1. ** 67/F C.C.: right pelvic pain for 3 months
PMHx : thyroid cancer OP history
What is your impression?
2) A first impression and three or less differential diagnoses are acceptable.
한강성심 영상의학과 이경규

2. ** Plain film: Bone scan
an expansile, lytic lesion involving medial aspect of right iliac wing
loss of medial cortical margin & extension across right SI joint
no internal matrix mineralization and no periosteal reaction
Bone scan
- decreased tracer uptake in right ilium consistent with lytic lesion seen on plain film
한강성심 영상의학과 이경규

3. **
DDX : Meta vs Myeloma
* Tumor uptake (-) : extremely aggressive or purely osteolytic
highly aggressive anaplastic tumors, reticulum cell sarcoma, RCC, thyroid ca, histiocytosis, neuroblastoma, and multiple myeloma
한강성심 영상의학과 이경규

4. ** Diagnosis : Thyroid cancer metastasis
Right iliac bone biopsy : metastatic thyroid carcinoma
Diagnosis : Thyroid cancer metastasis
한강성심 영상의학과 이경규

5. Metastasis Bone scan evaluation
한강성심 영상의학과 이경규

6. Target Sites Red Marrow Lumbar > Thoracic > Cervical
Uncommon sites
Mandible, Patella
distal to the knee and elbow
한강성심 영상의학과 이경규

7. Hematogeneous Route Venous > Arterial Batson’s plexus
Extensive comm.
Sluggish flow
Reflux
한강성심 영상의학과 이경규

8. Primary / Metastasis
Primary
+++ +
Metastasis +
+++ (10% solitary)
Bone expansion
Periosteal reaction
Soft tissue mass
Multiplicity
* Meta from lung ca,Thyroid ca, RCC : solitary, expansile
한강성심 영상의학과 이경규

9. Appearance on Plain Radiographs Appearance on Bone scan
Typical Radiologic Appearance of Metastases in Adults
Primary site   
Appearance on Plain Radiographs  
Appearance on Bone scan
Breast
Lytic,mixed or blastic
Increased isotope uptake
Prostate
Blastic; occasionally mixed or lytic
Lung
Lytic mixed; occasionally blastic
Kidney
Lytic, blow-out
Often decreased isotope uptake
Thyroid
Lytic, blow-out; sometimes normal
Often decreased or normal uptake
한강성심 영상의학과 이경규

10. Bone scan : Application
Tumor extent or localization
Initial tumor staging
Identify metastatic sites
Monitor disease progression or therapy response
한강성심 영상의학과 이경규

11. Bone Metastasis 1. Multiple lesions of varing intensity,size,shape
2. Irregular distribution in axial skeleton
3. Photon deficient lesion
extremely aggressive or purely osteolytic
4. Superscan pattern
5. Solitary lesion
한강성심 영상의학과 이경규

12. Metastasis Uptake of tracer Malignancy
- dependent on blood flow and on osteoblastic activity
Malignancy
↑ hot uptake
↑ sensitive than plain image
(3-5% vs 30-50%)
Cold uptake
extremely aggressive or purely osteolytic
한강성심 영상의학과 이경규

13. Rib metastasis vs Benign fracture
Focal rather than linear
Decreased uptake over 3-6mon
Aligned in same location
한강성심 영상의학과 이경규

14. Bone scan : Caution ! Cold uptake Insufficiency fracture Superscan
Flare phenomenon
한강성심 영상의학과 이경규

15. Bone scan : Cold uptake ** In cancer patients,
- due to metastatic disease (> 80%)
may occur
- aggressive or purely osteolytic tumor
- disruption of blood supply to bone
- significant marrow involvement, particularly in a vertebral body
cause - highly aggressive anaplastic tumors, - reticulum cell sarcoma, - RCC, thyroid carcinoma, - histiocytosis, neuroblastoma, and - especially multiple myeloma **
한강성심 영상의학과 이경규

16. Bone scan : Caution ! Cold uptake Insufficiency fracture Superscan
Flare phenomenon
한강성심 영상의학과 이경규

17. Bone scan : Insufficiency Fx
Kyphosis
Linear rib ↑
H-shaped sacral uptake
한강성심 영상의학과 이경규

18. Bone scan : Caution ! Cold uptake Insufficiency fracture Superscan
Flare phenomenon
한강성심 영상의학과 이경규

19. Bone scan : Superscan Superscan ?
- Poorly or non-visualization of kidney
- ↑ bone to background RI ratio
cause
far advanced bone metastasis
- prostate, breast, lung, bladder, stomach etc
metabolic condition
- superscan in both axial and peripheral skeleton
- Renal osteodystrophy, primary hyperparathyroidism
myelofibrosis
한강성심 영상의학과 이경규

20. Superscan : Metastasis
Meta - superscan
Normal
한강성심 영상의학과 이경규

21. Superscan : renal osteodystrophy
Metabolic - superscan diffuse skull & mandible (+)
Meta - superscan
한강성심 영상의학과 이경규

22. Bone scan : Caution ! Cold uptake Insufficiency fracture Superscan
Flare phenomenon
한강성심 영상의학과 이경규

23. Bone scan : Caution ! Insufficiency fracture Superscan
Cold uptake
Insufficiency fracture
Superscan
Flare phenomenon
transient increase in lesion activity secondary to healing under
antineoplastic treatment concomitant with increased sclerosis
한강성심 영상의학과 이경규

24. Bone scan : Flare phenomenon
increase in uptake intensity or appearance
of new lesion within 3-6 months of staisfactory response to therapy
improvement on F/U bone scan
incidence up to 20% in breast and prostate ca
good prognostic sign in breast cancer
DDX : progression of metastatic disease
한강성심 영상의학과 이경규

25. Bone scan : Flare phenomenon
3 month
6month
initial
Flare phenomenon
< 3 month
Disease progress
Number & intensity ↑ of
lesions beyond 6 months
한강성심 영상의학과 이경규

26. Bone scan vs MRI MRI : superior sensitivity Limitation of Scintigraphy
- specificity 
- intramedullary lesion Tumor is in marrow space only and has not elicited a reactive response in adjacent bone
- aggressive or purely osteolytic lesion
한강성심 영상의학과 이경규

27. 한강성심 영상의학과 이경규