Ebook Diagnostic imaging nuclear: Part 2

(BQ) Part 2 book Diagnostic imaging nuclear presents the following contents: Head and neck, thyroid and parathyroid, Gastrointestinal, genitourinary, HemeOnc procedures and therapies, oncology, other.

Diagnostic Imaging Nuclear

Table of Contents

Diagnostic Imaging Nuclear 7

Cover 7

Authors 7

Dedication 8

Foreword 9

Preface 9

Acknowledgments 10

Introduction 10

Section 1 - Musculoskeletal 11

I Benign Bone Tumors 11

Osteoid Osteoma 11

Enchondroma 18

Fibrous Cortical Defect 22

Bone Cyst, Aneurysmal 26

Bone Cyst, Solitary 30

Giant Cell Tumor 37

II Malignant Bone Tumors 41

Skeletal Metastases 41

Superscan 51

Osteosarcoma 58

Ewing Sarcoma 68

Chondrosarcoma 75

Prostate Cancer, Bone Metastases 82

III Therapy 86

Palliation of Metastatic Bone Pain 86

IV Infection 93

Cellulitis 93

Osteomyelitis, Appendicular 100

Osteomyelitis, Axial 110

Osteomyelitis, Temporal Bone 114

Osteomyelitis, Feet 118

Osteomyelitis, Pediatric 125

V Metabolic Bone Disease 135

Hyperparathyroidism 135

Osteomalacia 142

Hypertrophic Osteoarthropathy 149

VI Dysplasias 159

Paget Disease 159

Fibrous Dysplasia 166

Melorheostosis 170

Multiple Enchondromatoses 177

Multiple Hereditary Exostoses 184

VII Avascular Necrosis 191

Osseous Necrosis 191

Legg-Calve Perthes Disease 198

VIII Surgical Assessment 202

Joint Prostheses, Painful 202

Failed Back Surgery Syndrome 206

IX Skeletal Trauma 216

Insufficiency Fracture 216

Fracture 226

Trauma, Non-Accidental 230

Stress Fracture 234

X Regional Pain Evaluation 241

Arthritis, Non-Infectious 241

Complex Regional Pain Syndrome 248

Hip Pain 255

Wrist Pain 262

Calcaneal Pain 272

Knee Pain 279

XI Skeletal Muscle & Soft Tissues 286

Heterotopic Ossification 286

Skeletal Muscle Disorders 296

Amyloidosis 303

XII Bone Marrow Disorders 307

Hematoproliferative Disorders 307

Sickle Cell Disease, Bone Pain 317

Multiple Myeloma 324

Section 2 - Vascular and Lymphatics 331

I Lymphatic 331

Lymphedema 331

Sentinel Lymph Node Mapping 335

II Vascular 342

Large Vessel Vasculitis 342

Atherosclerosis 346

Vascular Thrombosis 353

Vascular Graft Infection 357

Section 3 - Cardiovascular 367

I Introduction and Overview 367

Cardiovascular Overview 367

II Cardiac 375

Cardiomyopathy 375

Valvular Heart Disease 385

Myocardial Ischemia 392

Myocardial Viability 402

Myocardial Infarction 409

Cardiac Transplant 419

Left-to-Right Intracardiac Shunts 426

Right-to-Left Intracardiac Shunts 430

Section 4 - Chest and Mediastinum 434

I Introduction and Overview 434

VQ Scan Overview 434

VI Mediastinum 512

Thymic Evaluation 512

Pericardial Disease, Malignant and Inflammatory 519

Section 5 - CNS 526

I Introduction and Overview 526

Brain Imaging Overview 526

II Vascular Assessment 531

Brain Death 531

Cerebral Vascular Occlusion 541

Blood Brain Barrier Disruption 548

III Seizure Assessment 552

Seizure Evaluation 552

IV Dementia & Neurodegenerative 562

Alzheimer Disease 562

Dementia and Neurodegenerative, Other 569

V Neurooncology 579

Gliomas and Astrocytomas 579

Primary CNS Lymphoma 586

Metastases, Brain 593

Radiation Necrosis vs Recurrent Tumor 600

VI CSF Imaging 610

CSF Leak 610

Ventricular Shunt Dysfunction 617

Normal Pressure Hydrocephalus 624

VII Miscellaneous 634

Heterotopic Gray Matter 634

Brain Infection and Inflammation 644

Psychiatry, Drug Addiction and Forensics 651

Section 6 - Head and Neck 661

I Squamous Cell Carcinoma of the Head and Neck 661

SCCHN, Staging 661

SCCHN, Primary Unknown 668

SCCHN, Therapeutic Assessment - Restaging 672

II Miscellaneous Primary Head and Neck Tumors 679

Parotid and Salivary Tumors 679

Neuroendocrine Tumors, Head and Neck 683

III Miscellaneous 690

Lacrimal Complex Dysfunction 690

Section 7 - Thyroid & Parathyroid 694

I Introduction and Overview 694

Thyroid Overview 694

II Parathyroid 702

Parathyroid Adenoma, Typical 702

Parathyroid Adenoma, Ectopic 710

III Hyperthyroidism 714

Graves Disease 714

Hashimoto Thyroiditis 721

Multinodular Goiter 728

Thyroid Adenoma, Hyperfunctioning 735

Subacute Thyroiditis 742

I-131 Hyperthyroid Therapy 749

IV Thyroid, Benign Miscellaneous 756

Ectopic Thyroid 756

Congenital Hypothyroidism 763

Benign Thyroid Conditions, PET 770

V Thyroid Cancer 777

Well-Differentiated Thyroid Cancer 777

I-131 Thyroid Cancer Therapy 787

Well-Differentiated Thyroid Cancer, PET 794

Medullary Thyroid Cancer 801

Section 8 - Gastrointestinal 808

I Introduction and Overview 808

GI Anatomy and Imaging Issues 808

II Biliary 812

Acute Calculous Cholecystitis 812

Acute Acalculous Cholecystitis 822

Chronic Cholecystitis 832

Biliary Leak 839

Common Bile Duct Obstruction 843

Choledochal Cyst 847

Biliary Bypass Obstruction 854

Biliary Atresia 858

Cholangiocarcinoma 865

Gallbladder Cancer 872

III Hepatic 879

Focal Nodular Hyperplasia 879

Hepatic Cirrhosis 886

Hypersplenism 896

Hepatic Metastases 903

Hepatoblastoma 910

Hepatocellular Carcinoma 917

Cavernous Hemangiomas 927

IV Adrenal 934

Adrenal Malignancy 934

Pheochromocytoma 944

Neuroblastoma 951

V Spleen 961

Asplenia-Polysplenia Syndromes 961

Accessory and Ectopic Splenic Tissue 968

VI Oropharynx & Esophagus 975

Esophageal Cancer 975

Esophageal Dysmotility 982

VII Stomach 989

Gastritis 989

Gastric Emptying Disorders 993

Carcinoid Tumor 1067

GI Stromal Tumors 1074

Peritoneal Systemic Shunt Evaluation 1081

Diaphragmatic Patency Determination 1088

Intraarterial Hepatic Pump Evaluation 1092

Section 9 - Genitourinary 1096

I Kidney 1096

Renal Cortical Scar 1096

Renal Ectopy 1103

Renovascular Hypertension 1110

Acute Renal Failure 1117

Renal Masses 1127

Renal Cell Carcinoma 1131

Pyelonephritis 1138

Renal Transplant 1145

Renal Function Quantification 1155

II Collecting System 1162

Obstructive Uropathy 1162

Reflux Uropathy 1169

Urinary Bladder and Epithelial Cancer 1176

III Testes 1183

Testicular Torsion 1183

Testicular Cancer 1190

IV Ovaries 1197

Ovaries, Normal and Benign Pathology 1197

Ovarian Cancer 1201

V Uterus 1208

Uterus, Normal and Benign Pathology 1208

Cervical Cancer 1212

Endometrial Cancer 1219

VI Prostate 1226

Prostate Cancer, Antibody Scan 1226

Section 10 - HemeOnc Procedures & Therapies 1230

I Therapy - Oncology 1230

Phosphorus-32 Therapies 1230

Hepatic Arterial Y-90 Microspheres 1234

Radiolabeled Antibody Therapy 1241

II Hematologic Procedures 1248

RBC Survival and Splenic Sequestration 1248

Red Cell Mass and Plasma Volume 1252

Schilling Test 1256

Section 11 - Oncology, Other 1260

I Lymphoma 1260

Lymphoma, Benign Mimics 1260

Hodgkin Lymphoma Staging 1267

Lymphoma Post-Therapy Evaluation 1274

Non-Hodgkin Lymphomas, Low Grade 1284

Non-Hodgkin Lymphoma Staging 1291

II Melanoma 1298

Melanoma Staging 1298

Melanoma Therapy Evaluation - Restaging 1305

III Breast Cancer 1312

Breast, Benign Disease 1312

Breast Cancer, Primary 1316

Breast Cancer, Staging - Restaging 1326

IV Miscellaneous 1336

Adenocarcinoma of Unknown Primary 1336

Paraneoplastic Disorders 1340

Index 1348

A 1348

B 1349

C 1351

D 1353

E 1353

F 1354

G 1355

H 1356

I 1358

J 1359

K 1359

L 1359

M 1361

N 1362

O 1364

P 1365

Q 1366

R 1366

S 1367

T 1368

U 1370

V 1371

W 1371

Y 1371

Z 1371

Diagnostic Imaging Nuclear

University of Utah School of Medicine

Salt Lake City, Utah

Paige B Clark MD

Assistant Professor of Nuclear Medicine

Department of Radiology

Wake Forest University Health Sciences

Winston-Salem, North Carolina

Assistant Professor of Radiology

University of Utah School of Medicine

Salt Lake City, Utah

Janis P O'Malley MD

Associate Professor of Radiology

Director of Nuclear Medicine and Clinical PET

University of Alabama

Birmingham, Alabama

Jeffrey S Stevens MD

Associate Professor of Radiology

Director of Nuclear Medicine

Oregon Health and Science University

Portland, Oregon

Crispin A Chinn MD

Director of Nuclear Medicine

Providence St Vincent Hospital

Portland, Oregon

Alan D Waxman MD

Director of Nuclear Medicine

Co-Chair, Department of Imaging

Cedars-Sinai Medical Center

S Mark Taper Imaging Center

Clinical Professor of Radiology

University of Southern California School of Medicine

Los Angeles, CA

Robert W Nance Jr MD

Assistant Professor Radiology/Nuclear Medicine

Oregon Health and ScienceUniversity

Portland, Oregon

Anita J Thomas MD

Assistant Professor of Nuclear Medicine

Department of Radiology

Wake Forest University Health Sciences

Winston-Salem, North Carolina

Ralph Drosten MD

Assistant Professor of Radiology

University of Utah School of Medicine

Salt Lake City, Utah

Thomas F Heston MD

Medical Director

The authors have succeeded in presenting a well-balanced and fair appraisal of the best imaging approach

to a vast array of common and not-so-common clinical problems that face diagnostic imagers in nuclear medicine The book defines the appropriate role of nuclear medicine in the context of other powerful imaging modalities today This includes important protocol information to allow optimization of a “best practice” imaging approach to specific problems Hundreds of superb well-reproduced images and graphic illustrations are included, a hallmark of the Diagnostic Imaging series Important clinical information

regarding the diseases addressed is also included The general organization is spare and direct in its

bulleted format, with key points highlighted, making this a quick and easy reference for the practicing radiologist, nuclear medicine practitioner, as well as clinicians Diagnostic Imaging: Nuclear Medicine should withstand the test of time as well-worn addition to any radiology reading room

Edward V Staab, MD

Professor of Nuclear Medicine

Department of Radiology

Wake Forest University Health Sciences

Winston-Salem, North Carolina

Preface

There are many outstanding radiology text books available today, addressing both general radiology as well

as specific imaging subspecialties In the face of literally hundreds of available text books, the Amirsys Diagnostic Imaging series has risen rapidly in popularity as one of the best selling imaging text book series

of all time Diagnostic Imaging: Nuclear Medicine rounds out this series, focusing on conventional nuclear medicine imaging, PET and PET/CT, radionuclide therapy, and the more commonly used in-vitro diagnostic determinations We have strived to fill an un-met need in providing a quick and practical guide for

radiologists and nuclear medicine physicians “in the trenches” The bulleted format is easy to digest and conveys clinically relevant information concisely and rapidly, providing a real-time reference for the reading room The hundreds of images included are clear and convey typical and atypical examples of specific diagnoses, as well as “mimics” and potential pitfalls that complicate diagnostic accuracy

This book is comprehensive in that it addresses the most common nuclear medicine diagnoses

encountered in daily practice, as well those with which most imagers have less experience The book provides thorough and concise information regarding nuclear medicine diagnostic and therapeutic

procedures, including appropriate study selection, protocol advice and interpretive guidance It also

summarizes the key findings shown by CT, MR, ultrasound and other radiographic modalities for each diagnosis Most importantly, it addresses the most appropriate role for nuclear medicine within the

framework of all imaging modalities and options available to answer a specific clinical question, without hype or subspecialty bias In short, this nuclear medicine book is practical, accessible and in-touch with the realities of multimodality diagnostic imaging

Kathryn A Morton, MD

Professor of Radiology

University of Utah School of Medicine

Salt Lake City, Utah

Nuclear medicine is an integral part of diagnostic imaging, yet it is relatively unfamiliar territory to many general and subspecialty radiologists The application of exciting new techniques such as PET/CT have brought nuclear medicine squarely to the forefront in cancer imaging We are thrilled to have Morton and Clark's DI: Nuclear Medicine join the Amirsys “family” of imaging textbooks They have done a superb job in bringing together standard imaging techniques such as high-resolution CT, MR and ultrasound and

correlating them with the most-up-to-date nuclear medicine scans available Because the DI series is printed with glorious full four-color illustrations throughout each book, studies such as SPECT and fused FDG PET/CT can be shown in all their magnificence DI: Nuclear Medicine is a feast for the eye as well as the intellect! Just look at the superb chapter on seizure evaluation as an example

As always, the unique bulleted format of the DI series allows our authors to present approximately twice the information and four times the images per diagnosis compared to the old-fashioned traditional prose textbook All DI books follow the same format, which means that our many readers find the same

information in the same place—every time! And in every body part! Our innovative visual differential diagnosis “thumbnail” provides you with an at-a-glance look at entities that can mimic the diagnosis in question and has been highly popular (and much imitated) For example, the chapter on Metastases to the

 Bone scan useful for localizing lesion (e.g., in young patient with back pain)

 Negative bone scan excludes the diagnosis

 Bone scan to evaluate for polyostotic lesions (rare)

 Bone scan helpful in identifying residual nidus in symptomatic patients post treatment

 SPECT images useful when attempting to localize lesion and planar images negative

Top Differential Diagnoses

 May spontaneously regress

 Initial treatment: Conservative

 Surgical treatment: Complete nidus removal curative

Coronal graphic shows intracortical osteoid osteoma in the femoral neck The nidus is red

Anterior bone scan of the right hip shows focal uptake in the right femoral head/neck in a patient with

a surgically proven osteoid osteoma (Courtesy B Manaster, MD)

TERMINOLOGY

Definitions

 Benign skeletal neoplasm

o Composed centrally of osteoid and woven bone in highly vascular connective tissue

o Surrounded by dense sclerotic bone

o Painful

IMAGING FINDINGS

General Features

 Best diagnostic clue

o Three-phase bone scan: Highly vascular lesion with intense uptake on angiographic, blood pool and delayed images

o Plain film: Lytic lesion, well-defined central nidus, ranging from lucent to dense depending

on amount of calcification, surrounded by sclerotic bone

 Location

o Cortical: Most common (80-90%)

 Femur and tibia: Most frequent sites (> 50%)

 Usually juxtaarticular

 Less associated sclerosis

o Subperiosteal

 Arises as soft tissue mass adjacent to bone

 Typically along medial aspect of femoral neck

 May also be in hands and feet; neck of talus

 Usually juxtaarticular or paraarticular

 May be associated with a large amount of periostitis

o Uncommon: Skull/facial bones

o Rarely polyostotic

 Size

o Usually < 1.5 cm

o Range: 0.5-2.0 cm

 Morphology: Lucent nidus with marked surrounding sclerotic reaction

Nuclear Medicine Findings

 Three-phase bone scan

P.1-3

o Hypervascular on flow and immediate static bone scan images

o Increased activity on delayed bone scan images

o Double density sign: Focal increased activity in nidus with surrounding focus of increased activity in sclerosis

 Whole body bone scan

o Increased activity in lesion(s)

Radiographic Findings

 Lytic bone lesion with well-defined central nidus

 Lesion ranges from lucent to dense depending on amount of calcification

 Lesion surrounded by sclerotic bone

 Well-delineated from adjacent bone

CT Findings

 Lytic bone lesion with well-defined central nidus, ranging from lucent to dense depending on

amount of calcification, surrounded by sclerotic bone

 Well-delineated from adjacent bone

 Best seen with thin sections

MR Findings

 Variable, nonspecific findings

 Nidus: Low-intermediate signal on T1WI; high signal on T2WI

 Calcification: Low signal intensity

Imaging Recommendations

 Best imaging tool

 Spot images over clinically painful region

 Angiographic phase: Dynamic 1-3 second images for one minute

 Blood pool phase: Static image for 3-5 minutes

 Delayed phase: Spot images over chest and axial skeleton with 500K to 1 million counts, 150-250K counts in extremities

 Often perform whole body scan as well, as primary lesion already characterized by plain film, CT

o Whole body bone scan

 Image anteriorly and posteriorly

 Spot views as necessary

 Pinhole collimator useful for small lesions

 SPECT images useful when attempting to localize lesion and planar images negative DIFFERENTIAL DIAGNOSIS

Osteomyelitis, Chronic

 Three phase bone scan

o Angiographic phase: Increased activity

o Blood pool phase: Increased activity

o Delayed phase: Increased activity; no double density sign

 Linear tract extends away from lesion on anatomic images

Stress Fracture

 Three phase bone scan: Positive three phase bone scan

o Angiographic phase: Increased activity

o Blood pool phase: Increased activity

o Delayed phase: Oval or fusiform increased activity with long axis parallel to axis of bone

 Anatomic imaging: Linear tract perpendicular to bone, adjacent new bone formation

P.1-4

Osteoma

 Bone scan: No increased activity in latent lesions, no nidus

o May have some uptake in active lesions

 Anatomic imaging: Well-defined, round, dense sclerotic lesion attached to underlying bone

 Size: 1-5 cm

Osteoblastoma

 Bone scan: Intense uptake of radiotracer

 Anatomic imaging: Expansile, circumscribed lytic lesion involving extremities and posterior

 Whole body bone scan: Increased activity in (usually) multiple, scattered sites

 Anatomic imaging: Irregular areas of lytic, mixed or sclerotic bone destruction

 Less likely to be solitary

 Axial skeleton predominance

Eosinophilic Granuloma

 Well-defined lytic lesion without sclerotic rim

 Bone scan usually shows increased uptake, but may have normal uptake or decreased uptake with surrounding halo

 Epidemiology: 10-12% of benign bone tumors

 Associated abnormalities

o Scoliosis if located in vertebral posterior elements

o Limb overgrowth if located near growth plate

Gross Pathologic & Surgical Features

 Granular bone, round or oval

 Sharp margins with adjacent bone

Microscopic Features

 Composed of osteoid and woven bone

 Tissue between the osteoid is fibrovascular

 Osteoblasts common at the edge of the osteoid

CLINICAL ISSUES

Presentation

 Most common signs/symptoms

o Classic presentation: Pain, worse at night, relieved by aspirin

o Systemic symptoms absent

o Pain may be referred to adjacent joint

 Other signs/symptoms

o Swelling may be associated with superficial lesions

o Joint effusions and synovitis can occur if intraarticular

o Almost always occurs in Caucasians

 Gender: Male predominance: 1.6-4.0:1

Natural History & Prognosis

 May spontaneously regress

 Complete surgical removal curative

 Symptoms recur if nidus not completely removed

 No growth progression

Treatment

 Initial treatment: Conservative

o May treat with NSAIDs

o Spontaneous regression possible

 Surgical treatment: Complete nidus removal curative

o Curretage

o En bloc resection

 Percutaneous

o CT-guided removal

4 Kransdorf MJ et al: Osteoid osteoma Radiographics 11(4):671-96, 1991

5 Helms CA et al: Osteoid osteoma: radionuclide diagnosis Radiology 151(3):779-84, 1984

P.1-5

Image Gallery

DDx: Mimics of Osteoid Osteoma

(Left) Anterior bone scan shows a focal area of increased uptake in a patient with new onset of painful scoliosis See next image (Right) Axial bone scan SPECT in same patient as left shows localization of uptake

in vertebral posterior elements See next image

(Left) Axial NECT in same patient as previous image shows central partially calcified nidus surrounded

by sclerotic rim (Right) Anterior bone scan immediate static image shows hyperemia in right hip in

a patient with hip pain See next image

(Left) Anterior bone scan delayed image in same patient as previous image shows marked uptake in right femoral neck and proximal femur See next image (Right) Axial CECT in same patient as left shows small lucent focus in femoral neck surrounded by sclerotic bone , signifying osteoid osteoma

 Assess for multiple lesions on whole body scan

Top Differential Diagnoses

Histopathology shows cartilaginous matrix with several chondrocytes in place of normal marrow and trabeculae (Courtesy A Mansoor, MD)

TERMINOLOGY

Definitions

 Benign cartilaginous neoplasm in bone

o 12-14% of benign bone neoplasms

o 3-8% of all osseous neoplasms

IMAGING FINDINGS

General Features

 Location

 Ollier disease, Mafucci syndrome Imaging Recommendations

 Best imaging tool

o Plain film and CT

 Chondroid matrix in medullary-centered lytic regions

 Pathologic fractures

 Aggressive characteristics worrisome for sarcoma

 Lytic-appearing areas in medullary space, +/- chondroid calcifications

 Additional nuclear medicine imaging options

o FDG PET: Focal hypermetabolic activity worrisome for sarcomatous degeneration if

Gross Pathologic & Surgical Features

 Ectopic hyaline cartilage rests in intramedullary bone

 Replaced trabeculae with mineralized, unmineralized cartilage

CLINICAL ISSUES

Presentation

 Most common signs/symptoms

o Pain (with or without pathologic fracture)

 Bone scan useful to rule out multiple enchondromatosis

 Highly increased activity on bone scan: May be due to sarcomatous degeneration, pathologic

fracture

SELECTED REFERENCES

1 Wang K et al: Bone scintigraphy in common tumors with osteolytic components Clin Nucl Med

30(10):655-71, 2005

2 Woertler K: Benign bone tumors and tumor-like lesions: value of cross-sectional imaging Eur Radiol 13(8):1820-35, 2003

3 Flemming DJ et al: Enchondroma and chondrosarcoma Semin Musculoskelet Radiol 4(1):59-71, 2000

4 Brien EW et al: Benign and malignant cartilage tumors of bone and joint: their anatomic and theoretical basis with an emphasis on radiology, pathology and clinical biology I Intramedullary cartilage tumors Skeletal Radiol 26(6):325-353, 1997

Image Gallery

DDx: Mimics of Solitary Enchondromas

(Left) Anterior bone scan of knees shows lesion in patient with painful distal femur Magnitude of uptake cannot reliably differentiate between enchondroma and chondrosarcoma (Courtesy D Sauser, MD) (Center) Plain film in same patient as previous image shows medullary chondroid matrix ,

indicative of enchondroma (Right) Coronal T1WI MR in same patient as previous image shows chondroid matrix against fat-replaced normal marrow

Fibrous Cortical Defect

Key Facts

Terminology

 FCD: Small, metaphyseal cortical fibrous bone lesion with sclerotic margin

 NOF: Larger, intramedullary bone lesion with sclerotic, scalloped margin

Imaging Findings

Anterior bone scan shows mildly increased uptake in the distal right femur and proximal tibia See next image

Plain film in the same patient as previous image shows FCDs corresponding to abnormal bone scan activity

in the distal right femur and proximal tibia

TERMINOLOGY

Abbreviations and Synonyms

 Metaphyseal fibrous defect: Fibrous cortical defect if small, non-ossifying fibroma if large

Definitions

 Fibrous cortical defect (FCD)

o FCD: Small, metaphyseal cortical fibrous bone lesion with sclerotic margin

o Nonaggressive

o Size < 3 cm

 Non-ossifying fibroma (NOF)

 Location

o Metaphyseal distal femur and tibia (80%)

 Less common: Mandible (often ossifying), proximal femur

 Unusual sites: Pelvis, ribs, vertebrae

o Commonly monostotic; may be polyostotic

Imaging Recommendations

 Best imaging tool

o Plain film usually diagnostic

o MR usually low on T1, T2, or enhanced imaging

DIFFERENTIAL DIAGNOSIS

Primary Bone Malignancy

 Osteosarcoma, chondrosarcoma, fibrosarcoma

 Increased activity on bone scan

P.1-9

Fibrous Dysplasia

 Ground-glass on plain film

 More likely polyostotic than FCD

 Cortical avulsion has similar location on bone scan

 More increased activity on bone scan than FCD

PATHOLOGY

Gross Pathologic & Surgical Features

 Cortically centered, white fibrous lesions

Microscopic Features

 Whorls of fibrous tissue

 Fibroblasts, giant cells, foam cells

o Pain from pathologic fracture

o Cutaneous cafe au lait spots with multiple NOF (Jaffe Campanacci syndrome)

Demographics

 Age: Usually presentation at 5-20 yrs

 Gender: Possible male predominance

Natural History & Prognosis

 Smaller lesions may spontaneously resolve

 Pathologic fracture rare

o Most occur where lesion extends > 50% in anteroposterior and transverse plane

 Progression in size, pathologic fracture in small lesion raises question of initial diagnosis Treatment

 If symptomatic, curettage and packing

DIAGNOSTIC CHECKLIST

Image Interpretation Pearls

 Bone scan: Monostotic focus of normal to mildly increased activity in metadiaphyseal location suggests diagnosis; plain film correlation diagnostic

SELECTED REFERENCES

1 Biermann JS: Common benign lesions of bone in children and adolescents J Pediatr Orthop

22(2):268-73, 2002

Image Gallery

DDx: Mimic of Fibrous Cortical Defects in the Forearms

(Left) Histopathology slide of fibrous cortical defect shows whorls of fibrous tissue in this section of cortical bone, with absence of osteocytes and osteoblasts (Center) Anterior bone scan in a patient with left knee pain shows mildly increased activity in the left distal femur See next image (Right) Radiograph in the same patient as previous image shows a large lucent lesion with sclerotic margin consistent with NOF This lesion is at risk for pathologic fracture

Bone Cyst, Aneurysmal

Key Facts

Terminology

 Benign bone tumor (˜ 1% of primary bone lesions)

 Expansile lytic lesion, thin wall, blood-filled, cystic

 Stage 1: Latent, stable, or heals spontaneously

 Stage 2: Active, progressive, no cortical destruction

 Stage 3: Locally aggressive, cortical destruction

Imaging Findings

Graphic of ABC shows the expanded vascular spaces, few coarsened thickened trabecula remaining, and expanded thinned cortex

Tissue pathology slide of ABC shows expanded blood spaces and vessels full of erythrocytes and remaining displaced trabeculae and bone tissue (Courtesy A Mansoor, MD)

TERMINOLOGY

Abbreviations and Synonyms

 Aneurysmal bone cyst (ABC)

Definitions

 Benign bone tumor (˜ 1% of primary bone lesions)

 Expansile lytic lesion, thin wall, blood-filled, cystic

o 70% primary; 30% secondary (in preexisting bone lesion)

 Staging

o Nuclear medicine: Tc-99m MDP bone scan

 Evaluate skeleton for multiple ABCs: ˜ 8% of patients with ABC have > 1

 Location: Lower leg 24%, femur 13%, upper extremity 21%, spine 16%, pelvis & sacrum 12%

Nuclear Medicine Findings

 Tc-99m MDP bone scan

o Moderate to intense activity with central photopenia = doughnut sign (˜ 65% of ABC)

 Also seen with giant cell tumors (check radiograph), chondrosarcoma (> 40 y, metaphyseal/diaphyseal), telangiectatic osteosarcoma

o Whole body bone scan to detect multiple lesions, fracture or aggressive portion of lesion

o Three-phase bone scan for degree of remodeling, stage

 Phase 1: ↑ Blood flow; phase 2: ↑ Blood pool; phase 3: Peripheral activity 2° to remodeling

P.1-11

DIFFERENTIAL DIAGNOSIS

Enchondroma

 Radiographic findings usually help distinguish

Giant Cell Tumor

 Histopathologic evaluation often necessary

Hyperparathyroidism, Primary or Secondary

Image Interpretation Pearls

 Doughnut sign: ABC, giant cell tumor, chondrosarcoma, telangiectatic osteosarcoma

 ˜ 8% of patients with ABC will have > 1 lesion

 Most recurrences within 2 y of treatment

Image Gallery

DDx: Mimics of Aneurysmal Bone Cyst

(Left) Anterior planar Tc-99m MDP bone scan (upper panel) shows photopenic lesion in left femoral neck , corresponding to the expansile, lytic ABC on plain film (lower panel) (Center) Axial NECT of left femoral neck in same patient as previous image shows markedly thinned cortex posteriorly in the ABC (Right) Medial angiogram shows tibial ABC during embolization treatment

Bone Cyst, Solitary

> Table of Contents > Section 1: - Musculoskeletal > Benign Bone Tumors > Bone Cyst, Solitary (Unicameral)Bone Cyst, Solitary (Unicameral)

Paige B Clark, MD

Key Facts

Imaging Findings

 Well-defined, central, lytic lesion on plain film, CT

 Bone scan: Mild increased activity peripherally with central photopenia; may be relatively normal

 Fallen fragment sign secondary to pathologic fracture on plain film = pathognomonic for SBC

Top Differential Diagnoses

 Aneurysmal Bone Cyst (ABC)

 Fibrous Dysplasia

 Fibroxanthoma

 Very intense increased activity on bone scan with acute pain may represent pathologic fracture

 Postsurgical bone scan: Increased activity after instrumentation, with bone healing; should

decrease over time

 Bone scan with SPECT/CT may be used for optimal characterization

Graphic of posterior foot shows a well-defined, cystic lesion representing SBC The calcaneus is a favored location of SBC in adults

Anterior radiograph of the right arm shows a well-defined lucent lesion with an associated fracture

an in young patient with arm pain due to SBC

TERMINOLOGY

Abbreviations and Synonyms

 Solitary or simple bone cyst (SBC)

 Unicameral bone cyst

Definitions

 Tumor-like lesion of unknown etiology, attributed to local disturbance of bone growth

IMAGING FINDINGS

General Features

 Morphology: Well-defined, lytic lesion

Nuclear Medicine Findings

 Bone Scan

o Vascular phase is usually negative

o Peripheral: Mild increased radiotracer activity

o Central: Decreased radiotracer activity

o May show no increased activity

o Focal significant uptake often indicates associated fracture

o Use of SPECT/CT evolving, may optimize characterization of primary bone lesions on bone scan

Radiographic Findings

 Radiography

o Centrally located, well-defined, expansile, lucent lesion

o Long axis parallel to long axis of host bone

o Sclerotic margin

o Scalloping of underlying cortex

P.1-13

o Cortex never completely disrupted

o Fluid-filled cavity (fluid/fluid levels)

o No periosteal reaction unless fractured

o No extension into soft tissues

o Fallen fragment sign secondary to pathologic fracture on plain film = pathognomonic for SBC

 Fragment migrates to dependent portions of cyst

o Increased density/sclerosis after steroid injection

CT Findings

 NECT

o Fluid-filled cavity

 HU: 15-20

 Can have fluid-fluid levels

o Helpful in evaluating anatomically complex areas (pelvis, spine)

o Determine extent of lesion

o High signal intensity

o Heterogeneous signal in case of fracture (blood products)

o Anterior and posterior whole body images to determine if lesion monostotic

o Static planar views over area of interest to evaluate primary lesion, pathologic fracture

o Three-phase bone scan may be useful to help characterize primary bone lesion (e.g., vascularity, soft tissue involvement)

DIFFERENTIAL DIAGNOSIS

Aneurysmal Bone Cyst (ABC)

 Eccentric, expansile lesion

 Ground glass, smoky appearance

 No “fallen-fragment sign” in case of fracture

 Associated with other features of HPT

o Subperiosteal resorption, osteopenia

P.1-14

PATHOLOGY

General Features

 General path comments

o Fluid containing lesion lined by mesenchymal cells

o Only primary true cyst of bone that conforms to pathologic definition of cyst

 Genetics: Case report of translocation (16;20) (p11.2;q13)

 Intact periosteum

Microscopic Features

 No epithelial lining in wall of lesion

o Fibrous and granulation tissue, hemosiderin deposits, small lymphocytes within cyst wall

o Giant cells of osteoclastic type in cyst wall

o Fibrinous debris may undergo calcification simulating cementum

 Fluid usually shows elevated alkaline phosphatase

 Fluid contains prostaglandins and interleukins (can cause bone resorption)

 Blood products in cyst fluid in case of prior fracture

CLINICAL ISSUES

Presentation

 Most common signs/symptoms

o Most lesions asymptomatic

o Pain

o Swelling

o Stiffness at closest joint

 Clinical Profile

o 66% of cysts present with pathologic fractures

 Sudden onset of pain

 Often occurs during exercise

o Growth arrest in 10% of patients

 Due to pathologic fracture (± surgical curettage), extension to physeal plate

o Older patients with involvement of atypical sites usually asymptomatic

 Calcaneus, talus, ilium Demographics

 Age: 10-20 years, 3-14 years: 80%

 Gender: M:F = 2-3:1

Natural History & Prognosis

 Benign lesion, no malignant transformation

 Enlarge during skeletal growth

 Inactive, latent after skeletal maturity

 Spontaneous regression in majority of cases

 Recurrence rate after injection, curettage: 20-45%

Treatment

 Trephination: Multiple holes drilled into lesion ± irrigation

o Performed under general anesthesia

 Dual needle aspiration and percutaneous injection of corticosteroids (80-200 mg

methylprednisolone)

o 1-3 injections at 2 month intervals

 Percutaneous injection of demineralized bone matrix and autogenous bone marrow

 Open curettage with bone graft in weight bearing bones

o Recurrence 40-45%

o Damage to growth plate may result in growth arrest

 Subtotal resection, allografting, packing with synthetic materials

DIAGNOSTIC CHECKLIST

Image Interpretation Pearls

 SBC on bone scan: Peripherally increased activity with central photopenia; may have minimal activity

 Very intense increased activity on bone scan with acute pain may represent pathologic fracture

 Postsurgical bone scan: Increased activity after instrumentation, with bone healing; should

decrease over time

 Bone scan with SPECT/CT may be used for optimal characterization

SELECTED REFERENCES

1 Horger M et al: The role of single-photon emission computed tomography/computed tomography in benign and malignant bone disease Semin Nucl Med 36(4):286-94, 2006

2 Wilkins RM: Unicameral bone cysts J Am Acad Orthop Surg 8(4):217-24, 2000

3 Lokiec F et al: Simple bone cyst: etiology, classification, pathology, and treatment modalities J Pediatr Orthop B 7(4):262-73, 1998

4 Abdel-Dayem HM: The role of nuclear medicine in primary bone and soft tissue tumors Semin Nucl Med 27(4):355-63, 1997

5 Capanna R et al: Unicameral and aneurysmal bone cysts Orthop Clin North Am 27(3):605-14, 1996

6 Conway WF et al: Miscellaneous lesions of bone Radiol Clin North Am 31(2):339-58, 1993

7 Struhl S et al: Solitary (unicameral) bone cyst The fallen fragment sign revisited Skeletal Radiol

(Left) Posterior bone scan in the same patient as previous 2 images, shows minimally increased activity

in SBC in left ilium Focal activity associated with a SBC is often due to fracture (Courtesy B Manaster, MD, PhD) (Right) Lateral radiograph of a 34 year old male with painful thigh, shows lytic lesion with

pseudotrabeculations occupying much of the patella , an unusual location for SBC Biopsy confirmed (Courtesy B Manaster, MD PhD)

(Left) Axial NECT shows a well-defined, expansile, lytic lesion in left ilium consistent with SBC See next image (Right) Posterior bone scan shows a lesion with peripherally mild increased activity and central photopenia in left ilium, typical in appearance for SBC

Giant Cell Tumor

Key Facts

Terminology

 Locally aggressive tumor composed of osteoclastic giant cells involving the epiphysis

Imaging Findings

 Best diagnostic clue: Lytic epiphyseal lesion on plain radiograph extending to subchondral bone

without surrounding sclerosis

 Location: Metaphyseal side of growth plate, usually long bones, knee most common

 Radionuclide angiogram, capillary phase, and delayed images will likely all be positive

 Plain radiograms and MRI preferred

 Bone scan is sensitive but not specific

 Protocol advice: Whole body bone scan should always be obtained to detect additional lesions

(GCT may be metastatic in 3-5%)

Anterior bone scan shows increased activity with a commonly seen central area of photopenia in proximal tibia Activity in distal femur is secondary to reactive hyperemia (All images courtesy D Sauser, MD)

Left lateral bone scan shows (same patient as previous image) the proximal tibial lesion with central photopenia and reactive hyperemia in the distal femur and patella

TERMINOLOGY

Abbreviations and Synonyms

 Giant cell tumor (GCT), osteoclastoma

Definitions

 Locally aggressive tumor composed of osteoclastic giant cells involving the epiphysis

IMAGING FINDINGS

General Features

 Best diagnostic clue: Lytic epiphyseal lesion on plain radiograph extending to subchondral bone

without surrounding sclerosis

 Location: Metaphyseal side of growth plate, usually long bones, knee most common

 Size: Range 2-20 cm, mean 5-7 cm

 Morphology: Lytic lesion without bone or cartilage matrix extending to subchondral bone

Nuclear Medicine Findings

 PET: Hypermetabolism (reported SUVs 1.8-9.4)

 Bone Scan

o Radionuclide angiogram, capillary phase, and delayed images will likely all be positive

o A central photopenic region is frequently present

o Additional sites of uptake may indicate metastatic GCT

Radiographic Findings

 Radiography: Well-marginated lytic lesion without marginal sclerosis with septations and no bone

or cartilage matrix