Presentation
Concern for bony metastases in patient with known prostate cancer.
Patient Data
Whole body bone scan images demonstrate multiple findings:
Moderately intense uptake in the right paranasal sinus region typical for sinusitis.
Adjacent uptake in the maxilla and right mandible typical for odontogenic disease vs recent procedures or hardware.
Indeterminate moderately intense focus of uptake in the proximal metaphysis, right humerus (almost certain for a benign enchondroma on additional imaging)
Intense uptake in the right antecubital fossa representing a small amount of dose extravasation.
Degenerative changes in the left>right shoulders, left>right sternoclavicular joints, sternomanubrial joint, right lower lumbar facets, and left patellar femoral joint.
No evidence of metastatic disease.
Axial and coronal non-contrast images of the paranasal sinuses shows extensive mucosal thickening of the right frontal and ethmoid sinuses as well as complete opacification of the right maxillary sinus. The walls of the right maxillary sinus are thickened, representing hyperostosis from prolonged mucoperiosteal inflammation. The right maxillary sinus is expanded with bone remodeling and resorption part of right medial maxillary sinus wall and the right uncinate process. Expanded right maxillary sinus represents mucocele which further obstructing the right ostiomeatal unit.
This pattern of sinus disease (frontal, ethmoidal and maxillary) is typical of the ostiomeatal unit pattern.
Case Discussion
Bone scintigraphy is used for a variety of indications - most commonly to detect bone metastases but also for infection and inflammation such as osteomyelitis and inflammatory arthritides. The radiotracers are all forms of phosphonates (Tc99m-MDP/HDP) and localize to sites of increased osteoblastic activity (with increased blood flow a lesser, secondary mechanism).
In this case, the mucoperiosteal reaction of sinusitis results in increased osteoblastic activity in the paranasal sinus walls which results in the radiotracer uptake seen. The soft tissue inflammation also results in a degree of increased blood flow, which also adds to the radiotracer accumulation.
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