67/F C.C.: right pelvic pain for 3 months PMHx : thyroid cancer OP history

** • 67/F • C.C.: right pelvic pain for 3 months • PMHx : thyroid cancer OP history • What is your impression? • 2) A first impression and three or less differential diagnoses are acceptable. 한강성심 영상의학과 이경규

** • Plain film: • an expansile, lytic lesion involving medial aspect of right iliac wing • loss of medial cortical margin & extension across right SI joint • no internal matrix mineralization and no periosteal reaction • Bone scan • - decreased tracer uptake in right ilium consistent with lytic lesion seen on plain film 한강성심 영상의학과 이경규

** DDX :MetavsMyeloma *Tumor uptake(-) :extremely aggressive or purely osteolytic highly aggressive anaplastic tumors, reticulum cell sarcoma, RCC, thyroid ca, histiocytosis, neuroblastoma, and multiple myeloma 한강성심 영상의학과 이경규

** Right iliac bone biopsy :metastatic thyroid carcinoma Diagnosis :Thyroid cancer metastasis 한강성심 영상의학과 이경규

MetastasisBone scan evaluation 한강성심 영상의학과 이경규

Target Sites • Red Marrow • Lumbar > Thoracic > Cervical • Uncommon sites • Mandible, Patella • distal to the knee and elbow 한강성심 영상의학과 이경규

Hematogeneous Route • Venous > Arterial • Batson’s plexus • Extensive comm. • Sluggish flow • Reflux 한강성심 영상의학과 이경규

Primary / Metastasis Primary +++ +++ +++ + Metastasis + + + +++ (10% solitary) Bone expansion Periosteal reaction Soft tissue mass Multiplicity * Meta from lung ca,Thyroid ca, RCC : solitary, expansile 한강성심 영상의학과 이경규

Typical Radiologic Appearance of Metastases in Adults 한강성심 영상의학과 이경규

Bone scan:Application Tumor extent or localization Initial tumor staging Identify metastatic sites Monitor disease progression or therapy response 한강성심 영상의학과 이경규

Bone Metastasis 1. Multiple lesions of varing intensity,size,shape 2. Irregular distribution in axial skeleton 3. Photon deficient lesion extremely aggressive or purely osteolytic 4. Superscan pattern 5. Solitary lesion 한강성심 영상의학과 이경규

Uptake of tracer - dependent on blood flow and on osteoblastic activity Malignancy ↑ hot uptake ↑ sensitive than plain image (3-5% vs 30-50%) Cold uptake extremely aggressive or purely osteolytic Metastasis 한강성심 영상의학과 이경규

Rib metastasis vs Benign fracture • Benign Fracture • Focal rather than linear • Decreased uptake over 3-6mon • Aligned in same location 한강성심 영상의학과 이경규

Bone scan :Caution ! • Cold uptake • Insufficiency fracture • Superscan • Flare phenomenon 한강성심 영상의학과 이경규

Bone scan:Cold uptake • In cancer patients, • - due to metastatic disease (> 80%) • may occur • - aggressive or purely osteolytic tumor • - disruption of blood supply to bone • - significant marrow involvement, particularly in a vertebral body • cause - highly aggressive anaplastic tumors, - reticulum cell sarcoma, - RCC, thyroid carcinoma, - histiocytosis, neuroblastoma, and - especially multiple myeloma ** 한강성심 영상의학과 이경규

Bone scan : Caution ! • Cold uptake • Insufficiency fracture • Superscan • Flare phenomenon 한강성심 영상의학과 이경규

Bone scan :Insufficiency Fx Kyphosis Linear rib↑ H-shaped sacral uptake 한강성심 영상의학과 이경규

Bone scan : Superscan • Superscan ? - Poorly or non-visualization of kidney - ↑ bone to background RI ratio • cause • far advanced bone metastasis • - prostate, breast, lung, bladder, stomach etc • metabolic condition • - superscan in both axial and peripheral skeleton • - Renal osteodystrophy, primary hyperparathyroidism • myelofibrosis 한강성심 영상의학과 이경규

Superscan :Metastasis Meta - superscan Normal 한강성심 영상의학과 이경규

Superscan :renal osteodystrophy Metabolic - superscandiffuse skull & mandible (+) Meta - superscan 한강성심 영상의학과 이경규

Bone scan :Caution ! • Cold uptake • Insufficiency fracture • Superscan • Flare phenomenon transient increase in lesion activity secondary to healing under antineoplastic treatment concomitant with increased sclerosis 한강성심 영상의학과 이경규

Bone scan :Flare phenomenon • increase in uptake intensity or appearance of new lesion within 3-6 months of staisfactory response to therapy • improvement on F/U bone scan • incidence up to 20% in breast and prostate ca • good prognostic sign in breast cancer • DDX :progression of metastatic disease 한강성심 영상의학과 이경규

initial 3 month 6month Bone scan :Flare phenomenon Flare phenomenon < 3 month Disease progress Number & intensity ↑ of lesions beyond 6 months 한강성심 영상의학과 이경규

Bone scanvsMRI • MRI : superior sensitivity • Limitation of Scintigraphy - specificity  - intramedullary lesion Tumor is in marrow space only and has not elicited a reactive response in adjacent bone - aggressive or purely osteolytic lesion 한강성심 영상의학과 이경규

한강성심 영상의학과 이경규

67/F C.C.: right pelvic pain for 3 months PMHx : thyroid cancer OP history