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⁹⁹Tc^m(V)DMSA scintigraphy in skeletal metastases and superscans arising from various malignancies: diagnosis, treatment monitoring and therapeutic implications

¹ Radiation Medicine Centre, Bhabha Atomic Research Centre and ² Tata Memorial Hospital, Jerbai Wadia Road, Parel, Bombay 400 012, India

View larger version (99K): [in a new window]   Figure 1. (a) 99Tcm MDP bone scan demonstrating increased tracer uptake around an osteolytic area in the proximal end of right humerus and mild increased uptake in the right sacroiliac (SI) joint. (b) 99Tcm(V)DMSA whole body scan of the same patient showing focal concentration in the same region corresponding to that seen in bone scan. (c) Multiplanar MRI of the pelvis showing a tiny focus of high signal intensity in the iliac aspect of the right SI joint in an axial short tau inversion recovery sequence suggestive of metastatic deposit. (d) 99Tcm MDP bone scan and (e) 99Tcm(V)DMSA whole body scan post therapy (chemotherapy and external radiotherapy over the right upper humerus) showing significant reduction of tracer uptake commensurate with the patient's clinical improvement.

View larger version (132K): [in a new window]   Figure 2. (a) 99Tcm MDP bone scan demonstrating increased tracer uptake in the right skull, left 6th and 7th ribs and left side of pelvis. (b) 99Tcm(V)DMSA whole body scan of the same patient showing focal concentration in the same regions to those seen in bone scan.

View larger version (95K): [in a new window]   Figure 3. (a) 99Tcm MDP bone scan (pre radiotherapy) demonstrating increased tracer uptake in the skull, left clavicle medial end, right shoulder, multiple ribs bilaterally, right sacroiliac joint, both sided proximal ends and shafts of the femurs, proximal shaft of right tibia. (b) 99Tcm(V)DMSA whole body scan (pre radiotherapy) of the same patient showing focal concentration in the same regions corresponding to those seen in the bone scan. (c,d) 99Tcm MDP bone scan and 99Tcm(V)DMSA scintigraphy of the same patient post lower hemibody radiation showing considerable reduction in tracer uptake in the metastatic sites in the lower half of the body whereas tracer uptake in the upper half remains the same.

View larger version (172K): [in a new window]   Figure 4. (a) Whole body skeletal survey with 99Tcm MDP showed focal uptake of tracer in the skull, proximal end of left femur, sacrum and right ischium. Non-visualization of right ilium was consistent with history of surgery. (b) 99Tcm(V)DMSA whole body scan at 3 h post injection showed uptake at similar sites. (c) The MRI coronal short tau inversion recovery image reveals hyperintense marrow signal at the proximal end of left femur. (Continued)(d, e) The patient received further chemotherapy and improved symptomatically. A repeat 99Tcm(V)DMSA whole body scan revealed much less concentration in the skull and proximal end of left femur, the sacral concentration was not seen. In view of the clinical and scan findings further chemotherapy was advised. (f) The bone scan after four cycles of chemotherapy continued to show increased uptake at the metastatic sites consistent with the "flare phenomenon".

View larger version (94K): [in a new window]   Figure 5. (a) 99Tcm MDP bone scan showing focally increased uptake of tracer in the right ilium just above the supra-acetabular margin and the horizontal ramus of the mandible. (b) 99Tcm(V)DMSA whole body scan of the same patient demonstrating abnormal focal concentration in the right ilium corresponding to the lesion seen in the bone scan. There is another increased uptake at the right lateral end of the horizontal ramus of the mandible. (c) MRI of the pelvis (coronal short tau inversion recovery sequence) revealing a focal area of high signal intensity in the right ilium in the supraacetabular region. (d) Orthopantomogram showing evidence of right partial mandibulectomy with silastic implant in situ and patchy sclerosis with few lucent areas involving the horizontal ramus of the mandible adjacent to the irregular cut margins, highly suggestive of recurrent disease.

View larger version (71K): [in a new window]   Figure 6. (a) 99Tcm MDP bone scan, (b) 99TcmDMSA whole body scan (3 h scan) and (c) radiograph of the pelvis of a case of thyroid carcinoma with big osteolytic pelvic metastases. The X-ray of the pelvis (c) shows a large osteolytic lesion involving right iliac bone with an associated soft tissue component. Note abnormal tracer uptake in the 99Tcm(V)DMSA scans at the metastatic site. The histopathological report was of a solid variant of papillary carcinoma with lymph node metastasis.

View larger version (71K): [in a new window]   Figure 7. (a) X-ray of the left humerus showing pathological fracture with evidence of plating, (b) 99Tcm MDP bone scan and (c) 99Tcm(V)DMSA whole body scan (3 h scan).

View larger version (164K): [in a new window]   Figure 8. (a) X-ray of the pelvis showing a large osteolytic lesion with sclerotic margins in the right iliac bone, abutting the right sacroiliac joint. A posterior abdomen and pelvis scan with 154 MBq I-131 shows no focal concentration. (b) 99Tcm MDP bone scan of the patient revealing an osteolytic lesion in the right ilium and sacroiliac joint with an increased uptake on the left side (probably representing the sclerotic margin) and the right mandible. (Continued) (c) The 99Tcm(V)DMSA whole body scan of the same patient showing increased concentration of tracer at the osteolytic lesion as well as the mandibular lesion.

View larger version (106K): [in a new window]   Figure 9. (a) 99Tcm MDP bone scan, and (b,c) 99Tcm(V)DMSA whole body scan at 3 h (b) and 24 h (c) are illustrated for a case of pro static carcinoma with extensive skeletal metastases. Note the identical focal abnormal tracer uptake at the skeletal metastatic sites in all.

View larger version (108K): [in a new window]   Figure 10. (a) Whole body skeletal survey with 99Tcm MDP showed focal uptake of tracer in the skull, multiple ribs bilaterally, multiple vertebrae, both sides of the pelvis and upper end of left femur. (b,c) 99Tcm(V)DMSA whole body scan at 3 h post injection (b) and 24 h (c) showed uptake at similar sites.

View larger version (99K): [in a new window]   Figure 11. (a) 99Tcm MDP bone scan, and (b,c) 99Tcm(V)DMSA whole body scan at 3 h (b) and 24 h (c) are illustrated for a case of breast carcinoma with numerous skeletal metastases. Note the identical focal abnormal tracer uptake by the two tracers at the various metastatic sites.

View larger version (142K): [in a new window]   Figure 12. (a) 99Tcm MDP bone scan and (b) 99Tcm(V)DMSA whole body scan at 3 h post injection both showing increased tracer uptake in the left iliac crest and L3 vertebra.

View larger version (121K): [in a new window]   Figure 13. (a) 99Tcm MDP bone scan showing focally increased tracer concentration at the proximal end of the left tibia and a diffuse tracer uptake in the medial aspect of left upper thigh and left mid leg. (b) 99Tcm(V)DMSA whole body scan revealing tracer uptake at the same region and several other regions. The patient was referred for further work-up and metastases in these soft tissue areas were confirmed.

View larger version (108K): [in a new window]   Figure 14. (a) 99Tcm MDP bone scan of the same patient showing increased uptake in the skull, lower end of sternum, upper end of left humerus and right femoral shaft. 99Tcm(V)DMSA whole body scan at 3 h (b) and at 24 h (c) of the same patient showing increased concentration of tracer in the metastatic areas corresponding to those seen in the bone scan along with increased uptake in the metastatic cervicothoracic mass and hepatic lesions.

View larger version (164K): [in a new window]   Figures 15–17. (a) 99Tcm MDP scintigrams of three patients with superscan appearance in the bone. In all of them the kidneys were either not visualized or were very faintly visualized. (b) 99Tcm(V)DMSA whole body scan at 3 h post injection showed diffusely increased tracer uptake in almost the entire axial skeleton and a few areas of focally increased uptake corresponding to those in the bone scans. Both the kidneys were well visualized in all three cases. Note the extent of skeletal involvement in the superscans cited is variable. This can be interpreted with a greater degree of certainty from the 99Tcm(V)DMSA scans, e.g. in Figure 16 the forearms distal to the lower end of both humeri are not involved, which is clearly depicted in 99Tcm(V)DMSA scintigraphy as only soft tissue visualization. This helps in better assessment of disease activity as well as better treatment monitoring.

View larger version (153K): [in a new window]   Figure 16.

View larger version (143K): [in a new window]   Figure 17.