"Skull on Fire": Monostotic Paget Disease of the Skull Bone

Hyperostosis frontalis interna on fluorine-18 sodium fluoride PET/computed tomography of obese cancer patients: a potential mimicker of metastasis

OBJECTIVE

The objective of this retrospective study was to identify the uptake patterns and suggest a quantitative method to detect hyperostosis frontalis interna (HFI) on fluorine-18 sodium fluoride ([ 18 F]NaF) PET/computed tomography (CT).

METHODS

Between January 2019 and December 2021, patients who underwent [ 18 F]NaF PET/CT with a BMI of 30 and above, were included. Three nuclear medicine consultants reviewed the studies to determine the presence and identify the uptake patterns of HFI. Quantitative evaluation was performed on PET images using the total number of counts over the frontal bone and the ratio of counts between the frontal bone and iliac crest.

RESULTS

A total of 105 out of 249 cases were included in this study. Among these scans, there were 67 positive HFI in [ 18 F]NaF PET scans representing 64% of the studied population. As for the [ 18 F]NaF PET uptake pattern, there were 53 with uniformly diffused and 14 with heterogeneous uptake pattern. There were 17 out of 67 with positive HFI in [ 18 F]NaF PET scans but negative CT scans.

CONCLUSION

HFI is a common finding on [ 18 F]NaF PET in obese patients and is probably underdiagnosed. HFI may present with a heterogeneous and diffuse pattern of uptake on [ 18 F]NaF PET. The proposed quantitative analysis using the count ratios is in agreement with the visual evaluation of [ 18 F]NaF PET images regardless of the CT findings. Awareness of this condition and its scintigraphic patterns is warranted since it can have clinical significance and may mimic other pathologies including metastasis in cancer patients.