Bone Scan with Confusing Appearance: Superscan or Metabolic Disorder

We present a patient with metastatic prostate cancer with known bone involvement and unknown osteomyelofibrosis. It has the general appearance of a superscan, with homogeneously increased tracer uptake and no visualization of the kidneys. However, while a superscan should have greater uptake in the axial skeleton compared to the appendicular skeleton, this scan is reverse, raising the suspicion of an overlying metabolic bone disorder. Subsequent laboratory-, bioptical findings confirmed a myeloproliferative syndrome with osteomyelofibrosis. As such, this scan demonstrates that in a patient with both affiliations, metabolic bone disease can override even severe osseous metastases on a bone scan.