Hyperostosis Frontalis Simulating Metastatic Deposits: Unmasked on SPECT-CT.

Skeletal scintigraphy has a pivotal role in detecting a number of bone pathologies, but it has its own limitations because of 2D image acquisition. Hybrid imaging acts as a savior in these cases where it is difficult to distinguish between benign and malignant lesions just on the basis of planar images. We present one such case of known breast carcinoma with abnormal increased radiotracer uptake in the skull which was difficult to characterize as benign lesion such as hyperostosis frontalis or metastatic osseous lesion. The importance of describing this case is to have a thorough understanding of hyperostosis patterns and to not confuse it with metastatic deposits in patients with known malignancies.

Solitary Osseous Metastasis of Hepatocellular Carcinoma on SPECT/CT.

Hepatocellular carcinoma (HCC), sixth most common cancer world-over, commonly metastasizes to lung, lymph nodes and adrenal glands. Incidence of osseous metastases in HCC has been reported to be 3-20 % which occurs predominantly in the axial skeleton. It only rarely occurs in the appendicular skeleton and that too as the solitary focus of metastatic deposit.3,4 We present a case of HCC with solitary osseous metastases to the proximal tibia.

Myxofibrosarcoma of the Chest Wall Detected on 99mTc-MDP Whole-Body Bone Scan.

Myxofibrosarcoma is a type of soft tissue sarcoma, predominantly characterized by a high propensity for local recurrence, albeit demonstrating a relatively diminished risk for distant metastasis. Its prevalence is notably higher in elderly patients. Here, we present a case of a 73-year-old woman diagnosed with Myxofibrosarcoma. She was subjected to a whole-body bone scan using 99mTc-methylene diphosphonate (MDP) to survey potential bony metastasis. It revealed marked MDP accumulation with peripheral soft tissue uptake in the right lateral chest region of this patient. This imaging phenotype could potentially be attributed to the augmented vascularity within the tumor, a finding that was prominently displayed in this particular case.

The clinical assessment of changes in bone density in rheumatoid arthritis patients': Role of DEXA scan and bone turnover biomarkers.

In addition to generalised of bone loss and a higher fracture risk, rheumatoid arthritis (RA) causes periarticular bone erosions. Improvements in bone density/erosion and turnover may not go hand in hand with a positive clinical response to biological anti-inflammatory drugs assesed by disease activity score 28 (DAS28) in RA patients. This study aimed to understand how biologic anti-inflammatory drugs affect bone density, erosion, and turnover in RA patients. We examined bone mineral density (BMD) and bone turnover biomarkers. The study population consisted of 62 RA patients, 49 (79%) of whom were female and 13 (21%) of whom were male. The patients ranged in age from 40 to 79 years old. The patients' BMD was measured using a DEXA scan, and their plasma levels of bone turnover biomarkers CTX and osteocalcin were quantified utilizing an ELISA. BMD of the hip and lumbar spine in responder patients rose after therapy by 0.001g/cm2 (0.11 percent, p0.001 vs. before treatment) and 0.0396g/cm2 (3.96 percent, p0.001 vs. before treatment), respectively. Clinically non-responder patients' DAS28 revealed minor reductions in hip BMD values of -0.008g/cm2 (-0.78 percent, p0.001 vs. before therapy), as well as an improvement in lumbar spine BMD of 0.03g/cm2 (3.03 percent, p0.001 vs. before treatment). After 12 weeks of therapy, the CTX levels in responder patients dropped from 164 125 pg/ml to 131 129 pg/ml. Osteocalcin levels in non-responder patients increased substantially from 11.6 ng/ml to 14.9 ng/ml after 12 weeks of therapy compared to baseline (p = 0.01). Treatment with biologic anti-inflammatory medicines decreases widespread bone loss in RA patients' hip and lumbar spine. The beneficial effects of therapy on BMD were not associated with changes in disease activity of RA patients. Changes in plasma levels of bone turnover biomarkers such as sCTX and osteocalcin confirmed the treatment's beneficial effects.

Flare phenomenon visualized by 99mTc-bone scintigraphy has prognostic value for patients with metastatic castration-resistant prostate cancer.

OBJECTIVE: This study aimed to determine the prognostic value of the flare phenomenon in patients with metastatic castration-resistant prostate cancer (mCRPC) using the bone scan index (BSI) derived from 99mTc-methylenediphosphonate (MDP) bone scintigraphy images. METHODS: We categorized 72 patients from the PROSTAT-BSI registry with mCRPC who were followed-up for 2 years after starting docetaxel chemotherapy to groups based on pre-chemotherapy BSI values of < 1, 1-4, and > 4. We assessed the effects of the flare phenomenon (defined as a > 10% increase in the BSI within 3 months of starting chemotherapy, followed by > 10% improvement within the next 3 months) on survival using Kaplan-Meier curves and Cox proportional hazard analyses. RESULTS: The flare phenomenon was found in 26 (36%) of the 72 patients. Prostate-specific antigen (PSA), alkaline phosphatase (ALP), and hemoglobin (Hb) levels steadily increased, then deteriorated in patients with and without flare, respectively. Elevated BSI and PSA values at 3 months after starting therapy and the absence of abiraterone or/and enzalutamide therapy led to poor 2-year overall survival (OS) in the group without flare. In contrast, no influence was noticeable in the group with flare. The results of multivariable analyses that included only factors associated with PSA and BSI showed that increased baseline BSI (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.04-1.86; P = 0.023) and PSA (HR, 7.15; 95% CI 2.13-24.04; P = 0.0015) values could be independent risk factors for patients with mCRPC without flare. However, these factors lost significance during flare. The risk for all-cause death was significantly higher among patients with BSI > 4 without, than with flare. The results of univariable analyses indicated that flare positively impacted survival (HR, 0.24; 95% CI 0.06‒0.91; P = 0.035). Multivariable analysis did not identify any factors that could predict outcomes. CONCLUSION: Favorable prognosis, with fewer disturbances from other factors such as the use of abiraterone or/and enzalutamide, PSA changes, and BSI, was attainable in cases when the mCRPC patient demonstrated flare phenomenon. Follow-up bone scintigraphy at least every 3 months could help to determine the prognosis of patients with bone metastasis of mCRPC.

Role of bone scintigraphy (bone scan) in skeletal osteosarcoma: A retrospective audit and review from tertiary oncology centre.

Introduction: Bone scan is a investigation which uses radionuclide phosphonate compound for whole skeletal survey. In this current study we have done the analysis of the role of bone scan in skeletal osteosarcoma at tertiary oncology care centre. Material & methods: This is a retrospective study conducted in a tertiary oncology centre from January 2022 to February 2023. A total of 92 patients with skeletal OGS were included in our study undergone 99 mTCcMDP whole body bone scan. 99 mTc MDP was prepared freshly every morning and dose for each patient were calculated as per EANM guidelines. Images were acquired 2-3 h of post injection. All images were acquired at GE infinia dual head machine with peak setting at 140Kev and LEAP collimator. Suspicious lesions on planer bone scan were correlated with SPECT fused with CT. All the bone scans were reviewed retrospectively by two independent nuclear medicine physicians. Results: In this study group, 86 patients with biopsy proven skeletal OGS underwent 99 mTCcMDP bone scan of which 63 were males and 23 were females (2.7:1) with age of study group ranging from 7years to 48years. Patients referred for bone scan were retrospectively categorized in two groups, first group patients (52) were referred for initial staging of disease and second group of patients (34) were referred for follow-up or re-staging of the disease. Total 09 patients showed distant skeletal metastases on bone scan, out of which 05 were in initial staging group and 04 in follow up group. Conclusion: Osteosarcoma has propensity to metastasize to many sites in the body however most common site being lung followed by skeletal, nodal and rarely soft tissue metastasis. Bone scan enjoys a optimal sensitivity in case of osteosarcoma to detect skeletal metastasis but have low specificity. However being a cost effective and faster investigation makes it a wise investigation of choice in case of osteosarcoma for skeletal metastasis evaluation.

Primary Hyperparathyroidism Mimicking Skeletal Metastasis - A Diagnostic Dilemma.

Introduction: Primary hyperparathyroidism (PHPT) is an intrinsic abnormality of the parathyroid glands in which there is an inappropriate secretion of parathormone (PTH), resulting in skeletal resorption and bone loss. The characteristic bony changes of fibrotic cystic lesions are called Brown's tumors. Clinical dilemmas exist due to the varied clinical presentation of hypercalcemia with multiple lytic lesions mimicking metastatic bone disease. The 99 mTc sestamibi scanning is the imaging modality of choice used for the preoperative localization of parathyroid adenomas. Surgery provides a definitive treatment, and the bony lesions resolve completely over a period of time. Case Report: We present four cases of PHPT where they presented with multiple lytic lesions and were evaluated for metastatic deposits. The diagnosis was confirmed with a biopsy. They were successfully treated by excision of the parathyroid gland. A high index of suspicion will avoid misdiagnosis and inappropriate treatment. Conclusion: PHPT must be considered as a differential diagnosis for multiple osteolytic bone lesions. Diagnosis can be aided by a thorough clinical examination, including an assessment for neck swelling, and laboratory testing of serum calcium levels and PTH levels. Surgical excision of the hyperactive gland serves as the definitive treatment for this condition, with bony lesions regressing gradually over time.

Autologous vascular proximal fibular graft in the treatment of giant cell tumor of the distal radius-a case report.

Giant cell tumor of bone (GCTB) represents an intermediate, locally aggressive tumor, with a peak of incidence in the third decade of life with female predominance (2:1). The distal radius is the third most common localization and especially challenging in the treatment is saving the wrist joint function. In this report, we present a case of a 32-year-old patient diagnosed with a giant cell tumor of the distal radius, primarily treated with curettage of the bone. Due to aggressive tumor recurrence, considering local control of the tumor, we decided to perform a resection of the distal radius and reconstruction with an autologous proximal vascular fibular graft. We performed a SPECT/CT scan to confirm the functionality of the graft. We find this procedure a safe technique for local control of tumor recurrence and an ideal substitute for a limb salvage procedure.

Potential Role of Bone Scintigraphy in the Diagnosis of Calciphylaxis.

Nonosseous abnormalities are often seen on bone scans and can be related to a wide variety of pathology ranging across vascular, infection, and inflammatory etiology. Diffuse soft tissue radiotracer uptake on bone scans is typically attributed to renal or metabolic derangements. Calciphylaxis is the deposition of calcium in small blood vessels, skin, and other organs leading to vascular obstruction and skin necrosis. It is a rare disorder with unknown pathophysiology. Diagnosis of calciphylaxis is challenging and requires an interdisciplinary approach including clinical findings, laboratory results, medical imaging, and skin biopsy. An early diagnosis is important as the disease is associated with high morbidity and mortality. The purpose of this review article is to highlight the role of bone scintigraphy in the evaluation of calciphylaxis and to correlate the findings with other imaging modalities and histopathology.

Ectopic Intrathoracic Kidney due to Diaphragmatic Eventration Detected on Bone Scan.

The technetium-99m methylene diphosphonate (99mTc-MDP) whole-body bone scan along with single-photon emission computed tomography (SPECT/CT) can detect challenging soft tissue uptake patterns. We present a case of a 67-year-old female in whom the 99mTc-MDP scan, performed 3 hours after injection, revealed abnormal soft tissue uptake in the right thoracic region. No functioning right kidney was seen in the right lumbar region. Hybrid SPECT/CT revealed an ectopic right kidney in the subdiaphragmatic location, accompanied by gut loops and eventration of the right-sided diaphragm. This case underscores the value of SPECT/CT in identifying and characterizing unexpected anatomical abnormalities, such as ectopic kidneys.

Case report: Exploring the utility of whole-body bone scintigraphy for pediatric Langerhans cell histiocytosis: insights from clinical practice.

Purpose: This mini-review delves into the realm of Langerhans cell histiocytosis (LCH) in children, focusing on its skeletal involvement. By synthesizing pertinent literature, we sought to provide a comprehensive understanding of LCH's clinical and radiographic spectrum. Our study then demonstrates the diagnostic prowess of whole-body 99mTc-methyl diphosphonate (MDP) scintigraphy in LCH cases, underscoring its value in tandem with existing knowledge. Methods: Our approach involved an extensive literature review that contextualized LCH within the current medical landscape. Subsequently, we presented a case series featuring five pediatric instances of skeletal LCH, one accompanied by soft tissue infiltration. The principal aim was to illuminate the diagnostic and staging potential of whole-body 99mTc-MDP scintigraphy, augmenting existing insights. Results: Through meticulous literature synthesis, we highlighted pediatric LCH's protean clinical manifestations and radiological variability. Aligning with this spectrum, our case series underscored the role of 99mTc-MDP scintigraphy in diagnosing and staging LCH. Among the five pediatric cases, one demonstrated concurrent soft tissue involvement. This aligns with the multifaceted nature of LCH presentations. Conclusion: Pediatric LCH can present with a wide range of clinical and radiologic features. By amalgamating our cases with extant literature, we stress the necessity of a multimodal strategy. 99mTc-MDP scintigraphy emerged as an indispensable tool for accurate staging and soft tissue detection. Our findings collectively advocate for a holistic approach to managing LCH, ensuring informed therapeutic decisions for optimal patient outcomes.

Advances in Imaging (Intraop Cone-Beam Computed Tomography, Synthetic Computed Tomography, Bone Scan, Low-Dose Protocols).

Spine surgery has seen a rapid advance in the refinement and development of 3-dimensional and nuclear imaging modalities in recent years. Cone-beam CT has proven to be a valuable tool for improving the accuracy of pedicle screw placement. The use of synthetic CT and low-dose CT have also emerged as modalities which allow for little to no radiation while streamlining imaging workflows. Bone scans also serve to provide functional information about bone metabolism in both the preoperative and postoperative monitoring phases.

Garré's Sclerosing Osteomyelitis of the Tibia in a Hispanic Adult Male: A Case Report.

Sclerosing osteomyelitis of Garré is a rare inflammatory pathology characterized by cortical thickening and loss of the medullary canal. Typically, this pathology affects the mandible. However, the involvement of long bones, such as the femur and tibia, is also possible. This condition predominantly affects children and young adults, especially females, and commonly emerges before age 25, with an average onset age of 16 years. The disease is characterized by an insidious onset, causing local pain, distention of the affected bone, and a moderately increased erythrocyte sedimentation rate. We aim to report a unique case involving a 25-year-old Hispanic male presenting with a one-year insidious onset of left anterior lower leg pain. The patient's clinical course, laboratory findings, and imaging results are discussed. Despite a three-month trial of conservative management, symptomatic relief was elusive, prompting a left tibia core biopsy. Biopsy results revealed an inflammatory-reactive process with a xanthogranulomatous reaction. The continuation of conservative measures post-biopsy led to significant symptom resolution, highlighting the potential efficacy of histopathological examination. This case contributes to the limited literature on adult sclerosing osteomyelitis of Garré, particularly in long bones and among Hispanic individuals. Successful management through biopsy and conservative treatment provides valuable insights into therapeutic options for this rare condition.

Incidentally Discovered 99mTc-MDP Uptake on Bone Scan in Otosclerosis.

Otosclerosis is a poorly understood clinical entity causing progressive conductive hearing loss. Here we present the first known evidence of otosclerosis demonstrating 99mTc-MDP uptake on bone scan. This presents an opportunity to explore the role of nuclear medicine imaging in early detection, staging, and even informing treatment and prognosis of this condition. Laryngoscope, 2024.

Incidental Bilateral Thighs Muscular Uptake of Technetium-99m MDP on Bone Scan in a Patient with Left Condylar Hyperplasia.

We present a case of a 22-year-old male patient who underwent a bone scan for evaluation of left condylar hyperplasia. Incidentally, the bone scan revealed bilateral thighs muscular uptake of technetium-99m methylene diphosphonate, which initially raised concerns for an underlying pathological process. However, further investigation revealed that the abnormal uptake was due to postexercise effects. This case report highlights the importance of considering benign causes of abnormal radiotracer uptake and the need for careful correlation with clinical history to avoid unnecessary diagnostic interventions.

No prognostic impact of staging bone scan in patients with stage IA non-small cell lung cancer.

OBJECTIVE: To investigate the survival benefit of preoperative bone scan in asymptomatic patients with early-stage non-small cell lung cancer (NSCLC). METHODS: This retrospective study included patients with radical resection for stage T1N0M0 NSCLC between March 2013 and December 2018. During postoperative follow-up, we monitored patient survival and the development of bone metastasis. We compared overall survival, bone metastasis-free survival, and recurrence-free survival in patients with or without preoperative bone scan. Propensity score matching and inverse probability of treatment weighting were used to minimize election bias. RESULTS: A total of 868 patients (58.19 ± 9.69 years; 415 men) were included in the study. Of 87.7% (761 of 868) underwent preoperative bone scan. In the multivariable analyses, bone scan did not improve overall survival (hazard ratio [HR] 1.49; 95% confidence intervals [CI] 0.91-2.42; p = 0.113), bone metastasis-free survival (HR 1.18; 95% CI 0.73-1.90; p = 0.551), and recurrence-free survival (HR 0.89; 95% CI 0.58-1.39; p = 0.618). Similar results were obtained after propensity score matching (overall survival [HR 1.28; 95% CI 0.74-2.23; p = 0.379], bone metastasis-free survival [HR 1.00; 95% CI 0.58-1.72; p = 0.997], and recurrence-free survival [HR 0.76; 95% CI 0.46-1.24; p = 0.270]) and inverse probability of treatment weighting. CONCLUSION: There were no significant differences in overall survival, bone metastasis-free survival, and recurrence-free survival between asymptomatic patients with clinical stage IA NSCLC with or without preoperative bone scan.

mSegResRF-SPECT: A Novel Joint Classification Model of Whole Body Bone Scan Images for Bone Metastasis Diagnosis.

BACKGROUND: Whole-body bone scanning is a nuclear medicine technique with high sensitivity used for the diagnosis of bone-related diseases [e.g., bone metastases] that can be obtained by positron emission tomography[PET] or single-photon emission computed tomography[SPECT] imaging, depending on the different radiopharmaceuticals used. In contrast to the high sensitivity of the bone scan, it has low specificity, which leads to misinterpretation, causing adverse effects of unwarranted intervention or interruption to timely treatment. OBJECTIVE: To address this problem, this paper proposes a joint model called mSegResRF-SPECT, which accomplishes for the first time the task of classifying whole-body bone scan images on a public SPECT dataset [BS-80K] for the diagnosis of bone metastases. METHODS: The mSegResRF-SPECT adopts a multi-bone region segmentation algorithm to segment the whole body image into 13 regions, ResNet34 as an extractor to extract the regional features, and a random forest algorithm as a classifier. RESULTS: The experimental results of the proposed model show that the average accuracy, sensitivity, and F1 score of the model on the BS-80K dataset reached SOTA. CONCLUSION: The proposed method presents a promising solution for better bone scan classification methods.

Unusual Soft Tissue Uptake of Tc-99m MDP in Radiation-induced Sarcoma: Diagnostic Conundrum.

Tc-99m methylene diphosphonate (MDP) is a bone imaging agent used for skeletal staging, but it can also be localized in extraosseous calcifying lesions. We report a case of an 84-year-old woman with breast carcinoma who underwent surgery followed by radiotherapy 10 years ago and now presented with a right axillary mass referred for Tc-99m MDP to exclude bone metastasis. Tc-99m MDP shows intense tracer uptake in the right thoracic region corresponding to the site of calcified soft tissue mass in the right lateral chest wall. Subsequent ultrasonography revealed an ill-defined lesion containing coarse calcifications. Biopsy showed radiation-induced sarcoma. Extra osseous Tc-99m MDP uptake may provide important diagnostic information that may alter patient management.

Metallosis: A Rare Complication to Common Procedure with Its Imaging Finding.

Metallosis is a medical condition that shows local and systemic clinical symptoms due to the deposition of heavy metal debris in soft tissues and bones due to metallic prostheses. The estimated incidence of Metallosis is around 5%. Clinical presentation and imaging findings can mimic tumor likely situation, However local reactions of Metallosis shows some peculiar features on cross-sectional imaging, and here we present two such cases of Metallosis with its imaging findings.

Evaluation of two-dimensional total bone uptake (2D-TBU) and bone scan index (BSI) extracted from active bone metastatic burden on the bone scintigraphy in patients with radium-223 treatment.

OBJECTIVE: Radium-223 is a first alpha-emitting radionuclide treatment for metastatic castration-resistant prostate cancer (mCRPC) patients with bone metastases. Although the spread-based bone scan index (BSI) and novel index of the intensity-based two-dimensional total bone uptake (2D-TBU) from bone scintigraphy may provide useful input in radium-223 treatment, they have not been evaluated in detail yet. This study aimed to fill this gap by evaluating BSI and 2D-TBU in patients treated with radium-223. METHODS: Twenty-seven Japanese patients with mCRPC treated with radium-223 were retrospectively analyzed. The patients were evaluated via blood tests and bone scans at baseline and 3 cycles intervals of treatment. BSI and 2D-TBU were analyzed via VSBONE BSI in terms of correlations, response to radium-223 treatment, association with treatment completion, and the Kaplan-Meier survival analysis was performed. RESULTS: Nineteen patients (70.4%) completed six cycles of radium-223 treatment, whereas eight patients (29.6%) did not complete the treatment regimen. A significant difference in baseline BSI and 2D-TBU was observed between these groups of patients. Both BSI and 2D-TBU were highly correlated (r = 0.96, p < 0.001). Univariate analysis showed an association between radium-223 completion in median BSI and 2D-TBU values (p = 0.015) and completion percentage differences (91.7% vs. 45.5%; p = 0.027). The Kaplan-Meier product limit estimator showed that the median overall survival was 25.2 months (95% CI 14.0-33.6 months) in the completion group and 7.5 months (95% CI 3.3-14.2 months) in the without completion group (p < 0.001). The overall survival based on median cutoff levels showed a significant difference in 2D-TBU (p = 0.007), but not in BSI (p = 0.15). CONCLUSIONS: The 2D-TBU may offer advantages over BSI in classifying patients towards radium-223 treatment based on the degree of progression of bone metastases. This study supports the importance of preliminary assessment of bone metastasis status using BSI and 2D-TBU extracted from VSBONE BSI for radium-223 treatment decisions.