Case Author(s): Zhiyun Yang, M.D. and Jerold Wallis, M.D. , 03/17/05 . Rating: #D3, #Q3

Diagnosis: Neuroblastoma

Brief history:

8-year-old girl with neuroblastoma.

Images:

Anterior and posterior images

View main image(bs) in a separate image viewer

View second image(bs). Spot images

View third image(bs). Current scan at left (ant/post) and prior scan at right (ant/post)

View fourth image(mb). MIBG Scintigraphy

Full history/Diagnosis is available below

Diagnosis: Neuroblastoma

Full history:

8-year-old girl with a neuroblastoma, treated in the past with bone marrow transplantation. The patient now presents with fevers and left hip pain. Plain radiographs are unremarkable. The patient does, however, have a left hip effusion by CT examination.

Radiopharmaceutical:

7.5 mCi Tc-99m MDP i.v. and 3.4 mCi I-123 metaiodobenzylguanidine (MIBG)

Findings:

Bone scintigraphy on mid 2004 demonstrated multiple areas of increased activity throughout the skeleton most likely representing metastatic disease, most evident in the femurs, tibias, and pelvis. Relatively decreased uptake is seen involving the left femoral neck and femoral head.

Bone scintigraphy early 2004 demonstrated normal bone scintigraphy.

I-123 metaiodobenzylguanidine (MIBG) within a week of the second bone scan demonstrated extensive bone and bone marrow uptake involving nearly the entire skeleton most consistent with metastatic disease.

Discussion:

Controversy persists as to the need for both MIBG and bone scanning (Tc-99m MDP) in routine evaluation of neuroblastoma. Studies demonstrated the following:

a. Both MIBG and MDP are useful for the detection of skeletal neuroblastoma. MIBG is the better agent for characterizing the extent of disease, and MDP is a valuable adjunctive agent that provides skeletal landmarks for comparison. MIBG is clearly superior for the detection of extraskeletal neuroblastoma.

b. Some studies (1,3) suggest that MIBG alone may fail to visualize skeletal involvement of neuroblastoma and should therefore be complemented by additional 99mTc-MDP scintigraphy. Therefore, Tc-99m-MDP bone scan should remain a part of routine assessment of patients with neuroblastoma. Studies show that underassessment of skeletal involvement by neuroblastoma occurred using 123I-MIBG scans and that one cannot therefore substitute 123I-MIBG for 99mTc-MDP bone scans in the staging of neuroblastoma.

I-131 MIBG proved especially useful in detecting neuroblastoma with negative Tc-99m MDP and also proved to be helpful with those cases in which I-131 MIBG was planned for therapy.

c. One study (5) found that MIBG imaging did not change the staging or alter treatment during therapy for any patient. However, other studies have found it valuable in staging and monitoring disease.

1. Barai S, Bandopadhayaya GP, Malhotra A, et al. Does I-131-MIBG underestimate skeletal disease burden in neuroblastoma? JPGM 2004; 50: 257-261

2. Sohara Y, Shimada H, Scadeng M, et al. Lytic bone lesions in human neuroblastoma xenograft involve osteoclast recruitment and are inhibited by bisphosphonate. Cancer Res 2003; 63:3026-31.

3.Bhogate BM, Samuel AM, Ramanathan P. Bone scans in neuroblastoma. Indian J Cancer 1993; 30:5-9.

4. Sautter-Bihl ML, Bihl H, Heinze HG. The place of 99mTc-MDP skeletal scintigraphy in neuroblastoma. Is a new assessment necessary? Nuklearmedizin 1991; 30:7-12.

5. Andrich MP, Shalaby-Rana E, Movassaghi N, Majd M. The role of 131 iodine-metaiodobenzylguanidine scanning in the correlative imaging of patients with neuroblastoma. Pediatrics 1996; 97:246-50.5.

6. Shulkin BL, Shapiro B, Hutchinson RJ. Iodine-131-metaiodobenzylguanidine and bone scintigraphy for the detection of neuroblastoma. J Nucl Med 1992; 33:1735-40.

7. Garty I, Friedman A, Sandler MP, Kedar A. Neuroblastoma: imaging evaluation by sequential Tc-99m MDP, I-131 MIBG, and Ga-67 citrate studies. Clin Nucl Med 1989; 14:515-22.

Followup:

Bone marrow, bilateral posterior iliac crests, core biopsies and aspirate smears on 05-11-04 demonstrated bilateral metastatic neuroblastoma.

ACR Codes and Keywords:

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

Search for similar cases.

Edit this case

Add comments about this case

Return to the Teaching File home page.

Case number: bs150

Copyright by Wash U MO