GAMUT Edited by Robert C. Stadalnik
M i x e d " H o t " a n d " C o l d " L e s i o n s on B o n e S c a n s Jayashree S. Parekh and Charles D. Teates CASE 1
A 50-year-old woman with a history of breast carcinoma with chest wall recurrence was referred for a bone scan to evaluate bony metastases. A technetium-99m (99mTc) methylene diphosphonate (MDP) bone scan was performed. The posterior image of the skull demonstrates asymmetric uptake in the calvaria (right temporoparietal bone; Fig 1A). The lateral image of the skull demonstrates a large photopenic lesion surrounded by a rim of increased activity (Fig 1B). Plain films of the skull showed a corresponding lucency in the right temporoparietal bone consistent with a metastatic deposit. CASE 2
A 70-year-old man with a history of pancreatic and thyroid carcinoma and complaints of back pain was referred for a bone scan. A whole-body [99mTc]MDP bone scan was performed. The posterior image shows increased uptake in the right 10th rib laterally (Fig 2A). A right posterior oblique image demonstrates a photopenic center surrounded by a hyperemic rim in the same rib (Fig 2B). Plain films of the ribs showed a destructive lesion, which supported the diagnosis of metastatic disease. These two cases demonstrate the importance of additional views to characterize lesions that were not well delineated on the routine views. These mixed "cold" and " h o t " lesions occur when there is bony destruction with predominant osteolytic activity. The lack of osteoblastic activity in the destroyed bone, together with diminished perfusion, causes a photopenic defect in the center of the lesion. Remodeling in the adjacent bone with increased osteoblastic activity a n d / o r increased perfusion causes a hyperemic rim.
Following are the causes of mixed hot and cold lesions on bone scan:
COMMON 1. Traumatic a. Healing avascular necrosis 1,2(including LeggPerthes disease b. Sickle cell disease c. Subperiosteal hematoma 3 d. Surgical defect (craniotomy) e. Nonunited fractures4 f. Nonviable bone grafts5 g. Radiation therapy6 2. Inflammatory a. Acute osteomyelitis7 b. Prosthetic joint infection8 c. Joint effusion9 or synovitis9 d. Septic arthritis z~ 3. Neoplastic a. Primary tumors: Lung xl Giant cell tumor ~2 b. Metastases from: Follicular thyroid carcinoma 13 Neuroblastoma 14 Multiple myelomaz5 Renal cell carcinoma16 Breast H Lung2 Osteosarcoma 17
From the Department of Radiology, Division of Medical Imaging, University of lffrginia Health Sciences Center, CharIottesville, VA. Address reprint requests to Jayashree S. Parekh, MD, Department of Radiology, University of Virginia Health Sciences Center, Charlottesville, VA 22908. Copyright 9 1992 by W.B. Saunders Company 0081-2998/92/2204-0008505.00/0
Seminars in Nuclear Medicine, Vol XXll,No4 (October),1992:pp 289-291
289
290
PAREKH AND TEATES
R
B Fig 1. (A) Asymmetric calvarial uptake (right temporoparietal bone) seen on posterior image of the [*J'Tc]MDP bone scan. (B) Right lateral image in the same patient shows a central photopenic lesion with a surrounding rim of increased activity in the right temporoparietal bone. The lesion is well characterized only on this view.
R %
R
A
B
Fig2. (A) Posterior [ ~ T c ] M D P bone scan demonctrates increased uptake in the right 10th rib laterally. (B) Right poaterior oblique image delineates this rib lesion as having a central photopenic area.
4. Miscellaneous a. Pagets disease 18 b. Eosinophilic granuloma ]9 5. Artifacts a. Barium in colon 2~ b. Cardiac pacemaker c. Prosthesis 21 UNCOMMON
6. Parietal thinning 22 7. Esophageal carcinoma
REFERENCES
1. Dumont M, Danais S, Taillefer R: "Doughnut" sign in avascular necrosis of bone. Clin Nucl Med 9:44, 1984 2. Goergen TG, Alazraki NP, Halpern SE, et ah "Cold" bone lesions: A newly recognized phenomenon of bone imaging. J Nucl Med 15:1120-1124, 1974 3. Mandell GA, Harcke HT: Subpefiosteal hematoma. Another scintigraphic "doughnut." Ciin Nucl Med 11:35-37, 1986 4. Desai A, Alavi A, Dalinka M, et al: Role of bone scintigraphy in the evaluation and treatment of nonunited fractures. J Nucl Med 21:931-934, 1980 (concise communication)
MIXED "HOT" AND "COLD" LESIONS ON BONE SCANS
5. Stevenson JS, Bright RW, Dunson GL, et al: 99mTc phosphate bone imaging: A method for assessing bone graft healing. Radiology 110:391-394, 1974 6. King MA, Weber DA, Casarett GW, et al: A study of irradiated bone. Part II. Changes in 99mTc pyrophosphate bone imaging. J Nucl Med 21:22-30, 1980 7. Teates CD, Williamson BRJ: "Hot and cold" bone lesions in acute osteomyelitis. AIR 129:517-518, 1977 8. Williamson BILl, McLaughlin RE, Wang G J, et al: Radionuclide bone imaging as a means of differentiating loosening and infection in patients with a painful total hip prosthesis. Radiology 133:723-725, 1979 9. Kloiber R, Pavlosky W, Portner O, et al: Bone scintigraphy of hip joint effusions in children. AJR 140:995-999, 1983 10. Murray IPC: Photopenia in skeletal scintigraphy of suspected bone and joint infections. Clin Nucl Med 7:13-20, 1982 11. Dhawan VM, Turner JW, Spencer RP: Osseous and nonosseous "doughnut" sign during bone scanning. Clin Nucl Med 5:423, 1980 12. Veluvolu P, Collier BD, lsitman AT, et al: Scintigraphic skeletal "doughnut" sign due to giant cell tumor of the fibula. C|in Nucl Med 9:631-634, 1984 13. Front D, Hardoft R: Doughnut phenomenon in bone scintigraphy. Clin Nucl Med 3:82-84, 1978
291
14. Weingrad T, Heyman S, Alavi A: Cold lesions on bone scan in pediatric neoplasms. Oin Nucl Med 9:125-130, 1984 15. Freeman M, Van Drunen M, Gergans G, et al: Accumulation of bone scanning agent in multiple myeloma. Clin Nuci Med 9:49, 1984 16. Kim EE, Bledin AG, Gutierrez C, et al: Comparison of radionudide images and radiographs for skeletal metastases from renal cell carcinoma. Ontology 40:284-286, 1983 17. Goris ML, Basso LV, Etcubanas E: Photopenic lesions in bone scintigraphy. Clin Nucl Med 5:299-301, 1980 18. Kunin JR, Strouse PJ: The "Yarmulke" sign of Paget's disease. Clin Nucl Med 16:788-791, 1991 19. Rajendrakumar, Balachandran S: Relative roles of radionuclide scanning and radiographic imaging in eosinophilic granuloma. Clin Nucl Med 5:538-542, 1980 20. Karelitz JR, Richards JB: Pseudophotopenic defect due to barium in the colon. Clin Nucl Med 3:414, 1978 21. Jayabalan V, Berry S: Accumulation of 99mTC pyrophosphate in breast prosthesis. Clin Nucl Med 2:452-453, 1977 22. Rao BK, Lieberman LM. Parietal thinning: A cause for photopenic on bone scan. Clin Nucl Med 5:313, 1980
M i x e d " H o t " a n d " C o l d " L e s i o n s on B o n e S c a n s Jayashree S. Parekh and Charles D. Teates CASE 1
A 50-year-old woman with a history of breast carcinoma with chest wall recurrence was referred for a bone scan to evaluate bony metastases. A technetium-99m (99mTc) methylene diphosphonate (MDP) bone scan was performed. The posterior image of the skull demonstrates asymmetric uptake in the calvaria (right temporoparietal bone; Fig 1A). The lateral image of the skull demonstrates a large photopenic lesion surrounded by a rim of increased activity (Fig 1B). Plain films of the skull showed a corresponding lucency in the right temporoparietal bone consistent with a metastatic deposit. CASE 2
A 70-year-old man with a history of pancreatic and thyroid carcinoma and complaints of back pain was referred for a bone scan. A whole-body [99mTc]MDP bone scan was performed. The posterior image shows increased uptake in the right 10th rib laterally (Fig 2A). A right posterior oblique image demonstrates a photopenic center surrounded by a hyperemic rim in the same rib (Fig 2B). Plain films of the ribs showed a destructive lesion, which supported the diagnosis of metastatic disease. These two cases demonstrate the importance of additional views to characterize lesions that were not well delineated on the routine views. These mixed "cold" and " h o t " lesions occur when there is bony destruction with predominant osteolytic activity. The lack of osteoblastic activity in the destroyed bone, together with diminished perfusion, causes a photopenic defect in the center of the lesion. Remodeling in the adjacent bone with increased osteoblastic activity a n d / o r increased perfusion causes a hyperemic rim.
Following are the causes of mixed hot and cold lesions on bone scan:
COMMON 1. Traumatic a. Healing avascular necrosis 1,2(including LeggPerthes disease b. Sickle cell disease c. Subperiosteal hematoma 3 d. Surgical defect (craniotomy) e. Nonunited fractures4 f. Nonviable bone grafts5 g. Radiation therapy6 2. Inflammatory a. Acute osteomyelitis7 b. Prosthetic joint infection8 c. Joint effusion9 or synovitis9 d. Septic arthritis z~ 3. Neoplastic a. Primary tumors: Lung xl Giant cell tumor ~2 b. Metastases from: Follicular thyroid carcinoma 13 Neuroblastoma 14 Multiple myelomaz5 Renal cell carcinoma16 Breast H Lung2 Osteosarcoma 17
From the Department of Radiology, Division of Medical Imaging, University of lffrginia Health Sciences Center, CharIottesville, VA. Address reprint requests to Jayashree S. Parekh, MD, Department of Radiology, University of Virginia Health Sciences Center, Charlottesville, VA 22908. Copyright 9 1992 by W.B. Saunders Company 0081-2998/92/2204-0008505.00/0
Seminars in Nuclear Medicine, Vol XXll,No4 (October),1992:pp 289-291
289
290
PAREKH AND TEATES
R
B Fig 1. (A) Asymmetric calvarial uptake (right temporoparietal bone) seen on posterior image of the [*J'Tc]MDP bone scan. (B) Right lateral image in the same patient shows a central photopenic lesion with a surrounding rim of increased activity in the right temporoparietal bone. The lesion is well characterized only on this view.
R %
R
A
B
Fig2. (A) Posterior [ ~ T c ] M D P bone scan demonctrates increased uptake in the right 10th rib laterally. (B) Right poaterior oblique image delineates this rib lesion as having a central photopenic area.
4. Miscellaneous a. Pagets disease 18 b. Eosinophilic granuloma ]9 5. Artifacts a. Barium in colon 2~ b. Cardiac pacemaker c. Prosthesis 21 UNCOMMON
6. Parietal thinning 22 7. Esophageal carcinoma
REFERENCES
1. Dumont M, Danais S, Taillefer R: "Doughnut" sign in avascular necrosis of bone. Clin Nucl Med 9:44, 1984 2. Goergen TG, Alazraki NP, Halpern SE, et ah "Cold" bone lesions: A newly recognized phenomenon of bone imaging. J Nucl Med 15:1120-1124, 1974 3. Mandell GA, Harcke HT: Subpefiosteal hematoma. Another scintigraphic "doughnut." Ciin Nucl Med 11:35-37, 1986 4. Desai A, Alavi A, Dalinka M, et al: Role of bone scintigraphy in the evaluation and treatment of nonunited fractures. J Nucl Med 21:931-934, 1980 (concise communication)
MIXED "HOT" AND "COLD" LESIONS ON BONE SCANS
5. Stevenson JS, Bright RW, Dunson GL, et al: 99mTc phosphate bone imaging: A method for assessing bone graft healing. Radiology 110:391-394, 1974 6. King MA, Weber DA, Casarett GW, et al: A study of irradiated bone. Part II. Changes in 99mTc pyrophosphate bone imaging. J Nucl Med 21:22-30, 1980 7. Teates CD, Williamson BRJ: "Hot and cold" bone lesions in acute osteomyelitis. AIR 129:517-518, 1977 8. Williamson BILl, McLaughlin RE, Wang G J, et al: Radionuclide bone imaging as a means of differentiating loosening and infection in patients with a painful total hip prosthesis. Radiology 133:723-725, 1979 9. Kloiber R, Pavlosky W, Portner O, et al: Bone scintigraphy of hip joint effusions in children. AJR 140:995-999, 1983 10. Murray IPC: Photopenia in skeletal scintigraphy of suspected bone and joint infections. Clin Nucl Med 7:13-20, 1982 11. Dhawan VM, Turner JW, Spencer RP: Osseous and nonosseous "doughnut" sign during bone scanning. Clin Nucl Med 5:423, 1980 12. Veluvolu P, Collier BD, lsitman AT, et al: Scintigraphic skeletal "doughnut" sign due to giant cell tumor of the fibula. C|in Nucl Med 9:631-634, 1984 13. Front D, Hardoft R: Doughnut phenomenon in bone scintigraphy. Clin Nucl Med 3:82-84, 1978
291
14. Weingrad T, Heyman S, Alavi A: Cold lesions on bone scan in pediatric neoplasms. Oin Nucl Med 9:125-130, 1984 15. Freeman M, Van Drunen M, Gergans G, et al: Accumulation of bone scanning agent in multiple myeloma. Clin Nuci Med 9:49, 1984 16. Kim EE, Bledin AG, Gutierrez C, et al: Comparison of radionudide images and radiographs for skeletal metastases from renal cell carcinoma. Ontology 40:284-286, 1983 17. Goris ML, Basso LV, Etcubanas E: Photopenic lesions in bone scintigraphy. Clin Nucl Med 5:299-301, 1980 18. Kunin JR, Strouse PJ: The "Yarmulke" sign of Paget's disease. Clin Nucl Med 16:788-791, 1991 19. Rajendrakumar, Balachandran S: Relative roles of radionuclide scanning and radiographic imaging in eosinophilic granuloma. Clin Nucl Med 5:538-542, 1980 20. Karelitz JR, Richards JB: Pseudophotopenic defect due to barium in the colon. Clin Nucl Med 3:414, 1978 21. Jayabalan V, Berry S: Accumulation of 99mTC pyrophosphate in breast prosthesis. Clin Nucl Med 2:452-453, 1977 22. Rao BK, Lieberman LM. Parietal thinning: A cause for photopenic on bone scan. Clin Nucl Med 5:313, 1980
