CASE REPORT

Tc99m
Oiphosphonate
• • •Imaging - .glant

cell tumours on
MOP scanning

MM Sathekge,
MJ

and

RP Clauss,
MBChB

Department of Nuclear Medicine
Ga-Rankuwa MEDUNSA

Abstract
Tenpatients with histologically
proven giant cell tumour (biopsy)
were imaged with 3-phase bone
scanning, using 99m Tc-MOP. The
perfusion (Phase I) and uptake (Phase
III) were compared to the normal
contralateral side and the rest of the
skeleton was inspected for other
abnormalities. Ninety per cent of
lesions showed a doughnut-type
pattern of uptake and presented with
moderately increased perfusion (2.9
normal ± O. 7) and markedly increased
uptake of tracer (7.5 normal ± 1.4).
The patient with diffuse uptake had a
pathological fracture.

Introduction
Giant cell tumour of bone is a primary skel-
etal neoplasm of unknown cellular ongm." It
is an expansile and highly vascular neoplasm

that usually arises in the metaphyseal regions
oflong bones such as distal femur, proximal
tibia and distal radius. It is now believed that
the true giant cell tumour (GeT) is always
malignant Although it is late to metastasise,
it has a high potential for local recurrence. 3

Radionuclide bone scan in Ga has been
used to determine the anatomic extent of the
lesion and to detect other skeletal lesions.4

WeclescribefeaturestodifferentiateGCT
onradionuclide bone scan from other lesions.

Materials and
methods

Ten patients (7 males and3 females,mean age
32,6) with biopsy proven Gcrwere evalu-
ated using a 3 phase bone scan. 99m Tc
Oiphosphonate (MOP)
was used as tracer and
imaging was performed us-
ing a Sophy OSX camera
with a low energy highrese-
lutioncollimator. 700Mbq
99mTc MDPwereinjected
into an antecubital vein at
60 frames per second
(Phasel] followed by a pool
imageofl minute (Phasell),
acquired 3 hours later
(phase III).The maximum
activity on the perfusion
curve (phase Dofthepatho-

3S SA JOURNAL OF RADIOLOGY· September 1996

logical side was compared to that of the nor-
mal side.Maximum uptake (phase III) in the
giant cell tumour was compared with
contralateral normal bone uptake by image
profile.

Results
Of the lOpatients,
9 (90%) showed a
doughnutpattem,
that is markedly
increased activity
in the periphery
of the lesion with
a cold centre (Fig-
ure 1).Thepatient
with diffuse up-
take had a patho-
logicalfracture.A1l
tumours were at
least 6cm in size
(mean8,6an±2,7)
and occurred Figure 1: Whole body scanwhich shows the lesion with
most commonly a cold centre.L.__ .....J
in the proximal
tibia in 4 patients and distal radius in 2
patients. Mean perfusion of the tumour was
2,9 times normal (SO ±O,7) while mean
uptake was 7,5 times normal (SO ± 1,4) see
Table 1. Normalised perfusion curves are
shown in Figure 2 and perfusion images in
Figure 3.An image profile of the uptake in

Table I: Results

Patient MA NJ LA MG MM TM MJ MF ME JM
Gender M M M F F M F M M M
Age 31 23 18 35 48 19 20 46 36 50
Position DH OF DR PT DR PH OT PT PT PT
Size (cm) 8 10 6 7 7 6 8 10 9 15
Doughnut N y Y y y y y y y y

Diffuse Y N N N N N N N N N
Fracture Y N N N N N N N N N
Perfusion 2,5:1 4:1 3:1 2,5:1 3:1 2:1 2:1 3:1 4:1 3:1
Uptake 7:1 6:1 7:1 6:1 8:1 10:1 9:1 8:1 8:1 6:1

DH • Distal humerus
OF • Distal femur
DR • Distal radius
PT • Proximal tibia
PH • Proximal humerus

to page 40



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Tc99m Diphosphonate inlaging - giant
cell tumours on MDP scanning

frompage38

the pathological to the normal region is
shown in Figure 4.

Figure 2: Normalised perfusion curves from
regions of interest Phase / (dark curve from the
contralateral, norma/ bone),

Figure 3: Perfusion 60 frames of 1 second
compressed to 15 frames of 4 second (Phase I).

Figure 4: An image profile of the uptake in the
pathological to the normal region (Phase 1//).

Discussion
Giant cell tumour is common between the
ages of20 and 40 as confirmed in our series.
Often patients present with pain following
trauma and sometimes with a mass or swell-
ing. A pathological fracture occurs in lOper
cent of cases. IThe origin of Ger iscontrover-
sial.It is formed by multinucleated giant cells

within intervening stromal cells and often
there is a striking sinusoidal vascular bed with
focal telangiectasia, sometimes with changes
such as fibrosis, necrosis and cyst formation. 5
Osteoblastic activityis usually confined to the
peripheral reactive margtn+we noted that
Ger rarely involves the joint space, as con-
firmed by other authors. However; not infre-
quently ajoint effusion may be present. 7

Osteoblastic activity with bone formation
in the periphery and little or none centrally
has been cited as the major reason for the
doughnut-type pattem of uptake in giant cell
tumours.' Other factors such as secondary
telangiectasia,cyst formation and necrosis may
also contribute to this patten." Imagingtech-
nique also contributes to the ability to dem-
onstrate a doughnut.' Some workers believe
that lesions should show a doughnut rather
than a diffuse pattern with improved tech-
niques.This isshown in our series (9/10 GeT)
and wascorrfumed with SPEer imaging (Fig-
ure 5). The differential diagnosis for this type

rONO LEGS tone LEGS

TOI1O LEGS tone LEGS

TONO l.EGS TOttO LEGS TONO LEGS TOI'IO LEGS

TOMO LEGS TOHO i..£Gs TOI'lO LEGS TOMO I..EGS

Figure 5: SPEeT images demonstrating a
doughnut-type pattern of uptake,

of uptake includes aneurysmal cone cyst and
nonosteogenic fibroma, which unlike GCT,
have an unimpressive degree of tracer uptake.
We found that the uptake was markedlyin-
creased while perfusion was moderately in-
creased.

The patient with diffuse uptake of tracer
in our serieshad a pathological futcture which
could explain the obliteration of a doughnut
pattem as suggested by other workers? The

40 SA JOURNAL OF RADIOLOGY. September 1996

reason for this could be osteoblastic activity
with focal tracer accumulation in the centre
ofthefutcture.1oGCfsarerarelymulticentric
but may occasionally cause skip metastases. II
These fractures are best evaluated by
radionuclidescan, thus being helpful with the
entire approach to the diagnosis and manage-
mentofGCfs.

Conclusion
A doughnutpattemin a metaphyseal region
oflong bone withmarkedlyincreased uptake
in the periphery and moderate perfusion
makesthedifferential diagnosisofGCflikely.
However, diffuse pattern can occur,especially
in the presence of a pathological fracture or
with poor imaging technique. Reasons for the
doughnut pattern could be increased periph-
eral uptake due to reactive secondary bone
formation or decreased activity in the centre
secondary to cyst, telangiectasis or necrosis.
Radionuclide bone scan is important in the
management of eer,especially in caseswith
skip lesions and multicentricity.

Refurenres
1 .Apley AG, Solomon L; Concise system of orthopaedics and
/ractures 1988. Butterworths pp67
2, Dahlin D: Giant CellTumour. In Bone Tumours . General
AspectsandDatain6221 ruses; 3rded.Springfle1d, CharlesC,
Thomas 1987,pp99-1IS
3. Du ToitJG: Osteoclastoma :A review of the condition and
areportof5 cases. S.Aji:Mai.J. 1983;64787-791.
4, Levine E, et al: Scintigraphic Evaluation of Giant Cell tu-
mourofbone:AJR 1984; 143-348
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turesofGiantCellTumour.ClinNudMai.1983;9:526
6.Jaffee HL: Histogenesis ofbone tumours, tumours ofbone
and soft tissue. 8thAnnual Clinical Conferenceatthe Univer-
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8.JaffeeHL:TumoursandTumoruusamditionsofdle&mesand
loint>, Philadelphia, Lea and Febiger, 1958,ppl8-43
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l~

Il .Peirner CA, Chiller AL, Mankin HJ, Smith RI: Multicentric
Giant Cell tumour of bone. J Bone Joint Surg (AM)
lffiJ;62:652-656