded Marrow : Anemias
Osteoporosis:

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

2. Mechanism OF DEXA & DPA Operation:

A. Highly Collimated Beam Of X-Rays Or Photons
Passes Through The Soft Tissues & Bony
Components Of The Body Part Examined
B. Detection Via A Scintillation Detector.
C. Because Bone Mineral Absorption (Body Part)
Examined Attenuates The Photon X-Ray Beam
The Intensity Of The Beam Exiting The Body Part
Is Indirectly Proportional To The Density Of The
Bone Structure Examined.
D. The Beam Consists Of Photons Or X-Rays
Of Two Discrete Energies Which Obviates
The Need For Assumptions About Soft Tissue
Shape & Attenuation.
 E. Purpose: Allows Evaluation Of Thicker Body Parts
& Bones Involving Complex Geometry Such As
The Spine& Femoral Neck
F. Scan Time =2-5 Minutes For DEXA
G. Scan Time = 20-40 Minutes For DPA
H. Precision & Image Quality Are Better For DEXA

3. Falsely Elevated Bone Mineral Content

When Evaluating The Spine:
A. Aortic Calcification
B. Scoliosis
C. Hypetrophic Degenerative Disease
D. Compression Fractures
E. Calcium Or Barium in The GI Tract
F. Renal Lithiasis
G. Bone Grafts
H. Focal Sclerotic Lesions
I. Recent Aluminum Containing Antacids Intake

4. Falsely Low Mineral Results

A. Laminectomy Patients
B. Bone Lytic Lesions

Plain Radiographs Are Suggested In These Cases

Prior To The Procedure/

5. Bone Mineral Density Scoring:

A. Z Score:
1. Compare Patient’s Bone Mineral Density
To Age Matched Control Group
B. T Score:
1. Compare Patient’s Bone Mineral Density
To Young Normal Population
C. T Scores:
Greater Than (Less Negative) Than -1.0
(<1 Standard Deviation Below Young Normal
Controls) = Normal

Between -1.0 & -2.5 Is Evidence Of Osteopenia

More Negative Than -2.5 Is Consistent With Osteoporosis.

Thus The Examination Can Determine The Presence Of

Osteopenia Or Osteoporosis.

Can Be Used To Evaluate Effectiveness Of A Therapeutic

Maneuver By Using Serial Scans In Which The Patient
Acts As His Or Her Own Control.

Classification Of Standard Deviation

For DEXA Studies ( T Scores)

-1.5 ---- -2.00 Mild Osteopenia

-2.0 ---- -2.25 Moderate Osteopenia

-2.25 ---- -2.49 Severe Osteoopenia

-2.5 ----- -3.0 Mild Osteoporosis

-2.5 ---- -3.0 Moderate Osteoporosis

- -3.5 Severe Osteoporsis

Therapy Of Osseous Therapy:

A. Procedure:
1. A Radionuclide Bone Scan Should Be Performed
Before Therapy To Ensure That There Will Be Uptake
Of The Therapeutic Radiopharmaceutical.

2. External Teletherapy Is Recommended If There

Are Only One Or Two Lesions Causing The Patient’s
Pain Or If There Is Impending Spinal Cord Compression

3. Palliative Symptomatic Improvement Usually Begins

7-20 Days After Treatment & Often Lasts 3-6 Months

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

B. Samarium 153 ( 153Sm) Ethylenediamine

Tetramethylene Phosphonic Acid (EDPMT)
(Also Known As Quadramet)
1. T ½= 46 Hours
2. A Beta Emitter& A Gamma Emitter
3. It Can Be Used For Imaging Done At
6 Hours After Administration
4. Pain Relief Occurs At About 1 Week
& Reaches A Maximum In About 3 Weeks
5. Recommended Dose: 1.0 mCi/ Kg
A. Given IV Over A Period Of 1 Minute
Followed By A Saline Flush
B. Hydration Is Recommended Also
To Reduce The Bladder Dose
C. Precautions Also When Using
The Toilet For 12 Hours Instead
Of A Urinal & Flushing For Several Times
6. Monitor Blood Counts Weekly For At Least 8 Weeks
7. Side Effects:
A. Bone Marrow Suppression
Therefore It Should Be Not Given
Concurrently With Radiation Therapy
Or Chemotherapy Unless The Bone Marrow
Status Has Been Adequately Examined
References:

1. Professor L. Hough CNMT: Nuclear Medicine Class Notes:

Manhattan College: 2008
2. Mettler’s: Essentials Of Nuclear Medicine Imaging : 2006
3. Professor M. Antar MD/PhD & Professor T. D’Alessandro MD :
Nuclear Medicine Class Notes: Northport Veterans Affairs Hospital:
1999-2000.
4, Henkin: Nuclear Medicine 2006
5.Ann Steve & Patricia Wells: Review Of Nuclear Medicine Technology
The Third Edition : 2004