The aims of this study were to assess the role of Tc-99m-tetrofosmin scintigraphy in the diagnosis of maligniant vs. benign musculoskeletal turnours and to determine the relationship between P-glycoprotein expression and tetrofosmin uptake in malignant lesions. Forty-six patients (32 malignant, 14 benign) with various musculoskeletal lesions were studied. Each patient underwent Tc-99m-methylene diphosphonate three-phase bone scanning initially. At least 2 days later, dynamic and static Tc-99m-tetrofosmin scans were obtained. The tetrofosmin scans were evaluated by visual and quantitative analysis. The count ratio of the lesion to the contralateral normal area (uptake ratio, UR) was calculated from the region of interest drawn on the tetrofosmin scan. The lesions were then resected by open biopsy to obtain a histopathological diagnosis. P-glycoprotein levels were determined immunohistochemically in 22 of 32 malignant lesions. A significant difference between the mean UR values of benign and malignant lesions was found (1.36 +/- 0.47 vs. 3.35 +/- 2.08, P = 0.000). Visual analysis showed an accuracy of 85%, and the accuracy of the quantitative analysis was 87% with the threshold level of UR as 1.76. When perfusion findings were added to the evaluation criteria, the accuracies of visual and quantitative analysis were increased to 87% and 89%, respectively. The relationship between the levels of P-glycoprotein and the UR values of tetrofosmin was not statistically significant (r = - 0.235, P = 0.2). In addition, the mean UR value of the patients with P-glycoprotein expression was not statistically different from that of the patients without P-glycoprotein expression (3.01 +/- 1.48 vs. 4.27 +/- 2.90, P = 0.297). In conclusion, visually significant tetrofosmin uptake and increased perfusion in a musculoskeletal lesion strongly suggest that the lesion is malignant (positive predictive value, 96%). P-glycoprotein expression was not found to be a major factor interfering with 30 min tetrofosmin uptake in a malignant musculoskeletal lesion. However, the relatively high false-negative rate among negative results (28%) limits the value of 99mTc-tetrofosmin scintigraphy as a single diagnostic tool in differentiating between benign and malignant musculoskeletal turnours. ((C) 2002 Lippincott Williams Wilkins).