Preliminary Diagnosis: PAGET'S DISEASE
I. What imaging technique is first-line for this diagnosis?
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Plain film radiography
II. Describe the advantages and disadvantages of this technique for diagnosis of Paget's disease.
Advantages
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Diagnostic with positive pertinent findings in the proper clinical scenario
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Can accurately identify complications: osteoarthritis, protrusio acetabuli, proximal femoral varus
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Provides superior resolution of the osseous structures.
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May be obtained quickly and in a cost-effective manner
Disadvantages
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Not sensitive for detecting certain complications of Paget’s, namely sarcomatous degeneration, superimposed neoplasm, osteomyelitis, and foraminal stenosis
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Less sensitive for detection of Paget’s disease involving the spine and skull
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Exposes the patient to ionizing radiation
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Given the variable appearance of Paget’s disease, plain film may be nonspecific
III. What are the contraindications for the first-line imaging technique?
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No significant contraindications exist.
IV. What alternative imaging techniques are available?
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Non-enhanced CT
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MRI without gadolinium
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99m-TC HDP/MDP bone scintigraphy
V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of Paget's disease.
Non-enhanced CT
Advantages
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Superior in evaluating Paget involvement of the skull
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Superior in evaluating Paget involvement of the spine
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More sensitive than plain film radiography in evaluating for superimposed neoplasm
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May be performed much more quickly than MR imaging, requires less patient cooperation, and is associated with less motion artifact compared with MR imaging
Disadvantages
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Exposes the patient to a large amount of ionizing radiation
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Less sensitive than MRI for detecting complications
MRI
Advantages
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Superior in the detection of Paget’s disease complications
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No exposure to ionizing radiation
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Only imaging modality that can accurately evaluate for regions of marrow fat preservation, a critical finding in ruling out sarcomatous degeneration and insufficiency fractures
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With three-phase application, can accurately identify areas of active disease
Disadvantages
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Provides less osseous detail
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Expensive
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Time consuming imaging modality
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Requires significant patient cooperation to minimize motion artifact
Bone Scintigraphy
Advantages
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Most sensitive imaging modality in diagnosing Paget’s disease
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Preferred for evaluation of disease extent and distribution
Disadvantages
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Lacks specificity, often requiring radiographic correlation
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Sensitive onlyin the setting of active disease
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Limited in patients with renal insufficiency
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Exposes patient to more radiation than if CT, plain film, or MR were utilized
VI. What are the contraindications for the alternative imaging techniques?
Non-enhanced CT
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Contraindicated in pregnant women, especially within the first two trimesters
MRI
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Contraindicated in patients with non–MR-compatible metallic hardware or foreign bodies
Bone Scintigraphy
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Contraindicated in the pregnant patient
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