Preliminary Diagnosis: PAGET'S DISEASE

I. What imaging technique is first-line for this diagnosis?

  • Plain film radiography

II. Describe the advantages and disadvantages of this technique for diagnosis of Paget's disease.

  • Diagnostic with positive pertinent findings in the proper clinical scenario

  • Can accurately identify complications: osteoarthritis, protrusio acetabuli, proximal femoral varus

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  • Provides superior resolution of the osseous structures.

  • May be obtained quickly and in a cost-effective manner

  • Not sensitive for detecting certain complications of Paget’s, namely sarcomatous degeneration, superimposed neoplasm, osteomyelitis, and foraminal stenosis

  • Less sensitive for detection of Paget’s disease involving the spine and skull

  • Exposes the patient to ionizing radiation

  • Given the variable appearance of Paget’s disease, plain film may be nonspecific

III. What are the contraindications for the first-line imaging technique?

  • No significant contraindications exist.

IV. What alternative imaging techniques are available?

  • Non-enhanced CT

  • MRI without gadolinium

  • 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
  • Superior in evaluating Paget involvement of the skull

  • Superior in evaluating Paget involvement of the spine

  • More sensitive than plain film radiography in evaluating for superimposed neoplasm

  • May be performed much more quickly than MR imaging, requires less patient cooperation, and is associated with less motion artifact compared with MR imaging

  • Exposes the patient to a large amount of ionizing radiation

  • Less sensitive than MRI for detecting complications

  • Superior in the detection of Paget’s disease complications

  • No exposure to ionizing radiation

  • Only imaging modality that can accurately evaluate for regions of marrow fat preservation, a critical finding in ruling out sarcomatous degeneration and insufficiency fractures

  • With three-phase application, can accurately identify areas of active disease

  • Provides less osseous detail

  • Expensive

  • Time consuming imaging modality

  • Requires significant patient cooperation to minimize motion artifact

Bone Scintigraphy
  • Most sensitive imaging modality in diagnosing Paget’s disease

  • Preferred for evaluation of disease extent and distribution

  • Lacks specificity, often requiring radiographic correlation

  • Sensitive onlyin the setting of active disease

  • Limited in patients with renal insufficiency

  • 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
  • Contraindicated in pregnant women, especially within the first two trimesters

  • Contraindicated in patients with non–MR-compatible metallic hardware or foreign bodies

Bone Scintigraphy
  • Contraindicated in the pregnant patient