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 Table of Contents     
CASE REPORT
Year : 2014  |  Volume : 29  |  Issue : 3  |  Page : 158-159  

Metastatic superscan on 99m Tc-MDP bone scintigraphy in a case of carcinoma colon: Common finding but rare etiology


Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication11-Jul-2014

Correspondence Address:
Rakesh Kumar
E - 81, Ansari Nagar (East), All India Institute of Medical Sciences Campus, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.136569

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   Abstract 

Bone scintigraphy in which there is excessive skeletal radioisotope uptake in relation to soft tissues along with absent or faint activity in the genitourinary tract is known as a 'superscan'. Prostate cancer is the most common malignancy associated with superscan along with others such as lung cancer, breast cancer and haematological malignancies. Here we present the case of a 41 year old woman with carcinoma colon with metastatic superscan on 99m Tc-MDP bone scintigraphy, a very rare cause for metastatic superscan.

Keywords: Colon cancer, metastasis, 99m Tc-MDP bone scintigraphy, superscan


How to cite this article:
Chakraborty PS, Sharma P, Karunanithi S, Bal C, Kumar R. Metastatic superscan on 99m Tc-MDP bone scintigraphy in a case of carcinoma colon: Common finding but rare etiology. Indian J Nucl Med 2014;29:158-9

How to cite this URL:
Chakraborty PS, Sharma P, Karunanithi S, Bal C, Kumar R. Metastatic superscan on 99m Tc-MDP bone scintigraphy in a case of carcinoma colon: Common finding but rare etiology. Indian J Nucl Med [serial online] 2014 [cited 2018 Oct 22];29:158-9. Available from: http://www.ijnm.in/text.asp?2014/29/3/158/136569


   Introduction Top


A bone scan in which there is excessive skeletal radioisotope uptake in relation to soft tissues along with absent or faint activity in the genitourinary tract is known as a 'superscan'. [1] Apart from prostate cancer, which is the most common condition associated with a superscan, other malignancies like breast cancer, lung cancer [1],[2],[3],[4] can cause superscan appearance on bone scintigraphy. Here we present a case of colon carcinoma with metastatic superscan on 99m Tc-MDP bone scintigraphy, a very rare cause for metastatic superscan.


   Case report Top


A 41-year-old woman underwent left hemicolectomy with excision of local lymph nodes two years back for carcinoma of the descending colon. No adjuvant chemotherapy was given and she was under routine follow up since then. Two years later she presented with backache. Her serum carcinoembryonic antigen (CEA) level was significantly elevated (490 ng/ml; normal: <2.5 ng/ml), as compared to her previous CEA levels (1.3 ng/ml) three months back. Plain radiography of the abdomen was normal. Contrast enhanced computed tomography (CT) of the abdomen, including the visualized bones was within normal limits [Figure 1]. Her serum alkaline phosphatase (805 IU/L; normal: 20-140 IU/L), serum calcium level (7.9 mmol/L; normal: 2.2-2.6 mmol/L) and serum phosphate level were all elevated (3.1 mmol/L; normal: 0.81-1.45 mmol/L). The patient was referred for 99m Tc-MDP bone scintigraphy for metastatic work up. Her bone scintigraphy revealed intense radiotracer uptake involving almost the entire skeleton with high bone to soft tissue uptake [Figure 2]. The kidneys were very faintly visualized. These findings suggested 'metastatic superscan'. Bone biopsy confirmed the diagnosis of metastatic carcinoma. The patient was started on chemotherapy, but she succumbed to her disease one month later.
Figure 1: Contrast enhanced computed tomography (CT) of the abdomen, including the visualised bones was within normal limits (a-d)

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Figure 2: 99mTc-MDP bone scintigraphy for metastatic work up. It revealed intense radiotracer uptake involving almost entire skeleton with high bone to soft tissue uptake (a and b). Bilateral kidneys were almost invisible (a and b). These findings are suggestive of 'metastatic superscan'

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   Discussion Top


Excessive skeletal radioisotope uptake in relation to soft tissues along with absent or faint activity in the genitourinary tract on bone scintigraphy is known as a 'superscan'. Non-visualization of the kidneys in a bone scan should alert the physician for presence of a superscan in case the renal function is normal. Common causes include malignancies like prostate cancer, breast cancer, and lung cancer. [1],[2],[3],[4] Hematological conditions like leukemia, lymphoma, myelofibrosis, Waldenstrom's macroglobulinemia have been reported to be associated with a superscan. [5],[6] It can also be seen in metabolic bone diseases like renal osteodystrophy, Paget's disease and hyperparathyroidism. [7] Occasionally superscan is seen in hyperthyroidism [8] and fibrous dysplasia. [9] Some of the rare causes for metastatic superscan include urinary tract transitional cell carcinoma and nasopharyngeal carcinoma. [10] However, to the best of our knowledge, superscan secondary to colon cancer has not been reported previously and is described here. Presence of a superscan usually indicates advanced stage of the disease, when there has already been extensive skeletal metastasis followed by an osteoblastic reaction. The patient prognosis is usually poor, as was in the present case.

 
   References Top

1.Osmond JD 3 rd , Pendergrass HP, Potsaid MS. Accuracy of 99m Tc-diphosphonate bone scans and roentgenograms in the detection of prostate, breast and lung carcinoma metastases. Am J Roentgenol Radium Ther Nucl Med 1975;125:972-7.  Back to cited text no. 1
    
2.Basu S, Nair N, Awasare S, Tiwari BP, Asopa R, Nair C. 99Tc(m)(V)DMSA scintigraphy in skeletal metastases and superscans arising from various malignancies: Diagnosis, treatment monitoring and therapeutic implications. Br J Radiol 2004;77:347-61.  Back to cited text no. 2
    
3.Massie JD, Sebes JI. The headless bone scan: An uncommon manifestation of metastatic superscan in carcinoma of the prostate. Skeletal Radiol 1988;17:111-3.  Back to cited text no. 3
    
4.Soloway MS, Hardeman SW, Hickey D, Raymond J, Todd B, Soloway S, et al. Stratification of patients with metastatic prostate cancer based on extent of disease on initial bone scan. Cancer 1988;61:195-202.  Back to cited text no. 4
    
5.Kim EE, DeLand FH. Myelofibrosis presenting as hyper metabolic bone disease by radionuclide imaging in a patient with asplenia. Clin Nucl Med 1978;3:406-8.  Back to cited text no. 5
[PUBMED]    
6.Frankel RS, Johnson KW, Mabry JJ, Johnston GS. "Normal" bone radionuclide image with diffuse skeletal lymphoma. A case report. Radiology 1974;111:365-6.  Back to cited text no. 6
[PUBMED]    
7.Wiegmann T, Rosenthall L, Kaye M. Technetium-99m-pyrophosphate bone scans in hyperparathyroidism. J Nucl Med 1977;18:231-5.  Back to cited text no. 7
[PUBMED]    
8.Swislocki AL, Barnett CA, Darnell P, Noth RH. Hyperthyroidism: An underappreciated cause of diffuse bone disease. Clin Nucl Med 1998;23:241-3.  Back to cited text no. 8
    
9.Cheng TH, Holman BL. Increased skeletal: Renal uptake ratio: Etiology and characteristics. Radiology 1980;136:455-9.  Back to cited text no. 9
[PUBMED]    
10.Buckley O, O'Keeffe S, Geoghegan T, Lyburn ID, Munk PL, Worsley D, et al. 99mTc bone scintigraphy superscans: A review. Nucl Med Commun 2007;28:521-7.  Back to cited text no. 10
    


    Figures

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