核醫(yī)學(xué)骨關(guān)節(jié)系統(tǒng)

1、Musculoskeletal system骨、關(guān)節(jié),Musculoskeletal system骨、關(guān)節(jié),,放射性核素骨顯像Radionuclide bone imaging,第一節(jié)解剖與生理,全身骨由骨連接構(gòu)成骨骼,其構(gòu)成人體支架.具有支持\運(yùn)動\保護(hù)內(nèi)臟的功能,同時(shí)對血液的生成與礦物質(zhì)儲存也起著重要作用.,骨的分類,體內(nèi)位置分:中軸骨,四肢骨基本形態(tài)分:長骨,短骨,扁骨,不規(guī)則骨.,骨的組成,骨質(zhì)：骨密質(zhì)與松質(zhì)。骨膜：內(nèi)

2、外兩層。骨髓：紅與黃骨髓。神經(jīng)：主要存在于骨膜內(nèi)。血管：滋養(yǎng)動脈，骨膜動脈，干骺端動脈，骺動脈等。,骨的化學(xué)成分,有機(jī)質(zhì): 約占1/3，骨膠原粘蛋白為主。無機(jī)質(zhì)：約占2/3，主要為鈣、磷等的鹽類，主要成分為羥基磷灰石。,關(guān)節(jié),關(guān)節(jié)面：關(guān)節(jié)頭，關(guān)節(jié)窩。關(guān)節(jié)囊關(guān)節(jié)腔血管神經(jīng),Static bone imaging (靜態(tài)骨顯像）,原理（ Principles ）,Bone,,Organic substances (有機(jī)物

3、) bone cell, collagen,Minerals: （礦物質(zhì)）hydroxyapatite (HAP),Ca10(PO4)6(OH)2 （羥基磷灰石晶體）with a 3×106m2 surface area,過程,Bone,Extracellular fluid (ECF),Blood flow,Radiopharmaceuticals (tra

4、cer),,,,Ions exchange,i. v.,,,Tracer uptake increase (hot spot，熱區(qū)),,,,,Tracer uptake decrease (cold defect，冷區(qū)/缺損),1.blood flow increased 2.bone turnover increased osteoblastic activity 3.new bone formation,1.

5、blood flow decreased 2.osteonecrosis change 3.destructive process.,Blood flow Metabolic change,The process of bone disease,Reaction stage Proliferate stage Stable stage 反應(yīng)期(6m),影響骨聚集磷酸鹽 的因素,骨的代謝活躍局部血流量交感神經(jīng)的影響

6、,顯像劑 Imaging agents （tracer）,P-O-P: Pyrophosphate (PYP, 焦磷酸鹽) P-C-P: Methylene diphosphonate (MDP,亞甲基二膦酸鹽), and HMDP (亞甲基羥基二膦酸鹽),劑量,99mTc-MDP is most widely used bone scan imaging agent. The usual dose of radiopharm

7、aceutical is 20-25 mCi (740-925 MBq). For pediatric patients, the recommended dose is approximately 9.25MBq or 0.25mCi/kg,Imaging protocol （顯像方法）,全身骨顯像局部顯像,Indications（適應(yīng)征）,早期尋找惡性腫瘤的骨轉(zhuǎn)移灶骨腫瘤或活檢定位，判定病變手術(shù)范圍局部骨痛疑似某些代謝性

8、骨病疑為急性骨髓炎觀察移植骨的血供和成活股骨頭血供狀態(tài)的觀察,Indications（適應(yīng)征）,判定X線攝影片難以觀察發(fā)現(xiàn)的骨折早期診斷某些職業(yè)性骨疾病鑒別陳舊性和新近發(fā)生的壓縮性骨折鑒別非膠原性疾病引起的血清堿性磷酸酶升高診斷和觀察正常骨外的骨化組織或病變燒傷后骨壞死的診斷,Scan interpretation（圖像分析）,正常圖象：全身骨骼呈對稱性分布；基本規(guī)律是扁平骨較長骨管狀骨清晰；管狀骨骼兩端放射性多于骨干，

9、大關(guān)節(jié)較小關(guān)節(jié)清晰；小兒和青少年骨質(zhì)生長活躍，在骨骺及干骺端顯影劑濃集較成人多。,正常圖象,adult child,正常圖象,,Pelvis SPECT imaging 骨盆的斷層顯像,異常圖象（Abnormal imaging ）,熱區(qū)冷區(qū),hot sp

10、ot,Paget’s disease,Paget’s disease,特殊骨顯像（Super bone scan ）,超級骨顯像(super-bong scan)閃爍（flare phenomenon)長骨骨密質(zhì)顯象濃集胸部軟組織顯影濃集,主要用途,Widespread metastases (廣泛性骨轉(zhuǎn)移，breast and prostate cancer) Hyperparathyroidism （甲狀旁腺功能亢進(jìn)）,Ab

11、normal radioactive decrease: cold defect（冷區(qū)/缺損）,doughnut sign (炸面圈征),Osteonecrosis in thorax and lumbar spine 胸椎和腰椎的骨質(zhì)破壞,,Multiple bone metastasis, abnormal tracer uptake in lung and right calf muscle.,骨外病變或人工偽影所致異常,

12、鈣化軟組織體位污染異物標(biāo)記率,骨顯像的敏感性與特異性,敏感性非特異性,Clinical applications,Search bone metastasis at early stage.,,Whole body metastasis of prostate cancer lung cancer metastasis 肺癌骨轉(zhuǎn)移 前列腺癌的全身骨轉(zhuǎn)移

13、 right femur doughnut sign, right hip joint hot spot 右股骨炸面圈征，右髖關(guān)節(jié)濃聚灶,,Whole body metastasis of prostate cancer 前列腺癌 Super

14、 bone scan (超級骨顯像),3 m after prostate cancer surgery,18 m after surgery,,A: Multiple bone metastases B: after 89Sr therapy (8 m),,2 m, 13m, 19m after prostate cancer surgery,,2. Primary bone tumor,Upper side, lower side

15、 of of left femur osteogenic sarcoma （成骨肉瘤）,multiple myeloma 多發(fā)性骨髓瘤,骨折（Fracture）,To find out fracture in early stage. Occult or covert fracture （隱匿性骨折） Stress fracture（應(yīng)力性骨折） Insufficiency fracture （不完全性骨折）,Calcaneus

16、 (跟骨),Left foot 4th toe,代謝性疾病,骨質(zhì)疏松甲狀旁腺功能亢進(jìn)骨軟化癥畸形性骨炎,Vertebral fracture in lumbar spine 骨質(zhì)疏松的腰椎椎體骨折,骨髓炎,12-48小時(shí)熱區(qū)與冷區(qū),移植骨,血供新骨形成,股骨頭血供,早期發(fā)現(xiàn)病變期與修復(fù)期,,,,,Dynamic bone imaging 骨動態(tài)顯像,,Principles and Method,三時(shí)相四時(shí)相,Three

17、、four-phase bone imaging,（three-phase bone imaging，骨三、四相） Imaging agent and dosage Imaging protocol（血流相、血池相、延遲相） Blood flow phase: 3s / frame, 60s Blood pool phase: 2-3 min after injection, 60s

18、 /frame, 5 f Delayed phase: 2-4hrs 24 hrs after injection, static imaging,Indications 適應(yīng)癥,Survey blood supply and metabolic situation of bone and soft tissue; Differentiate malignant tumor from benign tumor

19、 Ischemic necrosis of the femoral head (aseptic necrosis of femoral head) Differentiate acute osteomyelitis from cellulitis; Evaluate viability and blood supply of bone graft,顯像劑,P-O-P: Pyrophosphate (PYP, 焦磷酸鹽)P-C-

20、P: Methylene diphosphonate (MDP,亞甲基二膦酸鹽), and HMDP (亞甲基羥基二膦酸鹽),劑量,The usual dose of radiopharmaceutical is 20-25 mCi (740-925 MBq).,方法,3s / frame, 60s2-3 min after injection, 40-60s /frame, 5-10 frame2-4hrs24 hrs afte

21、r injection, static imaging,Normal imaging 正常影像,Blood flow phase Blood pool phase Delayed phase,Normal imaging 正常影像,A: Blood flow phase B: Time-active curve of ROI C: Blood pool phase

22、 感興趣區(qū)的時(shí)間－放射性曲線,Clinical applications and interpretation,Differentiate malignant tumor from benign tumor（骨腫瘤良惡性鑒別） Ischemic necrosis of the femoral head (aseptic necrosis of femoral head，股骨頭缺血性壞死) Differentiate acu

23、te osteomyelitis（急性骨髓炎 ） from cellulitis（蜂窩組織炎） Evaluate viability and blood supply of bone graft （移植骨存活的判斷）診斷血管疾病,Left femur osteogenic sarcoma A: Blood flow phase B

24、: Time-active curve of ROI 時(shí)間-放射性曲線 C: Blood pool phase D: Delayed phase,Right knee giant cell sarcoma A: Blood flow phase B: Time-active curve of ROI C: Delayed phase,Cold defect in right

25、 femur head,hot spot in right femur head Ischemic necrosis of the femoral head,Joint imaging關(guān)節(jié)顯像,Principles and method,關(guān)節(jié)炎癥、退變、骨性關(guān)節(jié)壓力異常，該部位無機(jī)鹽代謝增強(qiáng)，局部血供增加，導(dǎo)致關(guān)節(jié)周圍骨更新旺盛Tc-MDP +蛋白,顯像劑,反映炎癥滑膜局部血供的顯像劑：99mTc（ 99mTcO4）-白蛋白骨顯

26、像劑： 99mTc-MDP 選擇性聚集于炎癥病灶：111In（ 99mTc、Ga）- WBC（HIG ）,Imaging protocol （顯像方法）,檢查前口服過氯酸鉀400毫克確定興趣區(qū)three-phase bone imaging,Indications 適應(yīng)癥,Joint disease骨關(guān)節(jié)病 Arthritis 關(guān)節(jié)炎 Suspect joint disease, without radiography fi

27、nding 可疑骨關(guān)節(jié)病 Follow up of joint disease關(guān)節(jié)疾病的隨訪 Follow up of prosthesis人工關(guān)節(jié)的隨訪 Reflex sympathetic dystrophy syndrome, RSDS 放射性交感營養(yǎng)不良綜合征,Normal imaging,Normal imaging,異常表現(xiàn)Abnormal imaging,hot spotthree-phase bone imagi

28、ng,Clinical applications and interpretation,Rheumatoid arthritis類風(fēng)濕性關(guān)節(jié)炎 Osteoarthritis骨關(guān)節(jié)炎/退行性關(guān)節(jié)病 Prosthesis人工關(guān)節(jié) Reflex sympathetic dystrophy syndrome RSDS 反射性交感營養(yǎng)不良綜合征 Other joint diseases: gout 痛風(fēng), etc,Rheumatoid