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Year : 2015  |  Volume : 30  |  Issue : 3  |  Page : 288-289  

Diagnostic dilemma of degenerative joint disease, chronic avascular necrosis or metastasis in planar Tc-99m-methylene diphosphonate planar skeletal scintigraphy excluded by single positron emission computed tomography/computed tomography


1 Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication11-Jun-2015

Correspondence Address:
Rajender Kumar Basher
Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.158553

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   Abstract 

We present a 71-year-old male patient subjected to skeletal scintigraphy for metastasis work up of prostate cancer. Whole body planar images revealed a solitary focal tracer uptake in left femoral head mimicking as solitary metastatic focus. Single positron emission computed tomography/computed tomography images localized this increased tracer uptake to the subchondral cysts with minimal sclerosis in left femur head with no decrease in size of femur head and was reported as (degenerative joint disease).

Keywords: Avascular necrosis, degenerative joint disease, femur head, planar skeletal scintigraphy, single positron emission computed tomography/computed tomography


How to cite this article:
Jain TK, Phulsunga RK, Basher RK, Kumar N, Bhattacharya A, Mittal BR. Diagnostic dilemma of degenerative joint disease, chronic avascular necrosis or metastasis in planar Tc-99m-methylene diphosphonate planar skeletal scintigraphy excluded by single positron emission computed tomography/computed tomography. Indian J Nucl Med 2015;30:288-9

How to cite this URL:
Jain TK, Phulsunga RK, Basher RK, Kumar N, Bhattacharya A, Mittal BR. Diagnostic dilemma of degenerative joint disease, chronic avascular necrosis or metastasis in planar Tc-99m-methylene diphosphonate planar skeletal scintigraphy excluded by single positron emission computed tomography/computed tomography. Indian J Nucl Med [serial online] 2015 [cited 2020 Jan 26];30:288-9. Available from: http://www.ijnm.in/text.asp?2015/30/3/288/158553

A 71-year-old patient of prostate carcinoma post (trans-urethral resection of the prostate) presented with pain in the left hip for the last 8 months. He had no history of any trauma and serum prostate specific antigen level was normal (3.0 ng/mL). Patient was referred for metastatic work-up and underwent skeletal scintigraphy after intravenous administration of 740 99m Tc-methylene diphosphonate. Planar skeletal scintigraphy anterior [Figure 1]a] and posterior [Figure 1]b] views showed an abnormal focal increased tracer uptake in left femur head apart from the lateral aspect of L4 and L5 vertebrae. Single positron emission computed tomography/computed tomography (SPECT/CT) pelvis was acquired which localized the increased tracer uptake in the lateral aspect of L4 and L5 vertebrae indicating disc degenerative changes [Figure 1]c-e]. However, increased tracer uptake in the left femoral head localized to subchondral cystic (white arrow on SPCET/CT images in [Figure 1]c) and minimal sclerotic changes on CT images with no change in femur head size. A final impression of degenerative joint disease (DJD) was given instead of metastatic involvement of left femur head. However, possibilities of chronic AVN with joint degeneration also considered, but due to the same management of these two entities, further magnetic resonance image (MRI) was not prescribed.
Figure 1: 99mTc-methylene diphosphonate planar skeletal scintigraphy anterior and (a) posterior (b) views showing an abnormal focal increased tracer uptake in left femur head and lateral aspect of L4 and L5 vertebrae. On single positron emission computed tomography/computed tomography (SPECT/CT), (c-e) the increased tracer uptake in the left femoral head localized to subchondral cystic (white arrow on SPCET/CT images) with minimal sclerotic but no change in the size femur head changes on CT images

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Skeletal scintigraphy is most commonly used for detection of skeleton metastasis and any focal increased tracer uptake raise a suspicion of metastasis. Bone metastases are present in around 90% patients of prostate cancer. [1] Bone scan has a high sensitivity but lesser specificity because of false positivity in many benign pathologies and trauma. [2] Focal abnormal tracer uptake in bone scintigraphy should be critically evaluated because skeletal metastases are an independent prognostic marker in prostate carcinoma. [3],[4],[5]

Head of the femur is most common site for avascular necrosis (AVN) and most common cause of AVN is trauma. Nontraumatic AVN is usually bilateral and occurs in younger adults. [6],[7] Due to small sized fat cells, mucoid fluid between in fat cells and loose reticulum in the femoral head, elderly persons are at lesser risk to develop AVN. [8] DJD also reveals juxta-articular sclerosis, joint-space narrowing, and subchondral cyst. Absence of femoral head collapse differentiates DJD from AVN. In problematic cases, MRI may be helpful. However due to old age and similar management of these two conditions MRI may not be required. [9],[10] The present case revealed that SPECT/CT can avoid unnecessary radiotherapy treatment and emphasizes the careful inspection of the image before arriving at the final conclusion.

 
   References Top

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Higano CS. Understanding treatments for bone loss and bone metastases in patients with prostate cancer: A practical review and guide for the clinician. Urol Clin North Am 2004;31:331-52.  Back to cited text no. 1
    
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Gayed IW, Kim EE, Awad J, Joseph U, Wan D, John S. The value of fused SPECT/CT in the evaluation of solitary skull lesion. Clin Nucl Med 2011;36:538-41.  Back to cited text no. 2
    
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Sabbatini P, Larson SM, Kremer A, Zhang ZF, Sun M, Yeung H, et al. Prognostic significance of extent of disease in bone in patients with androgen-independent prostate cancer. J Clin Oncol 1999;17:948-57.  Back to cited text no. 3
    
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Noguchi M, Kikuchi H, Ishibashi M, Noda S. Percentage of the positive area of bone metastasis is an independent predictor of disease death in advanced prostate cancer. Br J Cancer 2003;88:195-201.  Back to cited text no. 4
    
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Rigaud J, Tiguert R, Le Normand L, Karam G, Glemain P, Buzelin JM, et al. Prognostic value of bone scan in patients with metastatic prostate cancer treated initially with androgen deprivation therapy. J Urol 2002;168:1423-6.  Back to cited text no. 5
    
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Aldridge JM 3 rd , Urbaniak JR. Avascular necrosis of the femoral head: Etiology, pathophysiology, classification, and current treatment guidelines. Am J Orthop (Belle Mead NJ) 2004;33:327-32.  Back to cited text no. 6
    
7.
Min BW, Song KS, Cho CH, Lee SM, Lee KJ. Untreated asymptomatic hips in patients with osteonecrosis of the femoral head. Clin Orthop Relat Res 2008;466:1087-92.  Back to cited text no. 7
    
8.
Kaushik AP, Das A, Cui Q. Osteonecrosis of the femoral head: An update in year 2012. World J Orthop 2012;3:49-57.  Back to cited text no. 8
    
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Brenner AI, Koshy J, Morey J, Lin C, DiPoce J. The bone scan. Semin Nucl Med 2012;42:11-26.  Back to cited text no. 9
    
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Buckwalter JA, Lohmander S. Operative treatment of osteoarthrosis. Current practice and future development. J Bone Joint Surg Am 1994;76:1405-18.  Back to cited text no. 10
    


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