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Normal Whole-Body Bone Scan Report Template (Tc-99m MDP)
Normal whole-body bone scintigraphy report template: Tc-99m MDP dose, anterior and posterior planar images, symmetric skeletal uptake, renal and bladder excretion, with notes on superscan, degenerative versus metastatic patterns and SPECT/CT wording.
EXAMINATION: Whole-body bone scan (skeletal scintigraphy). CLINICAL HISTORY: [indication, e.g. “Staging of prostate cancer, evaluate for osseous metastases”] COMPARISON: None available. TECHNIQUE: [x] mCi of technetium-99m methylene diphosphonate (MDP) was administered intravenously. Anterior and posterior whole-body planar images were obtained approximately [3] hours after injection. [Spot views of the x were obtained. / SPECT/CT of the x was performed.] [Flow and blood pool images were obtained of the x.] FINDINGS: Radiotracer distribution: Physiologic, symmetric uptake throughout the axial and appendicular skeleton. Normal uptake in the skull, spine, pelvis, ribs and long bones with expected relative accentuation at the sternoclavicular joints, sacroiliac joints and [growth plates in a skeletally immature patient]. Focal abnormalities: No focal area of abnormally increased or decreased radiotracer uptake to suggest osseous metastasis, fracture or osteomyelitis. No pattern of multifocal randomly distributed uptake. Joints: [No / Mild] periarticular uptake at the [shoulders, knees and hands], consistent with degenerative change. Soft tissues: No abnormal soft tissue uptake. Normal soft tissue background activity. Kidneys and bladder: Both kidneys are visualized with symmetric physiologic excretion. Normal bladder activity. No urinary tract obstruction pattern. Injection site: [Minimal] activity at the injection site in the [right antecubital fossa], of no significance. IMPRESSION: 1. Normal whole-body bone scan. No scintigraphic evidence of osseous metastatic disease.
Dictation notes
- Say whether the kidneys are seen: a “superscan” of diffuse osseous metastases shows intense uniform skeletal uptake with absent renal and faint soft tissue activity and can be misread as a beautiful normal — the missing kidneys are the clue.
- Describe the distribution before the diagnosis: multifocal, random, axial-predominant foci favor metastases; symmetric periarticular uptake favors degenerative disease; linear rib foci in a row favor fracture, a solitary rib focus is metastatic in only about 10%.
- A solitary focus in a cancer patient is indeterminate on planar imaging — recommend the correlative radiograph or SPECT/CT and report the SPECT/CT finding (sclerotic metastasis, facet arthropathy, pars defect) as the final answer when it is obtained.
- Soft tissue uptake is a finding: breast, lung, hepatic metastases from mucinous tumors, myositis ossificans, recent infarcts and hypercalcemia all take up MDP, and the lungs and stomach show it in hyperparathyroidism.
- Bone scan uptake lags behind treatment response and can flare for three months after starting hormonal or chemotherapy; a comparison showing increased uptake within that window should be worded as a possible flare response rather than progression.
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