Bone scan

Nuclear medicine department

Niu guangjun
 General View

Bone disease can be investigated with bone

seeking radiopharmaceuticals . Conventional
diagnostic indices, such as radiology, and serum
enzyme measurements , are important but are
often unreliable and convey insufficient
information. X-rays remain normal many months
after metastases have shown up on a bone scan.
Bone scintigraphy is a diagnostic imaging study which
records the distribution of a radioactive tracer in the
skeletal system in planar(two-dimensional) and/or
tomoigraphic(three-dimensional)images.

Whole body bone scintigraphy produces planar images of

the skeleton including antreior and posterior views of the
axial skeleton and the appendicular skeleton are also
obtained.

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Limited bone scintigraphy(regional bone scan )
records images of only a portion of the
skeleton.

Bone SPECT(single-photon emission computed

tomography)produces a tomographic image of
a portion of the skeleton.

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 Bone imaging is extremely sensitive for
the detection of bone lesions involving any part
of the skeleton. It is the most appropriate
screening test for these conditions, since
scan abnormalities are present long before
structural defects develop radiographically
( 3-6 month earlier ) .
 Bone scans are also accurate for
localizing lesions for biopsy ,
excision, or debridement. Stress
fractures can be diagnosed by bone
scan when radiographs are completely
normal.

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Principle and Radiopharmaceuticals

Bone,like other connective tissues , consists of

living cells and a predominant amount of
nonliving intercellular substance that is calcified .
It is a metabolically active tissue with large
amounts of nutrients being exchanged in the
blood supplying the bone. Thus the skeleton and
body fluids are in an equilibrium.
 The bone salt mineral (inorganic matter)
has the crystalline form of an apatite,and the
main anion constituent of bone is phosphorus
(as phosphate)
The accumulation of phosphate compounds
is related to the exchange of the phosphorus
groups onto the calcium of hydroxyapatite.
 The major radiopharmaceuticals used for bone scans are
the 99mTc-complexed organic and inorganic phosphate
compounds, some with an added hydroxyl group to
increase crystal binding . These includes

(1) pyrophosphate(PYP) , which is simply two phosphate molecules linked

together;

(2) polyphosphate, a short chain of phosphate groups;

(3) diphosphonate compounds that have a P-C-P linkage binding

replacing the P-O-P found in phosphates.
 Recently 99m Tc labeled diphosphonate
compound methylenediphosphonate (MDP) is
widely used in clinics. The accumulation of
tracer in bone is related to both vascularity
and rate of bone production (osteoblast
activity).
The mechanism of increased uptake
(increased activity) of the tracer in osseous lesions is
multifactorial:
a. Increased blood flow:
Bone in hyperemic regions is exposed to more
tracer over any given time period. Because the
extraction of the radiotracer is non-linear and tends
to plateau,increased flow will only result in an
increase in bone activity compared to normal bone of
about 1.5 to 2 times.

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b. Areas of new bone formation:
In these areas there is increased osteoid
formation and increased mineralization of
osteoid. Newly forming hydroxyapatite crystals
are of smaller size than mature crystals and
provide a greater surface area for binding.
c. Interruption of sympathetic supply.

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 Lesions with high regional
blood flow and metabolic activity
(osteoid formation) can uptake more
tracer ,
such as trauma ,fracture , inflammatory
diseases,metastasis etc.

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Lesions with low regional blood
flow and metabolic activity
can uptake fewer tracer ,
such as bone infarction,some necrotic lesion
etc.

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 Indications for Bone Scanning
The main indications for bone scanning at the
present time are:
1.Skeletal pain in patients with a history of
cancer and negative x-rays ;
2.In patients with x-rays suspicious but not
confirmatory of metastases ;
3.In excluding bony metastases in a patient
with cancer but no bone pain and a negative
x-ray skeletal survey;
4.In patients with a known metastasis, since the scan may reveal more
widespread lesions than were first suspected ;
5.For finding suitable sites for the biopsy of a bony lesion;
6.For planning radiotherapy of bony tumors ;
7.For the evaluation of treatment of bony tumors;
8. In patients with lymphoma and apparent solitary myelomas
where bony involvement may be suspected ;
9. In patients in whom osteomyelitis is suspected but the x-
ray is negative;
10. Occasionally in fractures to assess if they are recent or old,
to diagnose small bone fracture, e.g. scaphoid fracture and
occult fracture;
11. In the detection and assessment of joint disease in various
arthropathies and metabolic bone diseases.
12. In the detection of metabolic bone disease.

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 Scan Procedure
Patient preparation:
The patient for performing the procedure and the
details of the procedure itself should be explained to the
patient in advance .
The patient does not need to be fasting for this
procedure. Patient should be encouraged to drink
fluids and to urinate as often as possible during the
waiting period because it will help eliminate the tracer from
the body that is not going to the bones . before scanning
the patient will be asked to void just before scanning
begins.
 The patient receives an intravenous
injection of a 99mTechnetium (99mTc)
phosphonate radiopharmaceutical [usually
methylenediphosphonate (MDP) ]. The
usual administered activity of 99mtc-labeled MDP
is 740 MBq- 1110mbq (20 to 30 mCi ).
 2-5 hours after the injection, whole body and
appropriate regional skeletal images are acquired. An
initial dynamic flow study and/or early images may
also be acquired if osteomyelitis, osteonecrosis, septic
arthritis, or other inflammatory disease is suspected.
Three hours after the injection, delayed static
skeletal images are acquired (3-phase technique).

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 Image Acquisition

Routine delayed images are usually obtained

from 2 to 5hr after injection. Additional delayed
(6-24hr) images may permit better evaluation of
the pelvis if it was obscured by bladder activity
on the routine delayed images.
 6- 24hr delayed imaging may be particularly
helpful in patients with renal insufficiency and
patients with urinary retention. Whole body
scintigraphy can be accomplished with multiple
overlapping images or continuous images obtained in
anterior and posterior views.

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 SPECT imaging is helpful to better
characterize the presence, location and extent
of disease. SPECT imaging should be
performed as recommended by the camera
manufacturer. Typical acquisition an
processing parameters are 3600 circular
orbit.
Image
Acquisition

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Normal whole bone scanning

Normal Findings
homogeneous in axial
skeleton like
spinal,pelvis, vertebral
column etc. and
symmetric distribution
of activity throughout
all skeletal structures.
 In the normal adult, symmetric tracer
uptake of greatest in the axial skeleton(spine
and pelvis), with relatively less intense uptake
in the extremitis and skull. Background activity
is normally seen in the soft tissues. The kidneys
are routinely visualized in normal subjects and
should have less intensity than the adjacent
lumbar spine.

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Normal whole bone scanning
Normal
whole
bone
scanning
There is no
abnormal hot
spots and cold
spots being found.
The any irregularity
or asymmetry
should be viewed
with suspicion.

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The appearance of the normal skeletal
scintigraphy changes dramatically from
childood to mature adulthood. In
pediatric patients, there are marked
uptake of tracer in growth centers. On
normal bone scan, margins of growth
plate clearly demarcated.

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 Abnormal Radioactivity Distribution

• 1. Hot spots;
• 2. Cold spots ;
• 3. Hot spots without bone;
• 4. Super-bone scan;
• 5. Flare Phenomenon.
 Metastatic Bone Malignancies

Bone scan is more sensitive than radiographs in

detecting skeletal metastases. This is probably
because about 50% of the bone mineral content must
be lost before a met is evident on a radiograph.
Multiple and randomly distributed hot sports in
the skeleton are characteristic of bony metastases ;
serial hot spots in the ribs are often the result of
multiple fracture. .
 About 90% of patients with skeletal metastases
present with multiple lesions. Nearly 80% of all
metastatic lesions are in the axial skeleton. In patients
with a known malignancy, 60 to 70% of axial lesions
are due to mets, whereas about 40 to 50% of lesions in
the extremities or skull are due to mets. A solitary rib
lesion has about a 10% probability of representing a
met in a patient with a known malignancy .
 A single hot spot carries no diagnostic specificity and may
result from a variety of benign or malignant conditions .
A single lesion has about a 11% probability for being a
met in patients with known underlying malignancy. The
percentage increased to 35% when 2 new lesions were
detected, and reached 100% when 5 new lesions were
identified .
Solitary Pubic Bone
Metastasis

Prostate Cancer
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Widespread
metastatic
Prostate
Cancer

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Widespread metastatic prostate cancer

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Multiple bone metastases
lung cancer

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Multiple bone metastases
lung cancer
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Multiple bone metastases

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Primary Bone Malignancies: Extended Pattern

The "Extended pattern" refers to increased activity

(usually mild to moderate) in adjacent joints or along the
entire ipsilateral extremity in association with a primary
tumor of a long bone. This finding may be related to
generalized increased blood flow to the extremity. It can
lead to over-estimation of the extent of the tumor by
scintigraphy. It is also called “ skip phenomenon”.
Primary Bone tumour Osteosarcoma

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Primary bone
tumour
Femoral
Osteosarcoma
UWIN TUMOR
Synovial sarcoma 47
Vertebral Compression Fracture

By 1year, about 60% of compression

fractures will normalize and 95% will
become normal by 3 years. When multiple
fractures are present in different stages of
healing , osteoporosis is the most likely
diagnosis . Some reasons may be bone
metastasis without primary tumor site being
seen. Multiple myeloma may occasionally
mimic this appearance.
Vertebral Compression Fracture
Breast Cancer Single Metastasis
Vertebral Compression Fracture

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 Super-bone Scan and Metabolic Bone Disease

Some metabolic bone disease can be

test with bone scan.These include :
• Hyperparathyroidism;

• Renal osteodystrophy;

• Hypertrophic osteoarthropathy.
 Super-bone Scan and metabolic bone disease

When pathology affects the entire

skeleton with general increase in bone
tumour, a corresponding general
increase of tracer concentration will
lead to the so-called super bone scan.
 This is due to, a higher bone-to-tissue and a
higher bone-to-blood ratio of tracer distribution
with a corresponding increase in detail resolved
on the scan. Super scan can be found in patients
with Hypertrophic osteoarthropathy, diffuse
metastatic disease ,hyperparathyroidism and ,renal
osteodystrophy .

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 Super-bone Scan
1. diffusely increased skeletal uptake.
2. minimal soft tissue uptake .
3. minimal renal uptake .
4. no bladder activity.
5. Mask face.
6. Costal cartilage rosary changes.

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Super bone scan

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Mask face

Hyperparathyroidism

Post therapy 3y later 56

Renal osteodystrophy

Whole-body bone
scintigraphy
demonstrates
diffusely increased
skeletal uptake,
minimal soft tissue
and renal uptake and
no bladder activity.
There are no focal
bony lesions.

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 Hypertrophic
osteoarthropathy
Woman with a newly
diagnosed
posterior right
upper lobe lung
mass, super scan
and linear cortical
uptake of the
radiopharmaceuti
cal in the lower
extremities

ditrack sign
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 Diffused Metastatic
Diffuse areas of markedly
92-year old man
increased uptake of the
with known
radioactivity are noted throughout
metastatic prostate
the axial skeleton. The
carcinoma. The
appendicular skeleton is relatively
patient had
spared with the exception of the
complaints of
proximal aspect of the right
diffuse bony pain,
forearm. These findings are most
most severe in the
consistent with widespread
back.
metastatic disease.

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diffuse metastatic disease

78 year-old
male with
history of
prostate
cancer and
right arm
pain.

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 Pagets Disease

(1) Markedly increased activity is noted

throughout an expanded, deformed left lower
extremity. In addition, markedly increased
activity is noted in the third lumbar vertebrae
and in the manubrium.
(2) Moderately increased activity is noted in
the right knee, and shoulders bilaterally in a
pattern characteristic of degenerative
changes.
 Polyostotic fibrous dysplasia

multiple bilateral areas of abnormal

radiopharmaceutical uptake in the axial and
appendicular skeleton. Specifically, these areas
include the skull and both iliac wings, proximal and
mid femurs, and tibias. There is asymmetric
increased activity involving the acetabular regions,
right greater than left.Linear areas of decreased
activity are seen in both proximal femurs and
traversing both femoral necks.

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Polyostotic fibrous dysplasia
 Cold Spots

Areas of reduced tracer concentration (cold spts)

are rare .They can occur mainly in association with
bone infarction or predisposing pathology such as
sickle-cell aneamia .However, a bone infarct can show
up as hot spot reflecting the degree of bone reaction
around it . cold spots are most often associated
withy extraneous causes breast prosthesis, bone
nailing, hip prosthesis , earring or necklaces, medals,
etc.
Sternum and thoracic vertebra radioactive
sparseness

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Post radiotherapy

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Cold Spot

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 Hot Spots Without Bone
Soft tissues,normal or involved breast,
pleural effusions , scars from mastectomy
surgery with or without local recurrence,
calcified myoma , dental abscess, root
treatment ,myocardial infarction and sites of
bone biopsy may all lead to positive sites of
tracer concentration .
Soft Tissue Calcifying Without Bone

pelvis

bladder

Thigh
bone
Hot Spot Without Bone Lung Cancer
 Benign Bone Disease

The main areas of clinical application are:

• Early recognition of the pathological
process ;
• accurate assessment and localization of the
extent of the disease;
• quantitative analysis of tracer uptake and
monitoring of the disease.
 Less often bone scanning is used as a test for
differential diagnosis,although in certain areas
it does offer valuable information : is there
avascular necrosis of the femoral head;Is there
evidence for graft healing,or minor trauma to
the skeleton,or fissure and stress fractures etc.

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 Trauma

Fractures: general findings:

1) acute: (3-4 weeks)
There is increased flow and blood pool activity
with diffuse and somewhat poorly defined increased
delayed activity about the fracture site which is
wider than the fracture line.
2) Subacute: (2-3 months)
Flow and blood pool abnormalities
diminish considerably and delayed activity
becomes more localized (focal at the fracture
site) and intense.
3) healing:
A gradual decline in activity occurs over
time with about 65% of exams normalizing by
1 year, and 90% becoming normal by 2 years.

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 Occult Fracture

tibia
Metatarsal Fracture

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Multiple fracture

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Avascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral Head
Avascular Necrosis
of the Femoral Head

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Avascular Necrosis of the Femoral Head
Rheumatoid arthritis

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rheumatic arthritis

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osteomyelitis
 Cellulitis

Only view soft tissue imaging,can not

see any bone uptake radiation.

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 Flare Phenomenon

The flare phenomenon reflects a favorable

response of bone metastases to treatment.
Patients are typically asymptomatic and plain
films generally show sclerosis of the lesions.
 The phenomenon is typically seen
between 2 weeks to 3 months following
therapy, but can rarely be seen as late as 6
months after treatment. In general, it is
prudent to wait about 3 months following
completion of a new therapeutic
intervention prior to repeating the bone
scan.

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 The diagnosis of "flare" requires 2
criteria:
1. Increased intensity and/or number of lesions on
bone scan (felt to be secondary to increased
osteoblastic activity associated with healing)
2. Subsequent decrease uptake in these lesions on
repeat exam in 2-3 months.
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