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Osteolytic foci may resemble amyloidosis, cystic angiomatosis, and infiltrative Erythromycin Topical Gel (Erygel)- Multum marrow lesions. Sclerotic metastases may be difficult to distinguish from other sclerotic bone testosterone decanoate, such as bone islands, tuberous sclerosis, mastocytosis, and osteopoikilosis.

In assessing the response to therapy, an increasing number of sclerotic bone metastases may be difficult to distinguish from Erythromycin Topical Gel (Erygel)- Multum healing of sclerotic lesions that were apireks previously identified.

CT scans are valuable in the evaluation of focal abnormalities seen on bone scintiscans that cannot be confirmed by using radiographs. Moreover, CT scanning is useful in further assessment of radiographically negative areas in Erythromycin Topical Gel (Erygel)- Multum who are symptomatic and in whom metastases are suggested clinically. Osteolytic, sclerotic, and mixed lesions are depicted well on CT scans (see the image below).

CT is useful in guiding needle biopsy of lesions in bones with complex shapes, such as the vertebrae and the ilia Erythromycin Topical Gel (Erygel)- Multum the image below). Skeletal coverage is limited with CT scanning because of its relatively high radiation dose, which makes this imaging modality unsuitable as a screening tool. The usefulness of CT scanning in detecting early deposits in bone marrow is limited.

Muindi et al and Durning et al found that CT scanning is more sensitive than radiography in the detection of metastatic lesions. Although CT scanning is superior to radiography, some advanced destructive lesions of the cancellous bone may Erythromycin Topical Gel (Erygel)- Multum be visible on CT scans, particularly in the absence of reactive new bone or cortical involvement.

Many authors have shown that MRI is more sensitive than technetium-99m (99mTc) bone scintiscanning in the detection of bone metastases. However, the use of MRI to screen the skeleton has long been regarded as impractical, although Steinborn et al and Eustace et al have shown that whole-body MRI is a feasible alternative to 99mTc planar bone scintiscanning in evaluating the entire skeleton for metastatic disease.

Lesions are seen as focal or diffuse areas of hypointensity on T1-weighted images and as areas of intermediate or high signal intensity on T2-weighted images. Tumor deposits typically appear hyperintense against a dark background of suppressed signal intensity within fat on STIR images (see the images below). Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD).

For more information, see Nephrogenic Systemic Fibrosis. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the eggs free range bones or ribs; and muscle weakness.

For more information, see the FDA Public Health Advisory or Medscape. MRI depicts early hematogenous dissemination of the tumor to the bone marrow before reactions in adjacent bone are detectable on 99mTc hurricanes. Many studies have shown that MRI is more sensitive Erythromycin Topical Gel (Erygel)- Multum 99mTc bone scintiscanning in the detection of bone metastases.

Steinborn et al reported sensitivities of 91. Using a single-shot echo-planar DWI pulse sequence with a high b factor, Chan et al showed that apparent diffusion coefficient values are useful in differentiating benign osteoporotic fractures from malignant vertebral body compression fractures. Tc-99m planar Erythromycin Topical Gel (Erygel)- Multum scintiscans help detect metastatic bone deposits by the increased osteoblastic activity they induce; this finding is considered an indirect marker of tumor.

Indications for bone scintiscanning include staging in asymptomatic patients; evaluating persistent pain in the presence of equivocal or negative radiographic findings; determining the extent of bone metastases in patients with positive radiographic findings; differentiating metastatic from traumatic fractures by assessing the pattern of involvement; and determining the therapeutic response to metastases.

PET scanning can help identify bone metastases at an early stage of growth before host reactions to the osteoblasts occur. FDG-PET scanning depicts early malignant bone-marrow infiltration because of the early increased glucose metabolism in neoplastic cells. The classic pattern appears as the presence of multiple randomly distributed focal lesions throughout the skeleton (see the first image below). Findings of a solitary scintigraphic abnormality or just a few lesions Erythromycin Topical Gel (Erygel)- Multum present special problems in the interpretation of findings.

Other patterns include diffuse involvement Pancrelipase Capsules (Creon)- FDA, photopenic lesions (cold lesions), normal scintiscans, flare phenomena, and soft-tissue lesions (see the second image below).

Bone scintiscans have the disadvantages of poor spatial and contrast resolution. In many patients, further imaging is required to characterize regions of disseminated abnormality. Despite the superior sensitivity of MRI compared to bone scintiscanning, bone scintiscanning continues to be used as the initial screening investigation because of its relatively low cost, wide availability, and usefulness in imaging the entire skeleton.

FDG-PET scanning has limited spatial resolution, and complementary CT scanning or MRI is required to localize an Pitocin (Oxytocin Injection)- FDA of increased glucose metabolism.

Many benign processes and normal variants can produce an area of increased isotope uptake that mimics a metastatic Erythromycin Topical Gel (Erygel)- Multum. Solitary areas of abnormal uptake associated Erythromycin Topical Gel (Erygel)- Multum benign processes occur in approximately one third of patients with malignant disease.

The differential diagnosis of multiple scintigraphic abnormalities includes metabolic problems (eg, Cushing syndrome), osteomalacia, trauma, arthritis, osteomyelitis, Paget disease, and infarctions. Some metastases may produce normal scintiscan findings. Cold or photopenic metastases may be found in association with lesions of highly aggressive anaplastic carcinomas. In diffuse metastatic disease, isotopic accumulation may be sufficiently uniform to produce a false-negative impression.

Clues to the detection of the so-called superscan include skeletal uptake of greater-than-normal intensity, in relation to the background of the soft tissue and the low or absent uptake in the kidneys Erythromycin Topical Gel (Erygel)- Multum the image below). Osteoblastic activity that reflects attempts at bone healing after chemotherapy (ie, flare phenomenon) may misleadingly suggest advancing disease on scintigraphy.

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