Assessing Bone Scan Results: Is It Bone Metastasis or Avascular Necrosis?

Could you please help me check if this is bone metastasis?

The patient was diagnosed with stage 4A tongue cancer on August 30, 2018, and underwent 35 sessions of radiation therapy and 3 cycles of chemotherapy.
On March 3, 2021, a new diagnosis of hypopharyngeal cancer was made, which has since been surgically treated and is currently under normal follow-up.
Due to hip joint pain last year, the patient consulted an orthopedic specialist who diagnosed avascular necrosis of the hip joint.
A follow-up bone scan was performed on January 19 of this year, which indicated the presence of new hot spots, raising concerns about possible bone metastasis.
Since the follow-up appointment has not yet occurred, the patient is requesting assistance in reviewing the report.

1.
Findings are compatible with avascular necrosis (AVN) at both femoral heads.
Clinical correlation and additional studies are recommended to rule out superimposed osteomyelitis or bone metastases.
2.
There are likely dental issues present in the gums.
Correlation with clinical examination and MRI for locoregional status is suggested.
3.
Mild degenerative changes/arthritis are noted at the L4-5 spine and left knee.
4.
There are probable mild traumatic changes at the right clavicle, which are partially resolved.
INDICATIONS:
1.
Right hypopharyngeal cancer, pT1N0M0, stage I, status post excision (March 3, 2021).
2.
Left tongue base cancer, T3N2bM0, stage IV, status post concurrent chemoradiotherapy (radiation completed on December 10, 2019).
MRI on May 5, 2021, showed avascular necrosis of the femoral heads bilaterally.
NUCLEAR MEDICINE STUDY: Whole Body Bone Scan.
RADIOPHARMACEUTICAL: Tc-99m MDP 20 mCi IV.
PATIENT’S RESPONSE: None.
SCINTIGRAPHIC FINDINGS:
Comparing with the prior study on September 18, 2019:
1.
New intense hot areas are observed at both femoral heads, more pronounced on the left side.
2.
Partial resolution of previous mild focal uptake at the bilateral maxilla and mandible.
3.
Partial resolution of previous hot spots at the L4-5 spine and right clavicle; stationary mild uptake is noted at the left knee.
4.
Tracer was injected via the right hand.
Given the patient's cancer history, a follow-up bone scan is recommended in approximately 6 to 12 months.

Liu Xiaojie, 40~49 year old female. Ask Date: 2022/01/21

Dr. Zheng Xiaoyi reply Nuclear Medicine

Hello, Ms.
Liu.
A nuclear medicine bone scan is a functional imaging technique commonly used in the diagnosis of bone metastases from cancer.
It has the advantage of high sensitivity; however, its specificity for bone metastases is not very high.
Other benign lesions that are not bone metastases may also yield positive results on a bone scan.
Therefore, it is essential to correlate the findings with other anatomical imaging, clinical data, and comparisons of previous and subsequent images for a comprehensive interpretation.
Consequently, the physicians who have been providing long-term care for your husband are best positioned to make an accurate diagnosis based on the imaging results.
It is insufficient to rely solely on one report to address your concerns.
I recommend discussing the imaging results with your husband's doctors.
Finally, I wish you and your husband all the best and good health.

Reply Date: 2022/01/21

More Info

When interpreting bone scan results, particularly in a patient with a history of cancer, it is essential to differentiate between various potential causes of abnormal findings. In your case, the report indicates findings compatible with avascular necrosis (AVN) at the bilateral femoral heads, which is a condition characterized by the death of bone tissue due to a lack of blood supply. This can lead to pain and joint dysfunction, and it is often associated with risk factors such as previous trauma, corticosteroid use, or certain medical conditions.

The bone scan results show new intense hot areas at the bilateral femoral heads, which raises the question of whether these findings are due to AVN or possibly bone metastases. The report suggests correlating these findings with clinical symptoms and other imaging studies, such as MRI, to exclude the possibility of superimposing osteomyelitis (bone infection) or bone metastases.
In patients with a history of cancer, any new areas of increased uptake on a bone scan can be concerning for metastatic disease. However, it is important to note that not all areas of increased uptake indicate metastasis. Conditions such as AVN, osteomyelitis, and even benign bone lesions can also present with similar findings.
Given your history of tongue and hypopharyngeal cancers, the concern for bone metastasis is valid. However, the report does not definitively indicate the presence of metastasis; rather, it emphasizes the need for further evaluation. The recommendation for follow-up imaging in 6 to 12 months is standard practice in oncology to monitor any changes in the bone status and to ensure that any potential malignancy is identified early.

To summarize, while the findings on the bone scan are concerning, they are not conclusive for bone metastasis. The presence of AVN is noted, and this condition can explain the intense uptake observed in the femoral heads. It is crucial to follow up with your healthcare provider, who can correlate these findings with your clinical history, symptoms, and any additional imaging studies, such as MRI, to arrive at a more definitive diagnosis.
In conclusion, while the fear of bone metastasis is understandable given your medical history, the current evidence points more towards AVN. Continuous monitoring and further imaging will be key in managing your condition and ensuring appropriate treatment. Always feel free to discuss your concerns with your oncologist, as they can provide personalized insights based on your overall health status and treatment history.

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