FROM
T H E DEPARTMENTS O F DIAGNOSTIC RADIOLOGY
A N D OTORHINOLARYNGOLOGY,
KAROLINSKA SJUKHUSET, S-104 01 S T O C K H O L M , S W E D E N .
F A C I A L BONE S C I N T I G R A P H Y II. Diagnostic potential in neoplastic and inflammatory lesions
H. F. BERGSTEDT and M. G.
LIND
N e o p l a s t i c a n d i n f l a m m a t o r y l e s i o n s of b o n e often c a u s e a n a b n o r m a l a c c u m u l a t i o n of t e c h n e t i u m d i p h o s p h o n a t e (
9 9
M
T c - D P ) a n d b o n e scintigraphy is of clinical
interest b e c a u s e it offers e v a l u a t i o n p a r a m e t e r s principally different f r o m r a d i o graphy. M e t a s t a s i s t o t h e s k e l e t o n is o f t e n d e m o n s t r a t e d at a n earlier s t a g e of t h e disease b y scintigraphy t h a n b y c o n v e n t i o n a l r a d i o g r a p h y ( S I L B E R S T E I N et coll. 1 9 7 3 , P A P A D I M I T R I O U et c o l l .
1974, T H R A L L et c o l l .
1974, B E L L I V E A U
&
SPENCER
1975,
O S M O N D et coll. 1975, B E R G S T E D T & H A V E R L I N G 1978). H y p o t h e t i c a l l y , t h e c o m b i n a tion of results f r o m scintigraphy a n d r a d i o g r a p h y s h o u l d m a k e t h e d i a g n o s i s of t h e type a n d the e x t e n s i o n of p a t h o l o g i c p r o c e s s e s m o r e accurate a n d h e n c e facilitate t o c h o o s e t h e best treatment. P a t h o l o g i c p r o c e s s e s i n t h e facial r e g i o n are l o c a t e d c l o s e t o b o n e , a n d t h u s b y b o n e scintigraphy n o t o n l y t h e p r e s e n c e of skeletal m e t a stases b u t a l s o t h e i n v o l v m e n t of b o n e b y p r i m a r y i n f l a m m a t o r y a n d n e o p l a s t i c soft tissue p r o c e s s e s c a n b e e x a m i n e d .
Material and Methods F r o m a material of a b o u t 2 0 0 facial b o n e scintigrams 3 2 p a t i e n t s w e r e selected t o demonstrate
t h e scintigraphic i m a g e s
of different
inflammatory
and neoplastic
l e s i o n s of t h e face. T h e p a t i e n t s w e r e g r o u p e d A t o G . I n e a c h p a t i e n t t h e d i a g n o s i s w a s b a s e d o n careful clinical e x a m i n a t i o n a n d r a d i o g r a p h y . T h e m u c o u s cyst, t h e Submitted for publication 6 May 1977. Acta Radiologica Diagnosis 19 (1978) Fasc. 6 63-785841
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993
994
H . F . B E R G S T E D T A N D M. G . L I N D
Fig. 1. Varying normal facial skeleton uptake of "Te -diphosphonate with regional bone mass. In each row from left to right: right lateral, a.p. and left lateral projections of each patient. 9
m
i n f l a m m a t i o n s of t h e s i n u s e s a n d all t u m o u r s w e r e c o n f i r m e d by s u r g e r y a n d m i c r o scopy. F i v e h o u r s after i n t r a v e n o u s injection of 370 M B q (10 m C i ) of " T c - D P t h e d i s t r i m
b u t i o n of a c t i v i t y w a s r e c o r d e d b y a g a m m a c a m e r a ( N u c l e a r C h i c a g o , P h o G a m m a IV). A c o n v e r g i n g c o l l i m a t o r w a s used a n d 3 0 0 0 0 0 c o u n t s w e r e c o l l e c t e d in each p r o j e c t i o n . T h e h e a d w a s e x a m i n e d in a n a . p . projecti o n a s well a s in left a n d r i g h t
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995
FACIAL BON I; S C I N T I G R A P H Y . II
2
Fig. 2. Case 1: Mucous cyst of left maxillary sinus, normal distribution of activity. Case 2: Sinuitis of frontal, ethmoid and maxillary sinuses at conventional radiography, clinical history of one week's duration. Slight facial accumulation of activity in the region of the frontal sinuses, otherwise normal distribution.
lateral p r o j e c t i o n s . T h e i n h o m o g e n e i t y of t h e g a m m a c a m e r a field w a s c h e c k e d a t w e e k l y i n t e r v a l s . T h e c h e m i c a l i m p u r i t y of t h e t r a c e r w a s n o t a l l o w e d t o e x c e e d 5 per cent, with daily controls. R a d i o g r a p h y a n d scintigraphy were performed
within
a few d a y s in all p a t i e n t s . Group A. R e f e r e n c e . E i g h t p a t i e n t s w i t h m a m m a r y c a r c i n o m a a t a n e a r l y s t a g e w e r e s u b m i t t e d for r o u t i n e w h o l e b o d y b o n e s c i n t i g r a p h y . N o m e t a s t a t i c l e s i o n s w e r e d e m o n s t r a t e d in t h e a x i a l s k e l e t o n a t r a d i o g r a p h y . T h e p r e s e n c e of b o n e m e t a s t a s e s in t h e h e a d r e g i o n w a s t h e r e f o r e r e g a r d e d a s u n l i k e l y , w a r r a n t i n g t h e u s e of t h i s g r o u p of p a t i e n t s a s a r e f e r e n c e of n o r m a l d i s t r i b u t i o n of " T c - D P ( F i g . 1). m
Group
B. C a s e s 1 t o 5 ( F i g s 2 , 3). O n e p a t i e n t h a d a n o n - i n f e c t e d m u c o u s cyst a n d
4 h a d i n f l a m m a t o r y lesions of t h e s i n u s e s . A t c o n v e n t i o n a l r a d i o g r a p h y of all lesions, a i r w a s s u b s t i t u t e d b y soft t i s s u e in t h e i n v o l v e d c a v i t y w i t h o u t e v i d e n c e of b o n e r e a c t i o n . T h e i n f l a m m a t o r y lesions r a n g e d from o n e week t o several y e a r s of d u r a tion. Group
C. C a s e s 6 t o 9 ( F i g . 4). T h i s g r o u p c o n s i s t e d of p a t i e n t s w i t h t u m o u r s of
the e t h m o i d region, one had a papilloma d u r u m and 3 carcinoma. At conventional
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H . F . B E R G S T E D T A N D M. G . L 1 N D
Fig. 3. Chronic sinuitis. Case 3: Left maxillary sinuitis since 6 months. Case 4: Frontal sinuitis since several years. Case 5: Frontal, ethmoid and sphenoid sinuitis since several years. Intense focal accumulation of tracer to the involved regions.
r a d i o g r a p h y all l e s i o n s h a d soft t i s s u e m a s s e s filling t h e e t h m o i d a l cells, w i t h o u t demonstrable bone invasion. Group
D. C a s e s 10 t o 15 ( F i g s 5, 6 ) . T h i s g r o u p i n c l u d e d p a t i e n t s w i t h c a r c i n o m a
of t h e g i n g i v a w i t h o r w i t h o u t clinical s u g g e s t i o n of b o n e i n v o l v e m e n t . C a s e s 10 t o 13 h a d o s t e o l y t i c foci d e m o n s t r a t e d a t c o n v e n t i o n a l r a d i o g r a p h y , c a s e s 14 a n d
15
h a d n o e v i d e n c e of b o n e i n v o l v e m e n t . T h e s c i n t i g r a p h y in c a s e 10 w a s c a r r i e d o u t 3 w e e k s after i r r a d i a t i o n w i t h a t o t a l d o s e of 4 0 G y (4 0 0 0 r a d ) . T h e first s c i n t i g r a p h y in c a s e 15 ( F i g . 6) w a s d o n e b e f o r e a n d r e p e a t s c i n t i g r a p h y after i r r a d i a t i o n ; d u r i n g
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FACIAL BONE S C I N T I G R A P H Y . II
Fig. 4. Papilloma durum and carcinoma of the ethmoid region. Case 6: Papilloma durum of left ethmoid region. Case 7: Carcinoma of left ethmoid region. Case 8: Carcinoma of right ethmoid region. Case 9: Carcinoma of left ethmoid region. Moderately intense focal accumulation of activity to the involved regions.
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997
H . F . B E R G S T E D T A N D M. G . L I N D
Fig. 5. Gingival carcinoma engaging the bone tissue. Case 10: Carcinoma of left mandi bular gingiva. Case 11: Carcinoma of frontal mandibular gingiva. Case 12: Carcinoma of frontal mandibular gingiva. Case 13: Carcinoma of left mandibular gingiva. All these lesions were associated with radiographic bone destructive lesions corresponding to the regions of focal uptake of tracer (case 12 also had a severe maxillary parodontitis).
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999
FACIAL BONE S C I N T I G R A P H Y . II
Fig. 6. Case 14: Carcinoma of right maxillary gingiva. No evidence of bone destruction at conventional radiography. Case 15: Progressive involvement of the mandible by a buccal carcinoma, a) Without and b) with definite clinical engagement of mandibular gingiva, after radiation treatment. No evidence of bone destruction at conventional radiography. Slight focal uptake of tracer in case 14 and in case 15 (b). this time the c a r c i n o m a , originally confined t o the bucca, h a d involved the gingiva o v e r t h e e n t i r e a n t e r i o r p a r t of t h e m a n d i b l e . Group
E. C a s e s 16 t o 18 ( F i g . 7) h a d t u m o u r s of t h e j a w s w i t h t h e r a d i o g r a p h i c
a p p e a r a n c e of a cyst. In c a s e 18 t h e m a r g i n s of t h e lesion w e r e i n d i s t i n c t . Group
F. C a s e s 19 a n d 2 0 ( F i g . 8). T h i s g r o u p r e p r e s e n t s i n f l a m m a t o r y
affections
of t h e j a w s . C a s e 19 h a d n e c r o s i s a n d o s t e o m y e l i t i s of t h e left m a n d i b l e after r a d i a t i o n t h e r a p y several y e a r s p r e v i o u s l y b e c a u s e of a gingival c a r c i n o m a . N o
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tumour
1000
H . F . B E R G S T E D T A N D M. G . L I N D
w a s f o u n d in s p e c i m e n s t a k e n a t t h e t i m e of s c i n t i g r a p h y . C a s e 2 0 h a d
chronic
o s t e o m y e l i t i s of t h e m a n d i b l e since several y e a r s w i t h m i c r o s c o p i c i n d i c a t i o n also of t h e p o s s i b l e p r e s e n c e of f i b r o u s d y s p l a s i a . A t r a d i o g r a p h y b o t h o s t e o l y t i c a n d osteosclerotic regions were demonstrated. Group
G. C a s e s 21 t o 2 4 ( F i g . 9 ) . T h e c o n v e n t i o n a l r a d i o g r a p h i c f i n d i n g s in t h e s e
patients with dental i n f l a m m a t o r y affections
ranged from
n o r m a l (case 24) o v e r
m a r g i n a l r e s o r p t i o n of t h e a l v e o l a r b o n e ( c a s e 21) t o p e r i a p i c a l o s t e o l y t i c foci ( c a s e 22) w i t h a d d i t i o n a l o s t e o s c l e r o s i s ( c a s e 2 3 ) .
Results T h e d i s t r i b u t i o n of t h e t r a c e r in t h e facial s k e l e t o n w a s easily r e c o r d e d c o m p a r a t i v e l y d i s t i n c t i m a g i n g of a n a t o m i c d e t a i l s .
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with
FACIAL BONE S C I N T I G R A P H Y . II
1001
Fig. 8. Generalized osteomyelitis of the mandible with intense scintigraphic foci. Case 19: Bone necrosis and osteomyelitis several years after radiation treatment of a gingival carcinoma, without evidence of tumour recurrance. Case 20: Chronic osteomyelitis and fibrous dysplasia.
In t h e p a t i e n t s of g r o u p A with p r e s u m a b l y n o r m a l facial s k e l e t o n , n o difference existed b e t w e e n t h e r i g h t a n d t h e left sides of t h e face a n d n o local u p t a k e of t r a c e r n o t r e f e r a b l e t o n o r m a l a n a t o m y w a s f o u n d . T h e i n t e n s i t y of t h e t r a c e r u p t a k e a s e v a l u a t e d b y t h e g a m m a c a m e r a w a s closely c o r r e l a t e d t o t h e r e g i o n a l a m o u n t of b o n e tissue. T h u s , t h e u p t a k e w a s high in t h e s u p r a - a n d i n f r a o r b i t a l m a r g i n s , in t h e z y g o m a t i c b o n e , a n d a l s o in t h e s p h e n o i d r e g i o n ( F i g . 1). In g r o u p B, t h e n o n - i n f e c t e d cyst of o n e m a x i l l a r y s i n u s ( c a s e 1) w a s a s s o c i a t e d w i t h a n o r m a l d i s t r i b u t i o n of " T c - D P . T h e a c u t e sinuitis of o n e w e e k ' s d u r a t i o n m
(case 2) h a d o n l y a s u g g e s t e d focal i n c r e a s e of a c t i v i t y in t h e g l a b e l l a r e g i o n ( F i g . 2) b u t t h e c h r o n i c sinuitis of c a s e s 3, 4 a n d 5 c a u s e d e v i d e n t a b n o r m a l focal u p t a k e of h i g h i n t e n s i t y ( F i g . 3). In g r o u p C all p a t i e n t s h a d a n a b n o r m a l u p t a k e of t r a c e r t o t h e r e g i o n i n v o l v e d (Fig. 4). In g r o u p D , c a s e s 10 t o 13 ( F i g . 5) a n d 14 ( F i g . 6) w i t h c a r c i n o m a of t h e g i n g i v a , p r o b a b l y e n g a g i n g t h e u n d e r l y i n g b o n e of t h e a l v e o l a r p r o c e s s in e v e r y c a s e b u t w i t h o u t r a d i o l o g i c e v i d e n c e of b o n e i n v o l v e m e n t in c a s e 14, all h a d a focal a b n o r m a l u p t a k e ( F i g . 5). N o e v i d e n c e of a b n o r m a l u p t a k e w a s f o u n d a t s c i n t i g r a p h y b e f o r e t h e r a d i a t i o n t h e r a p y of c a s e 15 a n d b e f o r e s p r e a d of t h e b u c c a l c a r c i n o m a . L a t e r t h e c a r c i n o m a i n v a d e d t h e g i n g i v a of t h e a n t e r i o r p a r t of t h e m a n d i b l e ; t h e s c i n t i g r a p h y
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1002
H . F . B E R G S T E D T A N D M. G . L I N D
Fig. 9. Dental inflammatory affections with moderate to intense accumulation of tracer. Case 21: Parodontitis with marginal bone reduction at radio graphy. Case 22: Periapical osteolytic lesion of right upper canine. Case 23: Endodontic treatment of right lower third molar, with periapical osteolysis and sclerosis. Case 24: Reaction after extraction of impacted right lower third molar, without radiologic evi dence of further bone involvement. t h e n d e m o n s t r a t e d a n i n c r e a s e d u p t a k e in t h e affected r e g i o n ( F i g . 6 ) ; r e p e a t r a d i o g r a p h y failed t o reveal a n y b o n e l e s i o n . In g r o u p E , c a s e 16 w i t h a n a m e l o b l a s t o m a of t h e m a n d i b l e h a d a n i n t e n s e u p t a k e in t h e a r e a affected w h i l e c a s e 17 w i t h a n a p p a r e n t l y n o t infected d e n t a l cyst of t h e m a n d i b l e a n d c a s e 18 w i t h a n e o s i n o p h i l i c g r a n u l o m a a l s o h a d focal i n t e n s e u p t a k e , t h o u g h n o t a s e v i d e n t a s in c a s e 16 ( F i g . 7). In g r o u p F , c a s e s 19 a n d 2 0 w i t h o s t e o m y e l i t i s of t h e m a n d i b l e b o t h h a d a n i n t e n s e a c c u m u l a t i o n of t r a c e r t o t h e affected r e g i o n ( F i g . 8).
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FACIAL BONE SCINTIGRAPHY. II
1003
In g r o u p G , finally, i n f l a m m a t o r y reactions of t h e marginal alveolar b o n e c a u s e d a b n o r m a l u p t a k e (case 2 1 ) . R e a c t i o n t o periapical i n f l a m m a t i o n , e n d o d o n t i c treat m e n t and t o o t h extraction in cases 2 2 , 2 3 and 2 4 , respectively c a u s e d a local a c c u m u l a tion of tracer (Fig. 9 ) .
Discussion T h e facial s k e l e t o n is characterized by its c o m p l e x a n a t o m y a n d c l o s e relation t o t h e m u c o u s m e m b r a n e s of t h e oral a n d nasal cavities. I n f l a m m a t o r y a n d n e o plastic diseases in t h e oral a n d nasal regions generally originate i n these m e m b r a n e s a n d thus often affect t h e periosteum o r b o n e tissue. T h e c h o i c e of t r e a t m e n t a s well as t h e a s s e s s m e n t of t h e p r o g n o s i s are d e p e n d e n t o n t h e presence of b o n e e n g a g e m e n t . Surgery f o r a m a l i g n a n t t u m o u r is p l a n n e d t o b e m o r e radical if b o n e i n v o l v e m e n t is p r o b a b l e ; similarly, c h e m o t h e r a p y against infectious diseases is d e p e n d e n t o n t h e probability of b o n e e n g a g e m e n t . E x a m i n a t i o n of t h e facial s k e l e t o n b y b o n e scintigraphy is therefore of great potential interest in t h e d i a g n o s t i c a s s e s s m e n t of b o t h t h e type a n d t h e e x t e n t of p a t h o l o g y i n t h e oral a n d nasal r e g i o n s ( B E R G S T E D T 1975).
I n f l a m m a t o r y a n d n e o p l a s t i c affections of b o n e m a y b e d e m o n s t r a t e d b y a b n o r m a l M
u p t a k e of " T c - D P . B o n e scintigraphy is a s s u m e d t o b e m o r e sensitive in d e m o n strating a n d localizing skeletal metastatic lesions than is radiography. H o w e v e r , a n a b n o r m a l local u p t a k e of a b o n e - s e e k i n g nuclide m a y o c c u r in several p a t h o l o g i c processes such a s n e o p l a s i a , t r a u m a , infection, r h e u m a t i c reactions, e t c . ( T I L D E N et coll. 1 9 7 3 , D E S A U L N I E R S et coll. 1 9 7 4 , G E N A N T et coll. 1 9 7 4 , T H R A L L et coll., K A Y E et c o l l . 1 9 7 5 , L E T T S et c o l l . 1 9 7 5 , R O S E N T H A L L & K A Y E 1 9 7 5 , G A R C I A et c o l l .
1 9 7 6 ) . T h u s , a n a b n o r m a l u p t a k e a t b o n e scintigraphy d o e s n o t p r o v e m a l i g n a n t g r o w t h . A careful analysis of all p o s s i b l e c a u s e s of a b n o r m a l u p t a k e in t h e s k e l e t o n constitutes t h e necessary basis for a rational e v a l u a t i o n of b o n e scintigraphy. M
T h e facial b o n e a c c u m u l a t i o n of " T c - D P is of clinical interest o n l y if assessible as n o r m a l or a b n o r m a l . Therefore, t h e distribution of t h e tracer in the facial s k e l e t o n and its n o r m a l v a r i a t i o n m u s t b e k n o w n . T h e results f r o m t h e present series of patients indicate that t h e n o r m a l v a r i a t i o n in facial b o n e scintigraphy is small c o m pared t o variations d u e t o p a t h o l o g i c processes e n g a g i n g t h e b o n e . It is of practical i m p o r t a n c e that p a r o d o n t i t i s a n d other dental
inflammatory
lesions cause increased u p t a k e in the alveolar b o n e . T h e majority of patients e x a m i n e d b e c a u s e of neoplastic processes b e l o n g t o t h e a g e g r o u p i n w h i c h dental disorders are c o m m o n . Therefore, facial b o n e scintigraphy s h o u l d never b e u n d e r t a k e n w i t h o u t k n o w l e d g e of t h e dental c o n d i t i o n of t h e patient in order t o prevent e r r o n e o u s e v a l u a t i o n of t h e s c i n t i g r a p h y ( A L E X A N D E R 1 9 7 6 , G A T E S & G O R I S 1 9 7 6 , L U R I E MATTESON
&
1976).
C a s e 1 h a d a p a t h o l o g i c maxillary sinus a t r a d i o g r a p h y b u t t h e facial scintigraphy w a s n o r m a l . O p e r a t i o n revealed a m u c o u s cyst filling the sinus w i t h o u t i n f l a m m a t o r y r e a c t i o n s . T h e sinuses of case 2 w i t h acute sinuitis were a l s o c l o s e t o n o r m a l at scinti-
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1004
H. F . BERGSTEDT A N D M. G . L I N D m
g r a p h y . O n t h e other h a n d , c h r o n i c sinuitis c a u s e d a b n o r m a l focal u p t a k e of " T c D P . T h e s e findings indicate that a n a b n o r m a l u p t a k e is a sign of i n v o l v e m e n t of t h e periosteum or bone by the inflammatory process. F a c i a l b o n e scintigraphy m i g h t t h u s distinguish patients with paranasal
sinus
l e s i o n s e n g a n g i n g b o n e f r o m t h o s e w i t h o u t e n g a g e m e n t of b o n e ( G A T E S & G O R I S , BERGSTEDT & LIND
1977).
C a s e s 6 t o 9 illustrate that periosteal o r b o n e tissue i n v o l v e m e n t b y c a r c i n o m a of the ethmoid
r e g i o n is d e m o n s t r a b l e b y facial b o n e scintigraphy. If clinical a n d
r a d i o g r a p h i c e x a m i n a t i o n s are s u p p l e m e n t e d w i t h facial b o n e scintigraphy, t h e e x t e n s i o n of p a t h o l o g i c l e s i o n s is p r o b a b l y d e m o n s t r a t e d w i t h a higher degree of a c curacy t h a n b y a n y single m e t h o d . H o w e v e r , m i n o r n e o p l a s t i c b o n e i n v a s i o n m a y remain u n d e t e c t e d b y scintigraphy, in particular if m a s k e d b y a n a b n o r m a l l y high m
" T c - D P u p t a k e c a u s e d b y i n f l a m m a t o r y o r traumatic b o n e reaction. T h e c h o i c e of t r e a t m e n t a n d t h e t y p e of surgical intervention in patients w i t h c a r c i n o m a of the oral cavity is d e p e n d e n t , a m o n g other things, u p o n possible involve m e n t of the p e r i o s t e u m o r b o n e ( M A S H B E R G et coll. 1 9 6 9 , V E R A et coll. 1 9 7 1 , G A T E S & G O R I S ) . C a s e s 1 0 t o 1 5 illustrate t h e value of facial b o n e scintigraphy in such cases. It is p o s s i b l e that b o n e scintigraphy h a s a higher d i a g n o s t i c potential than radio g r a p h y i n distinguishing patients w i t h p e r i o s t e u m o r b o n e e n g a g e m e n t f r o m t h o s e w i t h o u t (cases 1 4 , 1 5 ) . T h e repeated scintigraphies of case 1 5 illustrate t h e possibility t o f o l l o w t h e course of a progressive m a l i g n a n t t u m o u r (Fig. 6 ) . D a t a reported ( C o x
1 9 7 4 , GATES & GORIS, LIND & NATHANSON 1977),
indicate
m
that radiation therapy d o e s n o t c a u s e a n a b n o r m a l u p t a k e of " T c - D P in b o n e , w h i c h is i m p o r t a n t f o r e v a l u a t i n g cases with o s t e o m y e l i t i s s e c o n d a r y t o b o n e necrosis i n d u c e d b y irradiation, a s in c a s e 1 9 . In case 2 0 , t h e o s t e o m y e l i t i s w a s possibly a s s o c i a t e d w i t h fibrous dysplasia a n d a high u p t a k e w a s f o u n d . B o n e scintigraphy in s u c h c a s e s s h o u l d b e of potential v a l u e t o r e c o g n i z e o s t e o m y e l i t i c reactions a n d t o evaluate the effect of treatment, w h i c h s h o u l d n o t influence the c o m p o n e n t of fibrous dysplasia. L e s i o n s of o d o n t o g e n i c origin, such a s a m e l o b l a s t o m a a n d cysts (cases 1 6 - 1 8 ) a s well a s dental i n f l a m m a t o r y l e s i o n s (cases 2 1 - 2 4 ) cause b o n e reactions p o s s i b l e t o detect a t facial b o n e scintigraphy ( G A T E S & G O R I S , L U R I E & M A T T E S O N ) . A t c o n v e n t i o n a l r a d i o g r a p h y t h e a t t e n u a t i o n a n d structure of t h e b o n e are a s sessed a n d at scintigraphy t h e m e t a b o l i c activity of t h e b o n e . T h e e x t e n s i o n of t h e r e g i o n w i t h increased u p t a k e m a y b e larger t h a n that of t h e c o r r e s p o n d i n g region w i t h structural c h a n g e s a t r a d i o g r a p h y . P r e s u m i n g l y , a z o n e of increased m e t a b o l i c activity s u r r o u n d s t u m o u r s a n d i n f l a m m a t o r y lesions c a u s i n g alterations of t h e b o n e , n o t p o s s i b l e t o d e m o n s t r a t e b y r a d i o g r a p h y ( S I L B E R S T E I N et coll., P A P A D I M I T R I O U et c o l l . , T H R A L L et c o l l . , B E L L I V E A U &
S P E N C E R , O S M O N D et c o l l . , B E R G S T E D T
&
HAVERLING).
T h e m e t h o d is limited b y factors s u c h a s t h e p o o r spatial r e s o l u t i o n a n d t h e i n i n h o m o g e n e i t y of t h e v i e w i n g field ( T O D D - P O K R O P E K et coll. 1 9 7 6 ) . F u r t h e r m o r e , the n o r m a l scintigraphic i m a g e varies slightly due t o differences in b o n e m a s s and b o n e
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F A C I A L B O N E S C I N T I G R A P H Y . II
m e t a b o l i s m . T h e scintigraphic b o n e i m a g e of elderly p a t i e n t s s e e m s t o b e c o m e less distinct a n d in s o m e i n d i v i d u a l s the difference b e t w e e n b o n e a n d soft tissue is r e d u c e d , p o s s i b l y b e c a u s e the m e t a b o l i c activity of the b o n e d i m i n i s h e s w i t h age ( T H R A L L et coll.; F i g . 1). M a n y p a t h o l o g i c entities c a u s e l o c a l a b n o r m a l i t i e s in t h e facial b o n e scintigraphic i m a g e s a n d it is therefore necessary t o c o m b i n e scintigraphy w i t h r a d i o g r a p h y a n d clinical e x a m i n a t i o n for a d e q u a t e e v a l u a t i o n .
S U M M A R Y
From a series of about 200 facial bone scintigraphies, 32 patients were selected to demon strate the uptake of " T c - d i p h o s p h o n a t e in various inflammatory and neoplastic diseases in the sinuses and oral cavity. The method was found of value in separating patients with inflammatory involvement of the bone from those without, as well as in assessing possible bone involvement in malignant lesions. m
Z U S A M M E N F A S S U N G
Von etwa 200 Gesichtsknochen-Szintigraphien wurden 32 Patienten ausgesucht, um die Aufnahme von " T c - D i p h o s p h o n a t bei verschiedenen inflammatorischen und neoplastischen Erkrankungen in den Sinus und der Mundhohle zu untersuchen. Die Methode wurde als brauchbar befunden um Patienten mit inflammatorischer Beteiligung des Knochens von solchen ohne Beteiligung zu unterscheiden sowie eine mogliche Knochenbeteiligung bei malignen Veranderungen festzustellen. m
R E S U M E
Sur une serie d'environ 200 scintigraphies osseuses faciales, 32 malades ont ete selectionnes pour mettre en evidence la fixation du " T c diphosphonate dans differentes affec tions inflammatoires et neoplasiques des sinus et de la cavite buccale. Cette methode s'est montree utile pour separer les malades ayant une atteinte inflammatoire de l'os de ceux qui n'ont pas d'atteinte osseuse ainsi que pour determiner l'atteinte osseuse possible dans les lesions malignes. m
R E F E R E N C E S
ALEXANDER J. M.: Radionuclide bone scanning in the diagnosis of lesions of the maxillo facial region. J. Oral Surg. 34 (1976), 249. BELLIVEAU R. E. and SPENCER R. P.: Incidence and sites of bone lesions detected by " T c polyphosphate scans in patients with tumors. Cancer 36 (1975), 359. BERGSTEDT H . F.: Bone scintigraphy of facial skeleton with T c - d i p h o s p h o n a t e . Acta radiol. Diagnosis 16 (1975), 337. — and HAVERLING M.: Facial bone scintigraphy. I. Metastatic lesions in the mandible. Acta radiol. Diagnosis 19 (1978), 859. — och L I N D M. G.: Ansiktsskelettskintigrafi. (In Swedish.) Svensk Otolaryngologisk fdrenings handlingar 1 (1977), 20. C o x P. H . : Abnormalities in skeletal uptake of T c - p o l y p h o s p h a t e complexes in areas of bone associated with tissues which have been subjected to radiation therapy. Brit. J. Radiol. 47 (1974), 851. m
89
99
m
m
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1006
H. F . BERGSTEDT A N D M. G . LIND
DESAULNIERS M., F U K S A . , H A W K I N S D . , LACOURCIERE Y . and ROSENTHALL L . : R a d i o -
technetium polyphosphate joint imaging. J. nucl. Med. 15 (1974), 417. m
GARCIA D . A . , T o w D . E., K A P U R K . K . and WELLS H.: Relative accretion of " T c - p o l y -
phosphate by forming and resorbing bone systems in rats. Its significance in the patho logic basis of bone scanning. J. nucl. M e d . 17 (1976), 93. GATES G. F . and GORIS M . L . : Maxillary-facial abnormalities assessed by bone imaging. Radiology 121 (1976), 677. G E N A N T H . K . , BAUTOVICH G. J., S I N G H M., LATHROP K . A. and H A R P E R P. V.: B o n e -
seeking radionuclides. A n in vivo study of factors affecting skeletal uptake. Radiology 113 (1974), 373. K A Y E M., SILVERTON S. and ROSENTHALL L . : Technetium-99m-pyrophosphate. Studies in
vivo and in vitro. J. nucl. Med. 16 (1975), 40. LETTS R. M., AFIFI A . and SUTHERLAND J. B.: Technetium bone scanning as an aid in the
diagnosis of atypical acute osteomyelitis in children. Surg. Gynec. Obstet. 140 (1975), 899. L I N D M . G. and NATHANSON A.: " T c - D P accumulation in rabbit skull bones after C o gamma irradiation. Acta radiol. Ther. Phys. Biol. 16 (1977), 489. LURIE A . G. and MATTESON S. R.: " T c - d i p h o s p h o n a t e bone imaging and uptake in healing rat extraction sockets. J. nucl. Med. 17 (1976), 688. m
6 0
m
MASHBERG A., STRAUSS H., SMALL M. J. and MILLER W . N . : Use of scintillation scanning
for the early detection of bone involvement by squamous cell carcinoma of the oral mucosa. Preliminary report. J. Amer. dent. Ass. 79 (1969), 1151. O S M O N D J. D . , PENDERGRASS H. P. and POTSAID M. S.: Accuracy of
99m
Tc-diphosphonate
bone scans and roentgenograms in the detection of prostate, breast and lung carcinoma metastases. Amer. J. Roentgenol. 125 (1975), 972. PAPADIMITRIOU J., VEZERIDIS M., CONSTANTINIDIS M., CHIOTELIS E., CONSTANDINIDIS C. m
and TOUNTAS C : The value of T c " - d i p h o s p h o n a t e ( H E D S P A ) as a skeletal scanning agent. Amer. J. Roentgenol. 121 (1974), 735. ROSENTHALL L . and K A Y E M.: Technetium-99m-pyrophosphate kinetics and imaging in metabolic bone disease. J. nucl. Med. 16 (1975), 33. SILBERSTEIN E. B., SAENGER E. L . , TOFE A. J., ALEXANDER J R G. W . and PARK m
Imaging of bone metastases with " T c - S n - E H D P (diphosphonate), radiography. Radiology 107 (1973), 551.
1 8
H.-M.:
F , and skeletal
T H R A L L J . H . , G H A E D N . , GESLIEN G. E., PINSKY S. M. and JOHNSON M. C : Pitfalls in m
T c " - p o l y p h o s p h a t e skeletal imaging. Amer. J . Roentgenol. 121 (1974), 739. 8
m
T I L D E N R. L . , JACKSON J R J . , E N N E K I N G W . F . , D E L A N D F . H. and M C V E Y J . T.: " T c -
polyphosphate. Histological localization in human femurs by autoradiography. J . nucl. Med. 14 (1973), 576. T O D D - P O K R O P E K A. E., SOUSSALINE F . , R A Y N A U D D . and ERBSMANN F . : T h e non-uniformity
of imaging devices and its impact in quantitative scintigraphic studies. International Symposium on Medical Radionuclide Imaging, L o s Angeles. I A E A 1976. VERA R., MINEIRO L . , SPENCER R. P. and KLIGERMAN M . M . : Determination of occult
invasion of bone by adjacent tumor. Radiology 101 (1971), 125.
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T H E DEPARTMENTS O F DIAGNOSTIC RADIOLOGY
A N D OTORHINOLARYNGOLOGY,
KAROLINSKA SJUKHUSET, S-104 01 S T O C K H O L M , S W E D E N .
F A C I A L BONE S C I N T I G R A P H Y II. Diagnostic potential in neoplastic and inflammatory lesions
H. F. BERGSTEDT and M. G.
LIND
N e o p l a s t i c a n d i n f l a m m a t o r y l e s i o n s of b o n e often c a u s e a n a b n o r m a l a c c u m u l a t i o n of t e c h n e t i u m d i p h o s p h o n a t e (
9 9
M
T c - D P ) a n d b o n e scintigraphy is of clinical
interest b e c a u s e it offers e v a l u a t i o n p a r a m e t e r s principally different f r o m r a d i o graphy. M e t a s t a s i s t o t h e s k e l e t o n is o f t e n d e m o n s t r a t e d at a n earlier s t a g e of t h e disease b y scintigraphy t h a n b y c o n v e n t i o n a l r a d i o g r a p h y ( S I L B E R S T E I N et coll. 1 9 7 3 , P A P A D I M I T R I O U et c o l l .
1974, T H R A L L et c o l l .
1974, B E L L I V E A U
&
SPENCER
1975,
O S M O N D et coll. 1975, B E R G S T E D T & H A V E R L I N G 1978). H y p o t h e t i c a l l y , t h e c o m b i n a tion of results f r o m scintigraphy a n d r a d i o g r a p h y s h o u l d m a k e t h e d i a g n o s i s of t h e type a n d the e x t e n s i o n of p a t h o l o g i c p r o c e s s e s m o r e accurate a n d h e n c e facilitate t o c h o o s e t h e best treatment. P a t h o l o g i c p r o c e s s e s i n t h e facial r e g i o n are l o c a t e d c l o s e t o b o n e , a n d t h u s b y b o n e scintigraphy n o t o n l y t h e p r e s e n c e of skeletal m e t a stases b u t a l s o t h e i n v o l v m e n t of b o n e b y p r i m a r y i n f l a m m a t o r y a n d n e o p l a s t i c soft tissue p r o c e s s e s c a n b e e x a m i n e d .
Material and Methods F r o m a material of a b o u t 2 0 0 facial b o n e scintigrams 3 2 p a t i e n t s w e r e selected t o demonstrate
t h e scintigraphic i m a g e s
of different
inflammatory
and neoplastic
l e s i o n s of t h e face. T h e p a t i e n t s w e r e g r o u p e d A t o G . I n e a c h p a t i e n t t h e d i a g n o s i s w a s b a s e d o n careful clinical e x a m i n a t i o n a n d r a d i o g r a p h y . T h e m u c o u s cyst, t h e Submitted for publication 6 May 1977. Acta Radiologica Diagnosis 19 (1978) Fasc. 6 63-785841
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993
994
H . F . B E R G S T E D T A N D M. G . L I N D
Fig. 1. Varying normal facial skeleton uptake of "Te -diphosphonate with regional bone mass. In each row from left to right: right lateral, a.p. and left lateral projections of each patient. 9
m
i n f l a m m a t i o n s of t h e s i n u s e s a n d all t u m o u r s w e r e c o n f i r m e d by s u r g e r y a n d m i c r o scopy. F i v e h o u r s after i n t r a v e n o u s injection of 370 M B q (10 m C i ) of " T c - D P t h e d i s t r i m
b u t i o n of a c t i v i t y w a s r e c o r d e d b y a g a m m a c a m e r a ( N u c l e a r C h i c a g o , P h o G a m m a IV). A c o n v e r g i n g c o l l i m a t o r w a s used a n d 3 0 0 0 0 0 c o u n t s w e r e c o l l e c t e d in each p r o j e c t i o n . T h e h e a d w a s e x a m i n e d in a n a . p . projecti o n a s well a s in left a n d r i g h t
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995
FACIAL BON I; S C I N T I G R A P H Y . II
2
Fig. 2. Case 1: Mucous cyst of left maxillary sinus, normal distribution of activity. Case 2: Sinuitis of frontal, ethmoid and maxillary sinuses at conventional radiography, clinical history of one week's duration. Slight facial accumulation of activity in the region of the frontal sinuses, otherwise normal distribution.
lateral p r o j e c t i o n s . T h e i n h o m o g e n e i t y of t h e g a m m a c a m e r a field w a s c h e c k e d a t w e e k l y i n t e r v a l s . T h e c h e m i c a l i m p u r i t y of t h e t r a c e r w a s n o t a l l o w e d t o e x c e e d 5 per cent, with daily controls. R a d i o g r a p h y a n d scintigraphy were performed
within
a few d a y s in all p a t i e n t s . Group A. R e f e r e n c e . E i g h t p a t i e n t s w i t h m a m m a r y c a r c i n o m a a t a n e a r l y s t a g e w e r e s u b m i t t e d for r o u t i n e w h o l e b o d y b o n e s c i n t i g r a p h y . N o m e t a s t a t i c l e s i o n s w e r e d e m o n s t r a t e d in t h e a x i a l s k e l e t o n a t r a d i o g r a p h y . T h e p r e s e n c e of b o n e m e t a s t a s e s in t h e h e a d r e g i o n w a s t h e r e f o r e r e g a r d e d a s u n l i k e l y , w a r r a n t i n g t h e u s e of t h i s g r o u p of p a t i e n t s a s a r e f e r e n c e of n o r m a l d i s t r i b u t i o n of " T c - D P ( F i g . 1). m
Group
B. C a s e s 1 t o 5 ( F i g s 2 , 3). O n e p a t i e n t h a d a n o n - i n f e c t e d m u c o u s cyst a n d
4 h a d i n f l a m m a t o r y lesions of t h e s i n u s e s . A t c o n v e n t i o n a l r a d i o g r a p h y of all lesions, a i r w a s s u b s t i t u t e d b y soft t i s s u e in t h e i n v o l v e d c a v i t y w i t h o u t e v i d e n c e of b o n e r e a c t i o n . T h e i n f l a m m a t o r y lesions r a n g e d from o n e week t o several y e a r s of d u r a tion. Group
C. C a s e s 6 t o 9 ( F i g . 4). T h i s g r o u p c o n s i s t e d of p a t i e n t s w i t h t u m o u r s of
the e t h m o i d region, one had a papilloma d u r u m and 3 carcinoma. At conventional
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H . F . B E R G S T E D T A N D M. G . L 1 N D
Fig. 3. Chronic sinuitis. Case 3: Left maxillary sinuitis since 6 months. Case 4: Frontal sinuitis since several years. Case 5: Frontal, ethmoid and sphenoid sinuitis since several years. Intense focal accumulation of tracer to the involved regions.
r a d i o g r a p h y all l e s i o n s h a d soft t i s s u e m a s s e s filling t h e e t h m o i d a l cells, w i t h o u t demonstrable bone invasion. Group
D. C a s e s 10 t o 15 ( F i g s 5, 6 ) . T h i s g r o u p i n c l u d e d p a t i e n t s w i t h c a r c i n o m a
of t h e g i n g i v a w i t h o r w i t h o u t clinical s u g g e s t i o n of b o n e i n v o l v e m e n t . C a s e s 10 t o 13 h a d o s t e o l y t i c foci d e m o n s t r a t e d a t c o n v e n t i o n a l r a d i o g r a p h y , c a s e s 14 a n d
15
h a d n o e v i d e n c e of b o n e i n v o l v e m e n t . T h e s c i n t i g r a p h y in c a s e 10 w a s c a r r i e d o u t 3 w e e k s after i r r a d i a t i o n w i t h a t o t a l d o s e of 4 0 G y (4 0 0 0 r a d ) . T h e first s c i n t i g r a p h y in c a s e 15 ( F i g . 6) w a s d o n e b e f o r e a n d r e p e a t s c i n t i g r a p h y after i r r a d i a t i o n ; d u r i n g
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FACIAL BONE S C I N T I G R A P H Y . II
Fig. 4. Papilloma durum and carcinoma of the ethmoid region. Case 6: Papilloma durum of left ethmoid region. Case 7: Carcinoma of left ethmoid region. Case 8: Carcinoma of right ethmoid region. Case 9: Carcinoma of left ethmoid region. Moderately intense focal accumulation of activity to the involved regions.
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997
H . F . B E R G S T E D T A N D M. G . L I N D
Fig. 5. Gingival carcinoma engaging the bone tissue. Case 10: Carcinoma of left mandi bular gingiva. Case 11: Carcinoma of frontal mandibular gingiva. Case 12: Carcinoma of frontal mandibular gingiva. Case 13: Carcinoma of left mandibular gingiva. All these lesions were associated with radiographic bone destructive lesions corresponding to the regions of focal uptake of tracer (case 12 also had a severe maxillary parodontitis).
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FACIAL BONE S C I N T I G R A P H Y . II
Fig. 6. Case 14: Carcinoma of right maxillary gingiva. No evidence of bone destruction at conventional radiography. Case 15: Progressive involvement of the mandible by a buccal carcinoma, a) Without and b) with definite clinical engagement of mandibular gingiva, after radiation treatment. No evidence of bone destruction at conventional radiography. Slight focal uptake of tracer in case 14 and in case 15 (b). this time the c a r c i n o m a , originally confined t o the bucca, h a d involved the gingiva o v e r t h e e n t i r e a n t e r i o r p a r t of t h e m a n d i b l e . Group
E. C a s e s 16 t o 18 ( F i g . 7) h a d t u m o u r s of t h e j a w s w i t h t h e r a d i o g r a p h i c
a p p e a r a n c e of a cyst. In c a s e 18 t h e m a r g i n s of t h e lesion w e r e i n d i s t i n c t . Group
F. C a s e s 19 a n d 2 0 ( F i g . 8). T h i s g r o u p r e p r e s e n t s i n f l a m m a t o r y
affections
of t h e j a w s . C a s e 19 h a d n e c r o s i s a n d o s t e o m y e l i t i s of t h e left m a n d i b l e after r a d i a t i o n t h e r a p y several y e a r s p r e v i o u s l y b e c a u s e of a gingival c a r c i n o m a . N o
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tumour
1000
H . F . B E R G S T E D T A N D M. G . L I N D
w a s f o u n d in s p e c i m e n s t a k e n a t t h e t i m e of s c i n t i g r a p h y . C a s e 2 0 h a d
chronic
o s t e o m y e l i t i s of t h e m a n d i b l e since several y e a r s w i t h m i c r o s c o p i c i n d i c a t i o n also of t h e p o s s i b l e p r e s e n c e of f i b r o u s d y s p l a s i a . A t r a d i o g r a p h y b o t h o s t e o l y t i c a n d osteosclerotic regions were demonstrated. Group
G. C a s e s 21 t o 2 4 ( F i g . 9 ) . T h e c o n v e n t i o n a l r a d i o g r a p h i c f i n d i n g s in t h e s e
patients with dental i n f l a m m a t o r y affections
ranged from
n o r m a l (case 24) o v e r
m a r g i n a l r e s o r p t i o n of t h e a l v e o l a r b o n e ( c a s e 21) t o p e r i a p i c a l o s t e o l y t i c foci ( c a s e 22) w i t h a d d i t i o n a l o s t e o s c l e r o s i s ( c a s e 2 3 ) .
Results T h e d i s t r i b u t i o n of t h e t r a c e r in t h e facial s k e l e t o n w a s easily r e c o r d e d c o m p a r a t i v e l y d i s t i n c t i m a g i n g of a n a t o m i c d e t a i l s .
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with
FACIAL BONE S C I N T I G R A P H Y . II
1001
Fig. 8. Generalized osteomyelitis of the mandible with intense scintigraphic foci. Case 19: Bone necrosis and osteomyelitis several years after radiation treatment of a gingival carcinoma, without evidence of tumour recurrance. Case 20: Chronic osteomyelitis and fibrous dysplasia.
In t h e p a t i e n t s of g r o u p A with p r e s u m a b l y n o r m a l facial s k e l e t o n , n o difference existed b e t w e e n t h e r i g h t a n d t h e left sides of t h e face a n d n o local u p t a k e of t r a c e r n o t r e f e r a b l e t o n o r m a l a n a t o m y w a s f o u n d . T h e i n t e n s i t y of t h e t r a c e r u p t a k e a s e v a l u a t e d b y t h e g a m m a c a m e r a w a s closely c o r r e l a t e d t o t h e r e g i o n a l a m o u n t of b o n e tissue. T h u s , t h e u p t a k e w a s high in t h e s u p r a - a n d i n f r a o r b i t a l m a r g i n s , in t h e z y g o m a t i c b o n e , a n d a l s o in t h e s p h e n o i d r e g i o n ( F i g . 1). In g r o u p B, t h e n o n - i n f e c t e d cyst of o n e m a x i l l a r y s i n u s ( c a s e 1) w a s a s s o c i a t e d w i t h a n o r m a l d i s t r i b u t i o n of " T c - D P . T h e a c u t e sinuitis of o n e w e e k ' s d u r a t i o n m
(case 2) h a d o n l y a s u g g e s t e d focal i n c r e a s e of a c t i v i t y in t h e g l a b e l l a r e g i o n ( F i g . 2) b u t t h e c h r o n i c sinuitis of c a s e s 3, 4 a n d 5 c a u s e d e v i d e n t a b n o r m a l focal u p t a k e of h i g h i n t e n s i t y ( F i g . 3). In g r o u p C all p a t i e n t s h a d a n a b n o r m a l u p t a k e of t r a c e r t o t h e r e g i o n i n v o l v e d (Fig. 4). In g r o u p D , c a s e s 10 t o 13 ( F i g . 5) a n d 14 ( F i g . 6) w i t h c a r c i n o m a of t h e g i n g i v a , p r o b a b l y e n g a g i n g t h e u n d e r l y i n g b o n e of t h e a l v e o l a r p r o c e s s in e v e r y c a s e b u t w i t h o u t r a d i o l o g i c e v i d e n c e of b o n e i n v o l v e m e n t in c a s e 14, all h a d a focal a b n o r m a l u p t a k e ( F i g . 5). N o e v i d e n c e of a b n o r m a l u p t a k e w a s f o u n d a t s c i n t i g r a p h y b e f o r e t h e r a d i a t i o n t h e r a p y of c a s e 15 a n d b e f o r e s p r e a d of t h e b u c c a l c a r c i n o m a . L a t e r t h e c a r c i n o m a i n v a d e d t h e g i n g i v a of t h e a n t e r i o r p a r t of t h e m a n d i b l e ; t h e s c i n t i g r a p h y
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H . F . B E R G S T E D T A N D M. G . L I N D
Fig. 9. Dental inflammatory affections with moderate to intense accumulation of tracer. Case 21: Parodontitis with marginal bone reduction at radio graphy. Case 22: Periapical osteolytic lesion of right upper canine. Case 23: Endodontic treatment of right lower third molar, with periapical osteolysis and sclerosis. Case 24: Reaction after extraction of impacted right lower third molar, without radiologic evi dence of further bone involvement. t h e n d e m o n s t r a t e d a n i n c r e a s e d u p t a k e in t h e affected r e g i o n ( F i g . 6 ) ; r e p e a t r a d i o g r a p h y failed t o reveal a n y b o n e l e s i o n . In g r o u p E , c a s e 16 w i t h a n a m e l o b l a s t o m a of t h e m a n d i b l e h a d a n i n t e n s e u p t a k e in t h e a r e a affected w h i l e c a s e 17 w i t h a n a p p a r e n t l y n o t infected d e n t a l cyst of t h e m a n d i b l e a n d c a s e 18 w i t h a n e o s i n o p h i l i c g r a n u l o m a a l s o h a d focal i n t e n s e u p t a k e , t h o u g h n o t a s e v i d e n t a s in c a s e 16 ( F i g . 7). In g r o u p F , c a s e s 19 a n d 2 0 w i t h o s t e o m y e l i t i s of t h e m a n d i b l e b o t h h a d a n i n t e n s e a c c u m u l a t i o n of t r a c e r t o t h e affected r e g i o n ( F i g . 8).
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1003
In g r o u p G , finally, i n f l a m m a t o r y reactions of t h e marginal alveolar b o n e c a u s e d a b n o r m a l u p t a k e (case 2 1 ) . R e a c t i o n t o periapical i n f l a m m a t i o n , e n d o d o n t i c treat m e n t and t o o t h extraction in cases 2 2 , 2 3 and 2 4 , respectively c a u s e d a local a c c u m u l a tion of tracer (Fig. 9 ) .
Discussion T h e facial s k e l e t o n is characterized by its c o m p l e x a n a t o m y a n d c l o s e relation t o t h e m u c o u s m e m b r a n e s of t h e oral a n d nasal cavities. I n f l a m m a t o r y a n d n e o plastic diseases in t h e oral a n d nasal regions generally originate i n these m e m b r a n e s a n d thus often affect t h e periosteum o r b o n e tissue. T h e c h o i c e of t r e a t m e n t a s well as t h e a s s e s s m e n t of t h e p r o g n o s i s are d e p e n d e n t o n t h e presence of b o n e e n g a g e m e n t . Surgery f o r a m a l i g n a n t t u m o u r is p l a n n e d t o b e m o r e radical if b o n e i n v o l v e m e n t is p r o b a b l e ; similarly, c h e m o t h e r a p y against infectious diseases is d e p e n d e n t o n t h e probability of b o n e e n g a g e m e n t . E x a m i n a t i o n of t h e facial s k e l e t o n b y b o n e scintigraphy is therefore of great potential interest in t h e d i a g n o s t i c a s s e s s m e n t of b o t h t h e type a n d t h e e x t e n t of p a t h o l o g y i n t h e oral a n d nasal r e g i o n s ( B E R G S T E D T 1975).
I n f l a m m a t o r y a n d n e o p l a s t i c affections of b o n e m a y b e d e m o n s t r a t e d b y a b n o r m a l M
u p t a k e of " T c - D P . B o n e scintigraphy is a s s u m e d t o b e m o r e sensitive in d e m o n strating a n d localizing skeletal metastatic lesions than is radiography. H o w e v e r , a n a b n o r m a l local u p t a k e of a b o n e - s e e k i n g nuclide m a y o c c u r in several p a t h o l o g i c processes such a s n e o p l a s i a , t r a u m a , infection, r h e u m a t i c reactions, e t c . ( T I L D E N et coll. 1 9 7 3 , D E S A U L N I E R S et coll. 1 9 7 4 , G E N A N T et coll. 1 9 7 4 , T H R A L L et coll., K A Y E et c o l l . 1 9 7 5 , L E T T S et c o l l . 1 9 7 5 , R O S E N T H A L L & K A Y E 1 9 7 5 , G A R C I A et c o l l .
1 9 7 6 ) . T h u s , a n a b n o r m a l u p t a k e a t b o n e scintigraphy d o e s n o t p r o v e m a l i g n a n t g r o w t h . A careful analysis of all p o s s i b l e c a u s e s of a b n o r m a l u p t a k e in t h e s k e l e t o n constitutes t h e necessary basis for a rational e v a l u a t i o n of b o n e scintigraphy. M
T h e facial b o n e a c c u m u l a t i o n of " T c - D P is of clinical interest o n l y if assessible as n o r m a l or a b n o r m a l . Therefore, t h e distribution of t h e tracer in the facial s k e l e t o n and its n o r m a l v a r i a t i o n m u s t b e k n o w n . T h e results f r o m t h e present series of patients indicate that t h e n o r m a l v a r i a t i o n in facial b o n e scintigraphy is small c o m pared t o variations d u e t o p a t h o l o g i c processes e n g a g i n g t h e b o n e . It is of practical i m p o r t a n c e that p a r o d o n t i t i s a n d other dental
inflammatory
lesions cause increased u p t a k e in the alveolar b o n e . T h e majority of patients e x a m i n e d b e c a u s e of neoplastic processes b e l o n g t o t h e a g e g r o u p i n w h i c h dental disorders are c o m m o n . Therefore, facial b o n e scintigraphy s h o u l d never b e u n d e r t a k e n w i t h o u t k n o w l e d g e of t h e dental c o n d i t i o n of t h e patient in order t o prevent e r r o n e o u s e v a l u a t i o n of t h e s c i n t i g r a p h y ( A L E X A N D E R 1 9 7 6 , G A T E S & G O R I S 1 9 7 6 , L U R I E MATTESON
&
1976).
C a s e 1 h a d a p a t h o l o g i c maxillary sinus a t r a d i o g r a p h y b u t t h e facial scintigraphy w a s n o r m a l . O p e r a t i o n revealed a m u c o u s cyst filling the sinus w i t h o u t i n f l a m m a t o r y r e a c t i o n s . T h e sinuses of case 2 w i t h acute sinuitis were a l s o c l o s e t o n o r m a l at scinti-
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H. F . BERGSTEDT A N D M. G . L I N D m
g r a p h y . O n t h e other h a n d , c h r o n i c sinuitis c a u s e d a b n o r m a l focal u p t a k e of " T c D P . T h e s e findings indicate that a n a b n o r m a l u p t a k e is a sign of i n v o l v e m e n t of t h e periosteum or bone by the inflammatory process. F a c i a l b o n e scintigraphy m i g h t t h u s distinguish patients with paranasal
sinus
l e s i o n s e n g a n g i n g b o n e f r o m t h o s e w i t h o u t e n g a g e m e n t of b o n e ( G A T E S & G O R I S , BERGSTEDT & LIND
1977).
C a s e s 6 t o 9 illustrate that periosteal o r b o n e tissue i n v o l v e m e n t b y c a r c i n o m a of the ethmoid
r e g i o n is d e m o n s t r a b l e b y facial b o n e scintigraphy. If clinical a n d
r a d i o g r a p h i c e x a m i n a t i o n s are s u p p l e m e n t e d w i t h facial b o n e scintigraphy, t h e e x t e n s i o n of p a t h o l o g i c l e s i o n s is p r o b a b l y d e m o n s t r a t e d w i t h a higher degree of a c curacy t h a n b y a n y single m e t h o d . H o w e v e r , m i n o r n e o p l a s t i c b o n e i n v a s i o n m a y remain u n d e t e c t e d b y scintigraphy, in particular if m a s k e d b y a n a b n o r m a l l y high m
" T c - D P u p t a k e c a u s e d b y i n f l a m m a t o r y o r traumatic b o n e reaction. T h e c h o i c e of t r e a t m e n t a n d t h e t y p e of surgical intervention in patients w i t h c a r c i n o m a of the oral cavity is d e p e n d e n t , a m o n g other things, u p o n possible involve m e n t of the p e r i o s t e u m o r b o n e ( M A S H B E R G et coll. 1 9 6 9 , V E R A et coll. 1 9 7 1 , G A T E S & G O R I S ) . C a s e s 1 0 t o 1 5 illustrate t h e value of facial b o n e scintigraphy in such cases. It is p o s s i b l e that b o n e scintigraphy h a s a higher d i a g n o s t i c potential than radio g r a p h y i n distinguishing patients w i t h p e r i o s t e u m o r b o n e e n g a g e m e n t f r o m t h o s e w i t h o u t (cases 1 4 , 1 5 ) . T h e repeated scintigraphies of case 1 5 illustrate t h e possibility t o f o l l o w t h e course of a progressive m a l i g n a n t t u m o u r (Fig. 6 ) . D a t a reported ( C o x
1 9 7 4 , GATES & GORIS, LIND & NATHANSON 1977),
indicate
m
that radiation therapy d o e s n o t c a u s e a n a b n o r m a l u p t a k e of " T c - D P in b o n e , w h i c h is i m p o r t a n t f o r e v a l u a t i n g cases with o s t e o m y e l i t i s s e c o n d a r y t o b o n e necrosis i n d u c e d b y irradiation, a s in c a s e 1 9 . In case 2 0 , t h e o s t e o m y e l i t i s w a s possibly a s s o c i a t e d w i t h fibrous dysplasia a n d a high u p t a k e w a s f o u n d . B o n e scintigraphy in s u c h c a s e s s h o u l d b e of potential v a l u e t o r e c o g n i z e o s t e o m y e l i t i c reactions a n d t o evaluate the effect of treatment, w h i c h s h o u l d n o t influence the c o m p o n e n t of fibrous dysplasia. L e s i o n s of o d o n t o g e n i c origin, such a s a m e l o b l a s t o m a a n d cysts (cases 1 6 - 1 8 ) a s well a s dental i n f l a m m a t o r y l e s i o n s (cases 2 1 - 2 4 ) cause b o n e reactions p o s s i b l e t o detect a t facial b o n e scintigraphy ( G A T E S & G O R I S , L U R I E & M A T T E S O N ) . A t c o n v e n t i o n a l r a d i o g r a p h y t h e a t t e n u a t i o n a n d structure of t h e b o n e are a s sessed a n d at scintigraphy t h e m e t a b o l i c activity of t h e b o n e . T h e e x t e n s i o n of t h e r e g i o n w i t h increased u p t a k e m a y b e larger t h a n that of t h e c o r r e s p o n d i n g region w i t h structural c h a n g e s a t r a d i o g r a p h y . P r e s u m i n g l y , a z o n e of increased m e t a b o l i c activity s u r r o u n d s t u m o u r s a n d i n f l a m m a t o r y lesions c a u s i n g alterations of t h e b o n e , n o t p o s s i b l e t o d e m o n s t r a t e b y r a d i o g r a p h y ( S I L B E R S T E I N et coll., P A P A D I M I T R I O U et c o l l . , T H R A L L et c o l l . , B E L L I V E A U &
S P E N C E R , O S M O N D et c o l l . , B E R G S T E D T
&
HAVERLING).
T h e m e t h o d is limited b y factors s u c h a s t h e p o o r spatial r e s o l u t i o n a n d t h e i n i n h o m o g e n e i t y of t h e v i e w i n g field ( T O D D - P O K R O P E K et coll. 1 9 7 6 ) . F u r t h e r m o r e , the n o r m a l scintigraphic i m a g e varies slightly due t o differences in b o n e m a s s and b o n e
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F A C I A L B O N E S C I N T I G R A P H Y . II
m e t a b o l i s m . T h e scintigraphic b o n e i m a g e of elderly p a t i e n t s s e e m s t o b e c o m e less distinct a n d in s o m e i n d i v i d u a l s the difference b e t w e e n b o n e a n d soft tissue is r e d u c e d , p o s s i b l y b e c a u s e the m e t a b o l i c activity of the b o n e d i m i n i s h e s w i t h age ( T H R A L L et coll.; F i g . 1). M a n y p a t h o l o g i c entities c a u s e l o c a l a b n o r m a l i t i e s in t h e facial b o n e scintigraphic i m a g e s a n d it is therefore necessary t o c o m b i n e scintigraphy w i t h r a d i o g r a p h y a n d clinical e x a m i n a t i o n for a d e q u a t e e v a l u a t i o n .
S U M M A R Y
From a series of about 200 facial bone scintigraphies, 32 patients were selected to demon strate the uptake of " T c - d i p h o s p h o n a t e in various inflammatory and neoplastic diseases in the sinuses and oral cavity. The method was found of value in separating patients with inflammatory involvement of the bone from those without, as well as in assessing possible bone involvement in malignant lesions. m
Z U S A M M E N F A S S U N G
Von etwa 200 Gesichtsknochen-Szintigraphien wurden 32 Patienten ausgesucht, um die Aufnahme von " T c - D i p h o s p h o n a t bei verschiedenen inflammatorischen und neoplastischen Erkrankungen in den Sinus und der Mundhohle zu untersuchen. Die Methode wurde als brauchbar befunden um Patienten mit inflammatorischer Beteiligung des Knochens von solchen ohne Beteiligung zu unterscheiden sowie eine mogliche Knochenbeteiligung bei malignen Veranderungen festzustellen. m
R E S U M E
Sur une serie d'environ 200 scintigraphies osseuses faciales, 32 malades ont ete selectionnes pour mettre en evidence la fixation du " T c diphosphonate dans differentes affec tions inflammatoires et neoplasiques des sinus et de la cavite buccale. Cette methode s'est montree utile pour separer les malades ayant une atteinte inflammatoire de l'os de ceux qui n'ont pas d'atteinte osseuse ainsi que pour determiner l'atteinte osseuse possible dans les lesions malignes. m
R E F E R E N C E S
ALEXANDER J. M.: Radionuclide bone scanning in the diagnosis of lesions of the maxillo facial region. J. Oral Surg. 34 (1976), 249. BELLIVEAU R. E. and SPENCER R. P.: Incidence and sites of bone lesions detected by " T c polyphosphate scans in patients with tumors. Cancer 36 (1975), 359. BERGSTEDT H . F.: Bone scintigraphy of facial skeleton with T c - d i p h o s p h o n a t e . Acta radiol. Diagnosis 16 (1975), 337. — and HAVERLING M.: Facial bone scintigraphy. I. Metastatic lesions in the mandible. Acta radiol. Diagnosis 19 (1978), 859. — och L I N D M. G.: Ansiktsskelettskintigrafi. (In Swedish.) Svensk Otolaryngologisk fdrenings handlingar 1 (1977), 20. C o x P. H . : Abnormalities in skeletal uptake of T c - p o l y p h o s p h a t e complexes in areas of bone associated with tissues which have been subjected to radiation therapy. Brit. J. Radiol. 47 (1974), 851. m
89
99
m
m
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H. F . BERGSTEDT A N D M. G . LIND
DESAULNIERS M., F U K S A . , H A W K I N S D . , LACOURCIERE Y . and ROSENTHALL L . : R a d i o -
technetium polyphosphate joint imaging. J. nucl. Med. 15 (1974), 417. m
GARCIA D . A . , T o w D . E., K A P U R K . K . and WELLS H.: Relative accretion of " T c - p o l y -
phosphate by forming and resorbing bone systems in rats. Its significance in the patho logic basis of bone scanning. J. nucl. M e d . 17 (1976), 93. GATES G. F . and GORIS M . L . : Maxillary-facial abnormalities assessed by bone imaging. Radiology 121 (1976), 677. G E N A N T H . K . , BAUTOVICH G. J., S I N G H M., LATHROP K . A. and H A R P E R P. V.: B o n e -
seeking radionuclides. A n in vivo study of factors affecting skeletal uptake. Radiology 113 (1974), 373. K A Y E M., SILVERTON S. and ROSENTHALL L . : Technetium-99m-pyrophosphate. Studies in
vivo and in vitro. J. nucl. Med. 16 (1975), 40. LETTS R. M., AFIFI A . and SUTHERLAND J. B.: Technetium bone scanning as an aid in the
diagnosis of atypical acute osteomyelitis in children. Surg. Gynec. Obstet. 140 (1975), 899. L I N D M . G. and NATHANSON A.: " T c - D P accumulation in rabbit skull bones after C o gamma irradiation. Acta radiol. Ther. Phys. Biol. 16 (1977), 489. LURIE A . G. and MATTESON S. R.: " T c - d i p h o s p h o n a t e bone imaging and uptake in healing rat extraction sockets. J. nucl. Med. 17 (1976), 688. m
6 0
m
MASHBERG A., STRAUSS H., SMALL M. J. and MILLER W . N . : Use of scintillation scanning
for the early detection of bone involvement by squamous cell carcinoma of the oral mucosa. Preliminary report. J. Amer. dent. Ass. 79 (1969), 1151. O S M O N D J. D . , PENDERGRASS H. P. and POTSAID M. S.: Accuracy of
99m
Tc-diphosphonate
bone scans and roentgenograms in the detection of prostate, breast and lung carcinoma metastases. Amer. J. Roentgenol. 125 (1975), 972. PAPADIMITRIOU J., VEZERIDIS M., CONSTANTINIDIS M., CHIOTELIS E., CONSTANDINIDIS C. m
and TOUNTAS C : The value of T c " - d i p h o s p h o n a t e ( H E D S P A ) as a skeletal scanning agent. Amer. J. Roentgenol. 121 (1974), 735. ROSENTHALL L . and K A Y E M.: Technetium-99m-pyrophosphate kinetics and imaging in metabolic bone disease. J. nucl. Med. 16 (1975), 33. SILBERSTEIN E. B., SAENGER E. L . , TOFE A. J., ALEXANDER J R G. W . and PARK m
Imaging of bone metastases with " T c - S n - E H D P (diphosphonate), radiography. Radiology 107 (1973), 551.
1 8
H.-M.:
F , and skeletal
T H R A L L J . H . , G H A E D N . , GESLIEN G. E., PINSKY S. M. and JOHNSON M. C : Pitfalls in m
T c " - p o l y p h o s p h a t e skeletal imaging. Amer. J . Roentgenol. 121 (1974), 739. 8
m
T I L D E N R. L . , JACKSON J R J . , E N N E K I N G W . F . , D E L A N D F . H. and M C V E Y J . T.: " T c -
polyphosphate. Histological localization in human femurs by autoradiography. J . nucl. Med. 14 (1973), 576. T O D D - P O K R O P E K A. E., SOUSSALINE F . , R A Y N A U D D . and ERBSMANN F . : T h e non-uniformity
of imaging devices and its impact in quantitative scintigraphic studies. International Symposium on Medical Radionuclide Imaging, L o s Angeles. I A E A 1976. VERA R., MINEIRO L . , SPENCER R. P. and KLIGERMAN M . M . : Determination of occult
invasion of bone by adjacent tumor. Radiology 101 (1971), 125.
Downloaded from acr.sagepub.com at UNIVERSITY OF WINDSOR on September 17, 2015
