Biomedical subjects
Publications and source records attributed to D Coupland.
The authors report a case of metastatic breast carcinoma that on investigation was shown to have a negative bone scan in spite of multiple densely sclerotic metastases on radiography and CT and a positive bone biopsy. The literature is reviewed with regard to the subject of negative bone scans in this situation.
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OBJECTIVES: To determine whether pretreatment serum prostate-specific antigen (PSA) levels in newly diagnosed prostate cancer patients can identify a group with a low probability of osseous metastasis and safely eliminate the need for a bone scan as a routine part of the staging evaluation. METHODS: We retrospectively reviewed 683 patients with prostate cancer between 1990 and 1993. Patients with prior therapy or serum PSA levels obtained longer than 3 months prior to bone scan were excluded. Bone scans were reviewed by two nuclear medicine physicians with a third deciding equivocal cases. RESULTS: Only 6% of 490 evaluable patients had a positive bone scan on initial evaluation. Scans were positive in 0 of 290 (0%) with PSA levels below 10 micrograms/L, 4 of 88 (4.5%) with PSA levels between 10 and 20 micrograms/L, and 24 of 112 (21%) with PSA levels above 20 micrograms/L. Although the risk of a positive bone scan increased with increasing PSA levels, PSA is a poor positive predictor of positive bone scans. The risk of a positive bone scan was 8% (5 of 64 patients) when PSA was between 20 and 50 micrograms/L, and increased to 40% (19 of 48 patients) for PSA levels greater than 50 micrograms/L. In contrast, serum PSA levels below 10 micrograms/L are strong negative predictors of positive bone scans, with no positive scans in 290 patients with PSA levels below 10 micrograms/L. Although the risk of a positive bone scan increased with increasing stage and grade, tumor stage and grade were poor negative predictors of positive bone scans. Up to 4% of patients with clinically confined or well-differentiated to moderately differentiated tumors had positive scans. Scans were positive in 12% of poorly differentiated tumors, but all these patients had PSA levels above 10 micrograms/L. CONCLUSIONS: Our data support the elimination of routine bone scintigraphy in patients with newly diagnosed prostate cancer and PSA levels below 10 micrograms/L. Bone scans are indicated when PSA levels are above 10 micrograms/L, or with T3 or poorly differentiated disease.
A patient with upper abdominal discomfort had Tc-99m IDA scintigraphy performed for suspected gallbladder disease. In addition to filling of the bile ducts and the gallbladder, tracer collected in the right side of the abdomen and was thought at first to be the right paracolic gutter, indicating a gallbladder rupture. Discussion with the surgeon and radiographic correlation indicated that the patient did not have gallbladder perforation but, rather, a malrotation of the bowel. This diagnosis became clear on delayed images.
An elderly patient with a complex history of organic dementia but a normal neurologic examination had a 99mTc-hexamethylpropylene-amine-oxime (HMPAO) brain scan for a suspected cerebrovascular accident or space-occupying lesion. The study showed no perfusion abnormality in the brain parenchyma, but bilateral flattening and inversion of the normal hemispheric convexities, with separation from the skull was identified. Bilateral subdural hematomas (SDH) were suspected and the patient had a computed tomographic scan that confirmed the diagnosis.