Letters to the Editor
To the Editor
With great interest, I read the article by Van den Wyngaert et al1 published in Clinical Nuclear Medicine (2011;36:17–20). Better late than never.
The authors reported on the potential detection of bisphosphonate osteonecrosis of the jaw (BP ONJ) using bone scintigraphy. They performed planar bone scintigraphy and SPECT in 22 patients with stage 1 to 3 BP ONJ and postulated that SPECT will detect BP ONJ lesions and provide prognostic information.
Apart from the very limited number of patients and sample power, there is something missing in the interpretation of results, which, in my opinion, ought to be resolved.
Bone scintigraphy as such, including SPECT acquisition, represents a surrogate parameter reflecting osteoblasts’ activity by tracer uptake in ROI. This is, in turn, the hallmark of osteomyelitic changes or a sign of reparative process after trauma, surgery, and bone remodeling.2–4
Although the pathogenesis of BP ONJ is not yet completely understood, it is assumed that this condition is related to alteration of bone remodeling because of the inhibition of osteoclast function and bone turnover.5
Taking these aspects into consideration, the findings presented in this study are “nonspecific” in the sense of not being related to osteonecrosis, which is “invisible” by bone scintigraphy, but to the more or less associated osteomyelitic lesion or reparative process. This is, at the same time, the simple explanation of the inhomogeneous distribution of scintigraphic findings among the 3 groups, namely the lesions induced various types of inflammatory and reparative changes in the affected bone.
I found the article by Van den Wyngaert et al very interesting; apparently, the reviewer did so too. However, I missed this critical aspect in the discussion and had to make up for the readers of Clinical Nuclear Medicine.
Samer George Hakim, MD, DMD, PhD
Department of Oral and Maxillofacial Surgery
University of Luebeck
1. Van den Wyngaert T, Huizing MT, Fossion E, et al.. Prognostic value of bone scintigraphy in cancer patients with osteonecrosis of the jaw. Clin Nucl Med
. 2011; 36: 17–20.
2. Hakim SG, Bruecker CW, Jacobsen H, et al.. The value of FDG-PET and bone scintigraphy with SPECT in the primary diagnosis and follow-up of patients with chronic osteomyelitis of the mandible. Int J Oral Maxillofac Surg
. 2006; 35: 809–816.
3. Mader JT, Shirtliff M, Calhoun JH. Staging and staging application in osteomyelitis. Clin Infect Dis
. 1997; 25: 1303–1309.
4. Schauwecker DS. The scintigraphic diagnosis of osteomyelitis. AJR Am J Roentgenol
. 1992; 158: 9–18.
5. Rogers MJ, Gordon S, Benford HL, et al.. Cellular and molecular mechanisms of action of bisphosphonates. Cancer
. 2000; 88: 2961–2978.