Case Author(s): Ed Grishaw, M.D. and Henry Royal, M.D. , 01/31/97 . Rating: #D2, #Q3

Diagnosis: Radiation nephritis

Brief history:

49-year old woman with metastatic breast cancer


Anterior and posterior whole body images are shown. What is the activity near the thoracolumbar junction?

View main image(bs) in a separate image viewer

View second image(bs). For comparison, bone scintigraphy from 9 months earlier.

View third image(bs). For comparison, bone scintigraphy from 6 months after the main image above.

Full history/Diagnosis is available below

Diagnosis: Radiation nephritis

Full history:

49-year old woman with breast cancer diagnosed in 1994, status post left mastectomy and adjuvant chemotherapy. The patient was subsequently discovered to have osseous metastatic disease and received radiation therapy to her thoracolumbar spine in the fall of 1995.


21.0 mCi Tc-99m MDP i.v.


The bone scintigram dated 6- 17-96 demonstrates geometrically increased uptake of radiopharmaceutical involving the medial superior poles of the kidneys. Multiple foci of abnormal radiopharmaceutical uptake compatible with osseous metastatic disease involve the left first rib anteriorly, the left fourth rib laterally, the right parietal skull, as well as the L2-L4 vertebral bodies. Compared to the previous examination of 9-14-95, these foci appear markedly less intense suggesting interval improvement. The previously noted metastatic foci involving T5-T7 on the study of 9-14-95 are no longer identified compatible with interval healing.

Prior whole-body bone scintigrams dated 9-14- 95 and 1-30-97 have been included to demonstrate interval appearance and resolution of the geometrically increased uptake involving the medial superior poles of the kidneys. These finmdings are due to focal radiation nephritis caused by inclusion of the medial superior poles of the kidneys in the spinal radiation therapy port.


Clinically, the manifestations of acute radiation nephritis present 6-12 months after treatment. Despite this term, the condition is neither acute nor does it represent nephritis. Pathologic correlation demonstrates a nephrosclerosis. If diffuse and severe, the patients typically present with anemia, edema, hypertension, proteinuria, uremia, oliguria, and in some cases frank anuria. Deaths secondary to acute radiation nephritis are typically secondary to malignant hypertension. Some patients also develop body cavity effusions, headaches, nausea and vomiting, and occasionally photophobia, which often are confused with recurrent tumor or the development of distant metastases. In general, renal radiation damage occurs with doses greater than 2300 cGy over a 5-week period. Renal injury is greater if there is concomitant chemotherapy. With the performance of a radionuclide bone scintigraphic study after radiation therapy, increased uptake is identified in the regions included within the radiation port, typically between 6 months and 2 years after treatment. The reason for this reversible abnormal radiopharmaceutical uptake is transient renal dysfunction.

Chronic radiation nephritis typically develops 1-5 years after radiation therapy with a mean time of approximately 2-3 years. Changes are irreversible and progressive and treatment at this point is usually symptomatic. Pathologically, the findings within the chronic clinical period demonstrate further progression of the processes that developed in the subacute clinical period. These findings include progressive nephrosclerosis, fibrointimal proliferation resulting in occlusion of the fine vasculature, glomerulosclerosis, tubular atrophy, and finally interstitial fibrosis.

Referemces: Mettler FA Jr and Upton AC. Medical effects of ionizing radiation, 2nd edition. Philadelphia: W.B. Saunders Co, 1995:254-255



Major teaching point(s):

See Discussion

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Inflammation,Infection)

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Case number: bs071

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