Research article
The role of Thallium-201 scintigraphy and Tc-99m pentavalent dimercaptosuccinic acid in diagnosis and grading of chondrosarcoma

https://doi.org/10.1016/j.ejrad.2020.108846Get rights and content

Highlights

  • Thallium scan may differentiate between enchondromas and low-grade chondrosarcomas.

  • Thallium uptake was associated with a higher grade chondrosarcoma.

  • DMSA (V) may be useful in distinguishing between benign and malignant tumours.

  • The combined use of Thallium and DMSA (V) scans increases diagnostic confidence.

Abstract

Purpose

Distinguishing between enchondromas and low-grade (grade 1) chondrosarcomas can be challenging. The aim of this study was to investigate the role of Thallium-201 scintigraphy and Technetium-99 m pentavalent dimercaptosuccinic acid (Tc-99 m DMSA (V)) in the diagnosis and grading of chondrosarcomas.

Methods

232 consecutive patients with pathologically proven cartilaginous tumours between the years 2000 and 2018 were evaluated. We included 197 patients (101 males and 96 females; median age 50 years; range 15–86 years) who underwent Thallium-201(n = 193) and/or Tc-99 m DMSA (V) scanning (n = 67). Increased uptake was defined as uptake greater than background. The reference standard was the histopathological assessment based on a grading system (grade 1–3). Data was analysed using multivariate modelling.

Results

There were 46 patients with enchondromas and 151 with chondrosarcomas. Of those, 64 (enchondroma n = 21, chondrosarcoma n = 43) underwent both Thallium-201 and Tc-99 m DMSA (V). Thallium-201 uptake had 7.92 times greater odds of grade 1 chondrosarcomas than enchondromas. Thallium-201 uptake was significantly associated with the odds of a higher grade chondrosarcoma (grade 2–3). DMSA (V) positivity was associated with 4.75 times the odds of a chondrosarcoma diagnosis over enchondroma (p = 0.024). DMSA (V) uptake revealed no association with chondrosarcoma grading.

Conclusion

Low-grade chondrosarcomas continue to pose a diagnostic dilemma. Thallium-201 scans may identify malignancy in benign appearing tumours as well as differentiate between low-grade and high-grade chondrosarcomas in said malignancies. DMSA (V) may be useful in distinguishing between benign and malignant entities as a whole.

Introduction

Chondrosarcoma is a cartilage forming malignant neoplasm of the bone [1]. It constitutes about a quarter of all primary bone tumours, with a peak incidence between the third and seventh decades of life [2]. Radiological evaluation of the grade of malignancy in cartilaginous tumours may be limited [1,3]. The differences in cortical scalloping, expansion or thinning between enchondroma and low-grade chondrosarcoma on morphologic tumour images can be subtle [1,4]. Furthermore, biopsy samples are prone to sampling error and under-grading due to the limitations of anatomical imaging in detecting the most malignant area of the tumour [5].

It is important to understand that the treatment of cartilaginous tumours depends on the diagnosis [6]. The vast majority of enchondromas are either left untreated or managed with intralesional curettage with a low recurrence rate [7]. If the clinical, radiological and histological assessments are indicative of a chondrosarcoma, the lesion should be treated with a wide resection [8]. Incorrect diagnosis and/or grading may result in under- or over-treatment of cartilaginous tumours, which may later manifest as local recurrence or unnecessary loss of function respectively [9]. Consequently, a more accurate means of preoperative assessment is sought after for guiding clinical decision-making and optimising patient outcome [3].

Functional imaging is a medical imaging technique of measuring or detecting metabolic processes through the use of radiotracers [10]. Thallium-201 and bivalent DMSA (V) scans have been traditionally utilised for assessing cardiac [11] and renal functions [12] respectively. In cartilaginous tumours, they have shown to offer a direct assessment of tumour metabolic activity [13,14]. There are a few studies that have investigated the uptake of Thallium-201 and/or DMSA (V) in chondrosarcomas [3,[15], [16], [17]]. These studies have been conducted with relatively small sample sizes (range 22–92) and thus any statistically significant results may lack clinical applicability.

The objective of this study is to elucidate the value of Thallium-201 and Tc-99 m DMSA (V) individually and in combination for the diagnosis and grading of chondrosarcomas.

Section snippets

Subjects and study protocol

232 patients who were diagnosed with pathologically proven cartilaginous tumours of the bone between January 2000 and December 2018 at a single sarcoma centre (Melbourne, Australia) were retrospectively evaluated. Cartilaginous tumours of soft tissues such as synovial chondromatosis were outside the scope of this study. 35 patients with chondromyxoid fibroma and chondroblastoma were excluded prior to the extraction of imaging data. This is due to their dissimilar histologic matrix, containing

Results

Results are presented separately and in combination for Thallium-201 scan and Tc-99 m DMSA (V).

Discussion

The distinction between grade 1 chondrosarcoma and enchondroma on anatomical imaging can be difficult despite the various anatomical imaging features described such as ill-defined margins, popcorn calcifications, lobulated contour and scalloping [22,23]. In a recent study involving 53 cartilaginous tumours, the sensitivities of plain radiography and MRI were reported to be 21 % and 58 % respectively for correctly diagnosing grade 1 chondrosarcomas [4]. Similarly, a poor discriminating power of

Conclusion

The uptake characteristics of Thallium-201 and DMSA (V) scintigraphy were explored. We found four important results in our study. Firstly, Thallium-201 uptake had 7.92 times greater odds of grade 1 chondrosarcomas than enchondromas. Secondly, positive Thallium-201 scan was significantly associated with the odds of higher grade (2–3) compared to grade 1 chondrosarcomas. Thirdly, DMSA (V) uptake individually was not associated with grade 1 chondrosarcoma nor higher grade chondrosarcomas. Lastly,

Declaration of Competing Interest

I Jo declares that she has no conflict of interest. S Schlitch declares that he has no conflict of interest. G Powell declares that he has no conflict of interest. C Di Bella declares that she has no conflict of interest. G Pang declares that he has no conflict of interest. T Spelman declare that he has no conflict of interest. PF Choong has received institutional research grants from Johnson & Johnson P/L and Medacta AB, and is a member of the Surgeon Advisory Board for Oncology for Stryker

Acknowledgements

This study has not received any funding. However, we declare that one of the authors has received institutional research grants from Johnson & Johnson P/L and MEdacta AB, and is a member of the Surgeon Advisory Board for Oncology for Stryker Corporation.

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