Case Author(s): Charles Pringle, M.D.,Farrokh Dehdashti, M.D. , 02/13/96 . Rating: #D4, #Q4

Diagnosis: Neuroblastoma

Brief history:

Intermittent back pain for three months.


Whole body delay images

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Full history/Diagnosis is available below

Diagnosis: Neuroblastoma

Full history:

5-1/2 year old boy complaining of worsening, intermittent back pain over the last three months.


Bone scintigraphy - 4.6 mCi Tc-99m MDP i.v. and Octreotide scintigraphy - 1.4 mCi In-111 octreoscan i.v.


The bone scintigraphy demonstrates multiple focal areas of increased radiopharmaceutical activity involving the thoracolumbar spine, the skull, and the left pelvis. Additionally, there are two photopenic areas present within the T12 vertebra and within the L4 vertebra. These findings are most suggestive of malignancy. The differential would include metastatic disease, lymphoma, or leukemia.

The octreotide scintigraphy demonstrates multiple focal areas of increased activity throughout the axial and appendicular skeleton including the skull, the face, the clivus, the sternum, bilateral proximal humeri, bilateral ribs, multiple areas within the entire spine, the pelvis, bilateral femora, and bilateral proximal tibiae. This appearance is consistent with somatostatin receptor-positive metastatic disease.


After the initial bone scintigraphy, this patient underwent a needle biopsy of a lumbar vertebra. This revealed a small round blue cell tumor. The most likely diagnosis was metastatic neuroblastoma. However, initial interpretation of magnetic resonance imaging and computed tomography of the chest, abdomen, and pelvis did not reveal a primary tumor. Therefore, this patient was scheduled for octreotide scintigraphy to evaluate for a primary neuroblastoma. As stated above, the octreotide scintigraphy did confirm the multiple areas of bony metastatic disease. However, no definite primary tumor was identified.

References: Krenning EP et al. Somatostatin scintigraphy with


This patient received a single dose of cisplatin chemotherapy. Two hours later, the patient began having opsoclonus and myoclonus. The patient went into full-blown status epilepticus and subsequently expired. The exact cause of death was not determined. However, at autopsy, a 1.5 - 2 cm left adrenal neuroblastoma was identified.

Major teaching point(s):

Neuroblastoma is the most common solid abdominal mass of infancy and the second most common tumor in childhood. These patients may present with pain and fever, a palpable abdominal mass, bone pain, or inability to walk. There is increased catecholamine production in 75- 90%. This is identified often as increased VMA and HVA in the urine. Octreotide scintigraphy visualized tumor deposits in about 90% of patients with neuroblastoma. Patients with somatostatin-receptor- positive tumor scans have a longer survival rate compared with receptor-negative patients. These tumors may also be identified using MIBG. Tumor visualization is very similar with octreotide and MIBG scintigraphy.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Genitourinary System, Category:Neoplasm, Neoplastic-like condition)

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Case number: bs052

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