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**. 67/F C.C.: right pelvic pain for 3 months PMHx : thyroid cancer OP history What is your impression? 2) A first impression and three or less differential diagnoses are acceptable. **. Plain film: an expansile, lytic lesion involving medial aspect of right iliac wing - PowerPoint PPT Presentation
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한강성심 영상의학과 이경규 1
**
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
**
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
**
한강성심 영상의학과 이경규 4
**
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
한강성심 영상의학과 이경규 12
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
**
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