Figure 11. Paget's disease of bone (osteitis deformans). Multifocal areas of increased uptake are scattered throughout the skeleton (arrows). Although some of these would be difficult to distinguish from metastatic lesions, the appearance of the tibia (diffuse involvement with bowing deformity) is characteristic for Paget's disease. The skull lesion shows peripheral uptake and central photpenia, a form of pagetic involvement known as osteoporosis circumscripta. (Case provided by Dr. W.D. Leslie.)

is usually a sign of disease progression. An exception is the "flare phenomenon" which occurs in 6% to 23% of treated patients with osseous deposits from prostate or breast cancer (Fig. 12). Even though the lesions are healing there is an initial increased intensity in the previously observed foci and it may also be associated with the appearance of new lesions, increased pain and hypercalcemia. This flare can last up to 6 months. During this interval the radiograph will show sclerotic changes, a

Figure 12. Metastatic flare reponse. (A) This 48 year old woman had breast cancer metastatic to liver (left) and bone (right). She was treated with a conventional doxorubicin-containing chemotherapeutic regimen and had follow-up bone/liver scans four (B) and eight months (C) later. There is dramatic improvement on both of the follow-up liver scans. In contrast, the bone scan shows transient worsening followed by later improvement. There had not been any alteration in the patient's therapy, and the improvement in the liver metastases shows that the tumor was sensitive to the chemotherapeutic regimen. (Case provided by Dr. W.D. Leslie.)

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