1. MUDr.Kateřina Táborská
THE SKELETAL SYSTEM
MUDr.Kateřina Táborská

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

3. Radiopharmaceuticals:
99mTc – 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
I. 3D rekonstrukce II. tomographic slices
transaxiální
3D rekonstrukce
sagitální
koronální

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

16. Abnormal scan 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. excretion via genitourinary tract
hydronephrosis
hydroureter
nefrocalcinosis

19. INDICATIONS metastatic disease primary malignant bone tumors
benign primary tumors
osteomyelitis
fracture
avascular necrosis
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, % 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 mo after therapy, compared with a postherapy baseline, is considered suspicious for local recurrence
21-year old man after chemotherapy and amputation

28. BENIGN PRIMARY TUMORS usually normal uptake osteiod osteoma
bone cysts
bone islands
fibrous cortical defects
osteiod osteoma
negative scan virtually rules out
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 h
X-rays normal for first 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. Myofasciitis of left thigh
1.phase
2.phase phase
Myofasciitis of left thigh
1.phase
6-year old boy with pain 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. Fracture of Th 8
13-year old boy after fall from tree

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

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.
normal early 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. ability to survey the entire skeleton without added radiation (5 mSv)
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)