Bone Scintigraphy in Primary Malignant Bone Tumor

H. CREUTZIG l

Bone scintigraphy reflects the intensity of metabolic activity in the bone and
therefore is a functional and not a morphological image. The sensitivity in de-
tecting metastatic tumors of the skeleton has been proven to be much higher
than X-ray techniques in many, but not in all, entities of primaries, while the
specificity of conventional static imaging is very low. In secondaries, an in-
crease in specificity by dynamic imaging is limited, the important differen-
tiation between primary bone tumor and atypical osteomyelitis is impossible
[1]. We will discuss the usefulness and limitations of dynamic bone scintigraphy
in the diagnosis and follow-up of primary malignant tumors of the skeleton.
Malignant bone neoplasms are rare. Their estimated incidence is less than
one case per 100 000 per year; they make up less than 1% of solid cancers. This
incidence, however, is age-related; peak is 8% of cancers in the group of 15-19
years. In this peak group 60% are osteosarcomas and 30% Ewing's sarcomas,
while in the aged group the most common tumor will be the chondrosarcoma.
There are no specific clinical signs: persistent local pain, especially in the
young and around knee or shoulder, will be suspicious of malignancy. Only
nonossifying fibroma and solitary enchondroma can be diagnosed by typical
X-ray findings. In all other cases with an abnormal X-ray, open biopsy with
histological examination is recommended as the only unequivocal test to ex-
clude the diagnosis of malignancy. .
The prognosis of malignant bone tumors depends on the grade and the stage
of the tumor and the effectiveness of treatment. Any staging system must in-
corporate the significant prognostic factors, stratify the stages, and provide
guidelines for adjunctive therapies.
The WHO system will not fullfil this and therefore should be only of histori-
cal interest as should our classification of uptake pattern in primary bone tu-
mors [2]. The system used today is proposed by the Musculoskeletal Tumor So-
ciety and adopted by the American Joint Comittee for Cancer Staging. It is
based on three factors: (i) grading (G O- 2), (ii) extension of the primary tumor
(To- 2 ), and (iiI) presence of metastases (Mo,l) [4].
Inactive benign lesions (Go, To, Mo) are latent, static, and self-healing.
Radiographic characteristics are lesions that are well-marginated by a mature
shell of cortical-like reactive bone (Lodwick Ia). In dynamic scintigraphy there
is neither a hyperperfusion nor an increase in the early or late static scans
(Table 1).

1 Abt. Nuklearmedizin, Hufelandstr. 55, D-4300 Essen

Nuclear Medicine in Clinical Oncology

Ed. by C. Winkler
© Springer-Verlag Berlin Heidelberg 1986
Bone Scintigraphy in Primary Malignant Bone Tumor 109

Table 1. Pattern of dynamic scintigraphy in primary bone tumors

Benign Benign Benign aggressive High-grade

inactive active low-grade sarcomas sarcomas

Perfusion N + ++ +-+++
Early uptake N ++ + +-+ + + +++
Late uptake N + ++ + +-+ + +
Size (X-ray) 0 equal larger much larger

Active, progressing benign lesions (Go, To, Mo) are mildly symptomatic and
occasionally associated with pathological fractures. They grow steadily, but re-
main encapsulated. Radiographic characteristics are irregular .marginated de-
fects; expansion, bulging, and deformation of overlying reactive bone or cortex
is frequently observed (Lodwick I b). In dynamic scintigraphy there is a distinct
hyperperfusion and an increase in the static images corresponding closely to the
radiographic defects.
Aggressive, invasive benign lesions (Go, T 1 '2, MO•1 ) are symptomatic and
grow rapidly, often associated with a pathological fracture. They penetrate the
capsule and the natural barriers and may appear inflammatory. Despite the re-
ally benign cytologic characteristics, distant, usually pulmonary, metastases
may occur. Radiographic characteristics are a ragged permeative interface with
adjacent bone, cortical destruction, endosteal buttresses and periosteal Cod-
man's triangles (Lodwick I c). In dynamic scintigraphy there is a marked hy-
perperfusion, a high uptake in the early and late static images, both beyond the
radiographic limits.
The behavior of Go benign lesions is often better predicted by the combi-
nation of radiographic staging and clinical features or the findings of dynamic
scintigraphy than by histology. Therefore, in all patients with radiographic
signs of Lodwick I b or I c a dynamic scan should precede any surgery.
Low-grade sarcomas (G p T1•2 , Mo) present as a slow-growing, painless mass
with an indolent, but steady, growth rate. They are not inhibited by the natural
barriers and often produce extraosseous extension and neovascular bundle in-
volvement. Radiographic characteristics are a generous reactive rim of can-
cellous bone admixed with defects of extracapsular and/or soft tissue extension
(Lodwick IT). Scintigraphic signs are the same as in aggressive benign lesions.
High-grade sarcomas usually appear as destructive symptomatic masses.
Radiographic characteristics are no, or a poorly marginated, border between
the lesion and the surrounding bone, patchy cortical destruction, early soft tis-
sue extension, obliteration of periostal reaction, and ill-defined intramedullary
extension (Lodwick III). In dynamic scintigraphy there is an extreme hy-
perperfusion, and a maximal uptake in both the early and the late scan, wide
beyond the radiographic signs.
Low-grade sarcomas are parosteal or enosteal osteosarcoma, giant cell tu-
mor, hemangioendothelioma; high-grade sarcomas the "classic" osteosarcoma,
postradiation and Paget's sarcoma, chondrosarcoma, and giant cell sarcoma.