‫در مرکز پزشکی هسته ای دکتر‬
‫دباغ – دکتر صادقی‬
‫در خدمت شما هستیم‬
‫مشهد‪ ،‬مالصدرا ‪ ، 11‬پالک ‪1/4‬‬
‫‪www.DSNMC.ir‬‬
‫‪Tel:+98(51) 38411524; +98(51)38472927‬‬
‫مرکز پزشکی هسته ای دکتر‬
‫دباغ‪-‬دکتر صادقی‬
‫‪‬‬
‫متخصصین این مرکز از اعضای هیئت علمی دانشگاه علوم پزشکی مشهد بوده که با همکاری‬
‫تکنولوژیستها وپرستاران کارآزموده‪ ،‬به ارائه خدمات پزشکی هستهای اشتغال دارند‪.‬‬
‫‪‬‬
‫تجهیزات و دوربین گامای نصب شده در این مرکز از نوع پیشرفته ‪Dual-Head Variable‬‬
‫‪Angle‬با سرعت زیاد برای تصویربرداری با کیفیت باال می باشد‪.‬‬
‫‪‬‬
‫دیدگاه ها و چشم اندازهای مرکز‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫نگرش اخالقی و انسانی که به تبع آن نهایت سعی در رفتار و برخورد محترمانه‬
‫تالش در ارائه خدمات تخصص ی با بهترین کیفیت ممکن‬
‫ارتقاء کیفیت خدمات‪ ،‬متناسب با پیشرفت های علمی و تکنولوژیک جهان‬
‫ارائه خدمات تشخیص ی و درمانی پزشکی هسته ای که تاکنون در ایران انجام نشده است‪.‬‬
‫‪V.R.Dabbagh; DSNMC; www.DSNMC.ir‬‬
Nuclear Medicine
in
Bones & Joints
(cases and a brief review)
V. R. Dabbagh Kakhki, M.D.
Nuclear Medicine Specialist
Associate Professor
DSNMC
Nuclear Medicine Research Center (NMRC; MUMS)
www.DSNMC.ir
Introduction
Of
Nuclear Medicine
Nuclear Medicine
FDG-PET
Gallium Scan (GS;
67Ga Scan)
Tc99m-Ciprofloxacin Scan
Tc99m-UBI Scan
Bone Scan (BS)
Three-Phase Bone Scan (TPBS)
Labeled Leukocyte
Scan (WBC Scan)
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Nuclear medicine

Disease diagnosis

Treatment
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The radioactive substances may be given in
one of two forms:
1) In their radionuclide form :
 81mKr


: Ventilation Scan
Tl-201 : for Myocardial perfusion SPECT, Tumoral agent
Ga-67 : Inflammatory and tumoral agent
2) Attached to a drug, known as a radiopharmaceutical
 99mTc


-MDP for bone imaging
99mTc –ECD for Brain perfusion imaging
99mTc –MIBI for Myocardial perfusion SPECT, Tumoral agent
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Radionuclide Imaging

Functional rather than anatomical images.

Low level of radiation
Administration of less than a microgram of the radioactive substance
under test.


Often detect certain disorders earlier than other diagnostic imaging
procedures )rely on functional rather than structural changes(
 The detection of bony metastases following primary cancer of the
breast or prostate )six months earlier than detection using
conventional radiographs)

Advancements in technology permits the acquisition of both
functional and anatomical data : SPECT/CT, PET/CT, PET/MRI
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Imaging Types
- Planar : 2-D images similar to X-ray
Tomographic: 3-D images
- SPECT: similar to CT scan
(Single Photon Emission Computed Tomography)
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Bone Scan: Planar: Anterior Views
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SPECT: Lumbar Vertebrae
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Brain Perfusion Scan
SPECT
Planar
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SPECT
-Sensitivity: increased
-Localization : sometimes useful in diagnosis
•Bone Scan
•Ga- 67 Scan
+ SPECT
SPECT
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Oncology: Nuclear Medicine

Diagnosis :Specific or non-specific

Staging : Important for proper therapy

Response to Therapy

Follow-up: Early detection of recurrens

Treatment: Specific or non-specific
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Bone Scan
Tracer: 99mTc-MDP
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Bone Scan
Sensitive but not Specific

Clinical applications
Bone metastases,
 Primary bone tumors,
 Trauma and fractures, Stress fractures,
 Osteonecrosis,
 osteomyelitis,
 Prosthesis evaluation,
 Metabolic bone disease,
 Arthritis,

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Applications in Extraskeletal
malignancies
(Carcinoma of breasts, prostate, lung, …)



Initial staging: Metastatic skeletal survey
Detection of areas at risk for pathological
fractures
Radiation therapy: Treatment field planning and
response to radiation therapy

Protocole monitoring: Response to chemotherapy
and decision to change therapy
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PRIMARY MALIGNANT BONE
DISEASE
In assessment of extension of the lesions or
metastatic involvement






Osteosarcoma
Ewing Sarcoma
Chondrosarcoma
Multiple Myeloma
Rhabdomyosarcoma
………
V.R.Dabbagh; DSNMC; www.DSNMC.ir
Primary Benign Bone Tumors
In metabolic characterization, diagnosis, localization,
complications and determination of the number of lesions











Osteoid Ostemoa
Osteoblastoma
Chondroblastoma
Osteochondroma
Aneurysmal Bone Cyst
Giant Cell Tumor (Osteoclastoma)
Adamantinoma (Ameloblastoma)
Enchondroma
Simple (Unicameral) Bone Cyst
Osteoma
Miscellaneous
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Different Applications of BS







Diagnosis & Localization of the source of complains
(pain,…)
Detection of complications (complicated simple bone
cyst;…..)
Additive value in localization of more lesions and
determination of the number of the lesions
Bone, joint and soft tissue infection
Vascular disorders (Paget’s disease, AVN, bone
infarction,…); Displastic disorders; Specific extra-osseous
lesions
Complications of Trauma
Metabolic bone disease, Arthritis, Enthesopathy
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Bone scan

Scan pattern
Increased Uptake
 Defect - cold lesion
 Flare phenomenon – Increased uptake and number of
lesions in the case of effective therapy
 Super-scan (spread malignancies) - diffusely increased
uptake

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Bone Metastases
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Osteosarcoma
A 16-year-old boy with
pain in the upper left
tibia diagnosed as
primary osteogenic
sarcoma
of the left femur
Bone scan reveals
disseminated bone and
lung metastases.
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Bone scan – multiple metastases
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Lung cancer – cold lesion
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Bone scan - prostate cancer
progression
Bone Metastases
Superscan: Disseminated bone metastases secondary to prostatic
cancer
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SPECT: Spondylolysis
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SPECT: Spondylolysis
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Hypertrophic
Osteoarthropathy
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3-phase Bone Scan

Flow phase

2-5 Sec Frames: 1 minute

Blood Pool phase
 5 minutes post injection

Delayed phase
 2-4 hr

Maybe added:


Fourth phase: 24-hr
Enhances specificity
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Ewing Sarcoma
Blood Pool
Delayed Bone images
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
Osteoblastomas and osteoid osteoma
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Osteoid Osteoma
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Osteoblastomas
and osteoid
osteoma:
posterior elements
of the spine
3 phase bone
scan+
SPECT
SPECT: Osteoid Osteoma
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Sacroiliitis
Ewing Sarcoma
Chondrosarcoma
may be
suggested from the bone scan
appearance where there is a
metaphyseal area arising from
the proximal physis of the left
tibia and showing nonhomogeneous
intense
increased uptake of isotope
but rather areas with absent
activity surrounded by areas
of increased activity.
Chondrosarcoma
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Aneurysmal Bone Cyst tumor
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Histiocytosis


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Neuroblastoma: Bone Metastais
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Osteoid Osteoma
The focal density on radiography
was erroneously diagnosed as a
"bone island“, while correlative
bone scan demonstrate metabolically
active lesion corresponding to the
density in radiography and this
finding was interpreted as “osteoid
osteoma”. Post-surgical pathology
revealed that the latter diagnosis was
correct.
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Two cases of Enchondroma
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Multiple Exostosis(case I)
A 17 year old boy with
swelling of the left
knee
Radiography of the knee
suggested
osteochondroma;
however, Whole body scan shows
abnormal increased uptake of
isotope in the left upper humerus
as well as in the distal left femur
and left foot.
Fibrous Dysplasia(two cases)
A 16 years old girl
A 6 years old boy
Extraosseous uptake
Heterotopic bone formation(Myositis ossificans)
Dermatomyositis
Rhabdomyolysis
Some malignant tumors
Soft tissue calcifications (malignant metastatic calcification)
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Dermatomyositis
blood pool
posterior whole body bone scan
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Paget's disease
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Traumatic
&
Athletic injuries
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Rib Fractures
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Bilateral Calcaneal Stress Fracture
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Fracture of the right cuboid bone
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Three-Phase bone scan:
Reflex sympathetic dystrophy
A 22-year-old female who had pain in the right
hand following trauma
Diffuse hyperactivity in the right hand
and forearm in three phases of the
study
Enthesopathies
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Shin-splints
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Bilateral Plantar Fascitis
History of bilateral heel pain with normal radiography
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Septic arthritis

Three-Phase Bone Scan:
Increased activity in the blood pool phase
 Increased activity in the both sides of joint

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SPECT of the left hip:
Is extremely helpful for demonstrating photopenia: AVN
Planar: Anterior View
SPECT
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Transient Synovitis
Bone Scan:May be either normal or show increased
activity
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Transient Synovitis
Bone Scan: May be either normal or show increased activity
Delayed Bone Images
Blood Pool
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Right Femoral Head AVN
3 month later
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Legg-Perthes disease
right hip
left hip
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Osteomyelitis
1) Plain films
 Initial procedure
2) Radionuclide imaging: image the entire skeleton



Bone Scan (TPBS)
Gallium Scan
Labeled Leukocyte Scan : WBC Scan (111In or 99mTc-WBC scan)
FDG-PET
 99mTc-Ciprofloxacin(Infecton)
 Tc99m-UBI
3) Magnetic Resonance Imaging (MRI)
4) Probe to Bone

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Three-Phase Bone Scan:
Cellulitis without Bone Infection
blood pool
posterior whole body bone scan
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Blood Pool


Delayed Bone Images
A 12-month-old girl who was acutely unwell and was
not moving her lower limbs
Case Diagnosis:
Acute osteomyelitis of the right tibia.
Anterior image of the lower limbs shows increased
uptake throughout the diaphysis and metaphysis of the
right tibia extending down to the distal epiphyseal plate
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Three-phase bone scintigraphy (TPBS)


Highly sensitive : as early as 24-48 hours after onset
In patients without prior bone changes: for osteomyelitis
 94% sensitive
 85%-95% specific
 Adequate
 Specificity
 Efficient
 Cost-effective
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Three-phase bone scintigraphy (TPBS)

In patients with complicating conditions:
 95% sensitive,
 30% specific.

Main benefit of BS: exclude osteomyelitis :
unequivocally normal

Combined with other modalities:

Gallium , 111In-WBC , Tc99m-UBI or TC99m-Ciprofloxacin :
Improve specificity
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Chronic active Osteomyelitis

Bone Scan (BS): Sen but no Spec
Chronic bone repair
 Increased activity on all phases



more suggestive of active disease
Normal: Exclude
 67Ga:
higher spec than BS but some false
positive

Combine: Gallium+BS: helpful
 111In-WBC:
useful: but has False Negative results
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Gallium Scanning

Sensitivity 80-85% and specificity 70%

To improve: Specificity:

Must be performed with a TPBS
Diagnostic criteria include



Gallium uptake exceeds TPBS scan uptake
Gallium and TPBS scan results are discordant
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No Osteomyelitis
Gallium Scan
Bone Scan
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Ga-67 scan


Detects abnormality in osteomyelitis 24 to 48 hours
after the onset of symptoms
Unlike a bone scan, 67Gaactivity generally returns to
baseline quickly after successful treatment:

monitor
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Labeled Leukocyte Scanning
 111In-WBC
or 99mTC- WBC

More Specific: for infection

Ability to detect infection at sites of bone remodeling

Sensitivity: 88% and Specificity: 91%

Bone scan: should be performed in conjunction with WBC
scan:
 Better localization
 Separation of bone from adjacent soft tissue infection
 SPECT very useful
V.R.Dabbagh; DSNMC; www.DSNMC.ir
Labeled Leukocyte Scanning

Best sensitivity, specificity, and cost compromise in
patients with and without prior bone abnormalities

Reduced sensitivity: chronic infection, previous antibiotic
therapy
No Useful in Spine

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Other Techniques

Immunoscintigraphy



Labeled monoclonal antigranulocyte Abs
IgG
FDG-PET:


Sens: 95-100%
Spec: 86-100%
 99mTc-Ciprofloxacin(Infecton)
 99mTc-UBI
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Bone Scan:
TPBS
Bone Scan



Ga-67 Scan
A 65-year old man: Diabetic foot +
Osteomyelitis:
The radiograph shows osteopenia of the first
digit, soft tissue swelling and bone resorption of
the first toe.
The intensity of the gallium uptake on the
bottom two images is greater than that of the
delayed bone scan on the top two images.
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Diabetic Foot: WBC (Leukocyte) Scan
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Knees Prosthesis: WBC Scan
Infection
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A focus of increased
leukocyte accumulation
is identified in the left
acromioclavicular joint
most consistent with
pyogenic arthritis
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Diabetic Foot Osteomyelitis

BS; Sens(85%) but Not Spec(54%)
 67Ga
+ BS
 111In-WBC:


Good Sens, Spec, accuracy
+Bone Scan
Bone Scan + Tc99m-UBI or Tc99m-Ciprofloxacin?
V.R.Dabbagh; DSNMC; www.DSNMC.ir
Vertebral Osteomyelitis


Bone Scan: may be Sensitive but Not Specific
111In-WBC: not generally useful


Low accuracy
Useful: Gallium + Bone Scan
Sens: 90%
 Spec: up to 100%


May be useful:
Tc99m-UBI or Tc99m-Ciprofloxacin (?) + Bone Scan

MRI: When a pelvic or vertebral locus is strongly suspected, MRI should be strongly
considered:


Epidural extension
Soft tissue involvement
V.R.Dabbagh; DSNMC; www.DSNMC.ir
Discitis and spondylodiscitis
SPECT increases the sensitivity of scintigraphy for the
diagnosis of diskitis and vertebral osteomyelitis. It is an
essential part of the examination whenever spinal infection is
considered likely and planar imaging is normal.
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Discitis and spondylodiscitis
V.R.Dabbagh; DSNMC; www.DSNMC.ir


T12
An 8-year-old girl with
backache
Case Diagnosis:
Osteomyelitis of the lower
thoracic spine
The appearances on the
bone scan are non-specific
and similar appearances
could be due to primary
benign bone tumour, e.g.
osteoid osteoma or
osteoblastoma, or
aneurysmal bone cyst or
trauma
V.R.Dabbagh; DSNMC; www.DSNMC.ir
Gallium
Problems in:
- Gallium availability
- Instrumentation: Needs to collimator change
- Imaging Time
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VERTEBRAL OSTEOMYELITIS
(INFECTIOUS SPONDYLITIS, SPONDYLODISKITIS)

Bone Scan:
High NPV
 not specific: degenerative arthritis or in healing
fractures,
 does not differentiate inactive from active
osteomyelitis, since uptake may persist for a
long time.

V.R.Dabbagh; DSNMC; www.DSNMC.ir
Laminectomy

The healing process : increase uptake: 67Ga

and BS in the absence of any disease process.
Gallium scan:



usually : increased uptake in the first 2 weeks after
laminectomy, often in a linear pattern along the
incision site, probably related to surgical trauma to
skin and muscle.
Gallium and bone scans may return to normal
at any time after the first month
Gallium Scan usually returns to normal by 12
months at the latest.
V.R.Dabbagh; DSNMC; www.DSNMC.ir
Laminectomy

Gallium scanning may be helpful in detecting
postoperative infection: Pattern Uptake:
nonlinear pattern,
 focally intense,
 extends well beyond the margin of the incisions,
 seen within a vertebra in high-resolution images.

V.R.Dabbagh; DSNMC; www.DSNMC.ir
No Osteomyelitis
Bone Scan
Gallium Scan
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Bone Infection


Gallium:
 No high specificity for infection
 Some problems in availability and acquisition images;
time consuming procedure
Labeled leukocytes (WBC):
 Technically difficult and time-consuming procedures
 Hazard of blood borne infections, such as hepatitis B,
hepatitis C, and HIV.
These tracers may not be available or physicians
usually refuse to perform Gallium or WBC scans
due to logistic problems.
V.R.Dabbagh; DSNMC; www.DSNMC.ir
UBI and Ciprofloxacin

Considering the:
Easy preparation
Safety
Rapid and
good tracer accumulation in the infected sites,
Very high sensitivity and specificity
obtain highly accurate results
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It is recommended:
UBI Scan or Ciprofloxacin Scan
in
hip prosthesis
(usually no need for other complementary methods)
 in other bone infections
UBI
or Ciprofloxacin Scan + Bone scan
V.R.Dabbagh; DSNMC; www.DSNMC.ir
FDG-PET

FDG PET/CT : as a valuable tool for the diagnosis of
spondylodiscitis
 sensitivity :94–100%
 Specificity:75–100%
 False positive: reported: recent bone fracture
 In contrast to MRI, PET can distinguish between initial


spondylodiscitis and degenerative changes in the vertebral body
endplates
MRI: limitations :in preoperated patients with metal implants.
The analysis of the FDG-PET uptake pattern provides reliable
results for diagnosis or exclusion of spondylodiscitis
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FDG-PET: spondylodiscitis
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PET in oncology:
General aspects(18FDG)
Cell membrane
18FDG
Glucose
18FDG
hexokinase
18FDG-6-P
Glucose
Glucose-6-P
Metabolites of Glucose
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PET in oncology:

Mainly:
 18FDG
18F-FDG
can be used for:
Focal lesions (malignancy potential)
 Staging
 Monitoring response to therapy
 Prognosis
 Evaluation of tumor recurrence

V.R.Dabbagh; DSNMC; www.DSNMC.ir
FDG PET

For several tumors


Mainly lymphomas, lung cancers, melanoma,
colorectal cancers and others
Not suitable for prostate cancer
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PET in oncology:
Breast cancer (Staging)
A 44 year old female with an
axillary nodule proved to be
carcinoma on biopsy. A FDG
PET exam was then
performed and revealed
extensive metastases to axillary
and supraclavicular lymph
nodes, as well as the primary
lesion in the right breast (black
arrow)
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PET in oncology:
Colon cancer (Recurrent cancer)
A patient with a history
of colon cancer,
evaluated for two
pulmonary nodules.
The FDG PET
demonstrated uptake in
the pulmonary nodules
(not shown) and also
revealed diffuse
omental metastases
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET in oncology:
Melanoma (Staging)
A 71 year old male with a history
of melanoma on the left
shoulder.On CT, the abdomen
had been interpreted as negative.
The FDG PET exam revealed
extensive metastatic disease
throughout the body.
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET------PET/CT
V.R.Dabbagh; DSNMC; www.DSNMC.ir
FDG PET
Tumor of unknown origin
Pharyngeal cancer
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET:100 %
CT:
0 %
Stomach cancer
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET: 80 %
CT: 20 %
Stomach cancer
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET: 60 %
CT: 40 %
Stomach cancer
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET: 40 %
CT: 60 %
Stomach cancer
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET: 20 %
CT: 80 %
Stomach cancer
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET: 0 %
CT: 100 %
Stomach cancer
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET in oncology:
Bronchogenic carcinoma (Staging)
A patient had a left lung
NSCLC . There was no
uptake of tracer within the
hila or mediastinum to
suggest nodal metastases,
however, unsuspected
bone metastases were
found in the right
humerus and right hip
(black arrows).
V.R.Dabbagh; DSNMC; www.DSNMC.ir
PET in oncology:
Bronchogenic carcinoma (Staging)
Uptake within the
patients primary lung
cancer can be seen
within the right chest.
Uptake within the
bilateral adrenal glands
(black arrows)
confirmed the
presence of adrenal
metastases.
V.R.Dabbagh; DSNMC; www.DSNMC.ir
GS in a patient with high grade
NHL and BM transplantation.
He presented with a palpable
spleen, fever, dyspnea and
pancytopenia. The MRI
showed findings most
consistent with multiple
peripheral splenic infarcts,
increasing splenomegaly and
no change in multiple small
retroperitoneal LNs.
V.R.Dabbagh; DSNMC; www.DSNMC.ir
V.R.Dabbagh; DSNMC; www.DSNMC.ir
Complete response and good prognosis of HL.
(A) Baseline PET: Abnormal FDG uptake in sites of lymphadenopathy in the left supraclavicular region, the right axilla, the mediastinum bilaterally, the left lung hilum, and
the porta hepatis region.
(B) Repeat FDG-PET, performed after one cycle of chemotherapy, is negative.
V.R.Dabbagh; DSNMC; www.DSNMC.ir
Stage IIA high-grade NHL.
Baseline:Highly hypermetabolic lymph nodes in the left axillary and cervical areas
PET performed after 3 courses of chemotherapy shows a complete metabolic response.
The patient is in complete clinical remission 6 months after completing the treatment.
V.R.Dabbagh; DSNMC; www.DSNMC.ir
HD :
A: Baseline FDG PET:Multiple foci of increased activity in cervical and mediastinal areas
as well as right hilar and lung infiltration.
B: FDG PET performed after 2 cycles of chemotherapy indicates residual 18F-FDG uptake
in a right cervical lymph node.
C: Treatment failure was observed at the end of treatment. V.R.Dabbagh; DSNMC; www.DSNMC.ir
V.R.Dabbagh; DSNMC; www.DSNMC.ir