Sestamibi and FDG-PET scans to support diagnosis of jaw osteonecrosis

Abstract

Osteonecrosis of the maxillary or mandibular bone is an infrequent but often severe event occurring in patients who undergo prolonged treatment with bisphosphonates. Histology is in some cases mandatory to differentiate it from neoplastic osteolysis, but a biopsy can further contribute to bone damage. Functional imaging obtained by a tracer that shows oncotropic properties, such as Tc99m-sestamibi, in comparison to a non-tumor-specific substance such as FDG-PET, can support the differential diagnosis, thus avoiding invasive procedures. Four patients affected by multiple myeloma and jaw osteonecrosis were prospectively evaluated by sestamibi and FDG-PET scans. Local diagnosis was performed by clinical, radiological and, in some cases, histological evaluations. Each patient was studied by Tc99m-sestamibi, performed by planar anterior and posterior whole-body scans and SPECT of the head and neck, and by PET/CT. Two nuclear medicine physicians, unaware of the final diagnosis, reviewed the images. No sestamibi uptake was evident in the four patients with jaw osteonecrosis, while FDG-PET/CT showed focal uptake in all of them. Our study suggests that the combined use of sestamibi scintigraphy and FDG-PET/CT could support the clinical diagnosis of oral osteonecrosis avoiding the risks of a surgical biopsy. Studies on higher number of patients are necessary to validate these preliminary observations.

Differentiating osteoradionecrosis from nasopharyngeal carcinoma tumour recurrence using99Tcm-sestamibi SPECT/CT

“…Our case demonstrates the possible use of 99 Tc msestamibi in differentiating osteoradionecrosis from viable tumour, in which negligible uptake of 99 Tc msestamibi is expected in areas of radiation necrosis, and our findings collaborate with a case series evaluating biphosphonate-induced mandibular osteonecrosis, in which no sestamibi uptake was evident in the patients with jaw osteonecrosis, while FDG-PET/CT showed focal uptake in all of them [12].…”

Pathophysiology of atypical femoral fractures and osteonecrosis of the jaw

“…Lesclous et al [59] reported the presence of TRAP-positive mononuclear and multinucleate cells in perinecrotic tissue, and in other studies, the presence of increased numbers of osteoclasts and active bone resorption have been reported. Furthermore, isotope studies using technetium-labelled diphosphonate or F-18 FDG PET have shown increased uptake in the regions surrounding the necrotic jaw [60][61][62][63]. Finally, ONJ does not occur in other conditions associated with low bone turnover; in autosomal dominant osteopetrosis (ADO), osteomyelitis of the jaw has been reported in approximately 13% of affected individuals [64], but distinguishing osteomyelitis and ONJ can be difficult, and it is uncertain whether the condition described in patients with ADO conforms fully to the clinical definition of ONJ currently in use.…”

18F-FDG PET/CT: a review of diagnostic and prognostic features in multiple myeloma and related disorders

“…To this end, the availability of reliable imaging techniques is essential. By comparing functional imaging with 99m Tc-sestamibi (a tracer with oncotropic properties) with the non-tumor-specific 18 FDG PET scans in 4 patients with ONJ, no uptake was detected with the first technique in any of the patients, whereas FDG PET was able to reveal focal uptake in all of them [62]. When 11 patients with ONJ were comparatively studied with different imaging tools, bone sclerosis and fragmentation were detected by plain radiographs and CT, whereas 18F F-FDG PET (to assess glucose metabolism) and 18 Fsodium fluoride PET (to evaluate bone mineralization) revealed, as expected, an increased SUVmax in the regions affected with ONJ, although the uptake was significantly higher for 18 F-sodium fluoride PET than for 18 F-FDG PET scans.…”

“…It has also been emphasized that bone necrosis may be enhanced by the anti-angiogenic properties of BPs [61], a hardly acceptable explanation given that both maxilla and mandible are frequently involved by ONJ, but the vascular supply of the maxilla is much higher than that of the mandible. Rather, it seems reasonable to hypothesize that ONJ is the final result of a number of factors, including abnormal bone remodeling and infection after tooth extractions and exposure of tooth socket, scanty or no repair of the physiological microdamage, the masticatory pressure [61], and genetic factors [62].…”