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Year : 2015  |  Volume : 30  |  Issue : 3  |  Page : 286-287  

Metastatic superscan on 99m Tc-methylene diphosphonate bone scintigraphy in pediatric neuroblastoma


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

Date of Web Publication11-Jun-2015

Correspondence Address:
Madhavi Tripathi
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.158552

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   Abstract 

Excessive skeletal radioisotope uptake in relation to soft tissues along with absent or faint activity in the genitourinary tract on bone scintigraphy (BS) is known as a "superscan." However the association of pediatric solid tumor malignancy with metastatic superscan has not been reported previously. We here describe two such cases of neuroblastoma who presented with metastatic superscan on 99m Tc-methylene diphosphonate BS. Presence of a superscan usually indicates an advanced stage of the disease. The patient prognosis is usually poor. Though extremely rare superscan can be associated with pediatric solid tumor malignancies and should be kept in mind while reporting such cases.

Keywords: 99m Tc-methylene diphosphonate, bone scintigraphy, metastatic, neuroblastoma, pediatric, superscan


How to cite this article:
Arora S, Dhull VS, Mukherjee A, Tulsyan S, Behera A, Tripathi M. Metastatic superscan on 99m Tc-methylene diphosphonate bone scintigraphy in pediatric neuroblastoma. Indian J Nucl Med 2015;30:286-7

How to cite this URL:
Arora S, Dhull VS, Mukherjee A, Tulsyan S, Behera A, Tripathi M. Metastatic superscan on 99m Tc-methylene diphosphonate bone scintigraphy in pediatric neuroblastoma. Indian J Nucl Med [serial online] 2015 [cited 2019 Dec 11];30:286-7. Available from: http://www.ijnm.in/text.asp?2015/30/3/286/158552

Excessive skeletal radioisotope uptake in relation to soft tissues along with absent or faint activity in the genitourinary tract on bone scintigraphy (BS) is known as a "superscan". [1] Common causes include prostate cancer, breast cancer, and lung cancer. [2] Hematological conditions like leukemia, lymphoma, myelofibrosis, Waldenstrom's macroglobulinemia are sometimes associated with metastatic superscan. Metabolic bone diseases such as renal osteodystrophy, Paget's disease and hyperparathyroidism are also reported as the rare causes of superscan. Occasionally superscan is seen in hyperthyroidism and fibrous dysplasia. Some of the other rare causes for metastatic superscan include urinary tract transitional cell carcinoma and nasopharyngeal carcinoma. [2],[3],[4] However, association of pediatric solid tumor malignancy with metastatic superscan has not been reported previously. We here describe two such cases of neuroblastoma (NB) who presented with metastatic superscan on 99m Tc-methylene diphosphonate (MDP) BS. First case was a 12-year-old male child, a known case of mediastinal NB [Figure 1]a, anterior and 1b, posterior] and second was a 4-year-old male child, a known case of abdominal NB [Figure 1]c, anterior and 1d, posterior] sent to our department to rule out cortical bone involvement. 99m Tc-MDP BS showed heterogeneously increased radiotracer uptake in the entire axial and appendicular skeleton in both the cases suggesting widespread skeletal metastases with cortical involvement and giving the appearance of a metastatic superscan. Though metastatic superscans on 123 I-Metaiodobenzylguanidine have been reported in patients of NB, [5] to our knowledge this is the first instance on 99m Tc-MDP BS. The bone scan shows uptake due to marrow edema and bone matrix irritation leading to increased osteoblastic turnover. The importance of bone scan in NB is to distinguish stage 4 from stage 4s. Stage 4s occurs in infants who have a localized tumor that does not cross the midline, with metastatic disease confined to the liver, skin, and bone marrow and with no evidence of cortical bone involvement observed. [6] Bone scan thus rules out cortical bone involvement. Superscan is often confused with normal skeletal scintigraphy. Nonvisualization of the kidneys in a skeletal scintigraphy should alert the physician for presence of a superscan in case the renal function is normal. Presence of a superscan usually indicates an advanced stage of the disease, when there has already been extensive bone marrow infiltration, followed by an osteoblastic reaction. The patient prognosis is usually poor. [2] Though extremely rare superscan can be associated with pediatric solid tumor malignancies and should be kept in mind while reporting such cases.
Figure 1: 99mTc-methylene diphosphonate bone scintigraphy (BS) in a 12-year-old case of mediastinal neuroblastoma (NB) (a, anterior; b, posterior) and 4-year-old case of abdominal NB (c, anterior; d, posterior) shows heterogeneously increased radiotracer uptake in the entire axial and appendicular skeleton suggesting widespread skeletal metastases with cortical involvement giving the appearance of a metastatic superscan

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   References Top

1.
Osmond JD 3 rd , Pendergrass HP, Potsaid MS. Accuracy of 99mTC-diphosphonate bone scans and roentgenograms in the detection of prostate, breast and lung carcinoma metastases. Am J Roentgenol Radium Ther Nucl Med 1975;125:972-77.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
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3.
Kim EE, DeLand FH. Myelofibrosis presenting as hypermetabolic bone disease by radionuclide imaging in a patient with asplenia. Clin Nucl Med 1978;3:406-8.  Back to cited text no. 3
    
4.
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. 4
    
5.
Ravizzini G, Pryma DA, Meirelles GS, Divgi CR. I-123 MIBG scan of metastatic neuroblastoma mimicking a bone scan. Clin Nucl Med 2006;31:558-60.  Back to cited text no. 5
    
6.
Thrall JH, Ziessman HA. Nuclear Medicine: The Requisites. Mosby-year Books, St Louis, MO; 1995. p. 47-8.  Back to cited text no. 6
    


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