POSITION PAPERS Procedure Guideline for Bone Scintigraphy: 1.0 KevinJ. Donohoe,Robert E. Henkin,Henry D. Royal,ManuelL. Brown,B. DavidCollier,RobertE. O'Mara and Robert F. Carretta Beth Israel Hospital, Boston, Massachusetts; Loyola University Medical Center, Mayville, Illinois; Mallinckrodt Institute of Radiology, St. Louis, Missouri; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Medical College of Wisconsin, Milwaukee, Wisconsin; University of Rochester School of Medicine and Dentistry, Rochester, Minnesota; Roseville Community Hospital, Roseville, California this point in the diagnostic work-up and (c) the effect of bone Key Words: bone scintigraphy; procedure guidelines scintigraphywill have on patient management. Bone scintigraphy J NucíMed 1996; 37:1903-1906 is oftenhelpfulinthe managementof patientswithneoplasticdisease. In these patients, tumor histology and clinical stage should be PART I: PURPOSE consideredto determinethe likelihoodof metastasisto the skeleton. The purpose of this guideline is to assist nuclear medicine The following is a partial list of common clinical settings for practitioners in recommending, performing, interpreting and which bone scintigraphy is indicated. This list is not all- reporting the results of bone scintigraphy. inclusive. The following indications are not listed in a specific order and bone scintigraphy is not necessarily the primary PART II: BACKGROUND INFORMATION AND diagnostic imaging study. DEFINITIONS A. Neoplastic disease A. Bone scintigraphy is a diagnostic imaging study which B. Occult fracture records the distribution of a radioactive tracer in the C. Osteomyelitis skeletal system in planar (2-dimensional) and/or tomo- D. Avascular necrosis graphic (three-dimensional) images. E. Arthritides B. Whole-body bone scintigraphy produces planar images F. Reflex sympathetic dystrophy of the skeleton including anterior and posterior views G. Bone infarcts of the axial skeleton. Anterior and/or posterior views of H. Bone graft viability the appendicular skeleton are also obtained. Additional I. Otherwise unexplained bone pain views are obtained as needed. J. Distribution of osteoblastic activity prior to X9Srtherapy C. Limited bone scintigraphy records images of only a portion of the skeleton. PART IV: PROCEDURE D. Bone SPECT (single-photon emission computed to A. Patient Preparation mography) produces a tomographic image of a portion The rationale for performing the procedure and the of the skeleton. details of the procedure itself should be explained to the E. Multiphase bone scintigraphy usually consists of blood patient in advance. Unless contraindicated, patients flow images, immediate images and delayed images. should be well hydrated and instructed to drink two or The blood flow images consist of a dynamic sequence more 8-oz glasses of water between the time of injec of planar images of the area of greatest interest ob tion and the time of delayed imaging. The patient tained as the tracer is injected. The immediate (blood- should be asked to urinate immediately prior to delayed pool) images consist of one or more static planar imaging and to drink plenty of fluids for at least 24 hr images of the areas of interest, obtained within IOmin after radiopharmaceutical administration. after injection of the tracer. Delayed images may be B. Information Pertinent to Performing the Procedure limited to the areas of interest or may include the whole 1. Question(s) to be answered by bone scintigraphy. body, may be planar or tomographic, and are usually 2. History of fractures, trauma, osteomyelitis, celluli- acquired 2 to 5 hr after injection. Further additional tis, edema, arthritis, neoplasms, metabolic bone delayed images obtained up to 24 hr following tracer disease or limitation of function. injection may be obtained if necessary. 3. Current symptoms, physical findings. 4. History of recent scintigraphy, especially with ml, PART III: COMMON INDICATIONS 67GaandmIn. Because metabolic changes usually precede anatomic changes, 5. Results of prior bone scintigraphy. bone scintigraphy can often detect abnormalities before ana 6. Results of prior imaging studies such as conven tomic imaging studies such as routine radiographs. In addition, tional radiographs, CT and MRI. because the radiopharmaceutical is distributed throughout the 7. Historyof therapy that might affect the results of bone body, examination of the entire skeleton is facilitated. scintigraphy (e.g., antibiotics, steroids, chemotherapy, Bone scintigraphy may be indicated in a diverse patient popu radiation therapy, diphosphonates, iron therapy). lation (children, adults, symptomatic and asymptomatic). Before 8. History of orthopedic (e.g., presence and location of bone scintigraphy, several factors deserve consideration: (a) the prosthetic implants) and nonorthopedic surgery likelihood of the suspected condition in view of the clinical (e.g., ileal conduit) that might affect the results of presentation, (b) whether bone scintigraphyis the best modality at bone scintigraphy. 9. Relevant laboratory results (e.g., PSA in patients Received May 20, 1996; accepted May 27, 1996. For correspondence or reprints contact: Joanna Wilson, Society of Nuclear Medicine, with prostate cancer). 1850 Samuel Morse Dr., Reston, VA 20190. 10. History of anatomic or functional renal abnormalities. PROCEDUREGUIDELINEFORBONESCINTIGRAPHY•Donohoe et al. 1903 C. Precautions 1-2 sec per frame. If film is used, 3-5 sec per frame 1. Elective bone scintigraphy should be deferred in may be used. The acquisition should be started just as pregnant women. Bone scintigraphy is not contrain- the tracer is injected. Blood-pool images should be dicated in pregnancy when the expected benefits of the acquired within 10 min of tracer injection for approxi examination outweigh the very small radiation risk. mately 3-5 min per image. After 10 min, some activity 2. When possible, breastfeeding should be discontin may be apparent in the skeleton. ued for 24 hr after radiopharmaceutical injection. When digital images are acquired, blood flow images D. Radiopharmaceutical may be obtained in 64 X 64 X 16 or greater matrix at 1 to 3 sec per frame. Blood-pool images are usually Several 99mTc-labeled radiopharmaceuticals (e.g., diphos- obtained in 128 X 128 X 16 or greater matrix with count density of approximately 300,000 counts/image phonates or pyrophosphates) are available for bone scintigra (150,000-200,000 counts/image may be adequate for phy. The usual administered activity for adult patients is 740 to extremities). 1110 MBq (20 to 30 mCi) injected intravenously. For markedly Routine delayed images are usually obtained from 2 to obese adult patients, the administered activity may be increased 5 hr after injection. Additional delayed (6-24 hr) to 11-13 MBq/kg (300-350 ¿iCi/kg).For pediatrie patients, the images will result in a higher target-to-background ratio administered activity is 9-11 MBq/kg (250-300 juCi/kg), with and may permit better evaluation of the pelvis if it was a minimum of 40-90 MBq (1.0-2.5 mCi). The maximum obscured by bladder activity on the routine delayed administered activity for pediatrie patients should not exceed images. Six- to 24-hr delayed imaging may be particu the administered activity for an adult. larly helpful in patients with renal insufficiency and Bone radiopharmaceuticals are subject to oxidation. Care patients with urinary retention. should be taken to avoid introducing air into the multidose vial. Whole-body bone scintigraphy can be accomplished Quality control should be performed prior to administration of with multiple overlapping images (i.e., spot imaging) or the radiopharmaceutical (see the Society of Nuclear Medicine with continuous images (i.e., whole-body scan) ob Procedure Guideline for Imaging with Radiopharmaceuticals, tained in anterior and posterior views. When spot views J NucíMed 1996: in press). are used as the primary method of acquiring bone Radiation Dosimetry for Adults* images, the areas of bony skeleton covered by the spot views must overlap to avoid missing regions of the skeleton. the The first spot view of the axial skeleton, usually the largest chest, is acquired for approximately 500,000 to 1 radiation doseT dosetmSv activity million counts. The remaining spot views are then Radiopharmaceuticals"Tc (mCi)740-1MBq mGy(rad)0.063 (rem)0.008 acquired for the same time as the first view. Spot phosphates 110 i.v. images may be obtained using a 128 X 128 X 16 or a and phosphoratesAdministered(20-30)OrganreceivingBone (0.030) 256 X 256 X 16 matrix. Whole-body views are usually (0.23)Effective obtained in 256 X 1024 X 16 or greater matrix. Computer acquisition, processing and display of images "ICRP 53, normal bone uptake, normal renal function, page 215. may be particularly helpful in pediatrie populations fper MBq (per mCi) because of extreme ranges of normal uptake. Films of See also MIRD Committee Dose Estimate Report No. 13. Radiation scintigrams photographed with different intensities may absorbed dose for technetium-99m-labeled bone imaging agents. J Nucí also be helpful if digital processing and review are not Medi 989:30:1117-1122. available. When whole-body scanning is used, the count rate (usually of the anterior chest) should be determined RadiationRadiopharmaceuticals""Tcold)Administeredfor Children* (5 year before image acquisition. The scanning speed should be adjusted so that routine (obtained 2-5 hr after injection) receiving the delayed anterior or posterior whole-body