Skeletal Scintigraphy: The Use of Technetium 99M-Labeled Complexes in the Detection of Early Osseous Involvement by Metastatic Tumors

Skeletal scintigraphy using Technetium-99m (^99mTc) complexes was carried out in a series of 332 cancer patients. The results of scintigraphy were compared with the results of roentgenography and with the diagnostic usefulness of serum alkaline and acid phosphatase levels and the presence or absence of bone pain. In 25 percent of cases, lesions were first identified with scintigraphs. When metastastic lesions were present on both scintigraphs and roentgenograms, the number was greater on scintigraphs in 72 percent of cases. Six false negative studies were recorded (1 percent). Sixty percent of patients with early metastasis—that is, those with abnormal scintigraphs and negative roentgenograms—were asymptomatic. Serum alkaline and acid phosphatase levels were normal in 40 percent and 42 percent respectively of those with early skeletal involvement. Skeletal scintigraphy with ^99mTc complexes is superior to other commonly employed techniques used to assess bone metastasis.     

Review of a 5-Year Experience with the Radiostrontium Bone Scintiscan

Radiostrontium (⁸⁵Sr) skeletal scintiscanning was done on 640 cases and 520 were included in a review. Forty-eight percent of 359 patients with biopsy-proved malignant disease had secondary skeletal involvement; in 17 percent the involvement was identified by scintiscanning alone. False-negative scintiscans were recorded in 0.9 percent. Unusual ⁸⁵Sr localization was found in a bone infarct, in proteus bursitis and in a pulmonary aspergillosis infiltrate. Serum alkaline phosphatase levels were found to be of little value in the evaluation for osseous metastasis, and normal acid phosphatase values in patients with prostatic carcinoma did not exclude the possibility of spread to the skeleton. Both the scintiscan and roentgenograms are essential in the evaluation of patients for metastatic bone disease.     

Therapy of Primary Breast Cancer

Most breast cancers are multicentric in origin. They drain into two primary lymphatic depots—the axilla and internal mammary chain of nodes. The incidence of metastasis to the internal mammary nodes rises as the location of the primary tumor approaches to the sternal margin of the breast.One hundred and thirty-seven patients primarily with in situ and non-infiltrating intraductal carcinoma were treated adequately by simple mastectomy and axillary dissection with preservation of the pectoral muscles.All have remained free of disease. Infiltrating cancers arising in the lateral portion of the breast are best treated by radical mastectomy since they spread mainly to the axillary nodes. Medial and central infiltrating cancers have been treated by radical mastectomy with internal mammary resection, since they show a higher incidence of internal mammary metastasis. Seventy-two percent of 500 patients treated in this fashion survived at five years and 65 percent were clinically free of disease. A five-year salvage rate of 60 percent and a ten-year salvage rate of 50 percent were obtained in patients with only internal mammary node metastasis or in those with only axillary involvement. When both nodal areas were involved 43 percent remained free of disease at five years and 20 percent at ten years.Mammography and biopsy of the contralateral breast at the time of radical mastectomy contributed to the detection of early localized breast cancer.     

Skeletal Scintigraphy

Skeletal scintigraphy, using phosphates or diphosphonates labeled with technetium 99m, is a sensitive method of detecting bone abnormalities. The most important and most frequent role of bone scanning is evaluating the skeletal areas in patients who have a primary cancer, especially a malignant condition that has a tendency to spread to bone areas. The bone scan is superior to bone radiographs in diagnosing these abnormalities; 15 percent to 25 percent of patients with breast, prostate or lung cancer, who have normal roentgenograms, also have abnormal scintigrams due to metastases. The majority of bone metastases appear as hot spots on the scan and are easily recognized. The incidence of abnormal bone scans in patients with early stages (I and II) of breast cancer varies from 6 percent to 26 percent, but almost invariably those patients with scan abnormalities have a poor prognosis and should be considered for additional therapies. Progression or regression of bony lesions can be defined through scanning, and abnormal areas can be identified for biopsy. The incidence of metastases in solitary scan lesions in patients with known primary tumors varies from 20 percent to 64 percent. Bone scintigraphy shows positive uptake in 95 percent of cases with acute osteomyelitis. Stress fractures and trauma suspected in battered babies can be diagnosed by scanning before there is radiological evidence. The procedure is free from acute or long-term side effects and, except in cases of very young patients, sedation is seldom necessary.Although the test is sensitive, it is not specific and therefore it is difficult to overemphasize the importance of clinical, radiographic, biochemical and scanning correlation in each patient.     

Tartrate-resistant acid phosphatase 5b as a serum marker of bone metastasis in breast cancer patients

Diagnosis and follow-up of bone metastases in breast cancer patients usually rely on symptoms and imaging studies. Tartrate-resistant acid phosphatase 5b (TRACP 5b) is a specific marker of osteoclasts and is herein proposed as a marker of bone metastasis in breast cancer patients. An immunoassay using a monoclonal antibody, 14G6, was used to measure the activity of serum TRACP 5b at pH 6.1 in 30 early breast cancer patients without bone metastasis and in 30 aged-matched breast cancer patients with bone metastasis. Another 60 normal volunteers were recruited as controls. Bone alkaline phosphatase (BAP), a traditional marker of bone turnover, was also measured in selected cases. The overall mean TRACP 5b activity in normal women was 2.83 ± 1.1 U/I, and it increased with age. The mean TRACP 5b activity in early breast cancer patients did not differ from that of the normal group (2.93 ± 0.64 vs. 2.83 ± 1.1 U/I; p=0.66), whereas it was significantly higher in breast cancer patients with bone metastasis (5.42 ± 2.5 vs. 2.83 ± 1.1 U/I; p<0.0001). BAP activity was significantly higher in breast cancer patients with bone metastasis than in early breast cancer patients (p=0.004). Serum TRACP 5b activity correlated well with BAP activity in breast cancer patients with bone metastasis (p<0.0001), but not in normal individuals or in patients without bone metastasis. TRACP 5b activity can be considered a surrogate indicator of bone metastasis in breast cancer patients.     

Disturbance of Calcium Metabolism by Anticonvulsant Drugs

A survey of calcium metabolism in epileptic patients in a residential centre showed a subnormal serum calcium level in 22·5% of patients and a raised alkaline phosphatase in 29%. Hypocalcaemia was related to high dosage of anticonvulsant drugs, to multiple drug therapy, and to the use of individual anticonvulsant drugs in the following order, with decreasing order of importance: pheneturide, primidone, phenytoin, phenobarbitone. Subnormal serum calcium levels occurred more commonly in patients with a raised liver alkaline phosphatase isoenzyme than in those whose phosphatase was mainly of bone origin.Preliminary results of treatment with calciferol suggested that the disturbance of calcium metabolism was the result of vitamin D deficiency. It is possible that anticonvulsant drugs accelerate the breakdown of vitamin D by liver enzyme induction.     

骨密度检测对婴幼儿佝偻病早期诊断的临床意义

目的:探讨骨密度检测在佝偻病早期诊断中的应用价值。方法:收集衡水市哈励逊国际和平医院门诊诊治的600例婴幼儿,以血清维生素D327.5 nmol/L为判定标准分为非佝偻病组和佝偻病组,比较两组婴幼儿维生素D3、骨碱性磷酸酶和骨密度,绘制维生素D3、骨碱性磷酸酶、骨密度诊断结果的ROC曲线图,对骨密度检测结果进行评价。结果:佝偻病组婴幼儿维生素D3和骨密度Z值明显低于非佝偻病组,骨碱性磷酸酶显著高于非佝偻病组(P0.05)。维生素D3诊断佝偻病的ROC曲线下面积为0.951,灵敏度为0.973,特异度为0.840;骨碱性磷酸酶诊断佝偻病的ROC曲线下面积为0.866,灵敏度为0.824,特异度为0.747;骨密度Z值诊断佝偻病的ROC曲线下面积为0.923,灵敏度为0.826,特异度为0.875,骨密度指标诊断佝偻病的曲线下面积和维生素D3比较无统计学意义(P0.05),但骨密度指标诊断佝偻病的曲线下面积大于骨碱性磷酸酶(P0.05)。结论:超声骨密度检测在婴幼儿佝偻病早期诊断中具有一定价值,其诊断敏感性、特异性、准确率与维生素D3诊断基本相当,且骨密度检测存在无创、可重复性高等优点。     

Comparative study of alkaline phosphatase isoenzymes,bone histology,and skeletal radiography in dialysis bone disease.

Liver, intestinal, and bone alkaline phosphatase isoenzymes were measured using heat stability and L-phenylalanine inhibition techniques in 78 patients on intermittent haemodialysis. Fifty-five patients had abnormalities in one or more of the isoenzymes. Changes in bone and intestinal alkaline phosphatase activities seemed to be related and raised liver isoenzyme activity was associated with the development of liver disease. Abnormal histological and radiological findings were better correlated with bone alkaline phosphatase levels than with total alkaline phosphatase, and serial estimations of bone isoenzyme activity were useful in assessing the response of renal osteodystrophy to treatment with a vitamin D analogue. Serum alkaline phosphatase isoenzyme measurement provides another useful and non-invasive index for monitoring metabolic bone disease in patients with chronic renal failure.     

Human bone marrow osteoprogenitors express estrogen receptor-alpha and bone morphogenetic proteins 2 and 4 mRNA during osteoblastic differentiation.

Understanding the mechanisms that control the proliferation and commitment of human stem cells into cells of the osteogenic lineage for the preservation of skeletal structure is of basic importance in bone physiology. This study examines some aspects of the differentiation in vitro of human bone marrow fibroblastic cells cultured in the absence (basal media) or presence of 1nM dexamethasone and 50 micrograms/ml ascorbate for 6, 10, 14, and 21 days. Northern blot analysis and in situ hybridisation with digoxygenin-labelled riboprobes for Type I collagen, osteocalcin, bone morphogenetic proteins 2 (BMP-2), and 4 (BMP-4) and the estrogen receptor alpha (ERalpha), together with immunocytochemical analysis of ERalpha expression and histochemical staining of alkaline phosphatase was performed. In basal media, alkaline phosphatase activity and collagen expressions were detected at day 6, ERalpha from day 10 and osteocalcin from day 10. In the presence of dexamethasone and ascorbate, cell proliferation and alkaline phosphatase were markedly stimulated over 10 to 14 days with a dramatic increase in the temporal expression of Type I collagen, ERalpha, and osteocalcin mRNAs in these cultures. Northern blot analysis showed cells cultured in basal media, expressed the highest levels of the mRNA for each marker protein at day 14, whereas in the presence of ascorbate and dexamethasone, the highest levels for alkaline phosphatase, ERalpha, osteocalcin, BMP-2, and BMP-4 were observed at day 21. ERalpha, BMP-2, and BMP-4 expression were found to correlate temporally with induction of the osteoblast phenotype as determined by alkaline phosphatase, collagen, and osteocalcin expression. These results give additional information on the development of the osteoblast phenotype from early fibroblastic stem cells and on the biological factors involved in this process. These studies suggest a role for estrogen and BMP-2 and -4 in the differentiation of osteoprogenitor cells.     

Characteristics of Bone Turnover in the Long Bone Metaphysis Fractured Patients with Normal or Low Bone Mineral Density (BMD)

The incidence of osteoporotic fractures increases as our population ages. Until now, the exact biochemical processes that occur during the healing of metaphyseal fractures remain unclear. Diagnostic instruments that allow a dynamic insight into the fracture healing process are as yet unavailable. In the present matched pair analysis, we study the time course of the osteoanabolic markers bone specific alkaline phosphatase (BAP) and transforming growth factor β1 (TGFβ1), as well as the osteocatabolic markers crosslinked C-telopeptide of type-I-collagen (β-CTX) and serum band 5 tartrate-resistant acid phosphatase (TRAP5b), during the healing of fractures that have a low level of bone mineral density (BMD) compared with fractures that have a normal BMD. Between March 2007 and February 2009, 30 patients aged older than 50 years who suffered a metaphyseal fracture were included in our study. BMDs were verified by dual energy Xray absorptiometry (DXEA) scans. The levels of BTMs were examined over an 8-week period. Osteoanabolic BAP levels in those with low levels of BMD were significantly different from the BAP levels in those with normal BMD. BAP levels in the former group increased constantly, whereas the latter group showed an initial strong decrease in BAP followed by slowly rising values. Osteocatabolic β-CTX increased in the bone of the normal BMD group constantly, whereas these levels decreased significantly in the bone of the group with low BMD from the first week. TRAP5b was significantly reduced in the low level BMD group. With this work, we conduct first insights into the molecular biology of the fracture healing process in patients with low levels of BMD that explains the mechanism of its fracture healing. The results may be one reason for the reduced healing qualities in bones with low BMD.     

Androgens increase osteoblast-stimulating activity of human breast cancer cells in vitro

Bone metastases of breast cancers produce not only osteolytic but also osteosclerotic lesions. The latter are often observed after androgenic treatment of the tumor. Potential production of osteoblast stimulating activity (ObSA) in breast cancer cell lines, and possible androgen control of this activity have been investigated. Conditioned media (CM) collected from 4 breast cancer cell lines (MCF-7, ZR75, MDA-MB 231, BT20) was tested in vitro on ROS 17/2,8 osteoblast-like cells and on osteoblasts derived from human bone biopsies. The parameters monitored in osteoblasts were [3H]thymidine incorporation, alkaline phosphatase activity, and osteocalcin secretion. Serum-free media conditioned during 24 h by MCF-7 cells presented the highest ObSA. CM decreased thymidine incorporation in DNA and increased alkaline phosphatase activity in a dose-dependent manner. Bone GLA protein (osteocalcin) secretion by human osteoblasts was not increased however in the presence of CM. MCF-7 cells were cultured in the presence of dihydrotestosterone (DHT) [1-100 nM] for 5 days. Serum-free, DHT-free CM collected after an additional 24 h, contained alkaline-phosphatase stimulating activity which was DHT dose-dependent. Estradiol and 1,25(OH)2D3 failed to elicit a comparable increase of the ObSA in the CM. In conclusion, MCF-7 cells product factor(s) that interfere with bone remodeling. The DHT modulation of ObSA parallels the estradiol control of MCF-7 cells osteolytic lesions in relation with Prostaglandin E secretion. Sex hormones at physiological and pharmacological levels might thus control both osteosclerotic and osteolytic lesions observed in bone deposits of hormone dependent cancers.     

SEQUENTIAL DEGRANULATION OF THE TWO TYPES OF POLYMORPHONUCLEAR LEUKOCYTE GRANULES DURING PHAGOCYTOSIS OF MICROORGANISMS

The sequential discharge of neutrophilic polymorphonuclear leukocyte (PMN) granules—azurophils and specifics—was investigated by electron microscopy and cytochemistry. Thus the enzyme content of PMN phagocytic vacuoles was determined at brief intervals after phagocytosis of bacteria, utilizing peroxidase as a marker enzyme for azurophil granules, and alkaline phosphatase for specifics. At 30 s, approximately half the phagocytic vacuoles were reactive for alkaline phosphatase, whereas none contained peroxidase. Peroxidase-containing vacuoles were rarely seen at 1 min, but by 3 min, vacuoles containing both enzymes were consistently present. Alkaline phosphatase was found in both small and large vacuoles, whereas peroxidase was visible only in large ones. By 10 min, very big phagocytic vacuoles containing considerable amounts of reaction product for both enzymes were evident. These observations indicate that the two types of PMN granules discharge in a sequential manner, specific granules fusing with the vacuole before azurophils. In an earlier paper, we reported that the pH of phagocytic vacuoles drops to 6.5 within 3 min and to ~4 within 7–15 min. Substances known to be present in specific granules (alkaline phosphatase, lysozyme, and lactoferrin) function best at neutral or alkaline pH, whereas most of those contained in azurophil granules (i.e., peroxidase and the lysosomal enzymes) have pH optima in the acid range. Hence the sequence of granule discharge roughly parallels the change in pH, thereby providing optimal conditions for coordinated activity of granule contents.     

Natural variation and differential diagnosis of skeletal changes in tuberculosis

Twenty-six documented cases (17 blacks, 9 whites) of skeletal tuberculosis from the Hamann-Todd Osteological Collection, Cleveland Museum of Natural History, were analyzed for lesion variability and patterns of multiple site involvement. In addition, several documented cases of pathologic conditions (osteomyelitis, vertebral fractures, and malignant bone tumors) that resemble skeletal tuberculosis were photographed and described for use in differential diagnosis. The range of variation of tuberculous lesions was found to be considerable. Thirty-eight percent (10/26) of the cases display skeletal lesions in two or more regions concomitantly. The average number of vertebrae affected, as well as the incidence of multiple bone involvement, were found to be higher in blacks. Certain combinations of skeletal lesions (e. g., spine-rib, spine-rib-sternum, and spine-hip) may be useful in the diagnosis of tuberculosis in dry bone material.     

Triamcinolone-Procaine in the Treatment of Zoster and Postzoster Neuralgia

Twenty-four patients with herpes zoster were treated with injections of 2 percent procaine hydrochloride containing 2 mg of triamcinolone per ml. The treatments were given subcutaneously under the cutaneous lesions and in areas of pain. The results were excellent in 22 patients. There was one failure—postzoster neuralgia in an 82-year-old woman.Of 12 patients with postherpetic neuralgia, eight had improvement of 70 to 90 percent and three had complete relief.There were no significant complications in either group.     

Treatment of Paget's Disease of Bone with Synthetic Salmon Calcitonin

Thirteen patients with painful Paget''s disease of bone were treated as outpatients with low doses of synthetic salmon calcitonin 22·5-50 μg three times weekly. Treatment produced full remission of pain in a mean time of 5·5 weeks and a mean depression of serum alkaline phosphatase activity of 33%.The interval before symptomatic relief could not be predicted from the variables studied. The ultimate fall in serum alkaline phosphatase activity, however, could be predicted from the initial levels and from the early rate of decrease (P < 0·001). Biochemical resistance to treatment, which occurred in three cases, could be related to the dose and duration of treatment.Prolonged remissions of pain may occur which are not related to biochemical remission, to the dose of calcitonin, or to the duration of treatment. The side effects attributable to salmon calcitonin were transient nausea (in nine patients), transient flushing (in four), diarrhoea (in two), and rash (in one) though in only one patient did treatment have to be withdrawn prematurely because of these effects.     

Growth requires bone resorption at particular skeletal elements in a teleost fish with acellular bone (Oreochromis niloticus, Teleostei: Cichlidae)

To date, little is known about bone resorption during skeletal development in teleostean fish with acellular bone. We report here about bone resorption with regard to growth in the tilapia Oreochromis niloticus. Nine skeletal elements obtained from growing juveniles were examined using histological and histochemical methods, and transmission electron microscopy (TEM). Tartrate-resistant acid phosphatase (TRAP) served as a marker for bone resorbing cells (osteoclasts), alkaline phosphatase (ALP) was used to identify osteoblasts, and alizarin staining indicated sites of bone formation. TRAP-activity was located at those skeletal elements where growth requires bone resorption, and at sites of cartilage degeneration. No TRAP-activity was found at those skeletal elements where resorption was not required for growth. The examination of the praeopercular shaft leads to a model of bone enlargement, including bone resorption by TRAP-positive cells located at the endosteal bone surface and bone formation by ALP-positive cells located at the periosteal bone surface. TRAP-positive cells were mononucleated and lacked a ruffled border. They appeared either as cell aggregates (resembling the shape of multinucleated giant cells) or as flat cells (resembling bone lining cells). Problems of osteoclast identification in bony fish are discussed.     

Skeletal Lesions in Human Tuberculosis May Sometimes Heal: An Aid to Palaeopathological Diagnoses

In three to five percent of active cases of tuberculosis, skeletal lesions develop. Typically, these occur on the vertebrae and are destructive in nature. In this paper, we examined cases of skeletal tuberculosis from a skeletal collection (Galler Collection) with focus on the manifestation of bony changes due to tuberculosis in various body regions in association with antibiotic introduction. This skeletal collection was created in 1925–1977 by a pathologist at the University Hospital in Zürich, Ernst Galler. It includes the remains of 2426 individuals with documented clinical histories as well as autopsies. It contained 29 cases of skeletal tuberculosis lesions. We observed natural healing of vertebral lesions through several processes including fusion of vertebrae, bone deposition and fusion of posterior elements. In these cases, we observed a higher frequency and proportion of bone deposition and fusion of posterior vertebral elements where pharmacological agents were used. There were also four cases of artificial healing through surgically induced posterior spinal fusion. With the introduction of pharmaceutical treatments, the number of individuals with multiple tuberculous foci decreased from 80% to 25% when compared to individuals who did not receive any drug therapy. Investigation of comorbidities showed that pneumonia, pleuritis and being underweight were consistently present, even with pharmaceutical treatment. Our results have applications in palaeopathological diagnoses where healing and consequent bone deposition may complicate differential diagnoses.     

Bone alkaline phosphatase in Paget's disease.

The measurement of bone proteins and peptides and their derived products has been very useful in the diagnosis and management of patients with skeletal disease. This group of assays includes alkaline phosphatase (AP) and bone Gla protein (BGP). We here describe the comparison of a new immunoassay that is specific for bone alkaline phosphatase (BAP) to measurements of total alkaline phosphatase (TAP) and BGP in Paget's disease. In our studies, we demonstrated that BAP was increased in the serum of patients with Paget's disease. Comparisons with the other measurements revealed that BAP correlated better with total AP (r = 0.92) than with BGP (r = 0.51); the lowest correlation occurred between BGP and total AP (r = 0.26). In patients with liver disease, the BAP was indistinguishable from normal whereas the TAP was elevated. These studies indicate that BAP assesses different aspects of bone cell function than BGP in Paget's disease. This discordancy also exists between BGP and total serum AP activity. BAP measurements by immunoassay offer a novel method of assessing skeletal status. Thus, the information that measurement of different bone-specific proteins provides should be separately useful in assessing the skeleton for a variety of metabolic bone diseases.     

Neonatal Necrotizing Enterocolitis: Clinical and Radiological Features

Necrotizing enterocolitis is an uncommon but dangerous disease in premature infants. Ten cases, seen over a three-year period at the Stanford University Medical Center, represented an incidence of 0.4 percent. The patients, six of whom died, derived from a general population, in contrast to the large series of patients reported in the literature in which the incidence was from 0.9 percent to 3.7 percent.^3-6The initial symptoms—rapid respiration, periodic breathing, lethargy and irritability—were identical to those which occurred in numerous infants who had respiratory disease. Subsequent symptoms (abdominal distension, in 100 percent; vomiting, 80 percent; apneic spells, 70 percent; jaundice, 70 percent; guaic-positive stools, 60 percent) were those of nonspecific acute abdominal disease.The radiologist first made the diagnosis in 90 percent of cases. Interstitial air in the wall of the gut and the retroperitoneum, and portal vein gas were the most diagnostic radiographic features. Barium contrast studies were not helpful, and in one case led to the erroneous diagnosis of small bowel volvulus.Plain abdominal radiographs must be taken of all premature infants with symptoms of nonspecific acute abdominal disease. If the radiographs are negative, but symptoms continue, they should be repeated at frequent intervals, for early diagnosis is critical to institution of proper therapy.     

Architecture of implanted bone matrix gelatin influences heterotopic calcification and new bone formation

Heterotopic bone formation in skeletal muscle induced by compacted demineralized bone matrix gelatin (BMG) was studied histologically and biochemically. BMG was obtained by dehydrating diaphyseal shafts of femora and tibiae of 4-week-old male Sprague-Dawley rats, cutting the bone into chips, and demineralizing and extracting the chips with various solutions. The BMG was treated with 4 M guanidine-HCl, and compacted BMG was prepared by centrifugation. The compacted BMG was implanted into the rectus abdominis muscle of 5-week-old male Sprague-Dawley rats. The resulting specimens were examined histologically, and their alkaline phosphatase activity and the calcium content of the tissues were measured 3, 5, 7, 10, and 15 days after implantation. The BMG (separated BMG) with 75- to 500-microns particle sizes were implanted into control rats. The results showed that calcification, alkaline phosphatase activity, and bone formation were suppressed by implantation of the compacted BMG and that scarcely any vascularization occurred. Calcification, vascularization, and alkaline phosphatase activity were related and were indispensable for bone formation. In the control group, bone formation was observed at sites of high activity of alkaline phosphatase and well-developed vascularization. These results suggested that compacting of BMG suppressed vascularization, decreased calcification, and consequently reduced the induction of bone formation.