Non-osseous abnormalities on bone imaging

I have always found non-osseous uptake of skeletal imaging agents to be of interest. In 2003 the Journal of Nuclear Medicine Technology published an excellent article on non-osseous abnormalities. During my years of teaching, students have brought in many examples which I wish to share...

In the area of altered biodistribution, whether due to faulty preparation or pharmaceutical interference:

Free technetium due to the presence of air in the container during preparation will lead to increased uptake of unbound technetium in the stomach, gastrointestinal tract, thyroid and salivary glands...

It was noted in the article that drug interaction with diphosphonates used in treatment of osteoporosis can lead to decreased skeletal uptake.

Male on hemodialysis, with a complaint of back pain. Findings include decreased skeletal uptake of the radiopharmaceutical. The patient medical history includes administration of PhosLo (calcium acetate tablets) 3-times a day with meals indicated for patients with hyperphosphatemia. The retention of phosphates in patients with renal insufficiency plays a role in causing secondary hyperparathyroidism. This scan was compared to another patient scanned with radiopharmaceutical from the same bath to verify this was not associated with poor radiopharmaceutical preparation. Due to the patient's condition his attending physician would not take him off the PhosLo for a repeat scan...

Uptake related to the urinary system, is the most common finding of non-osseous uptake. Findings include: dilated, obstructed ureters, hydronephrosis, renal cysts:

80-y female, history of melanoma, complains of back pain. Findings include a mild right side hydronephrosis, with a dilated ureter noted in the pelvis...

91-y female, fell 3 days prior to scan, complains of left hip pain. Findings include marked hydronephrosis of both kidneys with dilatation of both ureters. Possible obstructive uropathy near the urinary bladder...

25-y male, with history of right renal abscess. Skeletal imaging was ordered for a complaint of right side flank pain to rule out osteomyelitis. Findings include a photon deficient 4cm area in the upper pole of the right kidney consistent with a cysts, tumor or abscess...

38-y female with a history of right lung carcinoma. Findings include poorly defined uptake at the areas superior to both kidneys, suggestive of metastatic disease in the adrenal glands...

Soft tissue uptake may be found in various areas due to soft tissue calcification, which may point to specific pathology:

51-y female with a history of breast cancer. Findings include mild diffuse uptake in the liver, of uncertain clinical significance. The likelihood of interference of additional imaging procedures was reviewed. The patient did not have a prior liver scan, which would have been performed by calculation on Sunday when the department was closed for routine imaging. Gallium-67 for soft tissue imaging would present with considerable background activity. The pattern of uptake is not suggestive of hepatic metastatic disease, but may suggest necrosis or microcalcification...

Elderly female fell out of bed onto her left side, complains of left hip pain. Findings include increased cardiac uptake as well as uptake in several left ribs suggestive of cardiac contusion and rib fractures related to trauma...

76-y male with a history of right nephrectomy, on hemodialysis, complains of low back pain. Findings include cardiac uptake related to calcification of the pericardium, which was seen on a recent CT of the chest. This may be an indication of metastatic calcification, which can be seen in secondary parathyroid hyperplasia...

46-y male with a recent finding of multiple myeloma. Findings include intense uptake in the region of the myocardium, most likely secondary to calcified pericarditis, however diffuse myocardial infarction may also have this appearance...

Female with documented history of hypercalcemia. Findings include diffuse uptake of the the radiopharmaceutical in both lungs. This pattern of uptake has been implicated with hypercalcemia and related to metastatic calcification...

Thanks to Heny Shah, Dolores Ambrosy, Corrine Zenkel, 

Bone Scan - Post Reclast Therapy

Reclast is marketed by Novartis, was was approved by the FDA for treatment of Paget's Disease in 2007. Administered by infusion, the main ingredient, zoledronioc acid, is also marketed by Novartis as Zometa for use in the treatment of skeletal fractures in patients with cancers such as multiple myeloma and prostate. It has also been used to treat osteoporosis. For the treatment of Paget's patients recieve a single dose, annually. Results of studies for Reclast were published in the Sep 1, 2005 issue of the New England Journal of Medicine.

The cause of Paget's Disease is unknown. The disease causes an abnormal breakdown of bone tissue, followed by abnormal bone formation. The new bone is enlarged but weaker. The disease often effects the bones of the arms, collarbones, legs, pelvis, spine and skull.

2011

2013

The above patient studies were obtained at 3 hours following the injection of 25 mCi Tc MDP. Whole body bone scans with post void images of the pelvis were obtained. The study from 2013 demonstrates marked decreased activity in the right hemipelvis, following Reclast therapy, as compared to the study from 2011.