Infarctus osseux révélés par des arthralgies – Apport de la TEMP-TDM

We report the case of a 41-year-old woman, investigated for arthralgia of the knees, wrists and ankles who presented heterogeneous increased uptake of the distal extremities of femurs and the proximal extremities of tibias on the whole-body bone scintigraphy. A scintigraphy realized five years previously had shown a more homogeneous increased uptake in the same territory. The single photon emission computerized tomography guided by computerized tomography (SPECT-CT) centered on knees revealed several areas of heterogeneous increased uptake which corresponded to intraosseous “smoke twirled” lesions surrounded by calcifications. The clinical context, the location of the lesions and the morphological aspect are suggestive of bone infarcts. These infarcts were ascribed to a chronic alcoholism. Arthralgia could not be explained to this day.     

Diagnostic d’une fracture occulte isolée de la marge postérieure du tibia par la TEMP–TDM

We report the case of a 56-year-old woman, investigated for pains of the right ankle related to a traumatism of an unspecified mechanism. The radiographic assessment was negative. The ^99mTc-HDP 3-phase bone scintigraphy highlighted, on the blood pool and the delayed images, a located lesion on the right ankle. The single photon emission computerized tomography guided by computerized tomography (SPECT-CT) showed a focused uptake on the posterior margin of the right tibia and a sharp lucent line within the tomoscintigraphic spot of uptake. The diagnosis accepted was an isolated occult fracture of the posterior margin of the right tibia. The contribution of the ^99mTc-HDP 3-phase bone scintigraphy combined with the SPECT-CT in the diagnosis of the occult fractures is discussed.     

Une ostéomalacie liée à un diabète phosphoré – rôle de la scintigraphie osseuse couplée à la TEMP-TDM

We report the case of a 59-year-old woman, investigated for disabling pain of the left thigh, unrelated to any traumatic event. Interrogation had found diffuse pain of myalgia-type and arthralgia-type for approximately a year without local inflammatory signs and insufficiency fractures of both calcaneus two years before. The Technetium 99m-labeled hydroxymethylene diphosphonate (^99mTc-HDP) whole-body bone scintigraphy evidenced multiple hot spots on the higher third of left femur, rib cage, sternum, scapulae, pelvis, right hip and both calcaneus. Moreover, a more diffuse and heterogeneous prominent uptake appeared on rib cage, spine and pelvis. These images suggested a diffuse metastatic disease of the skeleton. The single photon emission computerized tomography guided by computerized tomography (SPECT/CT), centered on lumbar spine, pelvis and the upper end of femurs showed that the multiple hot spots were infact bone fractures. These findings pointed diagnosis to a metabolic disease. The clinical context was in favour of an osteomalacia. Further explorations showed an osteomalacia related to phosphate diabetes. A thorough work-up did not reveal any known aetiology. To date, idiopathic phosphate diabetes seems the most likely diagnosis. Nuclear medicine input in osteomalacia is discussed.     

Apport de la TEMP–TDM en complément de la scintigraphie osseuse planaire dans la pratique courante du service de médecine nucléaire de Nancy

ObjectiveThe purpose of our study was to evaluate the diagnostic performance of SPECT coupled to computed axial tomography (SPECT–CT) in our daily practice of bone scintigraphy.Subjects and methodsSPECT–CT obtained as a complement to the planar bone scintigraphy in 39 patients were studied. Each type of image was retrospectively read by two differents observers: a nuclear medicine physician who was unaware of SPECT–CT results analysed planar bone scintigraphy, a second one who was unaware of planar bone scintigraphy results analysed SPECT–CT images. In this population of patients, 17 patients were addressed in an oncologic setting. The 22 other patients were addressed for pain of indeterminate origin without neoplasic context.ResultsIn 13% of the cases, SPECT–CT specified the precise location of increased uptake foci seen on planar bone scintigraphy. In 38% of cases, SPECT–CT confirmed a diagnosis suspected by the planar bone scintigraphy. In 10% of cases, SPECT–CT established a diagnosis that was uncertain with planar bone scintigraphy. In 26% of cases, SPECT–CT brought no additional information. Finally in 3% of cases, SPECT–CT proved to be more sensitive than planar images.ConclusionOur study demonstrates the utility of SPECT–CT in the daily practice of bone scintigraphy, this complementary imaging study benefited to 74% of our patients.     

Apport de la fusion d’images tomoscintigraphiques avec la tomodensitométrie X ou l’imagerie par résonance magnétique en pathologie osseuse : expérience du service de médecine nucléaire de Sfax

The aim of our study was to assess the contribution of image fusion of SPECT combined with computed tomography (SPECT-CT) or magnetic resonance imaging (SPECT-MRI) in our daily practice of bone scintigraphy. Seventeen patients underwent a SPECT image fusion, SPECT-CT or MRI in addition to conventional bone scintigraphy. These acquisitions are made separately with images stored in DICOM format. The fusion was operated after a manual coregistration of the images. Results show that in 35.29% of cases, the image fusion allowed to pinpoint the exact location of increased uptake seen on the whole body scan and/or on static images. In 35.29% of cases, the fusion has confirmed a diagnosis doubtful in planar imaging. In five patients, representing 29.41% of cases, the fusion has corrected a diagnosis. In one patient (5.88% of cases), the fusion has eliminated a false positive related to increased uptake visualized on the whole body scan. In two patients (11.11% of cases), the fusion has eliminated false negative of bone scan in one case and of MRI in the other case. Finally, in nine patients (50% of cases), the fusion has influenced the therapeutic management.     

Absence de fixation du gril costal: Diagnostic d’un syndrome de Poland par la TEMP-TDM osseuse

We report the case of a 37-year-old man, investigated for pains of the right upper limb impairing the hand, the wrist and the shoulder after a surgery for fracture of the radius and the scaphoid. The ^99mTc-HDP three-phase bone scintigraphy confirmed the diagnosis of acute phase of a reflex sympathetic dystrophy. The delayed images highlighted a focal absence of tracer uptake of the left anterior rib cage. The single photon emission computerized tomography guided by computerized tomography showed that it was related to the absence of the anterior part of the third and the fourth left ribs highlighting an aplasia of the left pectoralis major muscle. These anomalies led to the diagnosis of congenital malformation in connection with a Poland's syndrome. The differential diagnosis of this syndrome resulted in discussing the multiple etiologies of the photopenic lesions of the rib cage.     

Apport de la médecine nucléaire dans la prise en charge du cancer de la prostate : analyse de 360 cas en milieu camerounais

Prostate cancer is the most frequent neoplasm affecting males above 50 years old in developed countries. Previous studies carried out in Cameroon have shown that, this condition is not infrequent. Late diagnosis is equally common. The advent of nuclear medicine technology in the year 2000 has enabled the possibility of prostate specific antigen (PSA) assay and imaging by bone scintigraphy. In this study, we aimed at assessing the contributions of PSA assay and bone scintigraphy in the management of prostate cancer in Cameroon. Within a 5 years period (January 2003–December 2007) 360 patients had biopsy proven (Gleason score) prostate adenocarcinoma. The age ranged from 50 to 85 years with a mean of 67 years. Those aged between 60 to 69 years were more affected. The patients were divided into 2 groups: a first one accruing of 250 patients with a previous bone scintigraphy carried out before treatment and a second group of patients who underwent a bone scintigraphy during treatment. Clinical features digital rectal examination, endorectal echography were noted. PSA levels and bone scintigraphy results were also noted. Most of these patients (80.56%) presented with advanced lesions with metastases. Orchiectomy and hormonotherapy were the most used methods of treatment due to late diagnosis. Bone scintigraphy-evidenced lesions were mainly located (92.25%) at the dorso-lombar region of the spine. There is a correlation between the following variables: clinical features, namely, digital rectal examinations, PSA blood levels, ultrasound, histology and bone scintigraphy. Therefore, we can conclude that, PSA is an important marker of prostate cancer. Its association with bone scintigraphy is appropriate for the detection of bone metastases.     

Place actuelle et perspectives futures de la scintigraphie de perfusion myocardique

Myocardial perfusion scintigraphy (MPS) is a well-established tool for coronary artery disease (CAD) detection and prognostic evaluation. By detecting viable myocardium in hypoperfused territories and assessing physiological significance of intermediate coronary stenosis after catheterization, MPS can help for decision-making. Electocardiogram (ECG) gated single photon emission computerized tomography (SPECT), bringing informations about left ventricular global function and segmental wall motion, has increased MPS diagnostic accuracy and offers additive and independent prognostic value. Nowadays, many improvements are in progress. Some, like new vasodilator agents as selective adenosine A2a receptor agonists might seem trivial, but others are more challenging. Indeed, the development of new SPECT detectors based on cadmium zinc telluride crystals or the availability of rubidium-82 generators for positron emission tomography (PET) will lead to increased spatial resolution, high sensitivity and time-saving imaging procedures. Moreover, integrated PET-CT systems allow efficient attenuation correction and offer the possibility for absolute quantification of myocardial blood flow. At last, the interest of combinating functional and anatomical data thanks to hybrid SPECT-CT or PET-CT scans will have to be evaluated.     

Corrélation entre la scintigraphie osseuse et le taux du marqueur tumoral CA15-3 dans le cancer du sein. À propos de 100 cas

AimTo display the correlation between the rate of tumor marker CA15-3 and the bone scintigraphy for extension or supervision check-up in breast cancer.MethodologyIn this study, we have randomly included 100 patients with a serum dosage of CA15-3 and a bone scintigraphy.ResultsWe compared the results of the bone scintigraphy and the rate of CA15-3. Among the 77 patients with elevated CA15-3, 57 presented a bone scintigraphy exhibiting secondary bone locations. Among 23 patients with a normal rate of CA15-3, 18 women presented a normal bone scintigraphy. The sensitivity of bone scintigraphy was estimated at 91.74%, while the specificity was estimated at 47.37%, and calculating the coefficient, which measures the intensity of linking the two variables, CA15-3 and bone scintigraphy, the Yule coefficient was 0.82.ConclusionIn this study, the intensity of the correlation between bone scintigraphy and the rate of CA15-3 proved very strong.     

Cancer de la prostate et masses abdominopelviennes fixant le 99mTc-HDP. Apport de la tomographie d’émission monophotonique couplée à la tomodensitométrie (TEMP–TDM)

We report the case of a 63-year-old man, investigated for staging of a prostatic cancer, diagnosed by biopsy, following a rise in the prostatic specific antigen (PSA) on a systematic assessment. The interrogation before examination revealed signs of beginning right crural neuropathy. The hydroxymethylene diphosphonate technetium 99m-labeled (^99mTc-HDP) whole-body bone scintigraphy highlighted two extraosseous uptake images, the first of moderated intensity in the right iliac area, the second milder, in the abdominal median area. Osseous metastases were not visualized. The single photon emission computerized tomography guided by computerized tomography (SPECT/CT) identified the median abdominal mass which corresponded to a bulky aneurysm of the under renal abdominal aorta. The right iliac mass could be accurately analyzed and differentiated from the various organs of the abdominopelvic cavity. Its lymphatic origin was hypothetised, but the diagnosis of lymphatic metastasis of the prostatic cancer was obtained by the pathologic examination of CT scan-guided biopsy.     

Diagnostics différentiels d’une lésion de la mandibule chez un patient aux antécédents de cancer ORL localement avancé

Eighteen months after completion of a radiochemotherapy treatment for a T4 tonsil cancer, a patient presented with a piece of bone coming out through a submandibular fistula and increasing pain. A CT scan, a bone scintigraphy and an 18-fluorodeoxyglucose positron-emission tomography were performed. Both diagnoses of osteoradionecrosis and tumor recurrence were suspected and then confirmed after mandibulectomy.     

Computer-designed prostheses for orbitocranial reconstruction

Three-dimensional imaging is an adjunct to preoperative evaluation and surgical management in some patients with complex anatomic defects of various etiologies. Deformities defined by conventional computerized tomography can be viewed as accurate three-dimensional images calculated from the original scan. The images are viewed on a high-resolution video monitor and can be photographed for a permanent record. A computer-controlled milling device can use these data to fabricate prostheses. The prostheses aid reconstructive surgery through use as an alloplastic implant, as a template to fashion autogenous bone grafts, or as a model for tissue removal. We have utilized three-dimensional imaging in combination with computer-assisted prosthesis manufacture in six patients with complex orbitocranial deformities. Four patients have undergone reconstructive surgery with satisfactory results and no complications thus far. The use of computer-designed prostheses adds a new aspect to orbitocranial reconstructive surgery that facilitates increased accuracy in the correction of anatomic defects.     

Quantification model for muscular forces and momentums in human lower extremities

The possibility of calculating muscular forces and momentums and their influence on skeleton was evaluated in this study by means of computerized tomography performed on a living person. Through this, the surface and corrected surface for each muscle cross section area were obtained, the distance from muscular centroide to the neutral bone axis was measured, and muscular force and muscular momentum on the bone were determined. Muscular momentum on the bone was obtained by multiplication of the muscular force and the distance between muscular centroide and neutral bone axis. The use of computerized tomography, as a method for creating a model for quantification of muscular forces and momentum, was proven to be reliable according to exactness in evaluation of all human lower extremity structures which is the basis for muscular biomechanical characteristic calculations.     

Pathologies de la prostate : actualités en médecine nucléaire (diagnostic et thérapeutique)

Nuclear medicine could significantly contribute to management of patients with prostate carcinoma. Apart from bone scintigraphy, and success of sentinel lymph node procedure, from a diagnosis point of view ¹⁸F-fluorocholine, which is now disposable, will certainly allow better staging accuracy, better efficiency of recurrences detection, and better treatments evaluation. Regarding to treatments, several radiopharmaceuticals demonstrated their efficiency as palliative treatment of painful bone metastasis, and maybe in the near future will contribute to curative treatment when associated to chemotherapy.     

Évaluation de la tomoscintigraphie de perfusion pulmonaire couplée à la tomodensitométrie dans la prédiction de la fonction respiratoire postopératoire

IntroductionThe aim of our study was to evaluate the performances of pulmonary perfusion single photon emission computed tomography-computed tomography (SPECT-CT) with semi-automatic analysis for preoperative assessment for lung cancer.Materiel and methodThirty-five patients underwent preoperative lung perfusion scintigraphy (planar and SPECT-CT acquisition) from august 2016 to December 2017. Predicted postoperative forced expiratory volume in one second (ppoFEV1 and FEV1) by both methods were compared between each other and with the actual FEV1 measured 3 months after surgery. We also evaluated interobserver reproductibility of SPECT-CT semi-automatic segmentation software and the concordance of the data simulating reductions of 30 and 50% of acquisition time.ResultsFor 30 lobectomies and 5 pneumonectomies, the mean ppoFEV1 was 69%, a difference with actual ppoFEV1 of ?8% for SPECT-CT and ?6.77% for planar (P < 0,001). Both methods were well correlated, correlation coefficient was 0,827, 95% CI [0.686–0.909] but underestimated the actual poppFEV1. For SPECT-CT, interobserver reproducibility was excellent for pulmonary and lobar evaluation. The lobar functions, without 30 and 50% of the time acquisition, had absolute difference < 3% in comparison to native data.DiscussionWe did not prove SPECT-CT superiority on planar scintigraphy, actual FEV1 being difficult to predict because of confounding factors. But this exam could be useful before lobectomy and in cases of heterogeneous perfusion. Easily made, this method is reproducible even on data simulating a reduction of 50% of time acquisition.     

Aspects des complications ostéoarticulaires de la drépanocytose en scintigraphie osseuse planaire (infection exclue). À propos de trois observations

Skeletal complications of sickle-cell anemia are multiple and can appear on the acute (osseous infarction, acute osteomyelitis) or chronic mode (osteonecrosis, chronic osteomyelitis). The radio-labelled diphosphonates bone scintigraphy remains an important tool in the early diagnosis and in the follow-up of these complications and must form part of the initial assessment of the disease. Through clinical observations, the authors undertake to sum up the bone scintigraphy aspects of these complications.     

Partie 2. Orthopedie – Traumatologie

Bone scintigraphy is a nuclear imaging scan using a radiopharmaceutical composed of a bisphosphonate coupled to a radionuclide (technetium 99 m). Radiopharmaceutical uptake is particularly important at the level of the bone structures having a strong osteoblastic activity. These uptakes can be due to a benign pathology (fracture, loosening of prosthesis, rheumatic pathologies, etc.) or to a malignant pathology (primary or secondary bone lesion). The high sensitivity of bone scintigraphy makes it particularly interesting at the initial stage of the pathology, especially when x-rays are normal. In addition, its specificity has clearly improved in recent years with the increasingly use of tomoscintigraphy coupled with X-ray scanning (SPECT/CT). We describe the operating principle of bone scintigraphy, normal uptakes with its variants as well as pathological uptake features in traumatic, rheumatic, prosthetic or cancerous pathologies.     

The diagnosis of osteomyelitis in patients with pressure sores

A prospective blind trial was undertaken to assess the usefulness of commonly used tests to diagnose osteomyelitis underlying pressure sores. Sixty-one pressure sores were studied, with a histopathologic diagnosis from the ostectomy specimen being available in 52. White cell count, erythrocyte sedimentation rate, plain pelvic x-ray, technetium-99m bone scan, computerized tomography, and Jamshidi needle bone biopsy were studied. The most useful individual test was a needle bone biopsy, with a sensitivity of 73 percent and a specificity of 96 percent. Technetium-99m bone scans and computerized tomography are not indicated in the diagnosis of osteomyelitis associated with pressure sores. Plain pelvic x-ray, white cell count, and erythrocyte sedimentation rate, with a diagnosis of osteomyelitis if any test is positive, is the most sensitive (89 percent), specific (88 percent), noninvasive workup. Jamshidi needle biopsy may be useful where these tests are negative and a clinical suspicion of osteomyelitis remains. Extent of surgical debridement and antibiotic therapy can then be rationally decided on the basis of this information.     

Place de la scintigraphie osseuse dans la maladie de Paget

The clinical and laboratory signs, as well as the imaging and course of Paget's disease of bone, are now well known. This chronic and usually benign disease is characterized by excessive remodelling of bone tissue, associated with an increase, sometimes considerable, of osteoclast resorption and osteoblast formation activities. The bone scan is a fundamental examination to establish initial mapping of the localizations of the disease. This examination has a greater sensitivity than X-rays for the flat bones. Through three clinical cases, we present the bone scan aspect, the various localizations and the diagnosis difficulties of the disease, especially when a context of neoplasm is present.     

Imaging in gout - What can we learn from MRI,CT, DECT and US?

There are many exciting new applications for advanced imaging in gout. These modalities employ multiplanar imaging and allow computerized three-dimensional rendering of bone and joints (including tophi) and have the advantage of electronic data storage for later retrieval. High-resolution computed tomography has been particularly helpful in exploring the pathology of gout by investigating the relationship between bone erosions and tophi. Magnetic resonance imaging and ultrasonography can image the inflammatory nature of gouty arthropathy, revealing synovial and soft tissue inflammation, and can provide information about the composition and vascularity of tophi. Dual-energy computerized tomography is a new modality that is able to identify tophi by their chemical composition and reveal even small occult tophaceous deposits. All modalities are being investigated for their potential roles in diagnosis and could have important clinical applications in the patient for whom aspiration of monosodium urate crystals from the joint is not possible. Imaging can also provide outcome measures, such as change in tophus volume, for monitoring the response to urate-lowering therapy and this is an important application in the clinical trial setting.