Nonosseous Accumulation of Bone-seeking Rarm1 Amilcare

Gentili,

Stefan

D. Miron,

Errol

M.

Bone

MD

Bellon,

MD

scintigrams

malities; However, the

are

usually

obtained

for

soft-tissue abnormalities are the recognition of specific

cumulation

of bone-seeking

diagnostic

value

osseous

uptake

volving

the

muscle,

in the

cumulation

of the

and

are

study.

Several

neoplastic

lung,

soft

scintigraphy

conditions. ma!ities, myositis,

heart,

bladder

tissues

are

ac-

enhances

of abnormal

nonneoplastic bowel,

abnor-

non-

processes

liver,

are

presented.

Examples

also

described.

Causes

spleen,

in-

skeletal

of artifactual for

nonosseous

ac-

discussed.

is an important

modality

um-phosphate thyroidism.

Index teresa: ing #{149} Soft tissues,

the

Departments

Rd, Cleveland, (5DM., E.M.B.).

27 and ©RSNA,

receivedjune

of skeletal

pathologic

the evaluation of soft-tissue abnorburns, polymyositis, and dermatoabout the nonosseous structures is

normally seen diphosphonates

on bone scintigrams are excreted

pni-

as it is in primary to explain uptake

on secondary in tissues

hyperparaother than

altered capillary permeability, presence of iron deposits, collagen, and binding to denatured proteins or enzyme

Bones, radionuclide studies, 40. radionuclide studies, 40.1299, 1990;

RadloGraphics

for

in soft tissues are similar to those for bones. Calcium where there is an excess of calcium in the tissue, to local tissue necrosis on damage or when the calci-

product is elevated, such Other mechanisms suggested

bone include hypenemia, adsorption onto immature receptors (1).

From

for examination

Although it is used occasionally such as myositis ossificans, electrical in most cases important information

The mechanisms of uptake and phosphate are deposited which may occur subsequent

land

greatly examples

and breast,

an incidental finding. Nonosseous structures are the kidneys and bladder, as technetium-99m manly via the urinary tract.

1

of skeletal

unexpected finding. with extraskeletal

INTRODUCTION

Bone

ington

evaluation

often an conditions

radiopharmaceuticals

in both

brain,

kidney,

uptake

U

MD

1 299 #{149} Kidney, radionuclide 70.1299, 80.1299

studies,

81 .1299

Western

Reserve

Radionuclide

imag.

#{149}

10:871-881 of Radiology, OH 44106 From the 8; acceptedJune

University

Hospitals

of Cleveland,

Case

(AG.) and MetroHealth Medical Center, 1989 RSNA scientific assembly. Received 18.

Address

reprint

requests

Case March to

University,

Western Reserve University, 19, 1990; revision requested

2074

Ab-

Cleve. April

AG.

1990

871

Figure 1. Anterior bone scintigram (a) obtained in a patient with cerebral infarction shows increased uptake in the right panetal region, a finding that corresponds to an area of decreased attenuation on an unenhanced computed tomographic (CT) scan

(b).

L

.

b.

a. Figure creased

2. Posterior (a) and lateral uptake in the right posterior

an unenhanced

CT scan

C.

(b) bone scintigrams fossa, a finding that

known.

U

RadioGrapbks

U

Gentili

in a patient with meningioma to a heavily calcified mass

show inseen on

(c).

We present examples of abnormal nonosseous accumulation of radiopharmaceuticals in the central nervous system, the chest (including the breast and myocardium) , gastrointestinal tract, genitouninary system, and skeletal muscle. We discuss mechanisms for uptake in those instances in which they are

872

obtained corresponds

et al

U

AREAS

.

Central

OF NONOSSEOUS Nervous

Tc-99m diphosphonates bral lesions only when

en has been

damaged

UPTAKE

System accumulate the blood-brain

by cerebral

infarction (2) Bonealso in cxhematomas, calcifica-

(Fig 1), tumor, on inflammation seeking radiotnacers accumulate tnaaxial lesions, such as subdural meningiomas (Fig 2), and dural lions.

Volume

in cencbarn.

10

Number

5

Figures

3-5. (3) Bone scintigram obtained in a patient with parathynoid adenoma and primary hyperparathyroidism shows diffuse increased uptake In the lungs and stomach in metastatic calcifications. (4) Bone scintigram obtained in a patient with neuroblastoma shows intense uptake in the mediastinum. Thirty-five percent to 74% of cases

of primary

neuroblastoma

accumulate

bone-seek-

ing agents, probably in dystrophic calcifications in the tumor. (5a) Bone scintigram shows diffuse accumulation of radiotracer in a malignant pleural effusion in the right hemithorax of a patient with hung carcinoma. (5b) CT scan helps confirm

the presence

. Any

of a right

pleural

effusion.

genic

Chest cause

of hypercalcemia-although

it

most commonly occurs due to primary or secondary hyperparathyroidism (Fig 3)can cause metastatic calcifications and ab-

normal osteosarcoma,

pulmonary

uptake

pncumonitis,

September

1990

may

demonstrate

uptake

of

(FigS)

(7).

(3,4).

ncuroblastoma

radiation

carcinoma

bone-seeking radiotracens. Accumulation of Tc-99m diphosphonate is also seen in pleurah effusions (usually malignant ones)

Mctastatic 4) (5,6), rarely, broncho(Fig

and,

Gentili

et al

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Ra4ioGrapbics

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873

Figure

gram

uptake

6.

Bone

demonstrates in the

region

scinti-

diffuse of the

heart of a patient with two previous myocardlal In-

farctions and ischemlc cardiomyopathy. The ejection

fraction

was

14%.

,,

8.

7. Figures

7, 8. (7) Scintigrams demonstrate bilateral symmetric uptake in normal gram obtained in a patient with breast carcinoma shows intense soft-tissue uptake heft breast. Calcifications in the mass were seen on xeromammogram (not shown).

874

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RadioGrapbks

U

Gentili

et a!

breasts.

(8)

in a large

Volume

Bone

mass

10

scinti-

In the

Number

5

S

4

Figure scan

9.

obtained

Total body 4 hours

bone after

the injection of the radiotracen shows free pertechnetate in the bowel,

stomach, thyglands. This finding was due to poor habeling of the radiopharmaceutical. Tc-99m colloid ac-

and salivary

nold,

cumulation

in the liver is

also present.

.

Myocardlum

Scintigraphy commonly infarction.

The

phosphate

scintigraphy

observed

with

findings

use

pyrophosphate acute myocardial from

Tc-99m

are similar of Tc-99m

is

It has

pyno-

age (Fig 6) Focal mural myocardial has been noted in Diffuse uptake has .

uptake

with

Patchy

unstable angina been observed

.

trans-

since

1990

it is seen

pectonis. with car-

but

to high

levels

of tissue

of the bone-seeking

receptor

sites

of acid

raphos-

(9).

Gastrointestinal

Tract

The most common cause of visualization the stomach on a bone scintigram Is poor

beling,

diomyopathies, pericandial tumors, and diffuse penicarditis. Other causes of myocardial uptake include myocardial contusion, defibnillation, and amyloidosis. Persistent uptake following infarction correlates with a higher rate of complications and with left ventricular aneurysm.

is nonspecific,

to the

phatase

uptake

. Breast Uptake of bone-seeking radiopharmaccuticals in the breast is a common finding,

related

or to binding

diotracer

diphosphon-

is seen

infarction.

been

calcium

to those

ates, when there Is an excess of tissue calciurn, following local tissue necrosis or dam-

September

(Fig 7) as well as in those with benign and malignant disease (Fig 8) (8). The exact mechanism of uptake is uncertain, but breasts

with Tc-99m used to detect

free

pertechnetate

concentrating

In the

stomach

(Fig

Hypercalcemia

with

metastatic

Is the

with

second

accumulation in the

small

cal diversion cntenocolitis,

resultant

most

common

bowel

of the urinary and lschemic

(10).

9)

calcifications cause

in the stomach or large

of la-

of tracer

(Fig Is seen

3)

.

with

Uptake sungi-

tract, necrotizing bowel infarction.

it

in normal

Gent!!!

et a!

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RadiOGraphiCs

U

875

Figures 10, 11. (10) Bone scintigram (a) obtained in a patient with metastatic colon carcinoma demonstrates patchy uptake in the liver, a finding that corresponds to multiple metastases seen on CT scan (b). (ha) Bone scintigram obtained in a patient with metastatlc osteosarcoma shows four areas of Intense uptake in the liver and in the left supraclavicular lymph nodes. (lib) CT scan of the liver demonstrates two ossified hepatic metastases and multiple small ossified splenic metastases.

Figure 12. Bone scintigram tient with sickle cell disease in the

spleen

(arrow)

cumulation

in multiple

.

Note

obtained in a pademonstrates uptake foci

of increased

ac-

rib infarcts.

I

876

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RadioGraphics

U

Gentill

et al

Volume

10

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5

CT scan (b).

.

.

Liver

A common

on bone static

cause

of focal

scintigrams

deposits

(Fig

in the

is the presence

(1 1) from

breast carcinoma, gastrointestinal coma

uptake lung

liver

of meta-

carcinoma,

adenocarcinoma tract (Fig 1 0), and

of the osteosar-

11).

The

differential diagnoses of diffuse liver uptake include residual radioactivity from a liver scintigraphic study done the previous day or administration of a poor-quality radiopharmaceutical with excess technetium colbid (1 2 , 1 3). Colloids can be caused by cxcess

aluminum

ions

of stannous

in the

chloride

or excessive

hydrolysis

to stannous

hydrolyzed (Fig 9).

preparation

eluate,

Muscle

ysis

may

ma,

electrical

severe

follow

in the

exercise,

muscular

common

Diffuse collagen

usually

sickle

cell

probably ed sp!cnic infarcted

cause

in

the

tissue tissue

and (iron

take can also mosiderosis.

be seen

1990

iron

complex)

abuse,

surgical

(1 6),

and

of mepenidine

tnau-

frostbite,

intraor iron

muscle vascular seen

with

in patients

sificans can scintigraphy CT (17).

uptake is also seen with diseases such as polymyosiUptake in the soft tissue myositis ossificans (Fig 1 5), with paraplegia on after

of a hip

be detected than with

prosthesis.

Myositis

earlier with bone plain radiography

os-

or

in the

have

in thalassemia

is

1 4)

This is of infarct-

deposition

deposits

of

spleen

disease (Fig 12) (14,15). due to both calcification

for the diphosphonate

September

of accumulation

radiotracers

alcohol

injection

implantation

bone-seeking

injuries,

(Fig

dextran.

is also

.

Spleen The most

crush

burns

tis and scheroderma.

hydroxide,

technetium

Skeletal

Uptake of bone-seeking radiopharmaccuticals in the skeletal muscle is seen when there is tissue injury, necrosis (Fig 1 3) , or ossification. Rhabdomyolysis is frequently a cause of diphosphonate uptake in muscle. Rhabdomyol-

.

affinity

Splenic and

uphe-

Gentili

et a!

U

RadioGrapbks

U

877

14. Figures

1,_I.

14, 15.

(14)

rhabdomyolysis

Bone

sclntlgnam

due to an electrical

shows

burn.

Increased

(iSa)

uptake

1_,_)_ in the muscle

Bone scintignam

diotracer In the soft tissues of both lower extremities around the knees. shows calcification in the soft tissues, a finding consistent with myositis

Figures

16, 17.

scintigram

with

(16)

obtained

sIckle

bilateral

cell large

of the forearm

demonstrates

marked

(15b)

caused

by

accumulation

Radiograph

of ra-

of the

heft knee

(Fig

1 7) and

ossificans.

Bone

in a patient

disease kidneys

shows with

intense uptake, probably due to mlcrolnfarcts and iron deposits. (17) Bone scintignam obtained in a patient with primary hypenparathyroldism (same patient as In Fig 3) shows diffuse intense uptake In both cinosis.

due to nephrocal-

kidneys

16.

.

(Fig

Kidney

The

kidneys

bone-seeking

creted,

and

are the primary

route

by which nadiopharmaceuticals arc cxthey normally arc well seen on

bone scintigrams. In up to 1 5% of bone scmtigrams, urinary tract abnormalities are detected as incidental findings (18,19). Diffuse increased renal uptake is usually

caused by dehydration seen with hypercalcemia,

878

U

RadiOGrapMCS

17.

U

Gent!!!

(20)

but sickle

et a!

can also be cell anemia

1 6),

and

nephrocalcinosis

after administration or gentamicin.

of antineoplastic

agents

Focal increased accumulation of activity often noted in normal on obstructed collect-

ing systems ry or metastatic

(Fig

1 8) (2 1) or rarely renal

neoplasms.

is

in primaIt may

also

be seen after radiation therapy. Focal areas of decreased renal uptake are generally seen with space-occupying lesions, such as abscesses, cysts, primary neoplasms (Fig 1 9) , and metastatic neoplasms.

Volume

10

Number

5

t7r;;:’

:

t

*

-

,..I.

18b.

18a.

19a. Figures 18, 19 lion of radiotracer (18b)

Sonogram

(18a) Bone scintigram in the dilated collecting of the

(posterior view) take in the lower

(a) pole

right

obtained of the

kidney

helps

in a patient right

kidney,

19b. obtained system

in a patient of the right

confirm

with

the

renal

a finding

with prostatic kidney. Note

presence

cell that

carcinoma corresponds

carcinoma shows accumulamultiple bone metastases.

of hydronephrosis.

shows to the

a large large

(19)

area mass

Bone

scintigram

of decreased seen

up-

on CT scan

(b).

September

1990

Gentili

et a!

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RadioGrapbics

U

879

,\

20a.

r’,

21.

Figures 20, 21. (20) Bone scmtigram (a) obtained in a patient with bladder carcinoma reveals a large photon-deficient lesion (arrow) in the superior aspect of the bladder, a finding that comesponds to a filling defect seen on a radiograph of the pelvis (b) obrained

during

intravenous

pyelog-

raphy. (21) Bone scintigram demonstrates a collection of activity below the symphysis pubis in the absence of activity in the usual location of the urinary bladder. Physical examination revealed bladder prolapse.

S

Bladder

The bladder is usually visualized on bone scintigrams, since diphosphonates are cxcreted by the kidneys. A large quantity of activity in the bladder may obscure the pelvic bones. Bladder diverticula may be misinter-

preted bladder

as pubic lesions. Distortion by pelvic masses (uterine,

ovarian,

fects ma

880

U

RadioGrapbks

or prostatic

neoplasms)

in the bladder [Fig

20],

stones,

U

(due blood

Gentili

of the cervical, , filling

to bladder clots),

et a!

de-

cancinoon abnor-

mal position of the lapse [Fig 2 1]) may scintignams. U

bladder (bladder probe detected on bone

SUMMARY

Soft-tissue seeking

common

or nonosseous radiopharmaccuticals

finding

uptake

on skeletal

of boneis not an un-

scintigrams.

It is

seen in a wide variety of pathologic processes involving almost any organ. Familiarity with the appearance of soft-tissue abnormalities on bone scintignams reduces the possibihity of confusion and error and provides important clinical information.

Volume

10

Number

5

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Davidson

Chaudhuni TK. Liver uptake of 99mTc.di. phosphonate. Radiology 1976; 119:485486. Hansen S, Stadalnik RC. Liver uptake of 99mTc.pophosphate Semin NucI Med

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