한강성심 영상의학과 이경규 1

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67/FC.C.: right pelvic pain for 3 monthsPMHx : thyroid cancer OP history

1) What is your impression? 2) A first impression and three or less differential diagnoses are acce

ptable.

한강성심 영상의학과 이경규 2

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Plain film: - 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

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한강성심 영상의학과 이경규 4

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Right iliac bone biopsy : metastatic thyroid carcinoma

Diagnosis : Thyroid cancer metastasis

한강성심 영상의학과 이경규 5

MetastasisBone 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

Bone expansion

Periosteal reaction

Soft tissue mass

Multiplicity

MetastasisMetastasis

+

+

+

+++ (10% solitary)

PrimaryPrimary

+++

+++

+++

+

* Meta from lung ca,Thyroid ca, RCC : solitary, expansile

한강성심 영상의학과 이경규 9

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 Increased isotope uptake

Lung Lytic mixed;

occasionally blastic Increased isotope uptake

Kidney Lytic, blow-out Often decreased isotope uptake

ThyroidLytic, 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

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Metastasis

Uptake of tracer - 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

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

• 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

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Bone scan : Cold uptake

한강성심 영상의학과 이경규 16

Cold uptake

Insufficiency fracture

Superscan

Flare phenomenon

Bone scan : Caution !

한강성심 영상의학과 이경규 17

Kyphosis

Linear rib ↑

H-shaped sacral uptake

Bone scan : Insufficiency Fx

한강성심 영상의학과 이경규 18

Bone scan : Caution !

Cold uptake

Insufficiency fracture

Superscan

Flare phenomenon

한강성심 영상의학과 이경규 19

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

Bone scan : Superscan

한강성심 영상의학과 이경규 20

Superscan : Metastasis

Meta - superscan Normal

한강성심 영상의학과 이경규 21

Superscan : renal osteodystrophy

Meta - superscan

Metabolic - superscandiffuse skull & mandible (+)

한강성심 영상의학과 이경규 22

Bone scan : Caution !

Cold uptake

Insufficiency fracture

Superscan

Flare phenomenon

한강성심 영상의학과 이경규 23

Bone scan : Caution !

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

increase in uptake intensity or appearance of new lesion within 3-6 months of staisfactory response to th

erapy

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

Bone scan : Flare phenomenon

한강성심 영상의학과 이경규 25

Bone scan : Flare phenomenon

Flare phenomenon < 3 month

Disease progress Number & intensity ↑ of lesions beyond 6 months

3 month 6monthinitial

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