Bone marrow immunoscintigraphy compared with conventional bone scintigraphy for the detection of bone metastases

The value of bone marrow scintigraphy using 99mTc monoclonal antigranulocyte antibodies in complement to bone scintigraphy in detecting bone metastases from primary breast cancer

This prospective study evaluates bone marrow scintigraphy (BMS) in detecting bone metastases from primary breast cancer when performed in complement to conventional bone scan (BS). Sixty women predominantly with low-stage disease underwent BS followed by BMS within 1-35 days using BW250/183 antigranulocyte antibodies. A receiver operating characteristic (ROC) analysis was performed to compare BS to BS+BMS on a patient-by-patient basis using a 'gold standard' composed of subsequent computed tomography, magnetic resonance imaging, X-ray or BS examinations and at least a 12 month follow-up. Metastases were present in eight out of 60 patients (13%). Specificity was improved by BS+BMS compared to BS alone (90%, 65%) as well as positive predictive value (62%, 27%), accuracy (87%, 72%), positive (10.4, 2.4) and negative (0.20, 0.00) likelihood ratios. Sensitivity (100%, 88%) and negative predictive value (100%, 97%) were similar for BMS+BS and BS alone. As a result of BMS, clinical management was modified in 15 patients (25%). In conclusion, BMS supplements BS by improving specificity, positive predictive value and accuracy in detecting breast cancer bone metastases. The ROC curves show improved specificity for BS+BMS at the same sensitivity compared to BS alone. Consequently, BMS may be useful in low-stage subjects with positive or equivocal BS for metastases.

Detection of Lymphoma in Bone Marrow by Whole-Body Positron Emission Tomography

Positron emission tomography (PET) is a whole-body imaging technique using 18 fluorine-fluorodeoxyglucose (FDG), whose uptake is increased in tumor cells. Published studies have shown PET to be an effective method of staging lymphoma and to be more sensitive than CT at detecting extranodal disease. The purpose of this study was to determine whether the increased marrow uptake of FDG observed in some lymphoma patients during routine staging PET scans represented marrow involvement by disease. PET scans of 50 patients with Hodgkin's (12) and non-Hodgkin's (38) lymphoma were analyzed by three independent observers and the marrow graded as normal or abnormal using a visual grading system. Unilateral iliac crest marrow aspirates and biopsies were performed on all patients. The PET scan and marrow histology agreed in 39 patients (78%), being concordant positive in 13 and concordant negative in 26 patients. In 8 patients the PET scan showed increased FDG uptake but staging biopsy was negative; in 4 of these 8 patients the PET scan showed a normal marrow background with focal FDG “hot spots” distant from the site biopsied. In 3 patients the marrow biopsy specimen was positive but the PET scan normal; 2 of these 3 patients had non-Hodgkin's lymphoma whose malignant cells did not take up FDG at lymph node or marrow disease sites. Therefore, there were only 5 patients (10%) in whom there was a difference between the PET scan and biopsy result which could not be fully explained. Visual interpretation of marrow FDG uptake during whole-body staging PET scans can correctly assess marrow disease status in a high proportion of lymphoma patients. PET has the potential to reduce the need for staging marrow biopsy.

Detection of Lymphoma in Bone Marrow by Whole-Body Positron Emission Tomography

Positron emission tomography (PET) is a whole-body imaging technique using 18 fluorine-fluorodeoxyglucose (FDG), whose uptake is increased in tumor cells. Published studies have shown PET to be an effective method of staging lymphoma and to be more sensitive than CT at detecting extranodal disease. The purpose of this study was to determine whether the increased marrow uptake of FDG observed in some lymphoma patients during routine staging PET scans represented marrow involvement by disease. PET scans of 50 patients with Hodgkin's (12) and non-Hodgkin's (38) lymphoma were analyzed by three independent observers and the marrow graded as normal or abnormal using a visual grading system. Unilateral iliac crest marrow aspirates and biopsies were performed on all patients. The PET scan and marrow histology agreed in 39 patients (78%), being concordant positive in 13 and concordant negative in 26 patients. In 8 patients the PET scan showed increased FDG uptake but staging biopsy was negative; in 4 of these 8 patients the PET scan showed a normal marrow background with focal FDG “hot spots” distant from the site biopsied. In 3 patients the marrow biopsy specimen was positive but the PET scan normal; 2 of these 3 patients had non-Hodgkin's lymphoma whose malignant cells did not take up FDG at lymph node or marrow disease sites. Therefore, there were only 5 patients (10%) in whom there was a difference between the PET scan and biopsy result which could not be fully explained. Visual interpretation of marrow FDG uptake during whole-body staging PET scans can correctly assess marrow disease status in a high proportion of lymphoma patients. PET has the potential to reduce the need for staging marrow biopsy.

Clinical manifestations and diagnostic approach to metastatic cancer of the mandible

In a 12-month period, metastatic cancer was diagnosed in eight patients. Six of them presented with pain mimicking toothache, temporomandibular joint disorders or trigeminal neuralgia, while two showed osteopenic bone lesions in the panoramic radiography, and perimandibular swelling. Anesthesia of the lower lip was the only common clinical feature. In seven of the eight patients, a whole body bone scintigraphy and single photon emission computed tomography (SPECT) of the skull in combination with a whole body and SPECT anti-granulocyte (Tc-99m MAK 250/183) bone marrow scintigraphy was performed. One patient did not have combined scintigraphy performed secondary to severe systemic illness. In six of the seven, the results were conclusive for a metastatic bone lesion. Biopsies confirmed three patients to have a previously unrecognized primary cancer, one patient to have previously unrecognized recurrent cancer, and three patients to exhibit new metastatic spread of an already diagnosed cancer. Histology revealed breast, lung, renal cancer and a malignancy of inconclusive origin. In the remaining patient, combined scintigraphy suggested osteomyelitis, yet biopsy revealed a prostate cancer metastasis with acute inflammatory cell infiltration. Thus, the scintigraphy pattern of a hot spot in the bone scan and a cold lesion in the bone marrow scintigraphy is highly suggestive of a mandibular metastasis, if accompanied by anesthesia of the lower lip.