DOI QR코드

DOI QR Code

MRI Evaluation of Suspected Pathologic Fracture at the Extremities from Metastasis: Diagnostic Value of Added Diffusion-Weighted Imaging

  • Sun-Young Park (Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Min Hee Lee (Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Ji Young Jeon (Department of Radiology, Gil Medical Center, Gachon University College of Medicine) ;
  • Hye Won Chung (Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Sang Hoon Lee (Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Myung Jin Shin (Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center)
  • Received : 2018.08.10
  • Accepted : 2018.12.04
  • Published : 2019.05.01

Abstract

Objective: To assess the diagnostic value of combining diffusion-weighted imaging (DWI) with conventional magnetic resonance imaging (MRI) for differentiating between pathologic and traumatic fractures at extremities from metastasis. Materials and Methods: Institutional Review Board approved this retrospective study and informed consent was waived. This study included 49 patients each with pathologic and traumatic fractures at extremities. The patients underwent conventional MRI combined with DWI. For qualitative analysis, two radiologists (R1 and R2) independently reviewed three imaging sets with a crossover design using a 5-point scale and a 3-scale confidence level: DWI plus non-enhanced MRI (NEMR; DW set), NEMR plus contrast-enhanced fat-saturated T1-weighted imaging (CEFST1; CE set), and DWI plus NEMR plus CEFST1 (combined set). McNemar's test was used to compare the diagnostic performances among three sets and perform subgroup analyses (single vs. multiple bone abnormality, absence/presence of extra-osseous mass, and bone enhancement at fracture margin). Results: Compared to the CE set, the combined set showed improved diagnostic accuracy (R1, 84.7 vs. 95.9%; R2, 91.8 vs. 95.9%, p < 0.05) and specificity (R1, 71.4% vs. 93.9%, p < 0.005; R2, 85.7% vs. 98%, p = 0.07), with no difference in sensitivities (p > 0.05). In cases of absent extra-osseous soft tissue mass and present fracture site enhancement, the combined set showed improved accuracy (R1, 82.9-84.4% vs. 95.6-96.3%, p < 0.05; R2, 90.2-91.1% vs. 95.1-95.6%, p < 0.05) and specificity (R1, 68.3-72.9% vs. 92.7-95.8%, p < 0.005; R2, 83.0-85.4% vs. 97.6-98.0%, p = 0.07). Conclusion: Combining DWI with conventional MRI improved the diagnostic accuracy and specificity while retaining sensitivity for differentiating between pathologic and traumatic fractures from metastasis at extremities.

Keywords

References

  1. Saad F, Lipton A, Cook R, Chen YM, Smith M, Coleman R. Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer 2007;110:1860-1867 https://doi.org/10.1002/cncr.22991
  2. Ward WG, Spang J, Howe D. Metastatic disease of the femur. Surgical management. Orthop Clin North Am 2000;31:633-645 https://doi.org/10.1016/S0030-5898(05)70181-4
  3. Bae JH, Lee IS, Song YS, Kim JI, Cho KH, Lee SM, et al. Bone tumors with an associated pathologic fracture: differentiation between benign and malignant status using radiologic findings. J Korean Soc Radiol 2015;73:240-248 https://doi.org/10.3348/jksr.2015.73.4.240
  4. Jung HS, Jee WH, McCauley TR, Ha KY, Choi KH. Discrimination of metastatic from acute osteoporotic compression spinal fractures with MR imaging. Radiographics 2003;23:179-187 https://doi.org/10.1148/rg.231025043
  5. Baur A, Dietrich O, Reiser M. Diffusion-weighted imaging of bone marrow: current status. Eur Radiol 2003;13:1699-1708 https://doi.org/10.1007/s00330-003-1873-0
  6. Padhani AR, van Ree K, Collins DJ, D'Sa S, Makris A. Assessing the relation between bone marrow signal intensity and apparent diffusion coefficient in diffusion-weighted MRI. AJR Am J Roentgenol 2013;200:163-170 https://doi.org/10.2214/AJR.11.8185
  7. Lee SY, Jee WH, Jung JY, Park MY, Kim SK, Jung CK, et al. Differentiation of malignant from benign soft tissue tumours: use of additive qualitative and quantitative diffusion-weighted MR imaging to standard MR imaging at 3.0 T. Eur Radiol 2016;26:743-754
  8. Zhou XJ, Leeds NE, McKinnon GC, Kumar AJ. Characterization of benign and metastatic vertebral compression fractures with quantitative diffusion MR imaging. AJNR Am J Neuroradiol 2002;23:165-170
  9. Geith T, Schmidt G, Biffar A, Dietrich O, Durr HR, Reiser M, et al. Comparison of qualitative and quantitative evaluation of diffusion-weighted MRI and chemical-shift imaging in the differentiation of benign and malignant vertebral body fractures. AJR Am J Roentgenol 2012;199:1083-1092 https://doi.org/10.2214/AJR.11.8010
  10. Sung JK, Jee WH, Jung JY, Choi M, Lee SY, Kim YH, et al. Differentiation of acute osteoporotic and malignant compression fractures of the spine: use of additive qualitative and quantitative axial diffusion-weighted MR imaging to conventional MR imaging at 3.0 T. Radiology 2014;271:488-498 https://doi.org/10.1148/radiol.13130399
  11. Hamimi A, Kassab F, Kazkaz G. Osteoporotic or malignant vertebral fracture? This is the question. What can we do about it? The Egyptian Journal of Radiology and Nuclear Medicine 2015;46:97-103 https://doi.org/10.1016/j.ejrnm.2014.11.010
  12. Bhugaloo A, Abdullah B, Siow Y, Ng K. Diffusion weighted MR imaging in acute vertebral compression fractures: differentiation between malignant and benign causes. Biomed Imaging Interv J 2006;2:e12
  13. Abowarda MH, Abdel-Rahman HM, Taha MM. Differentiation of acute osteoporotic from malignant vertebral compression fractures with conventional MRI and diffusion MR imaging. The Egyptian Journal of Radiology and Nuclear Medicine 2017;48:207-213 https://doi.org/10.1016/j.ejrnm.2016.11.001
  14. Del Grande F, Subhawong T, Weber K, Aro M, Mugera C, Fayad LM. Detection of soft-tissue sarcoma recurrence: added value of functional MR imaging techniques at 3.0 T. Radiology 2014;271:499-511 https://doi.org/10.1148/radiol.13130844
  15. Kim SH, Lee JM, Hong SH, Kim GH, Lee JY, Han JK, et al. Locally advanced rectal cancer: added value of diffusion-weighted MR imaging in the evaluation of tumor response to neoadjuvant chemo- and radiation therapy. Radiology 2009;253:116-125 https://doi.org/10.1148/radiol.2532090027
  16. Park HJ, Lee SY, Rho MH, Chung EC, Kim MS, Kwon HJ, et al. Single-shot echo-planar diffusion-weighted MR imaging at 3T and 1.5T for differentiation of benign vertebral fracture edema and tumor infiltration. Korean J Radiol 2016;17:590-597 https://doi.org/10.3348/kjr.2016.17.5.590
  17. Kivrak AS, Paksoy Y, Erol C, Koplay M, Ozbek S, Kara F. Comparison of apparent diffusion coefficient values among different MRI platforms: a multicenter phantom study. Diagn Interv Radiol 2013;19:433-437 https://doi.org/10.5152/dir.2013.13034
  18. Sasaki M, Yamada K, Watanabe Y, Matsui M, Ida M, Fujiwara S, et al. Variability in absolute apparent diffusion coefficient values across different platforms may be substantial: a multivendor, multi-institutional comparison study. Radiology 2008;249:624-630 https://doi.org/10.1148/radiol.2492071681
  19. Blazic IM, Lilic GB, Gajic MM. Quantitative assessment of rectal cancer response to neoadjuvant combined chemotherapy and radiation therapy: comparison of three methods of positioning region of interest for ADC measurements at diffusion-weighted MR imaging. Radiology 2017;282:615
  20. Ahlawat S, Khandheria P, Del Grande F, Morelli J, Subhawong TK, Demehri S, et al. Interobserver variability of selective region-of-interest measurement protocols for quantitative diffusion weighted imaging in soft tissue masses: comparison with whole tumor volume measurements. J Magn Reson Imaging 2016;43:446-454 https://doi.org/10.1002/jmri.24994
  21. Braithwaite AC, Dale BM, Boll DT, Merkle EM. Short- and midterm reproducibility of apparent diffusion coefficient measurements at 3.0-T diffusion-weighted imaging of the abdomen. Radiology 2009;250:459-465 https://doi.org/10.1148/radiol.2502080849
  22. Kim SY, Lee SS, Byun JH, Park SH, Kim JK, Park B, et al. Malignant hepatic tumors: short-term reproducibility of apparent diffusion coefficients with breath-hold and respiratory-triggered diffusion-weighted MR imaging. Radiology 2010;255:815-823 https://doi.org/10.1148/radiol.10091706
  23. Cha MJ, Yoon YC. Clinical relevance of the apparent diffusion coefficient value of metastatic bone tumours on diffusion-weighted MRI images: differences according to the types of primary tumour, the affected bones, and clinical factors. Clin Radiol 2015;70:1116-1121