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Case 207

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Female patient, 15 years old, complains of severe pain on the left shoulder associated with a tumor, edema and reduced local mobility. Was diagnosed with an osteosarcoma in the distal right femur 2 years ago, underwent neoadjuvant chemotherapy followed by surgical resection of the lesion and placement of an endoprosthesis. Developed chronic pain at the site of the primary lesion and the need for orthosis for locomotion. The attending physician ordered a bone scan.

Based on the medical history and on the principles of bone scintigraphy, which of the following alterations is not perceived in the exam in question?

a) Bone inflammation and arthritis

25%

b) Bone tumor implant

25%

c) Chronic osteomyelitis

25%

d) Bone metastases in the lung

25%
   

Image analysis

Image 1: Total body scintigraphy with 99mTc-MDP showing a homogeneous and physiological (growth epiphysis) distribution of the material throughout the skeleton. Uptake around the right femoral prosthesis and the patella (benign process). Asymmetrical uptake of great intensity in left shoulder consistent with tumor implant.

Highlights

- Bone scintigraphy with 99mTc-MDP is routinely used to evaluate the spread of tumors that metastasize to the bone and that trigger osteoblastic reaction.

- Bone scintigraphy with 99mTc-MDP allows diagnosis of bone metastases (osteoblastic reaction) with up to 18 months in advance compared to radiological methods.

- In primary bone tumors, it is indicated for evaluation of bone dissemination and evaluation of response to neoadjuvant chemotherapy.

- Since the 99mTc-MDP is not a tumor-specific marker, the patient's history, clinical status and medication use should be taken into account.

References

- Instituto Nacional de Câncer (Brasil). Câncer da criança e adolescente no Brasil: dados dos registros de base populacional e de mortalidade. Rio de Janeiro: INCA, 2011.

- CARTY Helen. Radionuclide boné scanning. Archives of Diseases in Childhood 1993; 69: 160-165.

- ELL Peter J. Nuclear Medicine. Postgrad Med J 1992; 68: 82-105.

- EVEN-SAPIR Einat. Imaging of Malignant Bone Involvement by Morphologic, Scintigraphic, and Hybrid Modalities. The Journal of Nuclear Medicine 2005;46(8): 1356-1367.

- HISTED Stephanie N. et al. Review of Functional/ Anatomical Imaging in Oncology. Nucl Med Commun, 2012; 33(4): 349-361.

- HUMPHRIES P.D, ZERIZER I. Imaging “the lost tribe”: a review of adolescent cancer imaging. Part 1. Cancer imaging 2009; 9:70-81.

- PICCI Piero. Osteosarcoma (Osteogenic sarcoma). Orphanet Journal of Rare Diseases 2007; 2:6.

Authors

Bárbara de Queiroz e Bragaglia, 6th year medical student at UFMG.

E-mail: barbara.bragaglia[at]gmail.com

 

Renato Gomes Campanati, General Surgery resident at Hospital das Clínicas – UFMG.

E-mail: campanati[at]ufmg.br

Supervisors

Stephanie Saliba de Freitas, Nuclear Medicine resident at Hospital das Clínicas – UFMG.

E-mail: stesaliba[at]hotmail.com

Reviewers

Carla Faraco, Daniela Braga, Débora Faria, Luísa Bernardino and Prof. Viviane Parisotto.

Translated by

Bárbara de Queiroz e Bragaglia, 6th year medical student at UFMG.

E-mail: barbara.bragaglia[at]gmail.com

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