1984, The British Journal of Radiology, 57, 677-680

AUGUST

1984

Chromium 51 EDTA/technetium 99m MDP plasma ratio to

measure total skeletal function
By A. Patric Nisbet, M.Sc, M.R.C.P.; Susan Edwards, B.Sc, Colin R. Lazarus, B. Pharm., Ph.D.
M.P.S., Julia Malamitsi, M.Sc, Michael N. Maisey, M.D., F.R.C.R., F.R.C.P., Gail D. Mashiter
and Patricia J. Winn
Departments of Nuclear Medicine, Radiology, and Clinical Physics and Bioengineering, Guy's Hospital,
London
(Received November 1983 and in revised form February 1984)

ABSTRACT

A method is described for the quantitation of total skeletal

activity during bone scans. The method requires a single
plasma sample only, taken at the time of imaging. The ratio of
% injected dose of 51 Cr EDTA to that of " T c m MDP is
calculated from this sample following combined injection of
the two radiopharmaceuticals. The 51 Cr EDTA level corrects
for the glomerular filtration of " T c m MDP. Using this
method, which only requires a gamma counter, significant
differences from normal controls have been shown in patients
with osteomalacia, renal osteodystrophy, Paget's disease and
hypercalcaemia. The method provides routine quantitative
data to add to the imaging information in the bone scan.

The measurement of total tracer uptake by the skeleton

is now an established method of investigation in the
management of metabolic bone disease. The wholebody retention of diphosphonates at 24 h has been
shown to be a sensitive means of identifying patients
with increased bone turnover (Fogelman et al, 1978).
The whole-body retention (WBR) method uses a
whole-body counter and requires two separate visits by
the patient. A method which could be used as an
adjunct to the routine bone scan to provide a
quantitative index of total skeletal function would be of
benefit in the determination of metabolic bone
disorders, identification of the superscan and possibly
for sequential measurements of activity of metastases
and Pagetic lesions.
The WBR is evaluated at 24 h so that (with the
exception of renal failure) renal excretion of diphosphonates can be assumed to be no longer significant.
Any method for evaluation of total skeletal activity
(using blood clearance or whole body retention) at the
time (3-4 h after injection) of the normal bone scan will
require correction for renal handling of diphosphonate.
Diphosphonates are filtered by the human kidney
without significant secretion or absorption, the filtration
fraction being similar to DTPA and EDTA (McAfee
et al, 1981). In rats there is evidence of some secretion
by the tubule (Troehler et al, 1975), but this is also true
Address for reprints: Susan Edwards, Dept. of Clinical Physics
& Bioengineering, Guy's Hospital, St. Thomas' Street, London,
SE1 9RT, England.

677

of EDTA, and diphosphonates can be treated as

glomerular filtration agents. If diphosphonates and
EDTA are injected simultaneously any difference in
plasma levels of the two tracers will represent
preferential diphosphonate uptake into bone and soft
tissue.
The WBR of diphosphonate in soft tissue has been
shown to be a constant fraction of the administered
dose (Smith et al, 1982) over a wide range of
conditions. Hence relative differences in EDTA and
diphosphonate plasma levels can be assumed to reflect
diphosphonate uptake into bone.
The purpose of the present study was to investigate
the possibility of a simple test for routine use, based on
the plasma level of " T c m MDP at 4 h with the 51 Cr
EDTA plasma level, providing a correction for renal
function.
PATIENTS

Eight normal patients, (aged 20-61, mean age 38)

and 20 patients with carcinoma of the breast, without
metastases and on no therapy (aged 39-80, mean 52),
were taken as the normal control group. The disease
groups comprised:
11 patients with chronic renal failure (aged 22-61,
mean 46); 10 patients with Paget's disease (aged
48-75, mean 53); 7 patients with osteomalacia (aged
32-84, mean 53); 20 patients with hypercalcaemia,
predominantly primary hyperparathyroidism, without signs of bone disease, but including three with a
primary neoplasm, without bone secondaries, having
humoral hypercalcaemia of malignancy (aged 22-11,
mean 51).
METHOD AND RESULTS

To study the clearance of " T c m MDP and 51 Cr

EDTA in vivo, 34 patients had plasma samples taken
over a 7-hour period, following simultaneous injections
of the two agents (Nisbet, 1982; Nisbet et al, 1983).
Typical results are shown in Figs. 1-4. In each figure
the three curves show percentage administered
dose/litre plasma for 51 Cr EDTA and " T c m MDP, and
the ratio of these two as a function of time to about 400

VOL.

57, No. 680

A. Patric Nisbet et al
15

Clearance and ratio curves for patient with osteomalacia

(see text).

FIG. 1.

Clearance and ratio curves for normal subject. The two

clearance curves (open triangles: 51 Cr EDTA; closed triangles:
" T c m MDP) show percentage injected dose per litre of plasma
for the two agents as a function of time. The third curve (open
squares) shows the ratio of these two concentrations as a
function of time. In normals the ratio is almost constant over
the seven hours of the study.

15
'O51EDTA
Tc99mMDP
-Ratio Cr/Tc
10

min after injection. In normals the plasma curves are

parallel for MDP and EDTA, with a constant ratio of
% administered 51 Cr dose/litre to % administered
" T c m dose/litre of around 1.2.
In Paget's disease, there is early separation of the
curves, with subsequent approximation. The 5 1 C r / " T c m
ratio rises early with a later plateau.
In osteomalacia, the curves separate early and remain
widely separated over the seven hours of the study. The
51
C r / " T c m ratio rises steeply throughout.
In hyperparathyroidism, there is a small but

15
Cr51EDTA
Tc99mMDP
Ratio Cr/Tc
10

100

200

300

400
minutes

FIG. 2.
Clearance and ratio curves for patient with Paget's disease
(see text).

100

200

300

400
minutes

FIG. 4.
Clearance and ratio curves for patient with hypercalcaemia
(see text).

significant separation in the majority of patients,

though a minority have normal curves.
The ratio of 51 Cr EDTA/"Tc m MDP % administered dose was measured during routine bone scans
using the following method.
A 51 Cr EDTA* and " T c m MDP* mixture was made,
in the ratio of approximately 3 MBq (100 /iCi) 51 Cr
EDTA to 550 MBq (15 mCi) " T c m MDP. The mixture
was then injected into the patient. Blood samples were
taken at 10, 30, 60 and 240 min (heparinised bottles
10 ml). The residue in the vial was used as a standard,
and the samples were counted on a two-channel
automatic gamma counter for 51 Cr and " T c m activity
at 24 h (3 ml plasma, standard diluted 1/10000). A
repeat count was performed after five days, when the

678

*Amersham International pic

AUGUST

1984

51

Cr EDTAj99Tcm ratio for total skeletal function

"Tc m activity had decayed to background level,

(standard dilution 1/250).
Following correction for background and crosstalk
from 51Cr in the " T c m channel, the ratio of %
administered dose/1 of plasma for 5 1 Cr/"Tc m was
calculated. Since only the ratio was used, knowledge of
volumes and activities injected was not necessary.
Chromatography studies showed the " T c m MDP/ 51 Cr
EDTA mixture to be stable for more than three hours.
The maximum ratio of the four samples was taken for
each patient. In practice this was the 4 h sample, except
for one patient with Paget's disease. Values of
maximum ratio in the five groups of patients are shown
in Fig. 5.
In the normal control group the ratios ranged from
0.80 to 1.4, with a mean of 1.19 and a standard
deviation of 0.12. The upper limit of normal was set at
1.43 (mean +2 SD). Values of range, mean and SD for
the different disease groups are given in Table I.
Statistical analysis used the non-parametric MannWhitney Rank Sum Test to determine the probabilities
of occurrence on the null hypothesis of the ratios
observed in the pathological groups compared to that in
the 28 normal control group. Probability levels (onetailed) were < 0.001 for the osteomalacia, renal
osteodystrophy and Paget's disease groups. For the
hypercalcaemia group the level was < 0.01.
DISCUSSION

The results show clear differences between normal

controls and patients with renal osteodystrophy,
osteomalacia, and Paget's disease. The hypercalcaemic
group showed a less marked but still significant
difference. Patients with active Paget's disease showed

Maximum ratio
7

TABLE I
RANGES AND STANDARD DEVIATIONS FOR MAXIMUM RATIO IN
VARIOUS PATIENT GROUPS

Group

Min

Normal
Renal osteodystrophy
Paget's disease
Osteomalacia
Hypercalcaemia

0.8
1.5
1.3
1.7
1.1

Maximum Ratio
Max
Mean SD
1.4
4.7
4.0
6.3
2.8

1.19
2.8
2.5
3.1
1.7

0.12
0.8
0.9
1.4

0.5

elevation of the ratio; patients in whom Paget's disease

had been treated successfully, as shown by return of
alkaline phosphatase to normal values and pain relief,
showed normal ratio values.The hypercalcaemic group
was an unselected group of undiagnosed hypercalcaemic patients still under investigation; 13 had
hyperparathyroidism without elevation of alkaline
phosphatase or radiological bone abnormality, three
had proven malignancy and the rest did not have a firm
diagnosis at the time of writing. There was no sign of
bone disease in any of the hyperparathyroid group,
apart from probable high uptake on the bone scan in
eight patients. The quantitation may assist in the
detection of bone disease in this group.
The finding that the highest ratio of the four occurs
between 3 and 4 h in the vast majority of patients
means that a single blood sample taken at the usual
time for bone scanning will provide quantitative
assessment of the total skeletal activity to add to the
qualitative information from the scan images. This
value appears to have highly significant discriminatory
ability in the detection of renal osteodystrophy,
osteomalacia and Paget's disease, though these conditions cannot be separated from each other by ratio
alone. It may provide valuable information as to the
extent of bone activity in hypercalcaemic bone
disorders. Single plasma values should be acceptably
sensitive for general patient screening, with several
samples providing further information in known cases
of metabolic bone disease. Early sampling may be of
value in disorders with high bone blood flow such as
Paget's disease, where the ratio may peak early after
injection.
CONCLUSION

Group number
FIG. 5.
Values of maximum ratio found in different disease groups.
Group 1: Normal controls; Group 2: Renal osteodystrophy;
Group 3: Paget's disease; Group 4: Osteomalacia; Group 5:
Hypercalcaemia.
The horizontal line shows the upper limit of normal
(Mean + 2 SD).

679

A single plasma sample technique, applicable to any

routine bone scan, has been shown to demonstrate
skeletal activity in metabolic bone disorders. The
technique may be instituted in any department,
requiring only a well counter; and sampling of all
patients having bone scans does not make much more
work for staff nor increase waiting time for patients.
ACKNOWLEDGMENTS

A.P.N. gratefully acknowledges the support of Guy's Special

VOL.

57, No. 680

l

Cr EDTAI"T<T ratio for total skeletal function

Trustees. We wish to thank Miss S. V. Ellam, Miss N.

Solaiman and Mrs F. Bradley for their invaluable assistance.

NISBET, A. P., 1982. The quantitation of Tc99m MDP uptake

in bone, using the relative clearances of Tc99m MDP and
Cr51 EDTA from the blood. Thesis for MSc in Nuclear
Medicine, University of London.

REFERENCES

NISBET, A. P., EDWARDS, S., MASHITER, G., WINN, P., HILSON,

FOGELMAN, I., BESSENT, R. G . , TURNER, J. G . , ClTRIN, D . L.,

BOYLE, I. T. & GREIG, W. R., 1978. The use of the Whole

Body Retention of Tc99m diphosphonate in the diagnosis of

metabolic bone disease. Journal of Nuclear Medicine, 19,
270-275.
MCAFEE, J. G., GROSSMAN, Z. D., GAGNE, G., ZENS, A. L.,
SUBRAMANIAN, G., THOMAS, F . D . , FERNANDEZ, P . &

ROSKOPF, M. L., 1981. Comparison of renal extraction

efficiencies for radioactive agents in the normal dog. Journal
of Nuclear Medicine, 22, 333-338.

A. J. W. & MAISEY, M. N., 1983. Quantitation of Tc99m

MDP retention during routine bone scanning. Nuclear
Medicine Communications, 4, 67-71.
SMITH, M. L., MARTIN, W., FOGELMAN, I. & BESSENT, R. G.,

1982. Relative distribution of diphosphonate between bone

and soft tissue at 4 and 24 hours: concise communication.
Journal of Nuclear Medicine, 24, 208-211.
TROEHLER, U., BONJOUR, J. P. & FLEISH, H., 1975. Renal

secretion of diphosphonates in rats. Kidney International, 8,

6-13.

Book review
Radiology of Skeletal Trauma. (2 vols). By Lee F. Rogers, pp.
xxviii + 920, 1982 (Churchill Livingstone, Edinburgh), 110.00.
ISBN 0-443-080380
This 900-page treatise is in two volumes with 1700
illustrations and, apart from one chapter on imaging
techniques by Dr. Ronald Hendrix, is the work of one man.
One cannot but marvel at Dr. Rogers' industry, not simply in
writing an authoritative and lucid text but in assembling such
an enormous collection of illustrations on such a difficult
subject as trauma where radiographic quality is not always the
greatest.
The first 160 pages are devoted to chapters on general
anatomy, skeletal biomechanics, and the epidemiology and
classification of fractures, as well as fracture-healing and
complications which are clearly explained and illustrated.
Special attention is also paid to children, notably in relation to
non-accidental trauma and epiphyseal injuries. In the latter
respect it was refreshing to see an American author give due
acknowledgment to the work of British pioneers in identifying
these injuries. The triangular metaphyseal fragment is

680

known in the US as "Thurston Holland's corner sign"-a

classic example of the prophet without honour in his own
country.
Subsequent chapters deal with injury on a regional basis.
About 200 pages each are devoted to the limbs, 50 to the pelvis
and 66 to the spine, and proportional amounts to skull, face
and thorax. I think it is remarkable that the coverage of spinal
injuries is so complete within the space available and the
author is able to include reference to such subjects as injury to
the spondylitic spine as well as fractures of the larynx.
The chapter on available imaging techniques by Dr. Hendrix
covers such subjects as macro-radiography, bone-scanning and
CT, although reference to these techniques is also made, where
appropriate, in the general text.
Criticisms are minor and mainly syntactical and must not be
allowed to detract from this tour-de-force. Dr. Rogers is to be
congratulated on producing what is obviously going to become
a classic work which will be essential in all radiological and
orthopaedic libraries.
J. T. PATTON