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Cold vertebrae on bone scintigraphy
GAMUTS
Edited by Robert C. Stadalnik
C o l d V e r t e b r a e on B o n e S c i n t i g r a p h y Vladimir Sopov, Aharon Liberson, Miguel Gorenberg, and David Groshar HE APPEARANCE OF vertebral lesions on bone scintigraphy is variable. It is important not only to recognize areas of increased uptake but also to look for cold lesions (ie, photon-deficient areas), which are usually more difficult to identify. Vertebral cold lesions may be an incidental finding.
T
CASE REPORT A 27-year-old woman was referred for bone scintigraphy because of pain in the right knee after a car accident and normal x-rays. In addition to increased uptake of 99mTc-MDP in the lateral condyle of the right femur caused by trauma, the whole-body scan showed a photon-deficient area at the level of the 9th thoracic vertebra (Fig 1). Single photon emission computed tomography (SPECT) was performed, which confirmed a photon-deficient lesion involving the 9th vertebral body (Fig 2). The patient had no complaints pertaining to her
back. This lesion on computed tomography (CT) scan (Fig 3) had a typical appearance of hemangioma. DISCUSSION Cold defects on bone scintigraphy are relatively rare but not unusual. The most frequent cause of photon-deficient lesions on bone scintigraphy is metastatic bone disease. ~ Hemangioma as a cause of cold lesions on bone scintigraphy is less common. This benign lesion is composed of vascular channels that are cavernous, capillary, or venous. 2 The vertebrae and the skull are the 2 most common sites of skeletal involvement. Cavernous hemangiomas are usually found in the skull, whereas capillary hemangiomas are more frequent in the vertebrae. It has been reported that the prevalence of vertebral hemangiomas at autopsy is approximately 10%. 2 The most commonly affected sites in the spine are the thoracic segment and the vertebral body. 2 Hemangiomas on bone scintigraphy may show moderate uptake of 99mTc-MDP or as a photopenic region, z Two major mechanisms have been proposed to cause a photon-deficient lesion in bones: (1) replacement of the bone by tumor and (2) compromise of blood supply to the bone, which results in decreased accumulation of radionuclide. 3,4 SPECT may help establish the localization and size of vertebral cold lesions. 5 Causes of photopenic lesions of a vertebra on bone scintigraphy are shown in the following list.
m
Fig 1. Whole-body bone scintigraphy shows a photondeficient area in the area of the 9th thoracic vertebra.
82
From the Departments of Nuclear Medicine and Orthopaedics, Bnai-Zion Medical Center; and the Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel Address reprint requests to David Groshar, MD, Department of Nuclear Medicine, Bnai-Zion Medical Center, POB 4940, Haifa, Israel 31048. Copyright 9 2001 by W.B. Saunders Company 0001-2998/01/3101-0009510.00/0 doi:l O.1053/snuc.2001.21076
Seminars in Nuclear Medicine, Vol XXXl, No 1 (January), 2001: pp 82-83
BONE $CINTIGRAPHY
83
/ / / t d,
d,
,!,'
Fig 2, Sagittal (upper arrow) and coronal (lower arrow) bone SPECT confirm that the photopenic lesion involves the 9th thoracic vertebral body.
ADULT PATIENTS
Common
Fig 3. Lumbar spine CT scan shows a mixed lytic and sclerotic lesion in the body of the T9 vertebra, which is characterized by enlarged thickened trabeculae.
3. B o n e i n f a r c t i o n (sickle cell a n e m i a , G a u c h e r ' s d i s e a s e ) 9,~~ 4. P l a s m o c y t o m a I~ 5. C o n g e n i t a l d e f e c t o f a v e r t e b r a ~2 6. R a d i a t i o n t3 7. O r t h o p e d i c s u r g e r y ~4 8. I m a g i n g artifact 4
B o n e m e t a s t a s e s (eg, lung, breast, r e n a l cell c a r c i n o m a , t r a n s i t i o n a l cell c a r c i n o m a o f b l a d d e r , u n k n o w n p r i m a r y ) 1.3.6,7
PEDIATRIC PATIENTS Common and Uncommon
Uncommon or Rare
P r i m a r y or m e t a s t a t i c n e o p l a s m s ( n e u r o b l a s t o m a , soft tissue s a r c o m a , E w i n g ' s s a r c o m a , Hodgkin's lymphoma, neuroectodermal tumor) 4
i. H e m a n g i o m a 7 2. C h o r d o m a 8
REFERENCES 1. Kagan AR, Steckel RJ, Bassett LW: Diagnostic oncology case study: Lytic spine lesion and cold bone scan. AJR Am J Roentgenol 136:129-131, 1981 2. Resnick D, Kyriakos M, Greenway GD: Tumors and tumorlike lesions of bone: Imaging and pathology of specific lesions, in Resnick D (ed): Diagnosis of Bone and Joint Disorders (ed 3). Philadelphia, PA, Saunders, 1995, pp 3821-3828 3. Goergen TG, Alazraki NP, Halpem SE, et al: "Cold" bone lesions: A newly recognized phenomenon of bone imaging. J Nucl Med 15:1120-1124, 1974 4. Weingrad T, Heyman S, Alavi A: Cold lesions on bone scan in pediatric neoplasms. Clin Nucl Med 9:125-130, 1984 5. Van der Wall H: The evaluation of malignancy: Metastatic bone disease, in Murray IPS, Ell PJ (eds): Nuclear Medicine in Clinical Diagnosis and Treatment (ed 1). New York, NY, Churchill Livingstone, 1994, p 952 6. Sy WM, Westring DW, Weinberger G: "Cold" lesions on bone imaging. J Nucl Med 16:1013-1016, 1975 7. Makhija M, BofiUER: Hemangioma, a rare cause of photopenic lesion on skeletal imaging. Clin Nucl Med 13:661-662, 1988
8. Brooks M, Kleefield J, O'Reilly GV, et al: Thoracic chordoma with unusual radiographic features. Comput Radiol 11:85-90, 1987 9. McAfee JG, Reba RC, Majd M: The musculoskeletal system, in Wagner HN (ed): Principles of Nuclear Medicine (ed 2). Philadelphia, PA, Saunders, 1995, p 1002 10. Dolen EG, Berdon WE, Ruzal-Shapiro C: "Cold bone scans" as a sign of hemorrhagic infarcts of the spine in Gaucher's disease. Pediatr Radiol 27:514-516, 1997 11. Hartshorne MF, Cawthon MA, Bauman JM: Plasmocytoma of the lumbar spine by SPECT. Clin Nucl Med 11:65-66, 1986 12. Tessler F, Lander P, Lisbona R: Congenital absence of a pedicle with photon deficiency on bone scan. Clin Nucl Med 10:498-499, 1981 13. Shih WJ, Li CY, Coffey CW, et al: Thoracic vertebral photopenia may predict fatty changes of the corresponding bone marrow following irradiation. Radiat Med 7:32-35, 1989 14. Gates GF: SPECT bone scanning of the spine. Semin Nucl Med 28:78-94, 1998
Edited by Robert C. Stadalnik
C o l d V e r t e b r a e on B o n e S c i n t i g r a p h y Vladimir Sopov, Aharon Liberson, Miguel Gorenberg, and David Groshar HE APPEARANCE OF vertebral lesions on bone scintigraphy is variable. It is important not only to recognize areas of increased uptake but also to look for cold lesions (ie, photon-deficient areas), which are usually more difficult to identify. Vertebral cold lesions may be an incidental finding.
T
CASE REPORT A 27-year-old woman was referred for bone scintigraphy because of pain in the right knee after a car accident and normal x-rays. In addition to increased uptake of 99mTc-MDP in the lateral condyle of the right femur caused by trauma, the whole-body scan showed a photon-deficient area at the level of the 9th thoracic vertebra (Fig 1). Single photon emission computed tomography (SPECT) was performed, which confirmed a photon-deficient lesion involving the 9th vertebral body (Fig 2). The patient had no complaints pertaining to her
back. This lesion on computed tomography (CT) scan (Fig 3) had a typical appearance of hemangioma. DISCUSSION Cold defects on bone scintigraphy are relatively rare but not unusual. The most frequent cause of photon-deficient lesions on bone scintigraphy is metastatic bone disease. ~ Hemangioma as a cause of cold lesions on bone scintigraphy is less common. This benign lesion is composed of vascular channels that are cavernous, capillary, or venous. 2 The vertebrae and the skull are the 2 most common sites of skeletal involvement. Cavernous hemangiomas are usually found in the skull, whereas capillary hemangiomas are more frequent in the vertebrae. It has been reported that the prevalence of vertebral hemangiomas at autopsy is approximately 10%. 2 The most commonly affected sites in the spine are the thoracic segment and the vertebral body. 2 Hemangiomas on bone scintigraphy may show moderate uptake of 99mTc-MDP or as a photopenic region, z Two major mechanisms have been proposed to cause a photon-deficient lesion in bones: (1) replacement of the bone by tumor and (2) compromise of blood supply to the bone, which results in decreased accumulation of radionuclide. 3,4 SPECT may help establish the localization and size of vertebral cold lesions. 5 Causes of photopenic lesions of a vertebra on bone scintigraphy are shown in the following list.
m
Fig 1. Whole-body bone scintigraphy shows a photondeficient area in the area of the 9th thoracic vertebra.
82
From the Departments of Nuclear Medicine and Orthopaedics, Bnai-Zion Medical Center; and the Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel Address reprint requests to David Groshar, MD, Department of Nuclear Medicine, Bnai-Zion Medical Center, POB 4940, Haifa, Israel 31048. Copyright 9 2001 by W.B. Saunders Company 0001-2998/01/3101-0009510.00/0 doi:l O.1053/snuc.2001.21076
Seminars in Nuclear Medicine, Vol XXXl, No 1 (January), 2001: pp 82-83
BONE $CINTIGRAPHY
83
/ / / t d,
d,
,!,'
Fig 2, Sagittal (upper arrow) and coronal (lower arrow) bone SPECT confirm that the photopenic lesion involves the 9th thoracic vertebral body.
ADULT PATIENTS
Common
Fig 3. Lumbar spine CT scan shows a mixed lytic and sclerotic lesion in the body of the T9 vertebra, which is characterized by enlarged thickened trabeculae.
3. B o n e i n f a r c t i o n (sickle cell a n e m i a , G a u c h e r ' s d i s e a s e ) 9,~~ 4. P l a s m o c y t o m a I~ 5. C o n g e n i t a l d e f e c t o f a v e r t e b r a ~2 6. R a d i a t i o n t3 7. O r t h o p e d i c s u r g e r y ~4 8. I m a g i n g artifact 4
B o n e m e t a s t a s e s (eg, lung, breast, r e n a l cell c a r c i n o m a , t r a n s i t i o n a l cell c a r c i n o m a o f b l a d d e r , u n k n o w n p r i m a r y ) 1.3.6,7
PEDIATRIC PATIENTS Common and Uncommon
Uncommon or Rare
P r i m a r y or m e t a s t a t i c n e o p l a s m s ( n e u r o b l a s t o m a , soft tissue s a r c o m a , E w i n g ' s s a r c o m a , Hodgkin's lymphoma, neuroectodermal tumor) 4
i. H e m a n g i o m a 7 2. C h o r d o m a 8
REFERENCES 1. Kagan AR, Steckel RJ, Bassett LW: Diagnostic oncology case study: Lytic spine lesion and cold bone scan. AJR Am J Roentgenol 136:129-131, 1981 2. Resnick D, Kyriakos M, Greenway GD: Tumors and tumorlike lesions of bone: Imaging and pathology of specific lesions, in Resnick D (ed): Diagnosis of Bone and Joint Disorders (ed 3). Philadelphia, PA, Saunders, 1995, pp 3821-3828 3. Goergen TG, Alazraki NP, Halpem SE, et al: "Cold" bone lesions: A newly recognized phenomenon of bone imaging. J Nucl Med 15:1120-1124, 1974 4. Weingrad T, Heyman S, Alavi A: Cold lesions on bone scan in pediatric neoplasms. Clin Nucl Med 9:125-130, 1984 5. Van der Wall H: The evaluation of malignancy: Metastatic bone disease, in Murray IPS, Ell PJ (eds): Nuclear Medicine in Clinical Diagnosis and Treatment (ed 1). New York, NY, Churchill Livingstone, 1994, p 952 6. Sy WM, Westring DW, Weinberger G: "Cold" lesions on bone imaging. J Nucl Med 16:1013-1016, 1975 7. Makhija M, BofiUER: Hemangioma, a rare cause of photopenic lesion on skeletal imaging. Clin Nucl Med 13:661-662, 1988
8. Brooks M, Kleefield J, O'Reilly GV, et al: Thoracic chordoma with unusual radiographic features. Comput Radiol 11:85-90, 1987 9. McAfee JG, Reba RC, Majd M: The musculoskeletal system, in Wagner HN (ed): Principles of Nuclear Medicine (ed 2). Philadelphia, PA, Saunders, 1995, p 1002 10. Dolen EG, Berdon WE, Ruzal-Shapiro C: "Cold bone scans" as a sign of hemorrhagic infarcts of the spine in Gaucher's disease. Pediatr Radiol 27:514-516, 1997 11. Hartshorne MF, Cawthon MA, Bauman JM: Plasmocytoma of the lumbar spine by SPECT. Clin Nucl Med 11:65-66, 1986 12. Tessler F, Lander P, Lisbona R: Congenital absence of a pedicle with photon deficiency on bone scan. Clin Nucl Med 10:498-499, 1981 13. Shih WJ, Li CY, Coffey CW, et al: Thoracic vertebral photopenia may predict fatty changes of the corresponding bone marrow following irradiation. Radiat Med 7:32-35, 1989 14. Gates GF: SPECT bone scanning of the spine. Semin Nucl Med 28:78-94, 1998