and Malignant Compression Fractures of the Spine : Value of Adding Axial Diffusion-weighted MR Imaging at 3.0 T

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1 and Malignant Compression Fractures of the Spine : Value of Adding Axial Diffusion-weighted MR Imaging at 3.0 T < SP47, Scientific abstract > Jinkyeong Sung, MD1, Won-Hee Jee, MD1, Joon-Yong Jung, MD1, Maria Choi, MD1, So-Yeon Lee, MD1, Young-Hoon Kim, MD3, Kee-Yong Ha, MD2, Chun-Kun Park, MD3 Corresponding author : Won-Hee Jee Departments of 1Radiology, 2Orthopedic Surgery, and 3Neurosurgery, Seoul St. Mary s Hospital College of medicine, The Catholic University of Korea

2 Disclosure The following authors of this research have no relevant financial relationships with commercial interests to disclose : Jinkyeong Sung, MD Won-Hee Jee, MD Joon-Yong Jung, MD Maria Choi, MD So-Yeon Lee, MD Young-Hoon Kim, MD Kee-Yong Ha, MD Chun-Kun Park, MD

3 Purpose To determine the value of adding qualitative and quantitative, axial DWI to a standard MRI protocol to differentiate acute osteoporotic and malignant compression fractures at 3.0 T

4 Materials & Methods - Patients Lumbar MRI + axial DWI for vertebral compression fracture (Mar 2011 ~ Dec 2012) (n=395) Exclusion criteria 1.5-T MRI (n=194) Image distortion (n=41) Trauma history (n=15) - traffic accidents - falls from more than standing height Severe collapse including burst fracture (n=83)

5 Materials & Methods - Patients Acute benign fracture n=32 (M:F=8:24), 45-95yrs (mean 76yrs) Final Diagnosis - Biopsy (2) - MRI follow up (2) bone marrow edema disappears and fat marrow redistributes in the fractured vertebrae - Clinical follow up (28) full regression or gradual decrease of pain without the progression of vertebral destruction on plain radiography and CT

6 Malignant fracture Materials & Methods - Patients n=30 (M:F=19:11), 34-84yrs (mean 61yrs) No sclerotic metastasis, No treated metastasis Final Diagnosis - Biopsy (12) - Unequivocal imaging finding (18) paravertebral soft tissue mass pedicle and posterior element involvement convex posterior border other multiple spinal metastases

7 Materials & Methods - MR imaging 3.0 T MRI (Verio; Siemens Medical Solution) Conventional sequences Sag T1, T2, T2F, Ax T2 (all patients) Gd enhancement n (n= 36) Single shot spin-echo DWI Ax DW imaging ADC map b=0 b=800 b=1400 b=0 & 800 b=0 & 1400 b=0, 800,& 1400 *b values are in units of sec/mm2

8 Materials & Methods - MR Imaging analysis interpreting MRI regarding malignancy in two steps by two radiologists 1. standard spine MRI alone 2. standard spine MRI + axial DWI with qualitative and quantitative analysis combined

9 Materials & Methods - MR Imaging analysis For the second step Qualitative analysis (Signals of the collapsed vertebrae ) Grade 1 : < normal bone marrow Grade 2 : = normal bone marrow Grade 3 : normal bone marrow < < spinal cord Grade 4 : = spinal cord Grade 5 : > spinal cord Quantitative analysis (ADC map) placing the region of interest (ROI) within the solid portion of collapsed vertebra, paraspinal muscle, and normal bone

10 Materials & Methods - Statistic analysis Comparison of ADC values between benign and malignant lesions - Collapsed vertebral body - Normal bone marrow - Paraspinal muscle - ADC ratios of collapsed vertebra to normal bone marrow - ADC ratios of collapsed vertebra to paraspinal muscle Mann-Whitney U test

11 Materials & Methods - Statistic analysis Cut off values Receiver operating characteristic (ROC) curve analysis Interreader variability for signal characteristics on DWI kappa statistics Interobserver reliability for ADC measurements Intraclass correlation coefficient (ICC) Sensitivity & Specificity McNemar s statistics

12 Results - Qualitative anlysis Benign(n=32) Malignant (n=23) Reviewer1 Reviewer2 Reviewer1 Reviewer2 >65% <21% Grade b=800 b=1400 b=800 b=1400 b=800 b=1400 b=800 b= % >87 % κ=0.65 at b= 800 s/mm2, κ=0.75 at b= 1400 s/mm2 -> fair to good agreement

13 Results - Quantitative anlysis Excellent interobserver agreement (ICC > 0.92) Benign Mean Malignant Mean Mann Whitney ADC of Collapsed vertebral body B=0, P<.001 B=0, P<.001 B=0,800, P<.001 ADC values are in units of μmm2/s

14 Results - Quantitative anlysis ADC values of normal bone marrow and paraspinal muscles no significant difference between acute osteoporotic and malignant groups at all three combinations of b values The ratios of ADC values of collapsed vertebral body to normal vertebral body and paraspinal muscle malignant fracture < benign fracture (P<.001) no significant difference among the ratios (all three combinations of b values)

15 Results - Cut off values The cut off values of ADCs using ROC curve Collapsed vertebra 1200 μmm2/s (b = 0 & 800 s/mm2) (sen: 100%, spe: % acc: %) 1000 μmm2/s (b = 0 & 1400 s/mm2,combination of all 3 b values) (sen: 100%, spe: %, acc: %) Collapsed vertebral body / normal bone marrow 3 at all 3 combinations of b values (sen: 81-88%, spe: 81-94%, acc: 81-90%) Collapsed vertebral body / paraspinal muscle 0.8 at all 3 combinations of b values (sen: 100%, spe: %, acc: %).

16 Results - Diagnostic performance Standard MRI alone Standard MRI & DWI combined Reviewer1 Reviewer 2 Reviewer1 Reviewer 2 Sensitivity 100% 97% 100% 100% Specificity 94% 78% 97% 97% Accuracy 97% 87% 98% 98% Added value = 1.6% (1/62) Added value =11.3% (7/62)

17 77/W Acute benign compression fracture T2 FS T2 DWI (b = 800 s/mm2) ADC (b= 0 & 800 s/mm2)

18 70/M Metastatic compression fracture CE FS T1 CE FS T1 DWI (b= 800 s/mm2) ADC (b= 0 & 800 s/mm2)

19 89/M Acute benign compression fracture CE FS T1 CE FS T1 DWI (b= 800 s/mm2) ADC (b= 0 & 800 s/mm2)

20 Limitations Relatively small study population --> Differences related to the location (thoracic, lumbar, or sacral) or primary tumor were not evaluated Pathologic confirmation was not available in all cases Comparison among different magnetic field strength, machines and pulse sequences were not performed

21 Conclusion The addition of axial DWI with qualitative and quantitative analysis to a standard MR imaging protocol improved the diagnostic accuracy for differentiation of benign from malignant compression fractures of the spine at 3.0 T

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