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whole - body bone scintigraphy ( wbbs ) with technetium-99 m methylene diphosphonate ( tc-99 m mdp ) is widely available and commonly used to detect metastases from malignant tumors because it is more sensitive than x - rays and allows the whole body to be surveyed .
however , multiple benign osteolytic lesions are very similar with bone metastasis in findings of bone scintigraphy . before sending out the report of multiple metastases ,
benign osteolytic lesions should be considered according to other imaging findings , detailed medical history , or even the preliminary pathology result . in this pictorial review
, we retrospectively studied the wbbs with tc-99 m mdp findings in 5 patients of selected multiple benign osteolytic lesions . for adult patients
a smaller dose was used dependent on patient body weight : adult dose/70  patient weight ( kg ) .
a 41-year - old man with left upper arm pain for 3 months was admitted for left humerus fracture after a tumble .
all of images of tc-99 m mdp wbbs ( figure 1 ) , left shoulder joint mri ( figure 2 ) , and thoracic ct ( figure 3 ) indicated bone metastases .
eg was diagnosed definitely by histopathological examination ( positive : cd1a , s-100 , lca , ki67 ( 6% ) and negative : cd68 , cd79a , cd138 , and p53 ) .
the patient received 4 courses of chemotherapy ( steroids , vinca alkaloids , and antimetabolites ) before discharge .
two years later , the patient was admitted again in our hospital for right femoral fracture caused by an accidental fall .
another tc-99 m mdp wbbs ( figure 4 ) was performed , and similar findings ( except for deterioration of right femur site ) were observed as shown in the previous one ( figure 1 ) .
a 45-year - old female patient suffered chest pain for 2 months that deteriorated recently .
g / l and 18.58  mg / l , respectively , and both were above the normal level .
tc-99 m mdp wbbs ( figure 5 ) was performed before chemotherapy and found multiple bones accumulated the agent abnormally .
clinical diagnosis was multiple myeloma igg stage iii ; then , chemotherapy of vad regimen was given to this patient .
a 25-year - old male patient suffered cough and chest pain for 1 month , and the pain extended to back and waist recently .
diffused military nodules with small cavities in both lungs , and multiple bone destructions in thoracic and lumbar vertebra were found on chest ct suggesting of disseminated tuberculosis .
an 18-year - old female patient suffered right hip pain after long walking for this year .
she received sectional resection of right femur and allograft for the reason of fibrous dysplasia when she was only 7 years old .
x - ray showed benign tumor changes in upper section of right femur , considering fibrous dysplasia .
wbbs ( figure 7 ) before operation found abnormal accumulation in right femur , tibia , and cotyle
a 14-year - old male patient found swelling of interphalangeal joint in left middle finger 11 years ago .
cr and mri illustrated multiple enchondroma in left hand . before the operation , tc-99 m mdp wbbs ( figure 8) found additional bones involvement .
this patient received sectional resection of multiple lesions in left hand and allograft the next day .
histopathological examination after operation was cracked cartilage tissue which is in accordance with multiple enchondroma .
eg , formerly termed histiocytosis x , is the most common and benign form of the langerhans cell histiocytosis which includes another two forms : the hand - schller - christian disease ( the triad of diabetes insipidus , exophthalmos , and lytic bone lesions ) and the letterer - siwe syndrome ( a rapidly - progressing multisystem disease with poor prognosis ) .
a 41-year - old man with eg admitted for pathologic fracture demonstrated multiple malignant metastases like bone involvement on both scintigraphic and radiographic imaging .
although multiple bones were involved in this case with eg , we can easily differentiate it from the hand - schller - christian disease for the absence of main characteristics of diabetes insipidus and exophthalmos .
the skeletal involvement is frequent and generally demonstrates as destroyed solitary or multiple bones in any age [ 14 ] , while the visceral involvement is rare and often occurs at age below 2 years old .
localized pain is always the first symptom of bone involvement , but it can also be presented as pathologic fractures after injuries .
the most commonly involved bones are skull , mandible , pelvis , spine , ribs , and long bones .
radiographic imaging is the main modality for the diagnosis of eg , although the radiographic characteristics of eg are considerably different according to the site and the activity of the lesion .
bone destruction in granulation tissue forming areas of osteolysis is the main pathological characteristic of eg and may involve any portion of any bone .
typical finding on tc-99 m mdp wbbs in the patients with eg is the lesion with intensive radioactive accumulation with a photopenic center [ 13 ] , because the bone involvement in eg always begins from osteolysis that arise in the bone marrow cavity and following periosteal reaction .
however , all the manifestations of the lesions with increased , decreased , or normal accumulation on tc-99 m mdp wbbs could be observed according to the amount of viable residual or reactive bone tissue .
those can significantly accumulate the radioactive tracer [ 6 , 8 ] . in eg , tc-99 m mdp wbbs is generally less sensitive than radiography in the detection of osseous lesions . the findings in this patient confirmed this opinion .
however , tc-99 m mdp wbbs may play roles in searching additional bone lesions and monitoring therapeutic response and is helpful when the radiographs are normal or equivocal .
in addition , tc-99 m mdp wbbs has the advantage of detecting the asymptomatic bone abnormalities possibly missed by other imaging modalities .
it is suggested that combination of various imaging modalities might be helpful to make a definite diagnosis when bone biopsy or operation is not available . in this patient
, all images of tc-99 m mdp wbbs , mri , and ct demonstrated the characteristics of disseminated bone metastases although eg was finally diagnosed by postoperative pathological examination .
multiple bone lesions in eg are relatively rare because solitary lesion predominates over multiple lesions , and only around 10% of solitary lesion may eventually develop into multiple lesions .
eg is a benign inflammatory disease , and the activity of this disease may remain stable during follow - up . in this case , the tc-99 m mdp wbbs performed 2 year later revealed only mild alternations in a wide range of bone involvement as shown in the previous one except the increased radioactive accumulation in fractured right femur , confirming the benignity of eg .
it can be mistaken radiographically for metastatic bone disease because it presents with multiple osteolytic lesions or diffuse osteopenia .
wbbs often fails to demonstrate a hyperconcentration at sites of skeletal involvement by myeloma despite extensive disease by radiography .
this occurs because reactive bone formation is not a feature of the disease ; this might be due to release of an inactivation factor by the tumor .
radiographs typically show either a solitary or multifocal osteolytic pattern . however , skeletal survey is not always a useful screening method , so other imaging modalities such as ct and wbbs are often used .
wbbs is sensitive in 75% of patients with myeloma , but only about 10% of lesions are shown .
therefore , wbbs may be helpful when there is focal pain and a negative radiograph .
skeletal tb occurs in only very small part of patients with tb , and therefore the diagnosis is often difficult due to the nonspecific nature of the clinical presentation .
the spine , particularly the thoracolumbar spine , is the most common site of skeletal involvement of tb .
back pain can affect anyone and in general can originate from the bone ( vertebrae ) , muscles , ligaments , tendons , or nerves .
tuberculosis of the spine is one of the causes for back pain , and early diagnosis and management can prevent complications .
the intense vertebra uptake on wbbs is nonspecific , so the differential diagnosis would include bone metastases from lung cancer .
it is important to obtain material for culture and sensitivity in the absence of confirmed pulmonary tb for a definitive diagnosis .
fibrous dysplasia is a benign tumor in which masses of fibroblasts and islands of cartilage replace bone marrow in one or more locations .
it is commonly found in young patients with mild bone pain or as an incidental finding , although the lesions may persist into late adulthood .
the main value of wbbs in fibrous dysplasia is to show polyostotic involvement , but sometimes these lesions may show only minimal uptake or even no uptake . from our case of multiple fibrous dysplasia , the differentiation from bone metastasis can be made by combining with their past medical history .
enchondroma is a common benign lesion that appears in the medullary portion of bone and is composed chiefly of mature hyaline cartilage .
when one side of the body exhibits greater involvement than the other , the condition is called ollier 's disease .
the combination of enchondromatosis and soft tissue hemangiomata is referred to as maffucci 's syndrome .
enchondroma can have high fdg and mdp uptake on scintigraphic imaging and occasionally may mimic metastatic lesions in patients being screened for metastatic disease .
taking one with another , wbbs is an effective and economic method in detecting multiple enchondromatosis .
given the low specificity of tc-99 m mdp wbbs and its sensitivity to increased bone remodeling from any cause , whether benign or malignant , the presence of multiple benign osteolytic lesions renders the interpretation indistinguishable from malignant metastasis .
therefore , we should be watchful of giving the diagnosis of disseminated bone metastasis during our daily work ; furthermore , detailed past medical history and various laboratory results might be helpful for accurate diagnosis .
multiple benign osteolytic lesions are very hard to differentiate from disseminated bone metastasis . 
 whole - body bone scintigraphy ( wbbs ) with technetium-99 m methylene diphosphonate ( tc-99 m mdp ) demonstrates multiple lesions with increased uptake in any bone involved . 
 even combined with medical history and multiple imaging results , such as mri and ct , the clinical diagnosis of metastasis lesion remains as a challenge . 
 these clinical characteristics are similar to multiple malignant bone metastases and therefore affect the following treatment procedures . in this paper 
 , we analyzed multiple benign osteolytic lesions , like eosinophilic granuloma ( eg ) , multiple myeloma ( mm ) , disseminated tuberculosis , fibrous dysplasia , or enchondroma , occurring in our daily clinical work and concluded that additional attention should be paid before giving the diagnosis of multiple bone metastases .