Bone Scintigraphy Department of Nuclear Medicine Dr (2023)

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Title: Bone Scintigraphy Department of Nuclear Medicine Dr

Bone Scintigraphy

  • Department of Nuclear Medicine
  • Dr. Pei-Shan Wu


  • Sr-85 high radiation absorbed dose, poor imaging
    characteristics, and delayed imaging time (57
  • Sr-87m Low target-to-background ratios
  • Fluorine 18 positron emission
  • Tc-99m MDP 140 KeV, 6-hour half-life
  • distributed rapidly throughout the extracellular
    fluid space
  • rapid uptake in bone
  • clearance from the body via the kidneys
  • the skeleton-to-background tissue ratio improves
    with time


  • 1. Patient preparation and follow-up
  • be well hydrated
  • void immediately before study
  • remove metal objects
  • 2. Dosage and route of administration
  • 20 mCi (740MBq) Tc-99m MDP
  • intravenous injection
  • adjust dosage for pediatric patients, minimum 2
  • 3. Time of imaging
  • 24 hr after tracer administration
  • 4. Images three-phase, whole body, SPECT

Normal bone scan

  • 1. Areas with normally increased activity
    include acromioclavicular joints,
    sternoclavicular joints, scapular tips,
    costochondral junctions, sacroiliac joints, lower
    neck, sternum, renal pelves and bladder
  • 2. Pediatric patients growth centers and cranial
  • 3. Pitfalls
  • - Patient rotation
  • - Urine retained in calyx may overlie lower rib
  • - Urine contamination
  • - Belt buckles, earrings, necklaces, and the like
    frequently create cold defects
  • - Recent dental procedures
  • - Radiopharmaceutical problems breakdown of tag
    leading to free pertechnetate causes activity in
    thyroid and GI tract

Abnormal bone scans

  • A. Metastatic disease
  • Tumors most likely to metastasize to bone
    include breast, lung, prostate, lymphoma,
    thyroid, renal and neuroblastoma
  • Tumors in which falsely normal bone scan can be
    expected include multiple myeloma, some
    anaplastic tumors, and pure lytic lesions
  • Location of metastases axial skeleton 80,
    skull 10, long bones 10
  • Super scan diffuse symmetrical increased uptake
  • _ tumors frequently causing super scan prostate,
    breast, lung bladder and lymphoma
  • _ nontumor causes of super scan
    hyperparathyroidism, osteomalacia, Pagets
    disease, and fibrous dysplasia

Abnormal bone scans

  • B. Primary malignant bone tumors
  • Osteogenic sarcoma, chondrosarcoma, Ewings
  • C. Benign primary tumors
  • Osteoid osteoma, bone islands, bone cysts,
    fibrous cortical defects, and others
  • D. Osteomyelitis and septic arthritis

Abnormal bone scans

(Video) What is a bone scan?

  • E. Fracture
  • 1. Traumatic fracture
  • positive within 24 hours
  • 2/3 return to normal by 1 year
  • child abuse
  • _will not detect old, healed fx
  • _difficult to evaluate around metaphyseal/epiphyse
    al region
  • _may miss some skull fractures

Abnormal bone scans

  • 2. Stress fractures
  • Fatigue fracture caused by repeated abnormal
    stress on normal bone
  • _fusiform, longitudinal shape, most often
    involving posterior tibial cortex
  • _focal, less than 1/5 length of tibia
  • _common located in junction of middle and distal
    third of tibia
  • Insufficiency fracture resulting from normal
    stress on abnormal bone
  • _seen in such diseases as osteoporosis,
    osteomalacia, pagets disease, fibrous dysplasia,
    and status postirradiation

Abnormal bone scans

  • F. Metabolic bone disease
  • 1. Osteoporosis normal or decreased uptake
  • 2. Osteomalacia
  • _vitamin D deficiency
  • _results in failure of bone matrix to calcify
  • _generalized increased skeletal uptake
  • 3. Pagets disease
  • _increased uptake in bone scan
  • _distribution of lesions pelvis (7080),
    lumbar-thoracic vertebrae, femur, skull, scapula,
    tibia, and humerus

Abnormal bone scans

  • 4. Hyperparathyroidism
  • a. Primary caused by hyperplasia or tumor of
  • 5080 normal bone scan
  • abnormal uptake at calvarium, mandible,
    acromioclavicular joint, sternum, lateral humeral
    epicondyles and hands
  • soft-tissue calcification in lungs, stomach,
    kidneys, heart and periarticular
  • b. Secondary associated with chronic renal
  • usually have abnormal bone scan
  • super scan
  • focal abnormalities

Abnormal bone scans

  • G. Avascular necrosis
  • result of fracture, metabolic disorder, fat
    embolization, steroids, hemolytic anemia, and
  • plain film is normal in early stage (6 months)
  • bone scan normal for first 48 hr ? decreased
    activity ? increased activity ? develop
    degenerative joint disease (increased uptake in
    the acetabulum)
  • Legg-Calve-Perthes disease afftects boys aged
    48 years

Abnormal bone scans

  • H. Heterotopic ossification
  • _associated with paraplegia and quadriplegia
  • _increased activity in soft tissue
  • I. Arthritides
  • 1. Degenerative joint disease - most common
    locations hands, feet, hips, knees, SI joints
    and shoulders
  • 2. Rheumatoid arthritis - symmetrical increased
    uptake hands feet, knees and cervical spine

Radionuclide inflammation scan and tumor scan

  • Department of Nuclear Medicine
  • Dr. Pei-Shan Wu

Application of Radionuclide Imaging in Infection

  • Radionuclide imaging for detection of infection
  • Ga-67 scan
  • Tc-99m (V) DMSA scan
  • Tc-99m HMPAO labeled WBC scan
  • Tc-99m labeled IgG scan
  • Utility in specific diseases
  • Osteomyelitis
  • Painful prosthesis
  • AIDS


  • Cyclotron produced
  • Half-life 78 hrs
  • Biological behavior similar to ferric ion
  • Binding to iron-binding molecules, including
    transferrin, lactoferrin, ferritin, siderophores

Gallium-67 scan Mechanism

  • Not thoroughly understood
  • Ga-67 citrate binds to transferrin in the blood
  • gt transported to site of inflammation/infection
  • Localization depends on a number of factors
  • Adequate blood supply
  • Increased vascular permeability
  • Leaking into areas inflammation/infection
  • Ga-67 can be used in leukopenic,
    immunocompromised patients
  • Within 12-24 hours Ga-67 firmly bound within

Ga-67 scan Technique

  • Dose
  • Inflammation 3-5 mCi
  • Tumor 5-10 mCi
  • Imaging time
  • 48-72 hr to 1 week
  • Inflammation 24 hr Earlier images high
    background false-negative
  • Imaging parameters
  • Energy 93, 185, 296 keV peaks
  • Total body scan, focal view, SEPCT
  • Medium energy collimator
  • Bowel activity bowel preparation

Ga-67 scan Normal distribution

  • Liver greatest Ga-67 uptake
  • Other Spleen, nasopharynx, lacrimal and salivary
    glands, bone marrow, scrotum, testes
  • First 24 hours kidneys, bladder
  • - 48-72 hours kidneys only faintly visualized
  • After 24 hours, biological clearance through
  • Breast uptake variable, womans hormonal cycle
  • Thymus children

Ga-67 scan image interpretation

  • Abnormal uptake
  • liver or spleen ? abscess
  • liver ? clinical important inflammation
  • lt bone marrow ? low-level inflammation
  • No difference in sensitivity fro acute or chronic
  • Less sensitivity in tuberculosis, fungal infection

Ga-67 scan Advantages

  • Whole body survey
  • Sensitive for detection of all inflammatory
    process whether or not they are discretely
    defined anatomically
  • For detecting source of sepsis
  • Leukopenic, immunocompromised patients
  • Tumor detection

Ga-67 scan Disadvantages

  • Time delay between injection and imaging
  • Poor spatial definition of anatomically discrete
  • Potential misinterpretation as a result of
    gallium uptake in adjacent organ (e.g. liver)
  • Bowel activity
  • Infection vs tumor

Tc-99m (V) DMSA scan

  • A tumor scan e.g. medullary carcinoma of
    thyroid, soft tissue tumor
  • Mechanism
  • unknown
  • hypothesis resemble phosphate ion distribution
  • Biodistribution Cardiovascular system, kidneys
  • Technique
  • 20 mCi Tc-99m (V) DMSA iv injection
  • Imaging 4 hr post-injection

Tc-99m (V) DMSA scan Advantages

  • Good availability
  • High resolution
  • Low price
  • Low radiation dose
  • Preparation technique Easy
  • Imaging 4 hr post-injection

Tc-99m (V) DMSA scan Disadvantages

  • GU tract infection
  • Infection vs tumor
  • Chronic infection
  • Further study

Scintigraphic diagnosis of osteomyelitis

  • ESR Sensitive, but nonspecific
  • Blood culture 40 negative
  • X-ray
  • First imaging study
  • Not detectable until 10-21 days after onset of
  • Scintigraphic methods
  • Three-phase bone scan
  • Ga-67 scan
  • Tc-99m (V) DMSA scan
  • WBC scan
  • IgG scan

Three-phase bone scan Osteomyelitis

(Video) Nuclear medicine explained in 2 minutes

  • Blood flow study Imaging at 3-5 sec intervals
    throughout the 1st-2nd minutes after radiotracer
  • Blood pooling study Obtain 5-20 min after
  • Delayed scan 2-4 hr post-injection
  • DD osteomyelitis and cellulitis
  • Cellulitis diffuse hyperemia, delayed negative
  • Osteomyelitis focal hyperemia, delayed positive
  • Positive
  • 24-48 hr after onset of symptoms
  • Remain positive for months after resolution
  • Sensitivity 90-100, specificity 75-90

Ga-67 scan Osteomyelitis

  • Positive
  • within 24-48 hr of symptomatic onset
  • Return to baseline quickly following successful
  • Sensitivity 80-90, specificity 70
  • Sequential bone and gallium scans
  • Positive Ga-67 uptake is incongruent with the
    bone scan
  • Negative low-trade uptake
  • Equivocal intense congruent uptake

Neonatal osteomyelitis

  • Diffuse nature, propensity for complications,
    paucity of associated signs gt whole body image
  • Three-phase bone scan
  • 22-68 falsely normal or cold defects
  • Resolution
  • Cold lesion subperiosteal abscess
  • Bone scan negative, clinically suspected gt
    Ga-67 scan

Scintigraphic diagnosis of painful prosthesis

  • Three-phase bone scan
  • Focally increased uptake loosening
  • Diffuse, uniformly distribution infection
  • Not very specific
  • Ga-67 scan
  • Differential between pure mechanical loosening
    and infection
  • Sequential bone-gallium imaging
  • Incongruent image Ga uptake exceed Tc-99m MDP
    bone radiotracer uptake (spatial, intensity of
  • sensitivity 70, specificity 90, Accuracy

Infection in immunosuppressed patients

  • Diffuse pulmonary uptake
  • PCP
  • CXR bilateral diffuse infiltrate from hilum to
  • Ga-67 diffuse bilateral pulmonary uptake without
    nodal or parotid uptake (often before CXR)
  • Severe in CXR but decreased uptake in Ga-67 ?
    deficient immune response ? poor prognosis

Infection in immunosuppressed patients

  • CMV
  • Low-grade diffuse lung uptake, perihilar
  • Maybe with ocular(retinitis), adrenal, renal
    uptake, persistent colon uptake(diarrhea)
  • Lymphoid interstitial pneumonia
  • Low-grade diffuse lung uptake, without nodal
    uptake, and symmetrically increased parotid uptake

Infection in immunosuppressed patients

  • Focal pulmonary uptake
  • Bacterial pneumonia a lobar like, without nodal
    and parotid uptake
  • Actinomyces, Nocardia and Aspergillus multiple
    sites of focal accumulation, frequently with
    local bone invasion
  • Nodal uptake
  • Mycobacterium avium-intracellulare (MAI),
    tuberculosis, cryptococcal, HSV infection and
    lymphadenitis, lymphoma
  • MAI 2550 of AIDS, patchy lung uptake with
    hilar and nonhilar nodal uptake

AIDS Radionuclide Studies

  • Ga-67 scan
  • Infection, Tumor (lymphoma)
  • Thallium-201 scan
  • tumor (Kaposis sarcoma, lymphoma)
  • Tc-99m HMPAO brain SPECT
  • Dementia

AIDS Ga-67 scan and Tl-201 scan

  • Kaposis sarcoma
  • Ga-67 (-), Tl-201 ()
  • Infection
  • Ga-67 (), Tl-201 (-)
  • Lymphoma
  • Ga-67 (), Tl-201 ()

Overview of Tumor Scintigraphy

  • Organ-specific tumor imaging radionuclides
  • Cold spot Thyroid scan, Liver scan
  • Hot spot Bone scan, conventional brain scan
  • Non-specific tumor imaging radionuclides
  • Ga-67
  • Tl-201
  • Tc-99m sestamibi
  • Tc-99m (V) DMSA
  • PET (F-18 FDG)
  • Tumor-type specific radionuclides
  • Thyroid cancer I-131
  • Adrenal tumors I-131 MIBG or NP-59
  • Hepatocyte origin tumors Tc-99m DISIDA
  • Hemangioma Tc-99m RBC

Ga-67 scan

  • Mechanism of tumor localization
  • Adequate blood supply
  • Vascular premeability
  • Specific tumor-associated transferrin receptor
  • Tumor metabolism

Ga-67 scan image interpretation

  • Salivary gland uptake is noted after C/T or R/T
  • Faint symmetrical hilar uptake may be seen
    normally and is common after C/T
  • Faint or absent liver uptake
  • Extensive tumor metastases
  • Hepatic failure
  • C/T (vincristine) given within 24 hrs of Ga-67
  • Iron overload

Ga-67 scan tumor detectability

  • Histology high grade
  • Lesion size
  • Location superficial gt deep
  • Tumor detection lymphoma, HCC, soft tissue
    sarcoma, melanoma, lung cancer, head and neck

Tl-201 Chloride tumor scan

  • Thallium-201 a potassium analog
  • Factors determining tumor cell uptake
  • Blood flow
  • Tumor viability
  • Tumor type
  • Sodium-potassium ATPase system
  • Cotransport system
  • Calcium ion channel system
  • Clearance by kidney, half-life 73 hrs

Tl-201 Chloride tumor scan
- Clinical application

  • Brain tumor
  • Correlated with gliomas grade
  • Post-op or post-R/T recurrent
  • Therapeutic effectiveness
  • In AIDS pt D.D. lymphoma and toxoplasmosis
  • Bone and soft tissue tumor
  • Correlation between Tl-201 uptake and response to
  • Lack of Tl-201 uptake ? tumor necrosis

Tl-201 Chloride tumor scan
- Clinical application

  • Thyroid cancer
  • Advantage
  • Continue thyroid hormone
  • Localized thyroid ca (when I-131 negative, but TG
  • Disadvantage
  • Not specific
  • Not predict the potential therapeutic
  • Kaposis sarcoma Ga(-), Tl()

Tc-99m sestamibi

  • A lipophilic cationic complex
  • Factors determining tumor cell uptake
  • Blood flow
  • Tumor viability
  • Tumor type
  • Lipophilic cation
  • Large negative transmembrane potential

Tc-99m sestamibi

  • Localized in liver, kidney, heart and skeletal
  • Difficult imaging
  • Sub-diaphragmatic tumor ? liver uptake and
    urinary clearance
  • Brain tumor ? choroid plexus uptake

Tc-99m sestamibi -
Clinical application

  • Breast cancer
  • Sensitivity 85, specificity 81
  • Higher in palpable, lower for lesion lt 1cm
  • Fibroadenoma is commonest false positive
  • Diffuse uptake is nonspecific and usually not
  • Useful in
  • Non-diagnostic mammogram
  • Dense breast or anatomical changed
  • Fibrocystic disease

F-18 FDG tumor imaging

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  • F-18 FDG
  • F-18 FDG enters the metabolic cycle like glucose,
    but it is trapped in the tissue in the form of
    F-18 FDG-6-phosphate without further metabolism
  • Increased glycolysis associated with malignancy
  • Excreted by kidney
  • Clinical lung cancer, colorectal cancer,
    lymphoma, breast cancer etc.


  • Clinical applications of lymphoscintigraphy
  • Distinguish lymphatic from venous edema,
    myxedema, lipedema, or other etiology
  • Assess pathways of lymphatic drainage
  • Identify sentinel nodes in patients with
    melanoma, breast, or genitourinary cancer
  • Identify patients at high risk for development of
    lymphedema after axillary lymph node dissection
  • Quantify lymphatic flow


  • Methodology
  • Radiotracers colloidal gold(198Au), Tc-99m
    labeled tracers (antimony sulfide colloid, sulfur
    colloid, albumin colloid, HSA)
  • Tracer injected into the tumor or surrounding
    tissue to identify the nodes receiving the
    lymphatic drainage of that tumor subcutaneous,
    Intradermal, and Subfascial Injection

Sentinel lymph node detection and imaging

  • Lymphatic effluent of a tumor drains initially to
    one or two lymph nodes before other nodes receive
    the tumoral drainage
  • Sentinel node develops lymphatic metastases
    before other nodes
  • Careful examination of the sentinel node can be a
    more accurate predictor of regional nodal
    metastases than examination of adjacent nodes
    even if they are located in the same drainage
    basin as the sentinel node

Sentinel lymph node detection and imaging

  • If the sentinel node is negative for tumor, then
    other nodes are not likely to contain metastases,
    and the patient can be spared the unnecessary
    morbidity and expense of a more extensive node
  • To localize the proximal or initial portion of
    the lymphatic chain, efferent from the tumor, for
    subsequent surgical excision and histologic

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Who performs bone scintigraphy? ›

Who does a bone scan? A specially trained and certified nuclear medicine technologist performs the test. A nuclear medicine physician is a medical doctor who uses tracers to diagnose and treat disease. A radiologist or a nuclear medicine physician oversees the technologist.

Why would a doctor order a nuclear bone scan? ›

A bone scan might help determine the cause of unexplained bone pain. The test is sensitive to differences in bone metabolism, which are highlighted in the body by the radioactive tracer. Scanning the whole skeleton helps in diagnosing a wide range of bone disorders, including: Fractures.

Is scintigraphy the same as nuclear medicine? ›

Scintigraphy is a special type of nuclear medicine procedure that uses small amounts of radioactive material to diagnose and assess the severity of a variety of bone diseases and conditions, including fractures, infection and cancer.

What is the difference between a bone scan and a bone scintigraphy? ›

Bone scans are also called bone scintigraphy. They can help diagnose many bone conditions, including cancer, inflammation, fractures, and infections. Functional imaging is possible, and bone scans allow for visualization of bone metabolism or remodeling, while most other imaging techniques cannot do this.

What is another name for bone scintigraphy? ›

A bone scan (skeletal scintigraphy) is a special type of nuclear medicine procedure that uses small amounts of radioactive material to diagnose and assess the severity of a variety of bone diseases and conditions, including fractures, infection, and cancer.

Is a bone scintigraphy the same as a bone density scan? ›

A DEXA scan specifically examines bone density to determine the chances of the development of osteoporosis. Healthcare specialists use a bone scan, also known as bone scintigraphy, to look at bone images and interpret their pathological conditions.

How long does it take to get the results of a nuclear bone scan? ›

The results of a bone scan are usually available within 2 days. Normal: The radioactive tracer is evenly spread among the bones. No areas of too much or too little tracer are seen.

Which is the most common indication for a nuclear bone scan? ›

Bone scans can be used to localise a lesion for biopsy. Listed below are some common reasons to refer for a bone scan: occult fractures, stress fracture, shin splints; osteomyelitis, cellulitis or assessing response to treatment (e.g. antibiotics);

Does a nuclear bone scan show inflammation? ›

Bone Scan is a study used to detect any inflammatory process in the body. When the source of pain is not clear the bone scan is able to direct the attention of your physician to the area inflammation. The inflammation may be caused by fracture, infection, tumor, or high bone turn over.

What does nuclear scintigraphy show? ›

Nuclear scintigraphy uses very small, tracer amounts of radioactive molecules to diagnose diseases involving bone, soft tissues and vessels. We can attach these molecules to agents that bind to bone lesions, soft tissue tumors and sites of infection.

Are you radioactive after scintigraphy? ›

The scan takes between thirty minutes and an hour. You can leave once it's finished. The small amount of radioactivity left in your body disappears within the next 24 hours. So during this time avoid close contact with babies, children and pregnant women.

What is a nuclear scintigraphy? ›

Nuclear scintigraphy is a diagnostic procedure that allows our veterinarians to diagnose difficult lameness cases. A very small amount of a radioactive substance is injected into the patient's vein.

What cancers can a bone scan detect? ›

Some cancers that might involve bone metastases include breast cancer, lung cancer, lymphoma, and others. A bone scan can also find changes in your bones much earlier than they might be noticed using a regular x-ray.

What is the cost of a nuclear bone scan? ›

On MDsave, the cost of a Bone Scan ranges from $284 to $1,286.

What should you not do before a bone scan? ›

Generally, no prior preparation, such as fasting or sedation, is required prior to a bone scan. Notify the radiologist or technologist if you are allergic to or sensitive to medications, contrast dyes, or iodine. If you are pregnant or suspect you may be pregnant, you should notify your health care provider.

Who can perform a bone biopsy? ›

A bone marrow aspiration and biopsy can be done in a hospital, clinic or doctor's office. The procedures are usually done by a doctor who specializes in blood disorders (hematologist) or cancer (oncologist). But bone marrow exams may also be performed by nurses with special training.

Is scintigraphy same as CT scan? ›

CT is better to discriminate hard tissues, while MRI is better in soft tissues. Scintigraphy is based on the uptake of isotopes and usually reflect the metabolic rate of a lesion. Nevertheless, misdiagnoses are still common when based on scintigraphy, CT, or MRI because of the low prevalence of the disease.

Is a bone scan considered radiology? ›

A bone scan is a specialized radiology procedure used to examine the various bones of the skeleton. It is done to identify areas of physical and chemical changes in bone. A bone scan may also be used to follow the progress of treatment of certain conditions. A bone scan is a type of nuclear radiology procedure.

Who do you see for a bone density scan? ›

The scan will usually be carried out by a radiographer, a specialist in taking X-ray images. During the scan, a large scanning arm will be passed over your body to measure bone density in the centre of the skeleton.


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