Extraosseous Tc-99m methylene diphosphonate concentration in the forearm following post-mastectomy lymphatic obstruction
Identifieur interne : 002245 ( Pmc/Corpus ); précédent : 002244; suivant : 002246Extraosseous Tc-99m methylene diphosphonate concentration in the forearm following post-mastectomy lymphatic obstruction
Auteurs : Anish Bhattacharya ; Madan Parmar ; Bhagwant Rai MittalSource :
- Indian Journal of Nuclear Medicine : IJNM : The Official Journal of the Society of Nuclear Medicine, India [ 0972-3919 ] ; 2012.
Abstract
A 42-year-old female patient with a past history of right breast cancer and recent onset swelling of the right forearm underwent routine whole-body bone scintigraphy with Tc-99m methylene diphosphonate, 2 years after a modified radical mastectomy. Diffuse soft tissue tracer concentration was seen in the right forearm. Subsequent lymphoscintigraphy using Tc-99m sulphur colloid revealed obstructed lymphatic drainage in the right upper limb.
Url:
DOI: 10.4103/0972-3919.110696
PubMed: 23723582
PubMed Central: 3665135
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Extraosseous Tc-99m methylene diphosphonate concentration in the forearm following post-mastectomy lymphatic obstruction</title><author><name sortKey="Bhattacharya, Anish" sort="Bhattacharya, Anish" uniqKey="Bhattacharya A" first="Anish" last="Bhattacharya">Anish Bhattacharya</name><affiliation><nlm:aff id="aff1">Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India</nlm:aff></affiliation></author><author><name sortKey="Parmar, Madan" sort="Parmar, Madan" uniqKey="Parmar M" first="Madan" last="Parmar">Madan Parmar</name><affiliation><nlm:aff id="aff1">Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India</nlm:aff></affiliation></author><author><name sortKey="Mittal, Bhagwant Rai" sort="Mittal, Bhagwant Rai" uniqKey="Mittal B" first="Bhagwant Rai" last="Mittal">Bhagwant Rai Mittal</name><affiliation><nlm:aff id="aff1">Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">23723582</idno><idno type="pmc">3665135</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665135</idno><idno type="RBID">PMC:3665135</idno><idno type="doi">10.4103/0972-3919.110696</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">002245</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002245</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Extraosseous Tc-99m methylene diphosphonate concentration in the forearm following post-mastectomy lymphatic obstruction</title><author><name sortKey="Bhattacharya, Anish" sort="Bhattacharya, Anish" uniqKey="Bhattacharya A" first="Anish" last="Bhattacharya">Anish Bhattacharya</name><affiliation><nlm:aff id="aff1">Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India</nlm:aff></affiliation></author><author><name sortKey="Parmar, Madan" sort="Parmar, Madan" uniqKey="Parmar M" first="Madan" last="Parmar">Madan Parmar</name><affiliation><nlm:aff id="aff1">Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India</nlm:aff></affiliation></author><author><name sortKey="Mittal, Bhagwant Rai" sort="Mittal, Bhagwant Rai" uniqKey="Mittal B" first="Bhagwant Rai" last="Mittal">Bhagwant Rai Mittal</name><affiliation><nlm:aff id="aff1">Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India</nlm:aff></affiliation></author></analytic><series><title level="j">Indian Journal of Nuclear Medicine : IJNM : The Official Journal of the Society of Nuclear Medicine, India</title><idno type="ISSN">0972-3919</idno><idno type="eISSN">0974-0244</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>A 42-year-old female patient with a past history of right breast cancer and recent onset swelling of the right forearm underwent routine whole-body bone scintigraphy with Tc-99m methylene diphosphonate, 2 years after a modified radical mastectomy. Diffuse soft tissue tracer concentration was seen in the right forearm. Subsequent lymphoscintigraphy using Tc-99m sulphur colloid revealed obstructed lymphatic drainage in the right upper limb.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Deo, Sv" uniqKey="Deo S">SV Deo</name></author><author><name sortKey="Ray, S" uniqKey="Ray S">S Ray</name></author><author><name sortKey="Rath, Gk" uniqKey="Rath G">GK Rath</name></author><author><name sortKey="Shukla, Nk" uniqKey="Shukla N">NK Shukla</name></author><author><name sortKey="Kar, M" uniqKey="Kar M">M Kar</name></author><author><name sortKey="Asthana, S" uniqKey="Asthana S">S Asthana</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Petrek, Ja" uniqKey="Petrek J">JA Petrek</name></author><author><name sortKey="Heelan, Mc" uniqKey="Heelan M">MC Heelan</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kissin, Mw" uniqKey="Kissin M">MW Kissin</name></author><author><name sortKey="Querci Della Rovere, G" uniqKey="Querci Della Rovere G">G Querci della Rovere</name></author><author><name sortKey="Easton, D" uniqKey="Easton D">D Easton</name></author><author><name sortKey="Westbury, G" uniqKey="Westbury G">G Westbury</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Brismar, B" uniqKey="Brismar B">B Brismar</name></author><author><name sortKey="Ljungdahl, I" uniqKey="Ljungdahl I">I Ljungdahl</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Tuncel, M" uniqKey="Tuncel M">M Tuncel</name></author><author><name sortKey="Erbas, B" uniqKey="Erbas B">B Erbas</name></author><author><name sortKey="Mahmoudian, B" uniqKey="Mahmoudian B">B Mahmoudian</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kaye, J" uniqKey="Kaye J">J Kaye</name></author><author><name sortKey="Hayward, M" uniqKey="Hayward M">M Hayward</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Manoli, Rs" uniqKey="Manoli R">RS Manoli</name></author><author><name sortKey="Soin, Js" uniqKey="Soin J">JS Soin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kida, T" uniqKey="Kida T">T Kida</name></author><author><name sortKey="Tsuda, F" uniqKey="Tsuda F">F Tsuda</name></author><author><name sortKey="Fujita, Y" uniqKey="Fujita Y">Y Fujita</name></author><author><name sortKey="Munakata, S" uniqKey="Munakata S">S Munakata</name></author><author><name sortKey="Sasaki, M" uniqKey="Sasaki M">M Sasaki</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Peller, Pj" uniqKey="Peller P">PJ Peller</name></author><author><name sortKey="Vincent, Bh" uniqKey="Vincent B">BH Vincent</name></author><author><name sortKey="Kransdorf, Mj" uniqKey="Kransdorf M">MJ Kransdorf</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Indian J Nucl Med</journal-id><journal-id journal-id-type="iso-abbrev">Indian J Nucl Med</journal-id><journal-id journal-id-type="publisher-id">IJNM</journal-id><journal-title-group><journal-title>Indian Journal of Nuclear Medicine : IJNM : The Official Journal of the Society of Nuclear Medicine, India</journal-title></journal-title-group><issn pub-type="ppub">0972-3919</issn><issn pub-type="epub">0974-0244</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">23723582</article-id><article-id pub-id-type="pmc">3665135</article-id><article-id pub-id-type="publisher-id">IJNM-27-105</article-id><article-id pub-id-type="doi">10.4103/0972-3919.110696</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Extraosseous Tc-99m methylene diphosphonate concentration in the forearm following post-mastectomy lymphatic obstruction</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Bhattacharya</surname><given-names>Anish</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Parmar</surname><given-names>Madan</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Mittal</surname><given-names>Bhagwant Rai</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib></contrib-group><aff id="aff1">Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Anish Bhattacharya, Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail: <email xlink:href="anishpgi@yahoo.co.in">anishpgi@yahoo.co.in</email></corresp></author-notes><pub-date pub-type="ppub"><season>Apr-Jun</season><year>2012</year></pub-date><volume>27</volume><issue>2</issue><fpage>105</fpage><lpage>106</lpage><permissions><copyright-statement>Copyright: © Indian Journal of Nuclear Medicine</copyright-statement><copyright-year>2012</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>A 42-year-old female patient with a past history of right breast cancer and recent onset swelling of the right forearm underwent routine whole-body bone scintigraphy with Tc-99m methylene diphosphonate, 2 years after a modified radical mastectomy. Diffuse soft tissue tracer concentration was seen in the right forearm. Subsequent lymphoscintigraphy using Tc-99m sulphur colloid revealed obstructed lymphatic drainage in the right upper limb.</p></abstract><kwd-group><kwd>Extraosseous</kwd><kwd>lymphoscintigraphy</kwd><kwd>mastectomy</kwd><kwd>Tc-99m methylene diphosphonate</kwd></kwd-group></article-meta></front><body><sec id="sec1-1"><title>INTRODUCTION</title><p>Lymphedema is a common complication of breast cancer treatment, especially after axillary lymph node dissection and radiotherapy. This condition may become apparent during routine bone imaging with Tc-99m methylene diphosphonate (MDP). In such cases, lymphoscintigraphy can be used to confirm obstruction to lymphatic drainage.</p></sec><sec id="sec1-2"><title>CASE REPORT</title><p>A 42-year-old female patient with a history of right breast cancer reported recent onset swelling of the right forearm. She had undergone modified radical mastectomy 2 years previously, with subsequent chemotherapy and radiotherapy. A routine whole-body bone scan was performed to assess any skeletal involvement. Following intravenous injection of 740 MBq (20 mCi) of Tc-99m MDP, imaging was performed after 3 hours under a dual head gamma camera (Ecam, Siemens, Germany) fitted with a low-energy high-resolution collimator. Diffuse soft tissue uptake of tracer in the right forearm, extending to the right elbow was noted [<xref ref-type="fig" rid="F1">Figure 1</xref>]. No bony abnormality was detected.</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>Anterior (a) and posterior; (b) whole-body bone scan images showing diffuse soft tissue uptake of tracer in the right forearm (arrows)</p></caption><graphic xlink:href="IJNM-27-105-g001"></graphic></fig><p>A provisional diagnosis of lymphatic obstruction in the right upper limb was made and lymphoscintigraphy was performed during the patient's next visit, 7 days later. Unfiltered Tc99m-sulphur colloid (20 MBq) was injected intradermally into the second and third web spaces of each hand, and whole body images were acquired after 10 min and 2 hours under the same gamma camera, with the arms raised above the head. The 10-min image showed rapid movement of tracer into the left trochlear and axillary lymph nodes, with minimal tracer movement in the region of the distal right forearm. The delayed image showed diffuse soft tissue concentration of tracer only in the distal part of the right forearm, with no further ascent, indicating lymphatic obstruction [<xref ref-type="fig" rid="F2">Figure 2</xref>].</p><fig id="F2" position="float"><label>Figure 2</label><caption><p>Lymphoscintigraphy at 10 minutes (a) and 2 hours; (b) with the arms raised, showing rapid movement of tracer into the left trochlear and axillary lymph nodes (arrows), and diffuse soft tissue tracer uptake in the distal part of the right forearm (arrowhead)</p></caption><graphic xlink:href="IJNM-27-105-g002"></graphic></fig></sec><sec sec-type="discussion" id="sec1-3"><title>DISCUSSION</title><p>Lymphedema is a common complication of breast cancer treatment, with a significantly higher incidence reported after axillary lymph node dissection and radiotherapy (38.3-42.4%) as compared to that by any one treatment modality alone (7.4-13.4%).[<xref ref-type="bibr" rid="ref1">1</xref>–<xref ref-type="bibr" rid="ref3">3</xref>] Post-mastectomy edema may be early and occur shortly after surgery, resulting from acute lymphatic overload, and decrease as compensatory pathways develop. Late lymphedema may develop months to years after surgery.[<xref ref-type="bibr" rid="ref4">4</xref>] This condition is often progressive, attributed to lymphatic obstruction by surgical interruption or fibrosis and precipitates overload in already compromised lymphatic channels.</p><p>Extraosseous soft tissue concentration of bone imaging agents like Tc-99m MDP and Tc-99m HMDP has been reported in conditions that cause hyperemia (i.e., inflammation, neovascularity, altered sympathetic tone with resultant vasodilatation) and altered capillary permeability, resulting in increased distribution of the tracer within the soft tissues.[<xref ref-type="bibr" rid="ref5">5</xref>–<xref ref-type="bibr" rid="ref7">7</xref>] The exact mechanism of non-osseous accumulation of bone scanning agents is still unclear; however, it has been proposed that Tc-99m MDP accumulates in serous effusions by directly exuding from the peripheral blood vessels to the serous cavity along with the increased blood 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