Ebook Diagnostic imaging nuclear: Part 1

Diagnostic Imaging Nuclear


Diagnostic Imaging Nuclear

Table of Contents
Diagnostic Imaging Nuclear.......................................................................................................................... 7
Cover ....................................................................................................................................................... 7
Authors.................................................................................................................................................... 7
Dedication ............................................................................................................................................... 8
Foreword ................................................................................................................................................. 9
Preface .................................................................................................................................................... 9
Acknowledgments ..................................................................................................................................10
Introduction ...........................................................................................................................................10
Section 1 - Musculoskeletal.....................................................................................................................11
I. Benign Bone Tumors ........................................................................................................................11
Osteoid Osteoma ............................................................................................................................11
Enchondroma .................................................................................................................................18
Fibrous Cortical Defect ....................................................................................................................22
Bone Cyst, Aneurysmal....................................................................................................................26
Bone Cyst, Solitary ..........................................................................................................................30
Giant Cell Tumor .............................................................................................................................37
II. Malignant Bone Tumors ..................................................................................................................41
Skeletal Metastases ........................................................................................................................41
Superscan .......................................................................................................................................51
Osteosarcoma .................................................................................................................................58
Ewing Sarcoma................................................................................................................................68
Chondrosarcoma.............................................................................................................................75
Prostate Cancer, Bone Metastases ..................................................................................................82
III. Therapy..........................................................................................................................................86
Palliation of Metastatic Bone Pain ...................................................................................................86

IV. Infection ........................................................................................................................................93
Cellulitis ..........................................................................................................................................93
Osteomyelitis, Appendicular .........................................................................................................100
Osteomyelitis, Axial.......................................................................................................................110
Osteomyelitis, Temporal Bone ......................................................................................................114
Osteomyelitis, Feet .......................................................................................................................118
Osteomyelitis, Pediatric ................................................................................................................125
V. Metabolic Bone Disease ................................................................................................................135
Hyperparathyroidism ....................................................................................................................135
Osteomalacia ................................................................................................................................142
Hypertrophic Osteoarthropathy ....................................................................................................149
VI. Dysplasias ....................................................................................................................................159
Paget Disease ................................................................................................................................159
Fibrous Dysplasia ..........................................................................................................................166
Melorheostosis .............................................................................................................................170
Multiple Enchondromatoses .........................................................................................................177
Multiple Hereditary Exostoses .......................................................................................................184
VII. Avascular Necrosis ......................................................................................................................191
Osseous Necrosis ..........................................................................................................................191
Legg-Calve Perthes Disease ...........................................................................................................198
VIII. Surgical Assessment ...................................................................................................................202
Joint Prostheses, Painful................................................................................................................202
Failed Back Surgery Syndrome ......................................................................................................206
IX. Skeletal Trauma ...........................................................................................................................216
Insufficiency Fracture ....................................................................................................................216
Fracture ........................................................................................................................................226
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Diagnostic Imaging Nuclear

Trauma, Non-Accidental ................................................................................................................230
Stress Fracture ..............................................................................................................................234
X. Regional Pain Evaluation ...............................................................................................................241
Arthritis, Non-Infectious ................................................................................................................241
Complex Regional Pain Syndrome .................................................................................................248
Hip Pain ........................................................................................................................................255
Wrist Pain .....................................................................................................................................262
Calcaneal Pain ...............................................................................................................................272
Knee Pain ......................................................................................................................................279
XI. Skeletal Muscle & Soft Tissues......................................................................................................286
Heterotopic Ossification ................................................................................................................286
Skeletal Muscle Disorders .............................................................................................................296
Amyloidosis...................................................................................................................................303
XII. Bone Marrow Disorders ..............................................................................................................307
Hematoproliferative Disorders ......................................................................................................307
Sickle Cell Disease, Bone Pain ........................................................................................................317
Multiple Myeloma.........................................................................................................................324
Section 2 - Vascular and Lymphatics......................................................................................................331
I. Lymphatic ......................................................................................................................................331
Lymphedema ................................................................................................................................331
Sentinel Lymph Node Mapping .....................................................................................................335
II. Vascular ........................................................................................................................................342
Large Vessel Vasculitis ...................................................................................................................342
Atherosclerosis .............................................................................................................................346
Vascular Thrombosis .....................................................................................................................353
Vascular Graft Infection ................................................................................................................357
Section 3 - Cardiovascular .....................................................................................................................367
I. Introduction and Overview.............................................................................................................367
Cardiovascular Overview ...............................................................................................................367
II. Cardiac ..........................................................................................................................................375

Cardiomyopathy ...........................................................................................................................375
Valvular Heart Disease ..................................................................................................................385
Myocardial Ischemia .....................................................................................................................392
Myocardial Viability ......................................................................................................................402
Myocardial Infarction ....................................................................................................................409
Cardiac Transplant ........................................................................................................................419
Left-to-Right Intracardiac Shunts ...................................................................................................426
Right-to-Left Intracardiac Shunts ...................................................................................................430
Section 4 - Chest and Mediastinum .......................................................................................................434
I. Introduction and Overview.............................................................................................................434
VQ Scan Overview .........................................................................................................................434
II. Lung Ventillation & Perfusion Abnormalities .................................................................................443
VQ, Pulmonary Embolism ..............................................................................................................443
VQ, Quantitative ...........................................................................................................................450
III. Lung Infection & Inflammation .....................................................................................................460
Pneumocystis Carinii Pneumonia...................................................................................................460
Interstitial Lung Disease ................................................................................................................467
Granulomatous Disease ................................................................................................................474
IV. Lung Cancer .................................................................................................................................481
Solitary Pulmonary Nodule ............................................................................................................481
Non-Small Cell Lung Cancer ...........................................................................................................488
Metastases, Lungs and Mediastinum.............................................................................................498
V. Pleura ...........................................................................................................................................505
Pleural Disease, Malignant and Inflammatory ...............................................................................505
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Diagnostic Imaging Nuclear
VI. Mediastinum ...............................................................................................................................512
Thymic Evaluation .........................................................................................................................512

Pericardial Disease, Malignant and Inflammatory ..........................................................................519
Section 5 - CNS .....................................................................................................................................526
I. Introduction and Overview.............................................................................................................526
Brain Imaging Overview ................................................................................................................526
II. Vascular Assessment .....................................................................................................................531
Brain Death ...................................................................................................................................531
Cerebral Vascular Occlusion ..........................................................................................................541
Blood Brain Barrier Disruption.......................................................................................................548
III. Seizure Assessment ......................................................................................................................552
Seizure Evaluation .........................................................................................................................552
IV. Dementia & Neurodegenerative ..................................................................................................562
Alzheimer Disease .........................................................................................................................562
Dementia and Neurodegenerative, Other .....................................................................................569
V. Neurooncology .............................................................................................................................579
Gliomas and Astrocytomas ............................................................................................................579
Primary CNS Lymphoma ................................................................................................................586
Metastases, Brain..........................................................................................................................593
Radiation Necrosis vs Recurrent Tumor .........................................................................................600
VI. CSF Imaging .................................................................................................................................610
CSF Leak ........................................................................................................................................610
Ventricular Shunt Dysfunction .......................................................................................................617
Normal Pressure Hydrocephalus ...................................................................................................624
VII. Miscellaneous .............................................................................................................................634
Heterotopic Gray Matter ...............................................................................................................634
Brain Infection and Inflammation ..................................................................................................644
Psychiatry, Drug Addiction and Forensics ......................................................................................651
Section 6 - Head and Neck ....................................................................................................................661
I. Squamous Cell Carcinoma of the Head and Neck ............................................................................661
SCCHN, Staging .............................................................................................................................661
SCCHN, Primary Unknown .............................................................................................................668

SCCHN, Therapeutic Assessment - Restaging .................................................................................672
II. Miscellaneous Primary Head and Neck Tumors .............................................................................679
Parotid and Salivary Tumors ..........................................................................................................679
Neuroendocrine Tumors, Head and Neck ......................................................................................683
III. Miscellaneous ..............................................................................................................................690
Lacrimal Complex Dysfunction ......................................................................................................690
Section 7 - Thyroid & Parathyroid .........................................................................................................694
I. Introduction and Overview.............................................................................................................694
Thyroid Overview ..........................................................................................................................694
II. Parathyroid ...................................................................................................................................702
Parathyroid Adenoma, Typical.......................................................................................................702
Parathyroid Adenoma, Ectopic ......................................................................................................710
III. Hyperthyroidism ..........................................................................................................................714
Graves Disease ..............................................................................................................................714
Hashimoto Thyroiditis ...................................................................................................................721
Multinodular Goiter ......................................................................................................................728
Thyroid Adenoma, Hyperfunctioning .............................................................................................735
Subacute Thyroiditis......................................................................................................................742
I-131 Hyperthyroid Therapy ..........................................................................................................749
IV. Thyroid, Benign Miscellaneous .....................................................................................................756
Ectopic Thyroid .............................................................................................................................756
Congenital Hypothyroidism ...........................................................................................................763
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Diagnostic Imaging Nuclear
Benign Thyroid Conditions, PET .....................................................................................................770
V. Thyroid Cancer ..............................................................................................................................777
Well-Differentiated Thyroid Cancer ...............................................................................................777
I-131 Thyroid Cancer Therapy .......................................................................................................787

Well-Differentiated Thyroid Cancer, PET .......................................................................................794
Medullary Thyroid Cancer .............................................................................................................801
Section 8 - Gastrointestinal ...................................................................................................................808
I. Introduction and Overview.............................................................................................................808
GI Anatomy and Imaging Issues .....................................................................................................808
II. Biliary ............................................................................................................................................812
Acute Calculous Cholecystitis ........................................................................................................812
Acute Acalculous Cholecystitis ......................................................................................................822
Chronic Cholecystitis .....................................................................................................................832
Biliary Leak....................................................................................................................................839
Common Bile Duct Obstruction .....................................................................................................843
Choledochal Cyst...........................................................................................................................847
Biliary Bypass Obstruction .............................................................................................................854
Biliary Atresia ................................................................................................................................858
Cholangiocarcinoma......................................................................................................................865
Gallbladder Cancer........................................................................................................................872
III. Hepatic ........................................................................................................................................879
Focal Nodular Hyperplasia.............................................................................................................879
Hepatic Cirrhosis ...........................................................................................................................886
Hypersplenism ..............................................................................................................................896
Hepatic Metastases .......................................................................................................................903
Hepatoblastoma ...........................................................................................................................910
Hepatocellular Carcinoma .............................................................................................................917
Cavernous Hemangiomas ..............................................................................................................927
IV. Adrenal ........................................................................................................................................934
Adrenal Malignancy ......................................................................................................................934
Pheochromocytoma ......................................................................................................................944
Neuroblastoma .............................................................................................................................951
V. Spleen...........................................................................................................................................961
Asplenia-Polysplenia Syndromes ...................................................................................................961

Accessory and Ectopic Splenic Tissue.............................................................................................968
VI. Oropharynx & Esophagus .............................................................................................................975
Esophageal Cancer ........................................................................................................................975
Esophageal Dysmotility .................................................................................................................982
VII. Stomach......................................................................................................................................989
Gastritis ........................................................................................................................................989
Gastric Emptying Disorders ...........................................................................................................993
Gastric Carcinoma ....................................................................................................................... 1000
VIII. Intestine .................................................................................................................................. 1007
Intestinal Cancer, Primary and Staging ........................................................................................ 1007
Intestinal Cancer, Therapy Eval - Restaging.................................................................................. 1014
Meckel Diverticulum ................................................................................................................... 1018
GI Bleeding Localization .............................................................................................................. 1025
Inflammatory Bowel Disease ....................................................................................................... 1032
IX. Pancreas .................................................................................................................................... 1039
Pancreatitis ................................................................................................................................. 1039
Pancreatic Adenocarcinoma ........................................................................................................ 1043
Islet Cell Tumors.......................................................................................................................... 1050
X. Miscellaneous ............................................................................................................................. 1057
Intraabdominal Infection............................................................................................................. 1057
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Diagnostic Imaging Nuclear
Carcinoid Tumor ......................................................................................................................... 1067
GI Stromal Tumors ...................................................................................................................... 1074
Peritoneal Systemic Shunt Evaluation.......................................................................................... 1081
Diaphragmatic Patency Determination ........................................................................................ 1088
Intraarterial Hepatic Pump Evaluation ......................................................................................... 1092
Section 9 - Genitourinary .................................................................................................................... 1096

I. Kidney .......................................................................................................................................... 1096
Renal Cortical Scar ...................................................................................................................... 1096
Renal Ectopy ............................................................................................................................... 1103
Renovascular Hypertension......................................................................................................... 1110
Acute Renal Failure ..................................................................................................................... 1117
Renal Masses .............................................................................................................................. 1127
Renal Cell Carcinoma................................................................................................................... 1131
Pyelonephritis ............................................................................................................................. 1138
Renal Transplant ......................................................................................................................... 1145
Renal Function Quantification ..................................................................................................... 1155
II. Collecting System ........................................................................................................................ 1162
Obstructive Uropathy .................................................................................................................. 1162
Reflux Uropathy .......................................................................................................................... 1169
Urinary Bladder and Epithelial Cancer ......................................................................................... 1176
III. Testes ........................................................................................................................................ 1183
Testicular Torsion ........................................................................................................................ 1183
Testicular Cancer......................................................................................................................... 1190
IV. Ovaries ...................................................................................................................................... 1197
Ovaries, Normal and Benign Pathology........................................................................................ 1197
Ovarian Cancer............................................................................................................................ 1201
V. Uterus......................................................................................................................................... 1208
Uterus, Normal and Benign Pathology ......................................................................................... 1208
Cervical Cancer ........................................................................................................................... 1212
Endometrial Cancer..................................................................................................................... 1219
VI. Prostate ..................................................................................................................................... 1226
Prostate Cancer, Antibody Scan................................................................................................... 1226
Section 10 - HemeOnc Procedures & Therapies .................................................................................. 1230
I. Therapy - Oncology ...................................................................................................................... 1230
Phosphorus-32 Therapies ............................................................................................................ 1230
Hepatic Arterial Y-90 Microspheres ............................................................................................. 1234

Radiolabeled Antibody Therapy .................................................................................................. 1241
II. Hematologic Procedures ............................................................................................................. 1248
RBC Survival and Splenic Sequestration ....................................................................................... 1248
Red Cell Mass and Plasma Volume .............................................................................................. 1252
Schilling Test ............................................................................................................................... 1256
Section 11 - Oncology, Other .............................................................................................................. 1260
I. Lymphoma ................................................................................................................................... 1260
Lymphoma, Benign Mimics ......................................................................................................... 1260
Hodgkin Lymphoma Staging ........................................................................................................ 1267
Lymphoma Post-Therapy Evaluation ........................................................................................... 1274
Non-Hodgkin Lymphomas, Low Grade ......................................................................................... 1284
Non-Hodgkin Lymphoma Staging ................................................................................................ 1291
II. Melanoma................................................................................................................................... 1298
Melanoma Staging ...................................................................................................................... 1298
Melanoma Therapy Evaluation - Restaging .................................................................................. 1305
III. Breast Cancer ............................................................................................................................. 1312
Breast, Benign Disease ................................................................................................................ 1312
Breast Cancer, Primary ................................................................................................................ 1316
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Diagnostic Imaging Nuclear
Breast Cancer, Staging - Restaging............................................................................................... 1326
IV. Miscellaneous ............................................................................................................................ 1336
Adenocarcinoma of Unknown Primary ........................................................................................ 1336
Paraneoplastic Disorders............................................................................................................. 1340
Index .................................................................................................................................................. 1348
A ..................................................................................................................................................... 1348
B ..................................................................................................................................................... 1349
C ..................................................................................................................................................... 1351

D ..................................................................................................................................................... 1353
E ..................................................................................................................................................... 1353
F ..................................................................................................................................................... 1354
G..................................................................................................................................................... 1355
H..................................................................................................................................................... 1356
I ...................................................................................................................................................... 1358
J ...................................................................................................................................................... 1359
K ..................................................................................................................................................... 1359
L ..................................................................................................................................................... 1359
M .................................................................................................................................................... 1361
N..................................................................................................................................................... 1362
O..................................................................................................................................................... 1364
P ..................................................................................................................................................... 1365
Q .................................................................................................................................................... 1366
R ..................................................................................................................................................... 1366
S ..................................................................................................................................................... 1367
T ..................................................................................................................................................... 1368
U..................................................................................................................................................... 1370
V ..................................................................................................................................................... 1371
W.................................................................................................................................................... 1371
Y ..................................................................................................................................................... 1371
Z ..................................................................................................................................................... 1371

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Diagnostic Imaging Nuclear

Diagnostic Imaging Nuclear
Cover

Authors
Authors
Kathryn A. Morton MD
Professor of Radiology
University of Utah School of Medicine
Salt Lake City, Utah
Paige B. Clark MD
Assistant Professor of Nuclear Medicine
Department of Radiology
Wake Forest University Health Sciences
Winston-Salem, North Carolina
Todd M. Blodgett MD
Chief of Cancer Imaging
Department of Radiology
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Carl R. Christensen MD

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Diagnostic Imaging Nuclear
Assistant Professor of Radiology
University of Utah School of Medicine
Salt Lake City, Utah
Janis P. O'Malley MD
Associate Professor of Radiology
Director of Nuclear Medicine and Clinical PET
University of Alabama

Birmingham, Alabama
Jeffrey S. Stevens MD
Associate Professor of Radiology
Director of Nuclear Medicine
Oregon Health and Science University
Portland, Oregon
Crispin A. Chinn MD
Director of Nuclear Medicine
Providence St. Vincent Hospital
Portland, Oregon
Alan D. Waxman MD
Director of Nuclear Medicine
Co-Chair, Department of Imaging
Cedars-Sinai Medical Center
S. Mark Taper Imaging Center
Clinical Professor of Radiology
University of Southern California School of Medicine
Los Angeles, CA
Robert W. Nance Jr. MD
Assistant Professor Radiology/Nuclear Medicine
Oregon Health and ScienceUniversity
Portland, Oregon
Anita J. Thomas MD
Assistant Professor of Nuclear Medicine
Department of Radiology
Wake Forest University Health Sciences
Winston-Salem, North Carolina
Ralph Drosten MD
Assistant Professor of Radiology
University of Utah School of Medicine

Salt Lake City, Utah
Thomas F. Heston MD
Medical Director
Northwest Molecular
Kellogg, Idaho

Dedication
Dedication
To my husband, Mike Poler. His unfailing support and encouragement made this book possible.
KAM
For my family.
PBC

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Diagnostic Imaging Nuclear

Foreword
Diagnostic Imaging: Nuclear Medicine is organized and edited in the popular format used for other books in
this series. The lead author, Dr. Morton is unusual in that she is both an excellent radiologist and an
outstanding clinical nuclear medicine physician. She is also well recognized and respected in the nuclear
medicine research community. Dr. Clark is a vibrant rising star in the nuclear medicine field, both in clinical
expertise as well as research. The contributing authors represent a well-balanced cadre of some of the
most experienced and respected names in nuclear medicine today, as well as experts with strong multimodality perspectives in diagnostic imaging. Together, they are an unbeatable team.
The authors have succeeded in presenting a well-balanced and fair appraisal of the best imaging approach
to a vast array of common and not-so-common clinical problems that face diagnostic imagers in nuclear
medicine. The book defines the appropriate role of nuclear medicine in the context of other powerful
imaging modalities today. This includes important protocol information to allow optimization of a “best
practice” imaging approach to specific problems. Hundreds of superb well-reproduced images and graphic

illustrations are included, a hallmark of the Diagnostic Imaging series. Important clinical information
regarding the diseases addressed is also included. The general organization is spare and direct in its
bulleted format, with key points highlighted, making this a quick and easy reference for the practicing
radiologist, nuclear medicine practitioner, as well as clinicians. Diagnostic Imaging: Nuclear Medicine
should withstand the test of time as well-worn addition to any radiology reading room.
Edward V. Staab, MD
Professor of Nuclear Medicine
Department of Radiology
Wake Forest University Health Sciences
Winston-Salem, North Carolina

Preface
There are many outstanding radiology text books available today, addressing both general radiology as well
as specific imaging subspecialties. In the face of literally hundreds of available text books, the Amirsys
Diagnostic Imaging series has risen rapidly in popularity as one of the best selling imaging text book series
of all time. Diagnostic Imaging: Nuclear Medicine rounds out this series, focusing on conventional nuclear
medicine imaging, PET and PET/CT, radionuclide therapy, and the more commonly used in-vitro diagnostic
determinations. We have strived to fill an un-met need in providing a quick and practical guide for
radiologists and nuclear medicine physicians “in the trenches”. The bulleted format is easy to digest and
conveys clinically relevant information concisely and rapidly, providing a real-time reference for the reading
room. The hundreds of images included are clear and convey typical and atypical examples of specific
diagnoses, as well as “mimics” and potential pitfalls that complicate diagnostic accuracy.
This book is comprehensive in that it addresses the most common nuclear medicine diagnoses
encountered in daily practice, as well those with which most imagers have less experience. The book
provides thorough and concise information regarding nuclear medicine diagnostic and therapeutic
procedures, including appropriate study selection, protocol advice and interpretive guidance. It also
summarizes the key findings shown by CT, MR, ultrasound and other radiographic modalities for each
diagnosis. Most importantly, it addresses the most appropriate role for nuclear medicine within the
framework of all imaging modalities and options available to answer a specific clinical question, without
hype or subspecialty bias. In short, this nuclear medicine book is practical, accessible and in-touch with the

realities of multimodality diagnostic imaging.
Kathryn A. Morton, MD
Professor of Radiology
University of Utah School of Medicine
Salt Lake City, Utah

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Diagnostic Imaging Nuclear

Acknowledgments
Acknowledgments
Illustrations
Richard Coombs, MS
James A. Cooper, MD
Lane R. Bennion, MS
Image/Text Editing
Douglas Grant Jackson
Amanda Hurtado
Christopher Odekirk
Medical Text Editing
Edward V. Staab, MD
Associate Editor
Kaerli Main
Production Lead
Melissa A. Hoopes

Introduction
We at Amirsys and Elsevier are proud to present Diagnostic Imaging: Nuclear Medicine, the thirteenth

volume in our acclaimed Diagnostic Imaging (DI) series. We began this precedent-setting, image- and
graphic-rich series with David Stoller's Diagnostic Imaging: Orthopaedics. The next volumes, DI: Brain, DI:
Head and Neck, DI: Abdomen, DI: Spine, DI: Pediatrics, DI: Obstetrics, DI: Chest, DI: Breast, DI: Ultrasound,
DI: Pediatric Neuroradiology and DI: Emergency are now joined by Kathryn Morton and Paige Clark's
fabulous new textbook, DI: Nuclear Medicine.
Nuclear medicine is an integral part of diagnostic imaging, yet it is relatively unfamiliar territory to many
general and subspecialty radiologists. The application of exciting new techniques such as PET/CT have
brought nuclear medicine squarely to the forefront in cancer imaging. We are thrilled to have Morton and
Clark's DI: Nuclear Medicine join the Amirsys “family” of imaging textbooks. They have done a superb job in
bringing together standard imaging techniques such as high-resolution CT, MR and ultrasound and
correlating them with the most-up-to-date nuclear medicine scans available. Because the DI series is
printed with glorious full four-color illustrations throughout each book, studies such as SPECT and fused
FDG PET/CT can be shown in all their magnificence. DI: Nuclear Medicine is a feast for the eye as well as the
intellect! Just look at the superb chapter on seizure evaluation as an example.
As always, the unique bulleted format of the DI series allows our authors to present approximately twice
the information and four times the images per diagnosis compared to the old-fashioned traditional prose
textbook. All DI books follow the same format, which means that our many readers find the same
information in the same place—every time! And in every body part! Our innovative visual differential
diagnosis “thumbnail” provides you with an at-a-glance look at entities that can mimic the diagnosis in
question and has been highly popular (and much imitated). For example, the chapter on Metastases to the
Lungs and Mediastinum shows beautiful images of sarcoidosis, reactivated tuberculosis, and normal
thymus in its differential diagnosis image gallery. The DDx gallery for Alzheimer Disease shows FDG PET in
normal pressure hydrocephalus, Lewy body disease, and stroke. How great is that??!!
In summary, Diagnostic Imaging: Nuclear Medicine is a product designed with you, the reader, in mind. The
old, worn-out joke about “unclear medicine” should be retired. Diagnostic Imaging: Nuclear Medicine
makes this fascinating, burgeoning field clear and vibrant to both subspecialty experts and general
radiologists alike. We think you'll find this new volume a highly efficient and wonderfully rich resource that
will significantly enhance your practice—and find a welcome place on your bookshelf. Enjoy!
Anne G. Osborn, MD
Executive Vice President & Editor-in-Chief, Amirsys, Inc.

H. Ric Harnsberger, MD
CEO & Chairman, Amirsys, Inc.
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Diagnostic Imaging Nuclear
Paula J. Woodward, MD
Senior Vice President & Medical Director, Amirsys, Inc.
B. J. Manaster, MD
Vice President & Associate Medical Director, Amirsys, Inc.

Section 1 - Musculoskeletal
I. Benign Bone Tumors
Osteoid Osteoma
Key Facts
Imaging Findings
 Three-phase bone scan: Highly vascular lesion with intense uptake on angiographic, blood pool and
delayed images
 Double density sign: Focal increased activity in nidus with surrounding focus of increased activity in
sclerosis
 Bone scan useful for localizing lesion (e.g., in young patient with back pain)
 Negative bone scan excludes the diagnosis
 Bone scan to evaluate for polyostotic lesions (rare)
 Bone scan helpful in identifying residual nidus in symptomatic patients post treatment
 SPECT images useful when attempting to localize lesion and planar images negative
Top Differential Diagnoses
 Osteomyelitis, Chronic
 Stress Fracture
 Osteoma
 Osteoblastoma

 Metastasis
 Eosinophilic Granuloma
Clinical Issues
 Classic presentation: Pain, worse at night, relieved by aspirin
 Young population
 May spontaneously regress
 Initial treatment: Conservative
 Surgical treatment: Complete nidus removal curative

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Coronal graphic shows intracortical osteoid osteoma in the femoral neck. The nidus is red

12

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Diagnostic Imaging Nuclear

Anterior bone scan of the right hip shows focal uptake in the right femoral head/neck
in a patient with
a surgically proven osteoid osteoma. (Courtesy B. Manaster, MD).
TERMINOLOGY
Definitions
 Benign skeletal neoplasm
o Composed centrally of osteoid and woven bone in highly vascular connective tissue

o Surrounded by dense sclerotic bone
o Painful
IMAGING FINDINGS
General Features
 Best diagnostic clue
o Three-phase bone scan: Highly vascular lesion with intense uptake on angiographic, blood
pool and delayed images
o Plain film: Lytic lesion, well-defined central nidus, ranging from lucent to dense depending
on amount of calcification, surrounded by sclerotic bone
 Location
o Cortical: Most common (80-90%)
 Femur and tibia: Most frequent sites (> 50%)
 Diaphyseal or metaphyseal
 Cortical lesions associated with large amount of sclerosis
o Medullary/cancellous
 Predilection for femoral neck, small bones of hands and foot, vertebral posterior
elements
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Diagnostic Imaging Nuclear



o

o
o


Usually juxtaarticular
Less associated sclerosis
Subperiosteal
 Arises as soft tissue mass adjacent to bone
 Typically along medial aspect of femoral neck
 May also be in hands and feet; neck of talus
 Usually juxtaarticular or paraarticular
 May be associated with a large amount of periostitis
Uncommon: Skull/facial bones
Rarely polyostotic

Size
o
o

Usually < 1.5 cm
Range: 0.5-2.0 cm
 Morphology: Lucent nidus with marked surrounding sclerotic reaction
Nuclear Medicine Findings
 Three-phase bone scan
P.1-3

o
o
o

Hypervascular on flow and immediate static bone scan images
Increased activity on delayed bone scan images
Double density sign: Focal increased activity in nidus with surrounding focus of increased
activity in sclerosis

 Whole body bone scan
o Increased activity in lesion(s)
Radiographic Findings
 Lytic bone lesion with well-defined central nidus
 Lesion ranges from lucent to dense depending on amount of calcification
 Lesion surrounded by sclerotic bone
 Well-delineated from adjacent bone
CT Findings
 Lytic bone lesion with well-defined central nidus, ranging from lucent to dense depending on
amount of calcification, surrounded by sclerotic bone
 Well-delineated from adjacent bone
 Best seen with thin sections
MR Findings
 Variable, nonspecific findings
 Nidus: Low-intermediate signal on T1WI; high signal on T2WI
 Calcification: Low signal intensity
Imaging Recommendations
 Best imaging tool
o Plain film, CT
 Lesion best delineated on these modalities
o Three-phase and whole body bone scan
 Bone scan useful for localizing lesion (e.g., in young patient with back pain)
 Negative bone scan excludes the diagnosis
 Bone scan to evaluate for polyostotic lesions (rare)
 Bone scan helpful in identifying residual nidus in symptomatic patients post
treatment
 Intraoperative scintigraphy may aid in identifying nidus
 Protocol advice
o Tc-99m MDP: 20-30 mCi (740 MBq to 1.11 GBq) IV
 Children: 250-300 µCi/kg (9-10 MBq/kg) Tc-99m MDP IV

o Three phase bone scan
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Diagnostic Imaging Nuclear





Spot images over clinically painful region
Angiographic phase: Dynamic 1-3 second images for one minute
Blood pool phase: Static image for 3-5 minutes
Delayed phase: Spot images over chest and axial skeleton with 500K to 1 million
counts, 150-250K counts in extremities
 Often perform whole body scan as well, as primary lesion already characterized by
plain film, CT
o Whole body bone scan
 Image anteriorly and posteriorly
 Spot views as necessary
 Pinhole collimator useful for small lesions
 SPECT images useful when attempting to localize lesion and planar images negative
DIFFERENTIAL DIAGNOSIS
Osteomyelitis, Chronic
 Three phase bone scan
o Angiographic phase: Increased activity
o Blood pool phase: Increased activity
o Delayed phase: Increased activity; no double density sign
 Linear tract extends away from lesion on anatomic images
Stress Fracture

 Three phase bone scan: Positive three phase bone scan
o Angiographic phase: Increased activity
o Blood pool phase: Increased activity
o Delayed phase: Oval or fusiform increased activity with long axis parallel to axis of bone
 Anatomic imaging: Linear tract perpendicular to bone, adjacent new bone formation
P.1-4

Osteoma
 Bone scan: No increased activity in latent lesions, no nidus
o May have some uptake in active lesions
 Anatomic imaging: Well-defined, round, dense sclerotic lesion attached to underlying bone
 Size: 1-5 cm
Osteoblastoma
 Bone scan: Intense uptake of radiotracer
 Anatomic imaging: Expansile, circumscribed lytic lesion involving extremities and posterior
elements of spine
o May also have some reactive sclerosis
 Larger nidus
 Tends to progress
Metastasis
 Whole body bone scan: Increased activity in (usually) multiple, scattered sites
 Anatomic imaging: Irregular areas of lytic, mixed or sclerotic bone destruction
 Less likely to be solitary
 Axial skeleton predominance
Eosinophilic Granuloma
 Well-defined lytic lesion without sclerotic rim
 Bone scan usually shows increased uptake, but may have normal uptake or decreased uptake with
surrounding halo
PATHOLOGY
General Features

 Etiology
o Controversial
o Post-traumatic, developmental, inflammatory etiologies postulated
15


Diagnostic Imaging Nuclear



Epidemiology: 10-12% of benign bone tumors
Associated abnormalities
o Scoliosis if located in vertebral posterior elements
o Limb overgrowth if located near growth plate
Gross Pathologic & Surgical Features
 Granular bone, round or oval
 Sharp margins with adjacent bone
Microscopic Features
 Composed of osteoid and woven bone
 Tissue between the osteoid is fibrovascular
 Osteoblasts common at the edge of the osteoid
CLINICAL ISSUES
Presentation
 Most common signs/symptoms
o Classic presentation: Pain, worse at night, relieved by aspirin
o Systemic symptoms absent
o Pain may be referred to adjacent joint
 Other signs/symptoms
o Swelling may be associated with superficial lesions
o Joint effusions and synovitis can occur if intraarticular

Demographics
 Age
o Young population
 Usually 10-20 years
 Rarely < 2 or > 50 years
o Almost always occurs in Caucasians
 Gender: Male predominance: 1.6-4.0:1
Natural History & Prognosis
 May spontaneously regress
 Complete surgical removal curative
 Symptoms recur if nidus not completely removed
 No growth progression
Treatment
 Initial treatment: Conservative
o May treat with NSAIDs
o Spontaneous regression possible
 Surgical treatment: Complete nidus removal curative
o Curretage
o En bloc resection
 Percutaneous
o CT-guided removal
o CT-guided radio-frequency ablation
o CT-guided drilling followed by ethanol injection
o CT-guided thermocoagulation
DIAGNOSTIC CHECKLIST
Consider
 Vascular lesion in young patient
 Consider medical management initially as lesions can regress
Image Interpretation Pearls
 Characteristic anatomic imaging findings of central nidus surrounded by sclerotic bone

 Markedly vascular on flow studies, increased uptake on delayed images
o May appreciate double density sign on bone scan
 Precise anatomic localization needed prior to treatment as entire nidus should be completely
removed
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Diagnostic Imaging Nuclear
SELECTED REFERENCES
1. Vanderschueren GM et al: Osteoid osteoma: clinical results with thermocoagulation. Radiology.
224(1):82-6, 2002
2. Gangi A et al: Interstitial laser photocoagulation of osteoid osteomas with use of CT guidance. Radiology.
203(3):843-8, 1997
3. Goldman AB et al: Osteoid osteomas of the femoral neck: report of four cases evaluated with isotopic
bone scanning, CT, and MR imaging. Radiology. 186(1):227-32, 1993
4. Kransdorf MJ et al: Osteoid osteoma. Radiographics. 11(4):671-96, 1991
5. Helms CA et al: Osteoid osteoma: radionuclide diagnosis. Radiology. 151(3):779-84, 1984
P.1-5

Image Gallery

DDx: Mimics of Osteoid Osteoma

(Left) Anterior bone scan shows a focal area of increased uptake
in a patient with new onset of painful
scoliosis. See next image. (Right) Axial bone scan SPECT in same patient as left shows localization of uptake
in vertebral posterior elements
. See next image.

17

Diagnostic Imaging Nuclear

(Left) Axial NECT in same patient as previous image shows central partially calcified nidus
surrounded
by sclerotic rim
. (Right) Anterior bone scan immediate static image shows hyperemia in right hip
in
a patient with hip pain. See next image.

(Left) Anterior bone scan delayed image in same patient as previous image shows marked uptake in right
femoral neck and proximal femur
. See next image. (Right) Axial CECT in same patient as left shows
small lucent focus in femoral neck surrounded by sclerotic bone
, signifying osteoid osteoma.

Enchondroma
Key Facts
Terminology
 Benign cartilaginous neoplasm in bone
Imaging Findings
 Often in small bones of feet or hands
 Diaphyseal regions of short tubular bones, metaphyseal regions of long bones
 Usually mildly ↑ or normal activity on bone scan
 Fracture, sarcomatous degeneration: Tend to have ↑ bone scan activity, hyperemia on vascular
phase
18

Diagnostic Imaging Nuclear


Assess for multiple lesions on whole body scan
Top Differential Diagnoses
 Multiple enchondromatosis
 Bone infarction
 Chondrosarcoma (typically ↑ on vascular phase)
 Nonossifying fibroma
 Simple bone cyst
 Fibrous dysplasia
 Eosinophilic granuloma

Graphic shows cartilaginous, partially calcified enchondroma in medullary space of proximal phalanx

19

.


Diagnostic Imaging Nuclear

Histopathology shows cartilaginous matrix
with several chondrocytes
in place of normal marrow
and trabeculae. (Courtesy A. Mansoor, MD).
TERMINOLOGY
Definitions
 Benign cartilaginous neoplasm in bone
o 12-14% of benign bone neoplasms

o 3-8% of all osseous neoplasms
IMAGING FINDINGS
General Features
 Location
o Often in small bones of feet or hands
o Diaphyseal regions of short tubular bones, metaphyseal regions of long bones
 Morphology
o Usually solitary
o If multiple, consider Ollier disease, Mafucci syndrome
Nuclear Medicine Findings
 Tc-99m MDP bone scan
o Usually mildly ↑ or normal activity on bone scan
o Fracture, sarcomatous degeneration: Tend to have ↑ bone scan activity, hyperemia on
vascular phase
 However, magnitude of uptake on bone scan not reliable in distinguishing from
enchondroma
o Assess for multiple lesions on whole body scan
20


Diagnostic Imaging Nuclear


Ollier disease, Mafucci syndrome
Imaging Recommendations
 Best imaging tool
o Plain film and CT
 Chondroid matrix in medullary-centered lytic regions
 Pathologic fractures
 Aggressive characteristics worrisome for sarcoma

 Lytic-appearing areas in medullary space, +/- chondroid calcifications
 Additional nuclear medicine imaging options
o FDG PET: Focal hypermetabolic activity worrisome for sarcomatous degeneration if
fracture excluded
 However, benign enchondroma can show ↑ FDG
 MR
o Lobulated borders
o May have ↑ T2 signal due to water in hyaline cartilage
P.1-7

DIFFERENTIAL DIAGNOSIS
With Calcification
 Multiple enchondromatosis
 Bone infarction
 Chondrosarcoma (typically ↑ on vascular phase)
Without Calcification
 Nonossifying fibroma
 Simple bone cyst
 Fibrous dysplasia
 Eosinophilic granuloma
PATHOLOGY
General Features
 Associated abnormalities
o Risk of sarcomatous degeneration
o Pathologic fracture
Gross Pathologic & Surgical Features
 Ectopic hyaline cartilage rests in intramedullary bone
 Replaced trabeculae with mineralized, unmineralized cartilage
CLINICAL ISSUES
Presentation

 Most common signs/symptoms
o Pain (with or without pathologic fracture)
o Often asymptomatic
 Other signs/symptoms: Growth through cortex + soft tissue mass highly suggestive of sarcomatous
transformation
Demographics
 Age: Pediatric to young adult, can be found later
DIAGNOSTIC CHECKLIST
Consider
 Bone scan useful to rule out multiple enchondromatosis
 Highly increased activity on bone scan: May be due to sarcomatous degeneration, pathologic
fracture
SELECTED REFERENCES
1. Wang K et al: Bone scintigraphy in common tumors with osteolytic components. Clin Nucl Med.
30(10):655-71, 2005
21


Diagnostic Imaging Nuclear
2. Woertler K: Benign bone tumors and tumor-like lesions: value of cross-sectional imaging. Eur Radiol.
13(8):1820-35, 2003
3. Flemming DJ et al: Enchondroma and chondrosarcoma. Semin Musculoskelet Radiol. 4(1):59-71, 2000
4. Brien EW et al: Benign and malignant cartilage tumors of bone and joint: their anatomic and theoretical
basis with an emphasis on radiology, pathology and clinical biology. I. Intramedullary cartilage tumors.
Skeletal Radiol. 26(6):325-353, 1997
Image Gallery

DDx: Mimics of Solitary Enchondromas

(Left) Anterior bone scan of knees shows lesion

in patient with painful distal femur. Magnitude of
uptake cannot reliably differentiate between enchondroma and chondrosarcoma. (Courtesy D. Sauser,
MD). (Center) Plain film in same patient as previous image shows medullary chondroid matrix
,
indicative of enchondroma. (Right) Coronal T1WI MR in same patient as previous image shows chondroid
matrix
against fat-replaced normal marrow.

Fibrous Cortical Defect
Key Facts
Terminology
 FCD: Small, metaphyseal cortical fibrous bone lesion with sclerotic margin
 NOF: Larger, intramedullary bone lesion with sclerotic, scalloped margin
Imaging Findings
 Bone scan: Normal or mildly increased activity compared with normal bone; significantly increased
activity suggests pathologic fracture, other lesion
Top Differential Diagnoses
 Primary Bone Malignancy
 Fibrous Dysplasia
 Osteoid Osteoma
 Trauma
Clinical Issues
 Smaller lesions may spontaneously resolve
 Pathologic fracture rare

22


Diagnostic Imaging Nuclear

Anterior bone scan shows mildly increased uptake in the distal right femur
next image.

23

and proximal tibia

. See


Diagnostic Imaging Nuclear

Plain film in the same patient as previous image shows FCDs corresponding to abnormal bone scan activity
in the distal right femur
and proximal tibia
.
TERMINOLOGY
Abbreviations and Synonyms
 Metaphyseal fibrous defect: Fibrous cortical defect if small, non-ossifying fibroma if large
Definitions
 Fibrous cortical defect (FCD)
o FCD: Small, metaphyseal cortical fibrous bone lesion with sclerotic margin
o Nonaggressive
o Size < 3 cm
 Non-ossifying fibroma (NOF)
o NOF: Larger, intramedullary bone lesion with sclerotic, scalloped margin
o Also called fibroxanthoma
o May be symptomatic, risk of pathologic fracture
o Size > 3 cm
IMAGING FINDINGS

General Features
 Best diagnostic clue
o Plain film: Metadiaphyseal, eccentric, ovoid bone lesion with sclerotic margin; may be
multiloculated
o Bone scan: Normal or mildly increased activity compared with normal bone; significantly
increased activity suggests pathologic fracture, other lesion
 Can be masked by normal epiphyseal activity in immature bone
24