Metastatic Bone Disease Case Study 01


Clinical History
A patient with a history of breast cancer presented with increasing back pain two weeks after her fall. The patient was referred for a whole body planar bone scan.

Imaging Findings
NUCLEAR MEDICINE BONE SCAN
STATED REASON FOR REQUEST: Staging breast cancer
RADIOPHARMACEUTICAL ADMINISTERED: 30 mCi 99mTc MDP
TECHNIQUE: A planar whole body bone scan was performed with, 3 hour delay, and spot views of the spine and pelvis.

NUCLEAR MEDICINE BONE SCAN FINDINGS: The bone scan revealed abnormal activity in the L2 vertebral body that could have been metastatic disease or a post-traumatic fracture. There was minimal focal activity in the left 7th rib, which was also suspicious for metastatic disease versus trauma (Fig. 1).

An MRI of the lumbar spine was suspicious for possible bone marrow metastases, and an FDG PET scan was ordered for restaging prior to treatment planning (MRI images are not shown).

NUCLEAR MEDICINE PET SCAN
STATED REASON FOR REQUEST: Staging breast cancer
RADIOPHARMACEUTICAL ADMINISTERED: 10 mCi 18F FDG
COMPARISON: Prior nuclear medicine planar bone scan

FDG PET FINDINGS: No abnormalities were seen.

Since FDG PET can be negative in sclerotic or osteoblastic bone lesions, further evaluation with was recommended. A sodium fluoride F 18 (18F NaF) bone PET scan was ordered to confirm the presence and extent of bone marrow metastasis prior to treatment planning.

NUCLEAR MEDICINE 18F NaF BONE PET SCAN
STATED REASON FOR REQUEST: Staging breast cancer
RADIOPHARMACEUTICAL ADMINISTERED: 10 mCi 18F NaF
COMPARISON: Prior nuclear medicine planar bone scan and prior FDG PET scan

18F NaF PET FINDINGS: The 18F NaF PET bone scan revealed abnormal uptake consistent with metastatic disease in the vertebral body of the L2 vertebra. Additional foci were noted in vertebral bodies L3, L5, the superior end plate of L4, and the right transverse process of L3; all consistent with metastatic bone disease that was not visualized in the FDG PET scan. Innumerable lesions were identified in the pelvis that were appreciated only in retrospect on a prior CT scan. Focal uptake in the left 7th rib and right glenoid were consistent with metastatic disease. Additional focus of activity was seen in the proximal metaphysis of the right femur that was faintly visualized, if at all, on the bone scan.

Diagnosis
The patient received appropriate systemic chemotherapy after accurate identification of the presence and the extent of bone disease with 18F NaF PET bone imaging.

Dr. David Haseley and Dr. Gustavo Mercier, Seattle Nuclear Medicine, Seattle, WA, USA

* Any of the protocols presented herein are for informational purposes and are not meant to substitute for clinician judgment in how best to use any medical devices. It is the clinician that makes all diagnostic determinations based upon education, learning and experience.