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Bone pain

1. What is this investigation?
2. What features does it show?

This image is taken from a bone scan of patient with breast cancer who complained of weight loss, lethargy and generalised bone pain. It show multiple metastases within both the axial and peripheral skeleton. Increased uptake of the isotope is seen in the ribs, scapulae, pelvis and skull.  Renal excretion of the isotope has highlighted both the kidneys and bladder.

Bone scintigraphy is performed using technitium-99m labelled substituted bisphosphonates. Following intravenous injection, the isotope is cleared from the blood stream into the skeleton with a high extraction efficiency. Over 50% of the injected dose is taken up by the skeleton by three hours. The two factors that determine isotope uptake are blood flow and osteoblastic activity. In order to produce the most satisfactory images 400 - 600 MBq of isotope are used and the images are obtained between 2 and 4 hours post-injection.  A full body scan takes approximately 20 minutes. The total body radiation dose is roughly 5mSv which is a similar does to that received from an IVU or lumbar spine series.

In the investigation of potential bone lesions plain X-rays should be the initial investigation. However, the sensitivity of plain films are limited and there is often a prolonged lag period between the onset of a pathological process and any radiological changes. This can range from days in infective processes (e.g. osteomyelitis) to weeks or months in neoplastic disease (e.g. bone metastases). Bone scintigraphy is the most sensitive imaging modality for the recognition of bone disease. It is useful in the detection of disease, assessing the extent of the process and estimating the function of any lesion that is identified. It is particularly useful in the 'screening' of patients for bone metastases and in detecting bone lesions in symptomatic patients with normal radiological findings.

Recent paper

Rosenthal D I.  Radiologic diagnosis of bone metastases.  Cancer 1997; 80 (Suppl 8).  1595-1607.

Robinson P J. Bone scanning. Br J Hosp Med 1992; 48: 99-103.

Ryan P J.  Fogelman I.  The bone scan: where are we now?  Semin Nucl Med 1995;  25:  76-91.

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