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Technetium-99M-MDP Patterns in Patients with Painful Shoulder Lesions

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Technetium-99M-MDP Patterns in Patients with Painful Shoulder Lesions tumors. The most widely used radiopharmaceutical for im REFERENCES aging of the adrenal cortex is 131I6-beta-iodomethyl-norcho- 1. Lamberts SW, Reubi JC. Krenning EP. Somatostatin and the concept of peptide lesterol (NP59), which delivers a high radiation dose, re receptor scintigraphy in oncology. Semin Oncol 1994:21:1-5. 2. Krenning EP, Kwekkeboom DJ, Bakker WH, et al. Somatostatin receptor scintigraphy quires blocking of the thyroid gland and has a limited with "'in-DTPA-D-Phe' and '23I-Tyr3 octreotide: the Rotterdam experience with resolution in addition to the considerable delay from injec more than 1000 patients. Ear J NucíMud 1993:20:716-731. 3. Reubi JC. Neuropeptide receptors in health and disease: the molecular basis for in vivo tion to imaging. imaging. J NucíMed 1995:36:1825-1835. CONCLUSION 4. Hoefnagel CA. Metaiodobenzylguanidine and Somatostatin in oncology: role in the Imaging of the adrenal cortex with ' ' 'In-DTPA octreotide management of neural crest tumors. Eur J NucíMed 1994:21:561-581. 5. Kwekkeboom DJ, Kho OS, Lamberts SW, Reubi JC, Laissue JA, Krenning EP. The using a SPECT technique has a good resolution, and it may value of octreotide scintigraphy in patients with lung cancer. Eur J NucíMed potentially differentiate bilateral adrenal hyperplasia secondary 1994:21:1106-1113. 6. Vanhagen PM, Krenning EP, Reubi JC, et al. Somatostatin analog scintigraphy in to over-secretion of ACTH and increased cortisol levels sec granulomatous diseases. Eur J NucíMed 1994;21:497-502. ondary to primary adrenal tumors. Although octreotide scintig- 7. Reichlin S. Somatostatin, part I. N EnglJ Med 1983:309:1495-1501. raphy is occasionally used to image pheochromocytomas and 8. Reichlin S. Somatostatin. part II. N EnglJ Med 1983:309:1556-1563. 9. Reubi JC, Laissue J, Waser B, Horisberger U, Schaer JC. Expression of Somatostatin neuroblastomas that originate in the adrenal medulla, imaging receptors in normal, inflamed and neoplastic human gastrointestinal tissues. Ann N Y of the adrenal cortex has not been described previously, AcadSci 1994;733:122-137. including the large series by Krenning et al. (2) with more than 10. Reubi JC, Mazzucchelli L, Laissue JA. Intestinal vessels express a high density of 1000 patients. Follow-up scintigraphy may also be used as an Somatostatin receptors in human inflammatory bowel disease. Gastroenterologi' 1994:106:951-959. indicator of the response to therapy. Further research is neces 11. Payer J. Huorka M, Duris I, et al. Plasma Somatostatin levels in ulcerative colitis. sary to evaluate this issue. Hepalogaslroenterolog}' 1994:41:552-553. Technetium-99m-MDP Patterns in Patients with Painful Shoulder Lesions Gavin Clunie, Jamshed Bomanji and Peter J. Ell Bloomsbury Rheumatology Unit, Middlesex Hospital, London; and Institute of Nuclear Medicine and University College London, United Kingdom patterns of abnormality in patients with painful shoulder lesions. There is no consensus on the optimum mode of imaging in patients Further studies to elucidate a role for 99rnTc-MDP scintigraphy in this with painful shoulder lesions. There is a particular paucity of scinti- patient group are warranted. graphic data. As a result, the strengths and weaknesses of scintig Key Words: shoulder lesions;bone scan; technetium-99m-methyl- raphy cannot be adequately compared to other imaging techniques used in shoulder imaging. This study evaluated whether specific ene diphosphonate patterns of scintigraphic abnormality could be detected in patients J NucíMed 1997; 38:1491-1495 with painful shoulders seen in rheumatological practice using 99mTc- methylene diphosphonate (MDP). Methods: Scintigraphic abnor malities were recorded in consecutive patients presenting to a J_/ocalizing the site of painful shoulder lesions can often be rheumatology clinic with unilateral shoulder pain. Patients were difficult due to the interdependent movement of several func subdivided according to patterns of clinical abnormality consistent tional articulations that make up the shoulder joint. Clinical with a working diagnosis of a lesion located in the subacromial diagnosis frequently relies on the presence of a characteristic region, adhesive capsulitis (frozen shoulder) or a lesion likely to be but complex pattern of examination findings (/). In addition, located in the glenohumeral joint. Patterns of radiopharmaceutical there is no consensus on the best imaging technique for distribution in different regions of the shoulder were evaluated in the identifying any specific shoulder lesion, or of the optimum light of clinical data and the results of shoulder radiographs. Results: Technetium-99m-MDP scans were abnormal in 19 of 24 (79%) imaging modality where the diagnosis is unclear (2). Available imaging methods include radiographs, arthrography (3), arth- patients, and radiographs were abnormal in 8 of 24 (33%) patients. Distinct patterns of 99nTc-MDP image abnormality were identified: rotomography (4), CT arthrography (5,6), MRI (7) and ultra an increase in 99mTc-MDP uptake in the coracoid, acromion and sound (8,9). The potential use of [99mTc]pertechnetatescintig medial humeral head on anterior planar images, together with an raphy for understanding the painful shoulder was recognized 20 absence of posterior planar image abnormality, frequently occurred yr ago (70). An association between 99mTc-methylenediphos in association with a working diagnosis of a lesion located in the subacromial region. Posterior planar ""Tc-MDP image abnormal phonate (MDP) scintigraphic abnormalities and clinically diag nosed frozen shoulder (adhesive capsulitis) subsequently has ities always occurred in patients with clinical features consistent with a diagnosis of adhesive capsulitis. There was an 85% agreement been recognized (11). There are few if any studies, however, between two observers' scores when 99mTc-MDP distribution in assessing the merits of scintigraphy, either alone or combined specific shoulder regions was graded. Conclusion: Distinct patterns with other imaging modalities, in evaluating patients with of 99mTc-MDP distribution may be associated with clinically-distinct shoulder pain. We performed shoulder scintigraphy on consecutive patients presenting to a rheumatology clinic with shoulder pain. Our Received Jun. 6, 1996; revision accepted Oct. 30, 1996. objective was to identify and evaluate whether specific 99mTc- For correspondence contact: Gavin Clunie, MD, Institute of Nuclear Medicine, Middlesex Hospital, Mortimer St., London W1N 8AA. MDP scintigraphic abnormalities could be associated with TECHNETiuM-99m-MDPPATTERNS•Clunie et al. 1491 TABLE 1 Characteristic Clinical Features Used as a Guide for Clinical Grouping* Subacromial lesiont •Hunching of the shoulder at the beginning of abduction •Reversal of scapulohumeral rtiythm •Painful arc Adhesive capsulitis (frozen shoulder)1^ •Spontaneous onset of pain •Limitation of all shoulder movements by >50% compared to asymptomatic shoulder Likely noncapsulitis glenohumeral lesions •No diagnosis of adhesive capsulitis •Pain on passive and active movements •Pain elicted by all humeral movements FIGURE 2. (A) Regions from anterior and (B) posterior bone scan images analyzed for 99mTc-MDP uptake: 1 = coracoid; 2 = anterior acromion; 3 = *For explanation of clinical grouping, see Methods. anteromedial humeral head; 4 = anterolateral humeral head; 5 = posterior tModified from Kessel and Bayley (12). acromion; 6 = posterior glenoid; 7 = posterior humeral head. according to clinical patterns of abnormality, were grouped sepa clinical patterns of abnormality in this patient group. We hoped rately. to gain some insight into whether bone scintigraphy can provide All patients had standard anteroposterior (AP) shoulder and more information than is currently recognized in patients with bilateral load-bearing AP ACJ radiographs of the affected shoulder. painful shoulder lesions. Radiographs were reported routinely. Scintigraphic images were obtained of both shoulders 3 hr MATERIALS AND METHODS following injection of 16 mCi (600 MBq) 99mTc-MDP using an Patients IGE single-headed camera fitted with a low-energy, high-resolu Consecutive patients presenting with unilateral shoulder pain tion collimator. Images were acquired on a 256 X 256 matrix. were recruited from a rheumatology outpatient population. Ex Bilateral anterior and posterior-prone planar views were obtained cluded from the study were patients with a possible diagnosis of a for 3 min. Anterior views were obtained with the detector 20°to the polyarticular inflammatory disease based on history, examination horizontal (tilted medially) over the supine patient. The angulation and raised erythrocyte sedimentation rate (>30 mm in the first of the detector was designed to reduce the possible effect of hour) or those with an acromioclavicular joint (ACJ) arthritis coracoid and anterior glenoid superimposition in the image. Pos defined by pain localizing to the ACJ on palpation and/or elicited terior images were obtained with the patient lying prone and the at the end of abduction range, increased by stressing the ACJ in arm hanging vertically. The detector was positioned parallel to the shoulder adduction and improved by local anesthetic injection into scapular blade (30-45°). This angle allowed the clearest view of the ACJ. A working diagnosis of the site and nature of the lesion the posterior glenohumeral joint space (Fig. 1). was made after clinical assessment. Patients were grouped accord Regions of the shoulder (Fig.
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