Bone scintigraphy and SPECT/CT in bisphosphonate-induced osteonecrosis of the jaw

Comparison of single photon emission computed tomography-computed tomography, computed tomography and magnetic resonance imaging of medication-related osteonecrosis of jaw by new calculated parameters

BACKGROUND

This study aimed to investigate parameters for medication-related osteonecrosis of jaw (MRONJ) patients using the bone SPECT/CT, especially bone mineral-based parameters.

METHODS

Sixty-three patients with MRONJ (43 osteoporosis and 20 bone metastasises) underwent CT, MRI and SPECT/CT. A commercially available software automatically detected lesion area and calculated the quantitative SPECT/CT parameters as bone mineral-based standardized uptake value (SUV).

RESULTS

Regarding stage of MRONJ patients, bone mineral based maximum SUV of stage 3 was significantly higher than stage 1, 2 (P=0.018). Regarding duration of medication therapy, bone mineral based maximum SUV 1 year or more was significantly higher than less than 1 year (P=0.019). Regarding present of periosteal bone proliferation on CT, bone mineral based maximum SUV was significantly higher than those of absent (P=0.029). Regarding spread of soft tissue inflammation on MRI, bone mineral based maximum SUV of 2 or more was significantly higher than those of less than 2 spaces (P=0.025). Regarding blood pool phase imaging with SPECT, bone mineral based maximum SUV of intense uptake was significantly higher than those of decrease uptake (P=0.002).

CONCLUSIONS

SPECT/CT bone mineral-based parameters indicated significant difference in staging, dosing period, periosteal bone proliferation on CT, spread of soft tissue inflammation on MRI, and blood phase imaging with SPECT. Bone SPECT/CT bone mineral-based parameters are helpful for the assessment of MRONJ.

Effect of morphological findings in computed tomography on the quantitative values in single-photon emission computed tomography for patients with antiresorptive agent-related osteonecrosis of the jaw: a cross-sectional study

OBJECTIVE

Quantitative analyses of gamma-ray accumulation in single-photon emission computed tomography (SPECT), and the evaluation of antiresorptive agent-related osteonecrosis of the jaw (ARONJ) have been reported recently. However, the relationship between the quantitative parameters calculated from SPECT and the detailed morphological changes observed in computed tomography (CT) remains unclear. This study aimed to investigate patients' characteristics and morphological changes observed on CT, and their effects on the quantitative values in SPECT.

METHODS

From April 2017 to March 2019, patients diagnosed with ARONJ at our hospital were enrolled. The data obtained before September 2017 were reviewed retrospectively, and other data were collected prospectively. CT scans were evaluated for internal texture, sequestrum formation, periosteal reaction, cortical perforation, bone expansion, and pathological fracture. For quantitative assessment, the ratio of the maximum standardized uptake value (SUV) to the mean SUV in the temporal bone (rSUVmax) was calculated from SPECT images. The factors affecting rSUVmax were investigated by multiple regression analysis. The statistical significance level was set at α = 0.05.

RESULTS

Overall, 55 lesions of 42 patients (median age and interquartile range, 75 [67-80 years], 27 female) were evaluated. Male sex (p = 0.007) and bilateral location (p < 0.0001) were selected as variables in the multivariate analysis. Adjusted coefficient of determination R² was 0.59 (p < 0.0001).

CONCLUSION

Sex and horizontal progression of the disease may affect individually calibrated SUVs in SPECT for patients with ARONJ.

Fluorescence-guided surgery for the treatment of medication-related osteonecrosis of the jaw: A prospective cohort study

INTRODUCTION

The delineation of the necrotic bone is a crucial step in the surgical treatment of medication-related osteonecrosis of the jaw (MRONJ). Several different approaches have been described including the innovative technique of fluorescence-guided surgery. However, until now there is a lack of data regarding the outcome. Therefore, the aim of the present study is to investigate the long-term success rates of fluorescence-guided surgery in the treatment of MRONJ.

PATIENTS AND METHODS

54 Patients were prospectively assigned for surgical treatment of medication-related osteonecrosis of the jaw using fluorescence-guided surgery. Patients received doxycycline 100 mg twice a day for at least seven days preoperatively. Surgical treatment of MRONJ included complete removal of necrotic bone, which was monitored using the visual enhanced lesion scope (Velscope), followed by smoothening sharp bony edges and meticulous wound closure. Procedure success was assessed as postoperative maintenance of full mucosal coverage without pain, infection or bone exposure during regular follow-up.

RESULTS

The study included a total of 54 patients (32 female and 22 male, mean age 71.4 ± 9.2 years). In the last follow-up an intact mucosa and absence of exposed bone, pain or signs of infection was identified in 47 of 54 patients (87%) and 56 of 65 lesions (86.2%) after first surgery using fluorescence-guidance. In 4 patients with 6 lesions a second fluorescence-guided surgery was necessary to achieve complete mucosal closure. Respectively, including the case with second surgical attempt 51 of 54 patients (94.4%) and 62 of 65 lesions (95.4%) showed complete mucosal healing.

CONCLUSION

The study shows that fluorescence-guided surgery is a safe and successful treatment option which can be considered for all stages of MRONJ. The technique seems also promising for MRONJ cases under denosumab.

Oral and Maxillofacial Imaging

This article provides the reader with the knowledge and skills of identification and diagnostic interpretative skills using planar images, tomographic images, CBCT, MDCT, pertinent MR images, as well as bone scans and PET images. The goal is to provide sufficient in-depth knowledge of the technique, anatomy, and radiographic identifiers for the diagnosis of local and systemic pathoses. The information will train the reader to be an advocate of selection criteria as well as a follower of the "Image Gently" campaign and philosophy supported by the organized dentistry in the United States, especially in Diagnostic Radiology.

Successful conservative treatment: multiple atypical fractures in osteoporotic patients after bisphosphate medication: a unique case report

Bisphosphonates have been commonly used for the treatment of osteoporosis. However, there have been recent case reports of atypical fractures citing their long-term use, which inhibits the turnover of bone components. A 64-year-old woman visited the outpatient clinic with pain in her right thigh and ambulation difficulty. We found fractures at both pedicles of L4 vertebra. subtrochanteric region of right femur, and left femoral shaft upon a radiologic examination. She had taken intravenous ibandronic sodium for osteoporosis over 3 years. We changed the bishophonates to a parathyroid hormone because it was suspected that the multiple fractures were caused by the medication. Further, rehabilitation, including progressive weight bearing, was started. After 3 months of the conservative treatment, she was able to walk independently. In conclusion, it is necessary to evaluate the possibility of atypical fractures in osteoporotic patients when they complain of lower extremity pain and to consider alternative treatments instead of bisphosphonates.

Bisphosphonate-related osteonecrosis of the jaw mimicking bone metastasis

Osteonecrosis of the jaw is usually a potential complication of bisphosphonate therapy. In a cancer patient, this disease entity can be misdiagnosed as a metastatic lesion. Our aim is to make clinicians aware of bisphosphonate associated osteonecrosis of the jaw to prevent misdiagnosis and initiate proper treatment at the earliest. We present the case of a breast cancer patient with multiple bony metastases and a jaw lesion presumed to be metastases. After no response to palliative radiation, repeat radiological imaging studies revealed osteonecrosis of the jaw. Correlating a patient's clinical information with findings on diagnostic imaging studies, such as SPECT bone and CT scans, can help identify this potential complication of bisphosphonate treatment. Early diagnosis helps minimize unnecessary biopsies and allows for the proper treatment to be instituted.

Role of nuclear medicine imaging in recognizing different causes of osteonecrosis of the jaw

The incidence of osteonecrosis of the jaw (ONJ) among patients with cancer and metastatic bone disease being treated with bisphosphonates is as high as 10%, which dictates that an understanding of the risk factors, preventative measures, means of early diagnosis, and treatment is critical. Despite ONJ occurring in the clinical setting of intravenous bisphosphonates, there are other causes associated with higher risk of ONJ, such as multiple dental extractions. Overall, it is important for imaging health care professionals to recognize, describe, and understand ONJ to help minimize biopsies and allow proper treatment to begin as soon as possible.

[Importance of SPECT/CT for resolving diseases of the jaw]

CLINICAL/METHODICAL ISSUE

Diseases of the jaw, such as osteomyelitis, condylar hyperactivity and tumors need adequate imaging to evaluate the extension and activity for therapy planning.

STANDARD RADIOLOGICAL METHODS

Conventional planar scintigraphy, orthopantomography, computed tomography (CT) and magnetic resonance imaging (MRI) can be used for the evaluation of jaw diseases.

METHODICAL INNOVATIONS

Single photon emission computed tomography/computed tomography (SPECT/CT) provides metabolic and morphologic information in one imaging step and is becoming increasingly more available in larger hospitals.

PERFORMANCE

The SPECT/CT is superior to planar scintigraphy alone, CT and orthopantomography in the evaluation of the extension and activity of osteomyelitis and jaw tumors.

ACHIEVEMENTS

In our hospital SPECT/CT has replaced the other imaging modalities in the evaluation of osteomyelitis and condylar hyperactivity.

PRACTICAL RECOMMENDATIONS

If available SPECT/CT should be performed for the evaluation of osteomyelitis of the jaw.