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Bone marrow lesions: A systematic diagnostic approach.

Del Grande F, Farahani SJ, Carrino JA, Chhabra A - Indian J Radiol Imaging (2014)

Bottom Line: Bone marrow lesions on magnetic resonance (MR) imaging are common and may be seen with various pathologies.The authors outline a systematic diagnostic approach with proposed categorization of various etiologies of bone marrow lesions.Utilization of typical imaging features on conventional MR imaging techniques and other problem-solving techniques, such as chemical shift imaging and diffusion-weighted imaging (DWI), to achieve accurate final diagnosis has been highlighted.

View Article: PubMed Central - PubMed

Affiliation: The Russell H. Morgan Departments of Radiology and Radiology Science, Johns Hopkins Hospital, Baltimore, MD 21287, USA.

ABSTRACT
Bone marrow lesions on magnetic resonance (MR) imaging are common and may be seen with various pathologies. The authors outline a systematic diagnostic approach with proposed categorization of various etiologies of bone marrow lesions. Utilization of typical imaging features on conventional MR imaging techniques and other problem-solving techniques, such as chemical shift imaging and diffusion-weighted imaging (DWI), to achieve accurate final diagnosis has been highlighted.

No MeSH data available.


Related in: MedlinePlus

Coronal T1W (A) and STIR (B) images through the knee show diffuse bone marrow lesions, homogeneously hypo-isointense on T1W and moderately hyperintense on STIR images, involving distal femur and proximal tibia with epiphyseal involvement (arrows). CSI confirms the marrow replacement due to lack of drop in signal intensity on the out-of-phase image (C) compared to in-phase image (D). Post intravenous gadolinium axial T1W subtraction imaging (E) at the level of the proximal tibia shows diffuse enhancement (large arrow) similar to adjacent vessels (small arrow). Bone marrow lesions category II
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Figure 2: Coronal T1W (A) and STIR (B) images through the knee show diffuse bone marrow lesions, homogeneously hypo-isointense on T1W and moderately hyperintense on STIR images, involving distal femur and proximal tibia with epiphyseal involvement (arrows). CSI confirms the marrow replacement due to lack of drop in signal intensity on the out-of-phase image (C) compared to in-phase image (D). Post intravenous gadolinium axial T1W subtraction imaging (E) at the level of the proximal tibia shows diffuse enhancement (large arrow) similar to adjacent vessels (small arrow). Bone marrow lesions category II

Mentions: Diffusely infiltrative malignancy, such as leukemia [Figure 2A–E], lymphoma, and breast metastases [Figure 3A–F], could be sometimes difficult to differentiate from diffuse red marrow reconversion. Problem-solving techniques, such as CSI [Figures 2C, D and 3E, F] and DWI [Figure 3G], are prudently used for diagnosis to differentiate tumors from focal islands of normal marrow or other benign bone marrow lesions. The use of in-phase and out-of-phase imaging is probably the best known problem-solving technique for bone marrow pathologies. Disler et al. found that in-phase and out-of-phase imaging was helpful to predict the malignancy in a bone lesion.[6] Several other articles confirmed the data and substantiated the utility of CSI to distinguish benign from malignant vertebral lesions.[73839] Recently, Zajick et al. proposed a cut-off decrease of more than 20% of the signal intensity in out-of-phase imaging to predict malignancy in vertebral body abnormality.[40] DWI is another technique which may help differentiate malignant from benign lesions. Several research articles have documented that restrictive diffusion with high signal intensity on DWI is observed in neoplastic (pathologic) fractures as compared to osteoporotic fractures.[9414243] To our knowledge, Bauer et al. were the first authors to address the utility of DWI to differentiate benign from malignant spine lesions.[9] The authors analyzed 39 compression fractures with DWI. According to their study, malignant vertebral fractures showed high signal intensity on DWI, whereas benign lesions showed low signal intensity. On the contrary, literature on osteomyelitis and tumors of the peripheral skeleton is very scant compared to that on spine. Yasumoto et al. found that DWI had a high specificity to detect bone marrow infiltration with malignant lymphoma.[44] Herneth et al. reported several cases of peripheral osteomyelitis with increased tissue diffusivity.[45] These findings were confirmed by some other studies on skull base osteomyelitis that did not show diffusion restriction either.[4647] Therefore, it seems plausible that ADC lower than 1.1-1.2×10-3 mm/s2 values can aid in distinguishing osteomyelitis from neoplasm. On the contrary, Pui et al. reported 69 tuberculous, 9 pyogenic, and 50 malignant marrow lesions that showed similarly restricted ADC values.[48] However, more studies are needed to explore the role of fractionated ADC values rather than mean ADC values using multiple b values (diffusion moments) to assess the utility of this novel technique.[49] MRS is an experimental technique, although Choline peak seems to be a reliable indicator of increased cellularity.[50] To the best of our knowledge, there is no data exploring MRS in osteomyelitis, except for an isolated case among 36 patients reported by Wang et al.[50] In this series, the patient with tuberculosis arthritis did not show a Choline peak. MRS has been reported to be useful in bone marrow lipid assessment in osteoporosis.[51]


Bone marrow lesions: A systematic diagnostic approach.

Del Grande F, Farahani SJ, Carrino JA, Chhabra A - Indian J Radiol Imaging (2014)

Coronal T1W (A) and STIR (B) images through the knee show diffuse bone marrow lesions, homogeneously hypo-isointense on T1W and moderately hyperintense on STIR images, involving distal femur and proximal tibia with epiphyseal involvement (arrows). CSI confirms the marrow replacement due to lack of drop in signal intensity on the out-of-phase image (C) compared to in-phase image (D). Post intravenous gadolinium axial T1W subtraction imaging (E) at the level of the proximal tibia shows diffuse enhancement (large arrow) similar to adjacent vessels (small arrow). Bone marrow lesions category II
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4126144&req=5

Figure 2: Coronal T1W (A) and STIR (B) images through the knee show diffuse bone marrow lesions, homogeneously hypo-isointense on T1W and moderately hyperintense on STIR images, involving distal femur and proximal tibia with epiphyseal involvement (arrows). CSI confirms the marrow replacement due to lack of drop in signal intensity on the out-of-phase image (C) compared to in-phase image (D). Post intravenous gadolinium axial T1W subtraction imaging (E) at the level of the proximal tibia shows diffuse enhancement (large arrow) similar to adjacent vessels (small arrow). Bone marrow lesions category II
Mentions: Diffusely infiltrative malignancy, such as leukemia [Figure 2A–E], lymphoma, and breast metastases [Figure 3A–F], could be sometimes difficult to differentiate from diffuse red marrow reconversion. Problem-solving techniques, such as CSI [Figures 2C, D and 3E, F] and DWI [Figure 3G], are prudently used for diagnosis to differentiate tumors from focal islands of normal marrow or other benign bone marrow lesions. The use of in-phase and out-of-phase imaging is probably the best known problem-solving technique for bone marrow pathologies. Disler et al. found that in-phase and out-of-phase imaging was helpful to predict the malignancy in a bone lesion.[6] Several other articles confirmed the data and substantiated the utility of CSI to distinguish benign from malignant vertebral lesions.[73839] Recently, Zajick et al. proposed a cut-off decrease of more than 20% of the signal intensity in out-of-phase imaging to predict malignancy in vertebral body abnormality.[40] DWI is another technique which may help differentiate malignant from benign lesions. Several research articles have documented that restrictive diffusion with high signal intensity on DWI is observed in neoplastic (pathologic) fractures as compared to osteoporotic fractures.[9414243] To our knowledge, Bauer et al. were the first authors to address the utility of DWI to differentiate benign from malignant spine lesions.[9] The authors analyzed 39 compression fractures with DWI. According to their study, malignant vertebral fractures showed high signal intensity on DWI, whereas benign lesions showed low signal intensity. On the contrary, literature on osteomyelitis and tumors of the peripheral skeleton is very scant compared to that on spine. Yasumoto et al. found that DWI had a high specificity to detect bone marrow infiltration with malignant lymphoma.[44] Herneth et al. reported several cases of peripheral osteomyelitis with increased tissue diffusivity.[45] These findings were confirmed by some other studies on skull base osteomyelitis that did not show diffusion restriction either.[4647] Therefore, it seems plausible that ADC lower than 1.1-1.2×10-3 mm/s2 values can aid in distinguishing osteomyelitis from neoplasm. On the contrary, Pui et al. reported 69 tuberculous, 9 pyogenic, and 50 malignant marrow lesions that showed similarly restricted ADC values.[48] However, more studies are needed to explore the role of fractionated ADC values rather than mean ADC values using multiple b values (diffusion moments) to assess the utility of this novel technique.[49] MRS is an experimental technique, although Choline peak seems to be a reliable indicator of increased cellularity.[50] To the best of our knowledge, there is no data exploring MRS in osteomyelitis, except for an isolated case among 36 patients reported by Wang et al.[50] In this series, the patient with tuberculosis arthritis did not show a Choline peak. MRS has been reported to be useful in bone marrow lipid assessment in osteoporosis.[51]

Bottom Line: Bone marrow lesions on magnetic resonance (MR) imaging are common and may be seen with various pathologies.The authors outline a systematic diagnostic approach with proposed categorization of various etiologies of bone marrow lesions.Utilization of typical imaging features on conventional MR imaging techniques and other problem-solving techniques, such as chemical shift imaging and diffusion-weighted imaging (DWI), to achieve accurate final diagnosis has been highlighted.

View Article: PubMed Central - PubMed

Affiliation: The Russell H. Morgan Departments of Radiology and Radiology Science, Johns Hopkins Hospital, Baltimore, MD 21287, USA.

ABSTRACT
Bone marrow lesions on magnetic resonance (MR) imaging are common and may be seen with various pathologies. The authors outline a systematic diagnostic approach with proposed categorization of various etiologies of bone marrow lesions. Utilization of typical imaging features on conventional MR imaging techniques and other problem-solving techniques, such as chemical shift imaging and diffusion-weighted imaging (DWI), to achieve accurate final diagnosis has been highlighted.

No MeSH data available.


Related in: MedlinePlus