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Year : 2011  |  Volume : 10  |  Issue : 2  |  Page : 210-215

Abstracts of Poster Presentations - (Bone Pain Palliation/ Radiosynovectomy)

Date of Web Publication12-Nov-2011

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. Abstracts of Poster Presentations - (Bone Pain Palliation/ Radiosynovectomy). World J Nucl Med 2011;10:210-5

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. Abstracts of Poster Presentations - (Bone Pain Palliation/ Radiosynovectomy). World J Nucl Med [serial online] 2011 [cited 2022 Oct 2];10:210-5. Available from: http://www.wjnm.org/text.asp?2011/10/2/210/89788


Detection of Bone Metastases by Planer Bone Scintigraphy and SPECT Bone Scintigraphy

M. S. R. Miah, M. R. I. Islam, S. S. Sardar, S. S. Sharmin

Centre for Nuclear Medicine and Ultrasound, Bangladesh Atomic Energy Commission, Comilla, Bangladesh

Objective: Bone scintigraphy (BS) is widely used method for evaluating bone metastases of cancer patients. The aim of our study was to compare the detection of bone metastases by Tc-99m MDP planar BS and SPECT BS. Materials and Methods: In a prospective study done in centre for Nuclear Medicine and Ultrasound, Comilla, Bangladesh during the period from January 2010 to April 2011, planar BS and SPECT BS were performed on the same day in 36 cancer patients for bone metastases. In 25 patients, planar BS was followed by single field of view (FOV) SPECT and in 11 patients by multi-FOV SPECT of the axial skeleton. Lesions were interpreted separately by two senior nuclear medicine physicians. Lesions were grouped as normal or malignant. Benign lesions were included in normal and equivocal lesions in malignant. Results: In patient-based analysis, 30 (83.3%) patients had skeletal metastases in SPECT BS and 21 (58.3%) in planar BS. In lesion-based analysis, 63 lesions detected by SPECT BS and 33 lesions in planar BS.

Conclusions: SPECT BS is superior in detecting bone metastases from that of planar BS in cancer patients.


Our First Experiences in Palliative Treatment of Painful Bone Metastases with Sm-153

Z. Rajkovaca, D. Stanimirovic, J. Mijatovic, P. Kovacevic

Department of Nuclear Medicine, Clinical Centre Banja Luka, Banja Luka, Bosnia and Herzegovina

Background: The role of Samarium-153 in pain palliation is well established. This systemic form of radionuclide therapy is simple to administer, with an overall reported pain response rate in the order of 70-80% of patients. It has been associated with marked pain reduction, improved mobility, reduced dependence on analgesics and improved quality of life. In this study we are presenting our first experiences in palliative treatment of painful osseous metastases with Sm-153. Materials and Materials and Methods: Seven patients with multiple bone metastases have been referred to our department. Prior to consideration for radionuclide therapy adequate selection of patients is necessary. Recent bone scans were evaluated in order to determine if the patient has painful osteoblastic lesions likely to respond to therapy. Relative contraindications for treatment included osteolytic lesions, spinal cord compression or pathologic fracture, preexisting severe myelosuppression, urinary incontinence, inability to follow radiation safety precautions and severe renal insufficiency. Patients that are not in good clinical condition pose an additional contamination danger to those attending them. Four patients did not fulfill these preconditions for treatment. Results: Three patients (one man and two women, age 39-66, one prostate and two breast cancers) received a single bolus infusion of Sm-153 (37 MBq/kg, up to 2,59 GBq). All patients had painful bone metastases to more than one anatomical region and had inadequate pain control to narcotic analgesics. Pain scores, adverse events, and hematologic parameters were assessed after each dose in period of four months. Onset of improvement took place a median of 7 days after Sm-153 EDTMP administration, maximum effect (50-70% reduction of pain) after 1 month and pain relief persisted for a mean of 3,5 months. Only mild and transient hematological toxicity was found in this period.

Conclusion: Sm-153 is a good therapeutic option for patients with painful bone metastases. It is an effective treatment for pain relief and improves the quality of life. Side effects, including hematological toxicity, after Sm-153 treatment was mild and transient.


Evaluation of Prostate Cancer with Serum Prostate Specific Antigen, Alkaline Phosphatase Level and Bone Scintigraphy

A. Shirin, S. Yasmeen

Institute of Nuclear Medicine and Ultrasound, Dhaka, Bangladesh

Objective: The aim of this study is to correlate progression of bone metastases by bone scintigraphy and the increasing rates of serum Prostatic Specific Antigen (PSA) and Alkaline Phosphatase (ALP) levels in cancer prostate.

Materials and Methods: A prospective cross sectional study was carried out at the Institute of Nuclear Medicine and Ultrasound (INMU), in randomly selected 100 patients with diagnosed prostate cancer. Serum PSA and ALP measured in recognized laboratory of BSMMU by ELISA method. Bone scans were performed with 99m Tc- MDP as bone seeking agent, given intravenously at a dose of 740-1110MBq (20-30 mCi). Imaging was done 2-4 hours after tracer injection by SPECT gamma camera (Siemens ECAM) using low- energy, high-resolution collimator. After reconstruction of images the scans were interpreted by experienced physicians. Numerical data obtained from this study were statistically analyzed by SPSS systems.

Results: In this study, bone scintigraphy was positive for metastasis in 59 patients while 41 had no evidence of secondary skeletal metastases. This study showed that the PSA and ALP levels are increased along with the increase in the extent of skeletal metastases in bone scan. The higher the level of serum PSA and ALP the greater is the probability of bony metastases. When PSA level was greater than 50 ng/ml, 37 (62.7%) patients out of 59 patients had bony metastases. By contrast, when the PSA level was below the normal level of 4 ng/ml, the scans were negative for bone metastasis in 28 (68.3%) out of 41 individuals. The overall relationship between PSA level and bone scan was significant (P < 0.001). When the ALP was within the normal level of 32-126 U/ml, the bone scans were negative for bone metastasis in 34 (82.9%) out of 41 individuals. By contrast when ALP level was greater than 126 U/ml, bone scans were positive for metastases in 56(95%) out of 59 patients. Again 30 patients with serum ALP concentrations higher than 200 U/ml showed that all of them had extensive skeletal metastases in bone scan. Both the PSA and ALP have high specificity 68% and 83% respectively for bone metastases in bone scan findings. Sensitivity for bone metastases of PSA is 90% and of ALP is 95%. Serum ALP level is found to be more sensitive than PSA and a valuable complementary marker in skeletal metastases in prostate cancer.

Conclusion: In patients who received treatment sometimes the PSA level is decreasing but ALP is still on the rise when there is metastasis or progression of diseases. So PSA level alone did not always correlate with progression of bone metastasis. But when applied together ALP enhance the clinical utility and validity of PSA and can more accurately predict metastases suggesting time to have a follow up bone scan for the patients, which is also cost effective. Raised PSA and ALP levels also add to the improvement of the sensitivity and specificity of bone scan in early screening and assessing the extent of metastasis in advanced stage thus helping in clinical staging of cancer prostate. As tumor marker (PSA) is not solely enough in predicting bone metastasis, so quantitative association of PSA level and serum ALP levels provides clear insight into the extent of metastasis in bone scan, helps in assessment of prognosis and management of patients with prostate cancer.


Bone Scintigraphy Findings of Multiple Osteoblastic Lesions in a Child with Primitive Neuroectodermal Tumor

K. M. dela Cruz

Radiology, Section of Nuclear Medicine, University of Santo Tomas, Manila, Philippines

Patient is a 7-year old male complaining of bone pains in both knees and ankles. He was reluctant to move his right knee and refused to walk. Patient was assessed to have reactive arthritis due to history of trauma. Patient actively plays football. However, even with intravenous morphine, pain persisted without any obvious anatomic abnormality. He was referred to our service for evaluation of any abnormal osseous pathology. Radionuclide blood flow imaging of both knee joints was done after the patient was given 18 mCi Tc-99m HDP intravenously. Anterior and posterior projections of both knee joints were acquired at five minutes for the soft tissue phase and whole body sectional imaging was obtained after three hours. Dynamic flow imaging exhibited the prompt and symmetrical flow of radiotracer into both knee regions. The five minute soft - tissue phase showed somewhat greater tracer localization in the right knee joint. Delayed sectional bone imaging shows satisfactory tracer uptake in all visualized osseous structures. Increased tracer deposition was seen in the following areas: left parietal bone; left humeral head; 8 th right posterior rib; 10 th -12 th thoracic vertebra; 1 st -3 rd lumbar vertebrae; and left acetabulum. Intense symmetrical and uniform radiotracer deposition was likewise seen in the epiphyseal and apophyseal growth centers particularly in both shoulders, sacro-iliac joints, knee joints and distal shaft of both tibia and fibula, which are normal physiologic findings at this age. Both kidneys were seen and appeared unremarkable. Report was signed out as "osteoblastic lesions in the skull, rib, thoraco-lumbar vertebra and acetabulum which may indicate an underlying malignant process". MRI of the spine showed a pre-sacral mass. Biopsy of this mass showed primitive neuroectodermal tumor. Primitive neuroectodermal tumor (PNET) is a highly aggressive malignancy belonging to the group of related tumors. This group includes Ewing sarcoma, peripheral primitive neuroectodermal tumor (PNET), neuroepithelioma, atypical Ewing sarcoma and Askin tumor. Histologically they are characterized as small round blue cell tumors. PNET is a small round cell tumor of neural crest origin. It has similar morphological, histochemical and immunogenetic descriptions as Ewing sarcoma. PNET is distinguished from Ewing Sarcoma by neural and immunocytochemical staining techniques (i.e. by the presence of Homer- Wright or Flexner-Wintersteiner rosettes; neuron-specific enolase (NSE), protein S100, Leucine 7, and neurofilaments protein, chromogranin A or synaptophysin.

In addition, PNET is usually seen in the metadiaphysis or diaphysis of long bones and flat bone of the pelvis. Studies have shown that it commonly targets the central nervous system, chest wall, lower extremities, trunk, kidney and orbit. It was observed the lesions were predominantly found in the leg, pelvis, humerus, diaphyseal and metaphyseal areas. However, for a small number of people, it affects the spine. As in this case, a tumor in the pre-sacral area was found. Fine needle aspiration cytology or open biopsy is still the definitive diagnostic procedure. In a study by He et al, 28 cases of primary intraspinal PNETs were studied retrospectively. It was concluded that PNET in the spine has poor prognosis and greater frequency of recurrence and metastases. Within the spine, the most common site is the sacrum. The bone marrow activity is filled with tumors that lead to cortical destruction and eventually large soft tissue mass formation. It could be completely lytic or sclerotic brought about by bone formation reaction. Local recurrence and distant metastatic lesions are commonly seen in the regional nodes, lungs, liver and bone. Radiogaphically, the lesions in PNET are usually described as aggressive, poorly demarcated tumor, with cortical destruction, periosteal reaction and soft tissue invasion. CT scan may show lytic, sclerotic or mixed features. In a study done by Vanel, et al records of 13 patients with PNET were reviewed retrospectively. There was an average of delay of 5 months from the onset and diagnosis. For patients with metastases, an average of 8 months before the patient dies is observed. On the other hand, patients with no metastases tend to live 36 months on average after the diagnosis is made. The average time from the operation to death was 18 months. Prognostic factors include the stage, age of the patient, extent of surgical resection and time to treatment. There is a need for immediate identification of the diagnosis to initiate therapy as early as possible. Bone pain in children can have multiple etiologies, including trauma, inflammatory, infection and malignancy. The etiology of unexplained bone pain in a pediatric patient after ruling out infectious and traumatic causes, should include malignancy in the differential diagnosis. This case report focuses on how the abnormal findings in bone scan aided the referring physician towards an early and correct diagnosis. Bone scan was the initial imaging done in this case and it pointed out the bone lesions, which prompted further radiologic investigations and eventually biopsy. Biopsy of the presacral mass revealed primitive neuroectodermal tumor (PNET). PNET is an aggressive tumor that is best if treated as early as possible. Bone scintigraphy findings are used in the staging, prognostication factors and treatment of patients with PNET. As in this case, the site of the tumor especially if in the sacrum is highly aggressive. The time interval between presentation of symptoms, diagnosis and treatment is of great importance. The findings in bone scan help expedite the justification to do biopsy in the affected area of the patient which may lead to the diagnosis of PNET. PNET is a highly aggressive lesion involving soft tissue mass and bone lesion as seen in this case.


Bone-seeking Radiopharmaceuticals for Pain Palliation in Prostate

R. Mititelu

Nuclear Medicine, Central University Military Hospital, Bucharest

It is estimated that in Romania, prostate cancer represents the second major cause of mortality for cancer in men, after pulmonary cancer. Data provided by the Center of Medical Statistics of Romanian Ministry of Health, also shown that in the past ten years the incidence of prostate cancer increased up progressively, along with a reduction in the median age of newly diagnosed patients. Bone metastases are a serious complication that occurs in advanced phases of the disease. These patients may survive for years with severe pain and serious impaired mobility. There are different etiologies of pain in patients with skeletal metastases, therefore there will be different therapeutic approaches. Vertebral body collapse, nerve root compression, or pathological fractures will need different approach to pain management than skeletal pain related to osteoblastic metastasis and release of pain mediators. This paper was focused to the second situation, in which patients suffer from generalized bone pain due to multiple osteoblastic foci demonstrated on the bone scan. There is no curative treatment of bone metastases at this moment. All we can do for patients in this condition is to try to manage with maximum advantage existing resources for bone pain palliation. This can be attempt by using several classes of drugs, in a 3-step approach: NSAIDs, weak opioids (e.g. codeine) and strong opioids (such morphine). All of them have significant side effects and all of them lead to significant increase of global costs of managing these patients. For this reason many efforts have continuously been made in order to determine the reduction of analgesic needs and a better control of pain. Localized bone metastases usually can benefit from radiation therapy or surgery, while for widespread disease the preferred method is systemic therapy with bone-seeking agents: biphosphonates or systemic radiopharmaceutical therapy. Several radionuclides are now available worldwide for the treatment of painful bone metastases: 32P, 153Sm, 89Sr, 186Re, 188Re, 177Lu, and 117mSn-Pentetate. The only one available now in Romania is 89Sr (Metastron, Amersham). This paper will discuss not only the main characteristics of these radiopharmaceuticals in terms of physical and pharmacologic properties but also in terms of efficacy as reported by main reviews in the literature. We will present our experience in treating patients with 89-Sr.


Present Day Utility of Whole Body Bone Scan in Evaluating Silent Skeletal Metastases in Apparently Operable Non-small Cell Lung Cancer when PET is not Available

A. Shinto, C. Joseph

Department of Nuclear Medicine and PET, KMCH CKE, India

Objectives: The management of patients diagnosed with non-small cell lung cancer is dependent on the stage of the disease, which is also crucial for prognosis and selection of an appropriate treatment regimen. Historically, a whole body bone scan has been used to identify skeletal metastases. The aim of this study was to investigate the usefulness of whole-body bone scanning (BS) in detecting bone metastases in newly diagnosed and apparently operable cases of lung cancer. Materials and Methods: Ninety-two patients with a diagnosis made between 2008 and 2010 were recruited (squamous cell carcinoma, n =29; adenocarcinoma, n=36; others n=27). None of these patients had clinical factors suggesting bone metastasis (skeletal pain, elevated alkaline phosphatase, hypercalcemia). BS was performed in all patients, and additional imaging or biopsy was ordered in patients where there were doubtful lesions. Results: Bone metastases were detected in 14.13 % (n =13) of 92 clinical factor-negative patients. Of the eighteen abnormal bone scan results (eleven positive and seven probable), thirteen were true positive and the five remaining were false positive. In our study, PPV of the BS was 72.2%. Skeletal metastases were found more commonly in adenocarcinoma than other cell types. In 13 patients diagnosed with metastases, 53.8 % (n=7) were patients with adenocarcinoma and 38.4% (n=5) were in patients with squamous cell carcinoma. 4 of the 18 patients (22.2%) in T2N0M0 clinical stage had bone metastases. The routine bone scanning prevented thirteen futile thoracotomies (14%) in 92 patients with apparently operable lung cancer.

Conclusions: Though clinical factors have a high NPV and the bone scans have less than desired specificity in diagnosing metastases, BS could be considered in those asymptomatic patients as a part of their work up and staging, in whom operative intervention is contemplated.


89Sr Bremsstrahlung SPECT Imaging in Bone Metastases

M. Ishiguro, H. Toyama, S. Ota, M. Uno, M. Kato, T. Natsume, K. Kikukawa, T. Ichihara, K. Katada

Department of Radiology, Fujita Health University, Toyoake, Japan

Objectives: 89Sr has been used for therapy of patients in bone metastases. Detecting the uptakes of 89Sr in abnormal lesions of bone scan would be significant for treatment strategy. Several papers have reported 89Sr Bremsstrahlung planar imaging. However, those images were not clear to detect the hot spots. 89Sr Bremsstrahlung SPECT imaging has been evaluated for detecting the more detailed whole body 89Sr distribution. Materials and Methods: 89Sr bremsstrahlung whole body planar and SPECT images were acquired by using two detectors type SPECT system. Energy window A (100keV±50%) for planar imaging, and energy window A plus energy window B (300keV±50%) for SPECT imaging were set on the continuous spectrum. Those images were compared with 99mTc−H−MDP whole body planar and SPECT images. Thirteen cancer patients (prostate: 4, nasopharynx: 1, lung: 2, breast: 2, liver: 1, urinary bladder: 2, stomach: 1) with bone metastases were evaluated. Bone metastases in both 99mTc−H−MDP whole body planar and SPECT images were compared with 89Sr Bremsstrahlung whole body planar and SPECT images respectively. To verify the accumulation obtained by Bremsstrahlung whole body planar and SPECT image, we made original hot phantom based on the counts of clinical study imaging.

Results: We have detected 194 bone metastases in both 99mTc−H−MDP whole body planar and SPECT images. Detection of the hot spots in 89Sr SPECT images (127 of 194; 66%) was higher than in 89Sr whole body planar images (108 of 194; 56%). In phantom study, counts of each concentration linearly increase as acquisition time and number of rotation increase on planar and SPECT images.

Conclusions: 89Sr Bremsstrahlung SPECT imaging would be useful for detecting the more detailed whole body 89Sr distribution than planar imaging. The linearity of accumulation obtained by Bremsstrahlung whole body planar and SPECT was verified by hot phantom study.


Comparison of the Value of 18 F-FDG PET and 99 Tcm-MDP Bone Scan in the Detection of Bone Metastases

S. Wu, J-J Liu, S. Song

Department of Nuclear Medicine, Xinhua Hospital, Shanghai Jiaotong University, Shanghai, China

Objective: To evaluate the diagnostic value of 18 F-2-deoxyglucose (18 F -FDG) PET imaging in the detection of bone metastases and to compare with that of Tc-99m MDP bone scan. Methods: 18 F -FDG PET/ CT and Tc-99m -MDP bone scan were performed in 97 patients having or being suspected malignant tumor. The interval of these 2 examinations was within 30 days. The results of the above-mentioned examinations were compared and analyzed. Results Of the 97 patients, 63 patients had clinical or pathology diagnosed bone metastases. Based on case to case analyses, 18 F -FDG-PET showed 62 patients with positive diagnosis, and 1 patient was false negative; Tc-99m -MDP showed 49 patients with positive diagnosis and 14 patients were false negative. The sensitivity was 98.4% vs. 77.8%, showing significant statistical difference (P<0.05). Of the 34 patients without bone metastases, 18 F FDG-PET showed 29 patients with true negative and 5 patients with false positive results, while 99Tcm-MDP had 21 true negative and 13 false positive cases. The specificity was 93.8% vs. 72.2% (P<0.05) and the accuracy was 93.8% vs. 72.2% (P<0.05) respectively. Based on focal lesion to lesion analysis, altogether there were 1261 bone regions in these 97 patients (the skeletal system was divided into 13 regions), with 226 regions having metastases, 14 regions were excluded due to indeterminate final diagnosis. Of these, 18 F -FDG-PET found 222 regions showing true positive diagnosis and 4 regions showing false negative; 99Tcm-MDP showed 154 regions had at least one positive lesion, 72 regions showed false negative. The sensitivity was 98.7 % vs. 68. 1% (P<0.05); with significant statistical difference as well. Of the 1021 regions did not have skeleton metastases, 18 F -FDG-PET showed 1010 true negative and 11 false positive regions, while Tc-99m MDP showed 1001 true negative and 20 false positive regions. The specificity and accuracy were 98.9% vs 98.0% (P>0.05) and 98.8% vs 92.6% (P<0.05) respectively. According to CT features,the detection rate of bone metastases with CT osteolytic lesion and no CT abnormality by 18 F -FDG-PET and Tc-99m -MDP were 99.4% vs 72.6% and 81.5% vs 40. 7% respectively, with significant statistical differences (P<0.05). Conclusion:18 F - FDG PET has higher sensitivity and accuracy than Tc-99m -MDP bone scan,no matter based on case or based on focal lesion analysis. Furthermore, for osteolytic and no abnormality CT lesions, the detection rate of 18 F -FDG PET was superior than bone scan.


Current Status of Radionuclide Therapy in Indonesia

A. D. Siswoyo, A. H. S. Kartamihardja, J. S. Masjhur

Department of Nuclear Medicine, School of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin Hospital, Bandung, Indonesia

Nuclear era in Indonesia began when first atomic Reactor Triga 2000 Bandung Atomic Center was built and operated in 1965. The era was continued with Nuclear Medicine Service in Bandung Atomic Center, which subsequently became Nuclear Medicine department in Dr. Hasan Sadikin Hospital/Padjadjaran University in 1967. Dr. L.F. Luhulima in collaboration with Ir. Djali Ahimsa and Ir. Iyos R Subki started nuclear medicine service at Dr. Hasan Sadikin hospital in 1971. There were subsequently 14 nuclear medicine departments were built among university hospital and community hospital in 1995. In the beginning, nuclear medicine units in Indonesia must face many challenges and constraints such as lack of radiopharmaceutical supply and logistic; few number of experts include nuclear medicine physician, technologists, physicist, and radiopharmacist; nuclear phobia among the general population, etc. The problem in radioisotope and pharmaceuticals supply was gradually solved when Multipurpose Atomic Reactor "Siwabessy" was built in 1988. National Energy Nuclear Agency could produce Tc-99m generator, I-131, various cold kits, and other radioisotope and radiopharmaceutical. Nowadays they are developing various radionuclide and radiopharmaceutical such as Re-186 EDTMP / HEDP, Ho-166 DOTMP / Chitosan, Sm-153, Lu-177, Sr-90, and Y-90 which are very potential as therapy and diagnostic in oncology field. They also enhance the cyclotron production of F-18 FDG and I-123, which can supply many PET centers in the future.

By the struggles of The Indonesian Society of Nuclear Medicine for its existence, Nuclear Medicine was finally recognized as an independent specialty in 1990. Padjadjaran University has officially become first and the only institution for post-graduate medical education of nuclear medicine. This was to overcome lack of nuclear medicine physician number in Indonesia. Based on Ministry of health regulation 2009, Nuclear Medicine Department must be independent as well as radio diagnostic and radiation oncology which gave positive impact to the development of NM department. By the year of 2011 there are 19 residents who are trained and educated to be qualified nuclear medicine specialist.

Nowadays there are 12 active NM centres. Eight centres have radionuclide therapy facilities. From these centres there are 4 PET/CT facilities (2 government hospital and 2 private hospital with cyclotrons), 3 SPECT/CT, 4 SPECT and 3 gamma cameras, as diagnostic modalities. Of 12 active NM centres, there are 31 qualified nuclear medicine physicians, 30 NM technologists, 4 NM physicists, 10 (2) radiopharmacists as human resources but unequally distributed because more than fifty percent of man power are located in Jakarta.

Radionuclide therapy in Indonesia still focuses in oncology and endocrinology field. Radionuclide therapy includes treatment for thyroid cancer and hyperthyroidism with I-131; palliative treatment of bone metastases with Sm-153, P-32, Sr-89; TAE with I-131 lipiodol; local therapy hemangioma and keloid with P-32. Radioablation for hyperthyroidism is the most frequent RNT. As national reference hospital, nuclear medicine department in DR Hasan Sadikin hospital treats about 400 hyperthyroidism patients per year and about 125 thyroid cancer patients per year. There are 1-6 isolation rooms for nuclear medicine department, which have RNT. Dharmais cancer centre is developing treatment for neuroendocrine tumors (neuroblastoma) with I-131 MIBG.

For development of nuclear medicine in the future, we still have several problems that must be solved regarding policy, equipment, radiopharmaceutical, manpower, and nuclear phobia. Nuclear medicine development programme is not priority in national health agenda. We have limited and unequally equipment distribution due to lack of financial support from government. The problem about availability and cost of radiopharmaceutical due to production and demand imbalance. This issue can be solved by the increasing number of NM departments as well as number of patients. Number of NM department must be increased and well distributed outside Java Island. In order to have qualified NM personnel we must have formal training programme for nuclear medicine technologists, technical staff, physicists, and radiopharmacists. Socialization about nuclear medicine must be enhanced to reduce nuclear phobia. The NM future in Indonesia depends on the good acceptance and appreciation of public authority and medical community, as well as good support facilities and qualified manpower.


Effectiveness of Bone Metastases Treatment by Sm-153 Oxabifore in Combination with Monoclonal Antibody Denosumab (Xgeva)

N. Rasulova, V. Lyubskin, V. Krylov

Department of Nuclear Medicine, Republic Specialized Centre for Surgery, Tashkent, Uzbekistan

Introduction: Breast and prostate cancer, have a propensity to metastasize to bone and cause osteolysis and abnormal new bone formation. Metastases locally disrupt normal bone remodeling. Although metastases from prostate cancer have been classified as osteoblastic based on the radiographic appearance of the lesion, data gleaned from a rapid autopsy program indicate that the same prostate cancer patient often has evidence of osteolytic and osteoblastic disease as shown by histologic examination. Thus bone metastases are heterogeneous and requiring combined treatment targeting on both: osteolytic and osteoblastic lesions.

While Sm-153 oxabifore treatment is widely used for the relief of pain in patients with osteoblastic metastatic bone lesions, Xgeva (Debosumab) is indicated for the prevention of skeletal-related events in patients with bone metastases from solid tumors being a fully human monoclonal antibody which designed to target RANKL (RANK ligand), a protein that acts as the primary signal to promote bone removal. In many bone loss conditions, RANKL overwhelms the body s natural defense against bone destruction.

Objective: To estimate effectiveness of combined treatment of bone metastases by Sm-153 oxabifore and Xgeva (Denosumab).

Materials and Methods: 5 patients (4 female and 1 male, aged 35-64, mean age 50,8+6,1) with multiple skeletal metastases from prostatic carcinoma (1) and breast carcinoma (4) were studied. Their mean objective pain score according to 10 score system was 7,8+0,5 (range 6-9). Sm-153 EDTMP was administered at the standard bone palliation dose of 37 MBq/kg body weight. Xgeva (Denosumab) was administrating in a dosage 120 mg every 4 weeks, under monitoring of calcium level and administration of calcium, magnesium and vitamin D. WB bone scan was performed before and 3 months after treatment in all patients.

Results: After Sm-153 oxabifore administration pain relief occurred within 4,4+1,25 days (range 2-9 days) and the objective pain score decreased to 0,2 +0,2 (range 0-1). There is statistically significant difference according to pain score system before and after treatment P< 0,0001. According to WB bone scan in one patient there was significant reduction of number and intensity of bone metastases and in four patients there was no evidence of bone metastases found.

Conclusion: According to our first experience combined treatment of bone metastases by Sm-153 oxabifore and Denosumab is effective and safe. However further evaluation is necessary in a larger patient population to validate our results in this study.


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