1. THE SKELETAL SYSTEM MUDr.Kateřina Táborská

2. Bone scintigraphy Bone physiology and skeletal anatomy balance osteogenesisbone resorption osteoblasts osteoclasts The response of bone to injury or disease ↓ reactive bone formation

3. Radiopharmaceuticals: 99m Tc – diphosphonates ( MDP –methylene diphosphonate) Concentration predominantly in the mineral phase of bone (crystalline hydroxyapatite and amorphous calcium phosphate) iv. distributed via blood flow throughout the body passively diffused into the extravascular and extracelular spaces binding to the hydration shell around the bone crystal unbound radiotracer clears from the plasma via urinary excretion

4. Uptake of RF depends on: 1. blood flow flow must be present for delivery increased blood flow increased deposition 2. metabolic bone activity bony turnover osteoblastic lesions growth centers

5. Patient preparation: good hydration to urinate immediately prior imaging Contraindiaction: pregnancy

6. Two types of bone scans: Standart bone scan: iv., imaging of the entire skeleton, 2-5 h Three-phase bone scan: 1. Phase – angiographic rapid sequence flow images of the area of interest (60 x 1 sec.) 2. Phase (blood pool, soft tissue uptake) ten minut delayed static images 3. Phase (bone) delayed images of the region in question, 2-5 h

7. 3F bone scan

8. whole body bone scintigraphy

9. Bone SPECT

10. Bone SPECT – improved sensitivity greater anatomic details 3D rekonstrukcesagitální koronální transaxiální I. 3D rekonstrukce II. tomographic slices

11. Static images

12. Static images with pinhole collimator ANT pinhole

13. Normal scan: axial and appendicular skeleton Symetry, the bones with minimal soft-tissue activity Both kidneys with mild activity, urinary bladder

14. Normal scan: children increased uptake in growth centers margins of growth plate clearly demarcated

15. Areas : increased uptake 95 - 98% (fracture, osteomyelitis, neoplasia, arthritis) decreased uptake (lytic lesions, early necrosis) Abnormal scan

16. superscan Diffuse symetrical increased uptake Lack of kidney activity

17. Soft tissue or extra-osseous uptake inflammation, calcification, muscle or tumor necrosis, myositis neuroblastoma rhabdomyolysis

18. hydronephrosis hydroureter excretion via genitourinary tract nefrocalcinosis

19. INDICATIONS 1.metastatic disease 2.primary malignant bone tumors 3.benign primary tumors 4.osteomyelitis 5.fracture 6.avascular necrosis 7.metabolic bone disease

20. METASTATIC DISEASE Tumors most likely to metastasize to bone: breast prostate lung lymphoma thyroid renal neuroblastoma

21. METASTATIC DISEASE more sensitive than plain RTG, 30-50% of bone mineral must be lost before a lesion can be detected surveying of the entire skeleton

22. Approximately 90% of metastases are multiple initial staging follow up diffuse bone pain laboratory findings (PSA) Prostate cancer

23. METASTATIC DISEASE flare fenomen 3-6 mo after chemotherapy, hormonal therapy increased uptake in known lesions and even new foci may be seen because of a healing response serial scanning

24. PRIMARY MALIGNANT BONE TUMORS Osteosarcoma Ewing‘s sarcoma 3F bone scan WB - skip lesions and metastatic foci

25. Osteosarcoma 19-year old man with pain of right knee, the initial staging

26. Ewing‘s sarcoma 17-year old man with pain of left knee, the initial staging

27. Osteosarcoma of left tibia Persistent increased uptake at the treatment site 6-12 mo after therapy, compared with a postherapy baseline, is considered suspicious for local recurrence 21-year old man after chemotherapy and amputation

28. usually normal uptake bone cysts bone islands fibrous cortical defects osteiod osteoma negative scan virtually rules out BENIGN PRIMARY TUMORS 16-years old girl with aching pain, worse at night, relieved with aspirin and exercise at right

29. OSTEOMYELITIS 3-phase bone scintigraphy flow – increased blood pool – increased delayed – increased dif.dg. cellulitis – increased only flow and blood pool high sensitive on unaffected bones positive during 24-48 h X-rays normal for first 10-14 days

30. 1.phase 2.phase 3.phase Osteomyelitis (left calcaneous) 1.phase (curve from the region of interest - ROI)

31. multifocal osteomyelitis 13-year old girl with OM of left clavicule

32. 6-year old boy with pain of left thigh 1.phase2.phase 3.phase 1.phase Myofasciitis of left thigh

33. FRACTURE TRAUMATIC will become positive within 24 h 90% normal by 2 years tu pick up old fractures such as in spine child abuse STRESS a) fatigue – caused by repeated abnormal stress on normal bone - runners b) insufficiency – resulting from normal stress on abnormal bone (osteoporosis, postirradiation)

34. polytrauma 27-year old woman after car crash

35. 13-year old boy after fall from tree Fracture of Th 8

36. Stress fracture of left tibia 17-year old girl with painful left leg after training for an athletic event ANT anterior lateral pinhole collimator

37. AVASCULAR NECROSIS Adults – as a result of fracture, metabolic disorder, steroids, hemolytic anemias, vasculitis Children: Legg-Calve- Perthes disease early: decreased activity followed by increasing activity if subsequent revascularisation and healing occur

38. Morbus Perthes l. sin. normalearly phase 5-year old boy with hip pain

39. METABOLIC BONE DISEASE OSTEOPOROSIS OSTEOMALACIA HYPERPARATHYROIDISM (primary, secondary) superscan or complication: pseudofracture,compresive fracture PAGET‘S DISEASE increased resorption of bone accompanied by increase in bone formation newly formed bone is abnormally soft increased uptake due to significant increase in blood flow

40. PAGET‘S DISEASE

41. ADVANTAGES high sensitivity early changes ability to survey the entire skeleton without added radiation (5 mSv)

42. DISADVANTAGES lack of specificity A specific diagnosis often can be made when the bone scan is correlated with other imaging (plain films, CT)