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The case studies of five patients with diffuse metastatic disease of the axial skeleton who had false-negative bone scans. The authors describe the use of a dual-probe rectilinear scanner and the importance of recognizing minor rib asymmetries and decreased visualization of the appendicular skeleton and kidneys in detecting diffuse axial-skeletal disease. The document also emphasizes the need to record counting rates over survey areas in the skeleton and the potential use of contrast enhancement or background subtraction in interpreting bone scans.
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Bone scan findings (using OtmTc.stanuaus pyrophosphate) in five patients with. diffuse metastatic carcinoma of the axial skeleton are reviewed Although there were few visually recognizable asymmetries of tracer localization, the diffuse involvement was diagnosed through abnormally elevated counting rates in the axial skeleton, decreased visualization of the kidneys, and faint or absent visualization of the appen dicular skeleton.
(6) suggested that these scans should replace the
of detecting early metastatic bone disease. However, Thrupkaew et al (7) and Frankel et al (8) recently described normal-appearing bone scans in patients
MATERIALS AND METHODS
carcinoma of the prostate and the fifth with a transi
ner (Ohio-Nuclear Model 84, Solon, Ohio) 3 hours
øOmTc..stannous pyrophosphate (Mallinckrodt, St.
line spacing, was used to determine scan speed.
Received Sept. 9, 1975; revision accepted Nov. 4, 1975. For reprints contact: L. R. Witherspoon, 1514 Jefferson Highway, New Orleans, La. 70121.
with carcinoma of prostate. Counting rate is 60,000 cpm over spine, 50,000 cpm over sternum.(B) Posterior scan on same patient employing contrast enhancement of 2. Note false accentuation of axial skeletonand loss of appendicular skeletal image.
Lynn R. Witherspoon, Lawrence Blonde, Stanton E. Shuler, and Donald B. McBurney
Ochsner Medical Center, New Orleans, Louisiana
No.PhysicalLaboratoryAge/SexPat. Initial complaint examinationfindings (^) Diagnosis Treatment Metastases No abnormality Radiation
AsymmetricThoracic.spineSternumactivity inAppendicularcountingratecountingrateaxial skeletonskeletal activity Renalactivity (cpm)(cpm)
WITHERSPOON, BLONDE, SHULER, AND MCBURNEY
1 771MBackache
(Lt ne- Elevated acid Adenocarci phrectomy 5 yrs phosphatase, noma pros earlier for ca anemia, ESR tate by kidney) 125 biopsyBlastic,
ii hip, and lumbar spine
68/MUrinary
obstruction Enlarged rock- Elevatedacid Adenocarci (Rt nephrectomy hard prostate phosphatase noma pros 12 yrs earlier and LDH, tate (poorly for calculi) anemia differenti ated)TURP,
estro gen, orchi ectomyPelvic
and spine3 thoracic
58/MBloody
ejaculate, Induration in Elevated acid Adenocarci backache prostate phosphatase noma pros and LDH, ane- tate (poorly mia, ESR33 differenti ated)TURP,
orchi ectomyPerineural
lym phatic, blastic pelvic
52/MAsymptomatic
Hypertension,ten- Elevatedacid Ca It renal dernessin phosphatase, pelvis sacroiliac areas anemia, ESR 113Nephrectomy,
radiation, chemother apyRibs,
pelvis, thoracic, spine5 lumbar
69/MLow
bock pain, Mass rt prostate, Elevated acid Ca prostate weight loss hepatomegaly, phosphatase, (Prostatectomy decreased LDH,SGOT, 7 yrs earlier breath sounds and uric acid; for ca) at lung base, anemia; ESR pleural effusionOrchiectomy,
estrogensPerineural,blastic in ribs, pelvisAbbreviations: spine,
ca—cancer;ESR—erythrocytesedimentation rate (Westergren method); transurethral resection of prostrate; SOOT—serumglutamic oxaloacetic transaminase.LDH—Iacticdehydrogenase;
TURP
Normal (Fig.1)NoNormalNormal60,00050,000Case 2)NoDecreasedDecreased110,000120,000Case1 (Fig. 2RibsDecreasedDecreased100,000100,000Case 3RibsDecreasedAbsent160,00080,000Case 4Ribs,spineAbsentAbsent170,000150,000Case 5 (Fig. 3)NoDecreasedDecreased150,000100,
baseline was set at 120 keY, with a 40-keV window.
ture intensity control was depressed with both the
counting rates (i.e., 70,000 cpm) over the sternum and thoracic spine. Whenever these areas were in volved by disease, the picture intensity control was
tamed.
marized in Table 2. Figure 1A shows a normal pos
(Nos. 1 and 5 ). Abnormal findings in these patients were (A) elevated counting rates from the spine and
.. -@
carcinoma of prostrate showing left humeral lesion. Diffuse involvement of axial skeleton was suggested by counting rate of 150,000 cpm over sternum (usually 50,000—70,000and decreased visualization of appendicu lar skeleton and kidneys (B) Radiograph showing diffuse skeletal involvement.
obvious when numerous lesions produce marked
et al (9), or it may only provide a clue to the dif fuse disease, as in our five patients. Although this was a consistent finding in our cases, the renal im
et al (8).
(Fig. 1B ). Neither (unless employed at high levels)
ground subtraction or enhancement of bone should
tients with diffuse disease of the axial skeleton, count ing rates over survey areas in the skeleton must be recorded at the time the scans are obtained. Know
disease scanned on rectilinear scanners and the nor
ary imaging devices is essential. Markedly elevated counting rates over the spine and anterior chest wall
CONCLUSION
in the axial skeleton, decreased kidney visualization, and faint or absent visualization of the appendicular
tracer distribution are minor. These findings should be sought in patients with those malignancies which commonly metastasize to bone (breast, prostate,
routine radiographic skeletal surveys as the primary, means of detection of bony abnormalities in such patients.
REFERENCES
1. SUBRAMANIAN 0, MCAFEE JG, BELL EG, et al: 9mTcLabeled polyphosphate as a skeletal imaging agent. Radiology102:701—704, 1972
256 JOURNAL OF NUCLEAR MEDICINE
DIAGNOSTIC NUCLEAR MEDICINE
2. CAsmoNovo FP, CALLAHAN RJ : New bone scanning agent: “mTc-labeled l-hydroxy-ethylidene-1,I-disodium phos phonate. I Nuci Med 13: 823—827, 1972 3. SILBERSTEIN EB, SAENGEREL, TOFE AJ, Ct al: Imaging of bone metastases with °‘mTc-Sn-EHDP(diphosphonate), “F,and skeletal radiography. Radiology 107: 55 1—555,
46—50, 1975
7. THRUPKAEWAK, HENKINRE, AUNGCHOYEK, Ct al: False negative bone scans in disseminated metastatic disease. **_Radiology113:383—386, 1974
June 8—i1, 1976 Dallas Convention Center Dallas, Texas
The ScientificExhibitsCommitteewelcomesthe submissionof abstractsfor the display of scientific exhibits for the 23rd Annual Meeting of the Society of Nuclear Medicine. This year there will be three categoriesof exhibits:1) regular and small viewbox; 2) residentsand fellows; and 3) jiffy exhibitscon taming materials presented in scientific papers. Regularexhibitsmay be large or small, free standingor illuminatedby viewbox, and offer a means whereby attendeescan take their time to view the material, assimilatingand digesting the information at their own pace. The special residentsand fellows category is designed to encourage physicianswho are training in the field of nuclear medicine to participate in the national meeting. The jiffy exhibits, whose introductionlast year was so successful,offer an opportunityfor thosepresentingscientificpapers to presentthe salient features of their paper in exhibit format so that participants in the meeting can review the data at their leisure. Scientific exhibits award: The Society is pleased to announce the presentationof awards in the following categories: 1) clinical nuclear medicine; 2) instruction; 3) biophysics and instrumentation; 4) residents and fellows exhibits. In each category there are gold, silver, and bronze medal awards for out standing exhibits. Judging is based on scientific merit, originality, display format, and appearance. Judg ing will occur on the first full meeting day.
is available from the Societyof Nuclear Medicine, 475 Park AvenueSouth,New York, New York 10016.
Abstract deadline for Jiffy Zibits—May 1, 1976. Send all abstract forms to: H. William Strauss,M.D. Division of Nuclear Medicine and Radiation Health The Johns Hopkini Medical Institutions 615 North Wolfe Street Baltimore, Maryland 21205