3 PHASE BONE SCAN
NNNR 3182
PENGIMEJAN RADIONUKLID KLINIKAL
Definition
Definition
Produces planar images of the vascular inflow and the soft tissue or blood pool phase, and delayed phase.
Vascular Phase
The images are acquired 60 second immediately post IV injection.
Soft Tissue Phase
The study of the soft tissue distribution of radio-pharmaceutical in the region of interest is performed within the first 5 to 10 min after injection.
Delayed Phase
Delayed Phase
Focal views and/ or tomographic images are usually acquired between 2 and 4 hours after injection of radio-pharmaceutical.
Indications & Contraindications
Indications & Contraindications
Advantages & Disadvantages
Common Indications
- Neoplastic disease
- Occult fracture
- Osteomyelitis
- Stress fracture
- Avascular necrosis
- Arthritides
- Reflex sympathetic dystrophy
- Bone infarcts
- Bone graft viability
Contraindications
- Pregnant women.
- Breastfeeding women.
- Obesity because most scanning tables have a maximum weight capacity of 220 pounds.
- Allergic to medications.
- Renal impairment.
- Metallic things.
Advantages and Disadvantages
Patient Preparations
Patient Preparation
Patient History
Patient History
- History of fractures, trauma, osteomyelitis, cellulitis, edema, arthritis, neoplasms, metabolic bone disease, or limitation of function.
- Current symptoms, physical findings.
- History of recent scintigraphy, especially with 131I, 67Ga or 111In.
- Results of prior bone scintigraphy.
- Results of prior imaging modalities, such as conventional radiographs, CT and MRI.
Patient History (cont)
- History of orthopaedic and non-orthopedic surgery that may affect the results of bone scintigraphy.
- History of therapy that might affect results of bone scintigraphy, such as antibiotics steroids, chemotherapy, radiotherapy or iron therapy.
- Relevant laboratory result, such as prostate specific antigen.
- History of anatomic of functional renal abnormalities.
- Possible contraindications to hydration.
- Possible pregnancy or breastfeeding.
- Possible allergy to medications.
Patient Preparations
Patient Preparation
- Explain the details and rationale for performing the procedure to patient.
- Ensure patient is well hydrated by drinking 2 to 4 glasses of water between the time of injection and the time of delayed imaging to ensure high enough bone to background ratio will be achieved.
- Change to hospital gown and remove any metallic items within region of interest.
Radiopharmaceuticals
Radiopharmaceutical
- Tc-99m-MDP
- 20-30mCi
- Inject through IV
Diagnostic Procedure
- Patient lies down in supine, head first position on table.
- Remind patient to stay still throughout the whole procedure.
- Tc-99m-MDP injected intravenously.
- Observe for any extravasation.
- Flow images taken immediately after injection, blood pool images taken within 10 minutes of tracer injection at anterior and posterior views while delayed phase taken from 2 to 5 hours after injection at anterior, posterior and lateral views.
Flow Phase
- A dynamic imaging.
- Also known as angiographic phase.
- Images taken at region of interest only.
- Each frame is a summation of the radioactivity counts for the obtained image.
- Demonstrates and characterizes relative perfusion to a particular area.
Blood Pool Phase
- Images obtained in same field of views as flow phase.
- Characterizes blood pool accumulation in soft tissue and bone as a result of flow and capillary dilatation.
Delayed Phase
- May obtain either images of the same FOV as previous scan, whole body or lower half of the body.
- If images of whole body or lower half of the body are taken, anterior and posterior projections will be done.
- If images of same FOV as previous scan are taken, different projections which show different views should be done to characterize the accumulation of radiotracer in osseous structures.
- Clearing of radiotracer from the soft tissues can be assessed as well.
Post Procedure
- Check patient’s conditions, vital sign or any allergic reaction before release patient.
- Remind patient to drink plenty of water and empty bladder frequently for 1 to 2 days so that radioactive source can be eliminated via urine.
- Avoid direct contact with children and women for 24 to 48 hours.
- Breastfeeding patient should stop breast feed for 24 to 48 hours.
Case Study 1
A 28 years old man had persistent pain in the right anatomical snuffbox following a fall onto his outstretched right hand. X-ray was normal, prompting referral for a bone scan. It demonstrated focally increase radiotracer accumulation in the scaphoid on both blood pool and delayed images, typical of scaphoid fracture.
Figure 1: Scaphoid fracture with corresponding intense localised blood pool (A) and delayed phase activity (B). Magnified (pinhole) delayed image (C).
Case Study 2
A 22 years old gentleman, a known case of thalassemia major, presented with complaints of pain and swelling in the left ankle since 8 months; no history of trauma was reported. MRI performed on two occasions 8 months apart raised suspicion of inflammation or infection (with minimal bone marrow edema) of ankle joint region on the left side. He was referred to Nuclear Medicine Department for evaluation of joint pain and swelling, to rule out arthritis or infection of the left ankle and subsequently distant joints.
The absence of perfusion and cortical uptake of tracer clinched the diagnosis of avascular stenosis of the left talus.
Case Study 3
A 65 years old male with a history of non-insulin dependent diabetes mellitus, alcohol abuse and severe peripheral vascular disease presented with a non-healing ulcer of the left first toe.
In osteomyelitis, there is a high tracer uptake in all the three phases during 3 phase bone scan. To ensure much accurate diagnosis, galium scan is also done and must show higher uptake compared to 3 phase bone scan.
References
- Lee, J.C., Hennessy, A.D. & Khafagi, F.A. 2012. Bone Scans. 41(9): 689–692.
- Donohoe, A.K.J., Israel, B., Medical, D., Brown, M.L. & Ford, H. 2003. Society of Nuclear Medicine Procedure Guideline for Bone Scintigraphy. Society of Nuclear Medicine Procedure Guidelines Manua. 205–209.
- Van den Wyngaert, T., Strobel, K., Kampen, W.U., Kuwert, T., van der Bruggen, W., et al. 2016. The EANM Practice Guidelines for Bone Scintigraphy. European Journal of Nuclear Medicine and Molecular Imaging. 43(9): 1723–1738.
- Lee, Y.J., Sadigh, S., Mankad, K., Kapse, N. & Rajeswaran, G. 2016. The Imaging of Osteomyelitis. Quantitative Imaging in Medicine and Surgery. 6(2): 184–198.
- Kamra, A., Pawar, S., Shetye, S. & Singh, P. 2017. Avascular Necrosis of Talus Diagnosed on Tc-99m MDP Bone Scan. Indian Journal of Nuclear Medicine. 32(3): 211.
- Bombardieri, E., Aktolun, C., Baum, R.P., Bishof-Delaloye, A., Buscombe, J., et al. 2003. Breast Scintigraphy: Procedure Guidelines for Tumour Imaging. European journal of nuclear medicine and molecular imaging. 30(12): BP107-1
Group Members
FARAH WAHIDA BINTI ZAMBAHARI
[A158924]
SHARNIAH A/P MURTY [A160130]
AHMAD FAEZ BIN MOHAMED RIDHWAN [A161484]