1. BONE DISEASE A Diagnostic Look

2. NORMAL  Normal uptake  Sacroiliac joints  Hip joints  Glenoid fossa  Acromioclavicular joints  Sternoclavicular joints  Ends of long bones  Growing epiphyses  Vertebral column  What is the hot spot in the patient’s left arm?

3. LABEL THE SCAN – ANT/POST – L/R

4. NORMAL SPECT BONE AND WHOLE BODY On the left is a WWB On the right are the Views generated from a SPECT Display may be compared To Maximum-Intensity Projection (MIP) MIP allows for “dynamic triangulation of the Le vertebra

5. Bone Examples - Prostate Mets  Hx. prostate cancer  serum PSA  Widespread foci  uptake  Spine, most ribs, skull, pelvis, proximal femurs, and both humeri  Pattern consistent of widespread metastatic disease Images Courtesy of: J e r o l d W a l l i s, M. D w a l l i s @ n u c s 3 d. w u s t l. e d u

6. BONE EXAMPLES - PROSTATE METS  69 year old man  Prostatic carcinoma with radical prostatectomy, treated with leuprolide (Lupron®), hepatic and osseous metastatic disease.  Right femoral neck, L2, the left scapula, and pelvis  Abnormal activity in the RUQ abdomen diffuse hepatic metastases abnormal soft tissue Images Courtesy of: J e r o l d W a l l i s, M. D w a l l i s @ n u c s 3 d. w u s t l. e d u

7. BONE EXAMPLES - LUNG CANCER Lung cancer Pelvic metastasis Lesion in the left ileum Tell me about the hot spots.

8. Bone Examples - Prostate Mets  Hx. prostate cancer  Widespread foci uptake  Spine, most ribs, skull, pelvis, proximal femurs, and both humeri  Pattern consistent of widespread metastatic disease Images Courtesy of: J e r o l d W a l l i s, M. D w a l l i s @ n u c s 3 d. w u s t l. e d u

9. BONE EXAMPLES - RENAL CA  59 year old female  Hx renal cell carcinoma  Absence left kidney post nephrectomy  Uptake vertex of the skull  The next page has several spot views Images Courtesy of: J e r o l d W a l l i s, M. D. w a l l i s @ n u c s 3 d. w u s t l. e d u

10. BONE EXAMPLES - RENAL CA Vertex View Images Courtesy of: J e r o l d W a l l i s, M. D. w a l l i s @ n u c s 3 d. w u s t l. e d u Right lateral Anterior Left lateral Vertex view of skull shows a lesion with a rim of activity and a central area of no activity central area of no activity

11. BONE EXAMPLES - BREAST CANCER  61 year old female  Hx. Infiltrating ductal CA  Patient refused surgery  Large mass right breast partially calcified tumor mass  MVA 2 years prior - multiple pelvic fractures Images Courtesy of: J e r o l d W a l l i s, M. D. w a l l i s @ n u c s 3 d. w u s t l. e d u

12. METASTASES  This is a patient with metastatic prostate cancer. Note the widespread increased activity. The marked uptake in the tumor makes the normal bone appear faint. While this picture looks dramatic, this patient was alive 1.5 years after this study.  Known as a Super Scan http://gamma.wustl.edu/bs119te143.html

13. BONE SPECT OF METS

14. BONE EXAMPLES - PAGET’S DISEASE  65 year old man  Paget's Disease  New prostate cancer  R/O metastatic disease  High activity deformed left lower extremity  High activity in the 3rd lumbar vertebrae & manubrium.  Moderately right knee, shoulders bilaterally- pattern of degenerative changes Images Courtesy of: J e r o l d W a l l i s, M. D. w a l l i s @ n u c s 3 d. w u s t l. e d u

15. OTHER EXAMPLES OF PAGET’S DISEASE Patient 1 Patient 2

16. EWING’S SARCOMA The child underwent 3-months of treatment. Exact type was not identified. http://www.nucmed.com/nucmed/cases/edited/Bone_31143555332.htm

17. OSTEOSARCOMA  11 Year old male with knee pain  Palpable mass in R proximal Tibia  Bone scan reveals primary bone cancer Images Courtesy of: J e r o l d W a l l i s, M. D. w a l l i s @ n u c s 3 d. w u s t l. e d u

18. OSTEOMYELITIS Blood flow and blood pools images demonstrated increased vascularity of the metaphysis of the left proximal tibia.. Bone scan consistent with osteomyelitis involving the left proximal tibia.

19. CELLULITIS  A and B are blood pooling images where the Left hand has increase uptake  Delayed images show relatively normal tracer distribution

20. AVASCULAR NECROSIS Initially absence of uptake in the avascular and infarcted bone. Later in the healing phase, bone repair with activation of osteoblasts there is an increased accumulation of nuclide. Seen in fractures, sickle- cell disease, alcoholism, steroid administration, or can occur spontaneously. http://www.med.harvard.edu/JPNM/BoneTF/ Case13/WriteUp13.html

21. ARTHRITIS  Blood pooling shows normal flow  Delayed images indicate increased uptake in the articulating processes (joints)

22. STRESS FRACTURE  This patient was a long distance runner who presented with unilateral lower extremity pain. A plain film x-ray the day before was normal. This bone scan demonstrates a focus of increased activity in the proximal tibia on the left. This is typical of a stress fracture. The plain film will not be positive for about 10 days.

23. FRACTURE TRAUMA  Dropped a steel drawer on her left foot 3 months ago. X-rays were negative (Upper row are immediate images and lower row are delayed images)

24. BONE EXAMPLES - RSD  Reflex sympathetic dystrophy (Sudeck¹s atrophy and causalgia) Reflex sympathetic dystrophy  Sympathetic mediated disorder of the extremities  Symptoms: pain, stiffness, swelling, weakness, skin changes, vasomotor instability  3 Phase study - usually increase activity in all phases Images Courtesy of: J e r o l d W a l l i s, M. D. w a l l i s @ n u c s 3 d. w u s t l. e d u

25. BONE EXAMPLES - RSD WRISTS  Wrists are another common area for RSD  Also Carpel Tunnel Disease  3 - Phase  Inj. in opposite arm or foot  0-20 wks  all 3 phases  20-60 wks normal uptake in 1st & 2nd and  in 3rd  60-100 wks normal or  uptake 1st & 2nd, normal bone 3rd  References: Diagnostic Nuclear Medicine. 1996, 3rd edition. ed., Sandler, et al Images Courtesy of: J e r o l d W a l l i s, M. D w a l l i s @ n u c s 3 d. w u s t l. e d u

26. PAGET’S DISEASE  This individual has Paget's disease that has invaded the pelvis and both hips. In addition, disease can be noted in the skull. Stolen From MB Nuker’s Website

27. OSTEOSARCOMA WITH SOFT TISSUE UPTAKE Patient with Osteosarcoma Of the left parietal and surrounding bone Soft tissue uptake is further noted In the left lung Further investigation via CT showed “gross” plueral effusion with coplase of underlying left lung parenchyma http://www.cancerjournal.net/viewimage.asp?img=JCanResTher_2012_8_4_655_106594_f1.jpg

28. FINAL THOUGHT – ROLE OF FUSING CT WITH SPECT A primary role with CT is to Add attenuation correction. However, there is so much more! Look how the CT assists in identifying The exact location of disease. Diease is facet joint arthropathy www.ijnm.in/article.asp?issn=0972-3919;year=2012;volume=27;issue=3;spage=156;epage=163;aulast=Harisankar

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