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Society of Nuclear Medicine Procedure Guideline for Bone Scintigraphy Version 3.0, Approved June 20, 2003

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Society of Nuclear Medicine Procedure Guideline for Bone Scintigraphy Version 3.0, Approved June 20, 2003 Society of Nuclear Medicine Procedure Guideline for Bone Scintigraphy version 3.0, approved June 20, 2003 Authors: Kevin J. Donohoe, MD (Beth Israel Deaconess Medical Center, Boston, MA); Manuel L. Brown, MD (Henry Ford Hospital, Detroit, MI); B. David Collier, MD (Faculty of Medicine, Kuwait University, Kuwait); Robert F. Carretta, MD (Amersham Health, Princeton, NJ); Robert E. Henkin, MD (Loyola University Medical Center, Maywood, IL); Robert E. O’Mara (University of Rochester School of Medicine and Dentistry, Rochester, NY); and Henry D. Royal, MD (Mallinck- rodt Institute of Radiology, St. Louis, MO). I. Purpose III. Common Indications The purpose of this guideline is to assist nuclear A. Neoplastic disease medicine practitioners in recommending, perform- B. Occult fracture ing, interpreting, and reporting the results of bone C. Osteomyelitis scintigraphy. D. Stress reaction/stress fracture E. Avascular necrosis F. Arthritides II. Background Information and Definitions G. Reflex sympathetic dystrophy A. Bone scintigraphy is a diagnostic study used to H. Bone infarcts evaluate the distribution of active bone forma- I. Bone graft viability tion in the body. J. Otherwise unexplained bone pain B. Whole-body bone scintigraphy produces planar K. Distribution of osteoblastic activity before ra- images of the skeleton, including anterior and dionuclide therapy for bone pain posterior views of the axial skeleton. Anterior and/or posterior views of the appendicular IV. Procedure skeleton also are obtained. Additional views are obtained as needed. A. Patient Preparation C. Limited bone scintigraphy records images of 1. The rationale for performing the procedure only a portion of the skeleton. and the details of the procedure itself should D. Bone single-photon emission computed tomog- be explained to the patient in advance. Unless raphy (SPECT) produces a tomographic image of contraindicated, patients should be well hy- a portion of the skeleton. drated and instructed to drink 2 or more 8-oz E. Multiphase bone scintigraphy usually includes glasses of water between the time of injection blood flow images, immediate images, and de- and the time of delayed imaging. The patient layed images. The blood flow images are a dy- should be asked to urinate immediately be- namic sequence of planar images of the area of fore delayed imaging and to drink plenty of greatest interest obtained as the tracer is injected. fluids for at least 24 h after radiopharmaceuti- The immediate (blood pool or soft tissue phase) cal administration. images include 1 or more static planar images of B. Information Pertinent to Performing the Proce- the areas of interest, obtained immediately after dure the flow portion of the study and completed 1 . Question(s) to be answered by bone scintig- within 10 min after injection of the tracer. De- r a p h y layed images may be limited to the areas of in- 2. History of fractures, trauma, osteomyelitis, cel- terest or may include the whole body, may be lulitis, edema, arthritis, neoplasms, metabolic planar or tomographic, and are usually acquired bone disease, or limitation of function 2–5 h after injection. If necessary, additional de- 3. Current symptoms, physical findings layed images may be obtained up to 24 h after 4. History of recent scintigraphy, especially with tracer injection. 131I, 67Ga, or 111In 206 • BONE SCINTIGRAPHY 5. Results of prior bone scintigraphy of Radiopharmaceuticals). 6. Results of prior imaging studies, such as con- E. Image Acquisition ventional radiographs, computed tomogra- 1. Flow images phy, and magnetic resonance imaging If flow images are acquired, the camera 7. History of therapy that might affect the re- should be positioned over the region of inter- sults of bone scintigraphy (e.g., antibiotics, est before tracer injection. The acquisition steroids, chemotherapy, radiation therapy, computer should be programmed to acquire diphosphonates, or iron therapy) approximately 30 frames. When digital im- 8. History of orthopedic (e.g., presence and loca- ages are acquired, blood flow images may be tion of prosthetic implants) and nonorthope- obtained in a 64 × 64 × 16 or greater matrix at dic (e.g., ileal conduit) surgery that might af- 1–3 s/frame. If film is used, 3–5 s/frame may fect the results of bone scintigraphy be used. 9. Relevant laboratory results (e.g., prostate-spe- 2. Blood pool (tissue phase) images cific antigen in patients with prostate cancer) Blood pool images should be acquired imme- 10. History of anatomic or functional renal abnor- diately after the flow portion of the study and malities completed within 10 min of tracer injection, C. Precautions for approximately 3–5 min/image. After 10 None min, some activity may be apparent in the D. Radiopharmaceutical skeleton. Blood pool images are usually ob- Several 99mTc-labeled radiopharmaceuticals (e.g. tained in a 128 × 128 × 16 or greater matrix, diphosphonates) are available for bone scintigra- with count density of approximately 300,000 phy. The usual administered activity for adult counts/image (150,000–200,000 counts/im- patients is 740–1,110 MBq (20–30 mCi) injected age may be adequate for extremities). intravenously. For markedly obese adult pa- 3. Delayed (skeletal phase) images tients, the administered activity may be in- Routine delayed images are usually obtained creased to 11–13 MBq/kg (300–350 µCi/kg). For from 2–5 h after injection. pediatric patients, the administered activity is Whole-body bone scintigraphy can be ac- 9–11 MBq/kg (250–300 µCi/kg), with a mini- complished with multiple overlapping im- mum of 20–40 MBq (.05–1.0 mCi). The maximum ages (i.e., spot imaging) or with continuous administered activity for pediatric patients images (i.e., whole-body scan) obtained in an- should not exceed the administered activity for terior and posterior views with a high-resolu- an adult. tion or ultrahigh-resolution collimator. When Bone radiopharmaceuticals are subject to oxi- spot views are used as the primary method of dation. Care should be taken to avoid introduc- acquiring bone images, the areas of bony ing air into the multidose vial. Quality control skeleton covered by the spot views must over- should be performed before administration of lap to avoid missing regions of the skeleton. the radiopharmaceutical (see the Society of Nu- The first spot view of the axial skeleton, clear Medicine [SNM] Procedure Guideline for Use usually the chest, is acquired for approxi- Radiation Dosimetry in Adults Ra d i o p h a r m a c e u t i c a l s Administered Organ Receiving the Effective Activity Largest Radiation Dose* Dose MBq mGy/MBq mSv/MBq (mCi) (rad/mCi) (rem/mCi) 99mTc-phosphates 740–1110 Bone 0.0080 and phosphonates (20–30) 0.063 (0.030) Intravenously (0.23) *International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals. ICRP re- port 53. London, UK: ICRP; 1988:215. Values for normal bone uptake and normal renal function. See also Medical Internal Radiation Dose Committee dose estimate report No. 13: radiation absorbed dose for 99mTc-labeled bone imaging agents. J Nucl Med. 1989;30:1117–1122. SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL AUGUST 2003 • 207 Radiation Dosimetry in Children (5 Years Old) Ra d i o p h a r m a c e u t i c a l s Administered Organ Receiving the Effective Activity Largest Radiation Dose* Dose MBq/kg mGy/MBq mSv/MBq (mCi/kg) (rad/mCi) (rem/mCi) 99mTc-phosphates 9–11 Bone 0.025 and phosphonates (0.20–0.30) 0.22 (0.093) Intravenously (0.81) Min: 0.50 mCi Max: 30 mCi *International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals. ICRP report 53. London, UK: ICRP; 1988:215. Values for normal bone uptake and normal renal function. See also Medical Internal Radiation Dose Committee dose estimate report No. 13: radiation absorbed dose for 99mTc-labeled bone imaging agents. J Nucl Med. 1989;30:1117–1122. mately 500,000–1 million counts. The remain- 60–120 stops, 64 × 64 × 16 or greater matrix, ing spot views are then acquired for the same and 10–40 s/stop. An equivalent total number time as the first view. Spot images may be ob- of counts should be acquired if continuous ac- tained using a 128 × 128 × 16 or 256 × 256 × 16 quisition is used. matrix. Whole-body views are usually ob- 5. Other imaging tained in a 256 × 1024 × 16 or greater matrix. Additional delayed (6–24-h) images will re- Computer acquisition, processing, and dis- sult in a higher target-to-background ratio play of images are very helpful and particu- and may permit better evaluation of the pelvis larly so in pediatric populations because of if it was obscured by bladder activity on the extreme ranges of normal uptake. Films of routine delayed images. Six- to twenty-four-h scintigrams photographed with different in- delayed imaging may be particularly helpful tensities also may be helpful when digital pro- in patients with renal insufficiency or urinary cessing and review are not available. retention. When whole-body scanning is used, the A pinhole collimator may be used if very count rate (usually of the anterior chest) high-resolution images of a specific area are should be determined before image acquisi- necessary. Approximately 75,000–100,000 tion. The scanning speed should be adjusted counts should be obtained for pinhole colli- so that routine delayed (obtained 2–5 h after mator views. Zoom magnification or a con- injection) anterior or posterior whole-body verging collimator also may be used to im- images contain >1.5 million counts. If the prove resolution, particularly when small scanner electronically joins multiple passes, structures or pediatric patients are being im- care must be taken to avoid having the “zip- aged.
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