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Proton density fat fraction (PDFF) MR imaging for differentiation of acute benign and neoplastic compression fractures of the spine

  • Magnetic Resonance
  • Published:
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Abstract

Objectives

To evaluate the diagnostic performance of proton density fat fraction (PDFF) magnetic resonance imaging (MRI) to differentiate between acute benign and neoplastic vertebral compression fractures (VCFs).

Methods

Fifty-seven consecutive patients with 46 acute benign and 41 malignant VCFs were prospectively enrolled in this institutional review board approved study and underwent routine clinical MRI with an additional six-echo modified Dixon sequence of the spine at a clinical 3.0-T scanner. All fractures were categorised as benign or malignant according to either direct bone biopsy or 6-month follow-up MRI. Intravertebral PDFF and PDFFratio (fracture PDFF/normal vertebrae PDFF) for benign and malignant VCFs were calculated using region-of-interest analysis and compared between both groups. Additional receiver operating characteristic and binary logistic regression analyses were performed.

Results

Both PDFF and PDFFratio of malignant VCFs were significantly lower compared to acute benign VCFs [PDFF, 3.48 ± 3.30% vs 23.99 ± 11.86% (p < 0.001); PDFFratio, 0.09 ± 0.09 vs 0.49 ± 0.24 (p < 0.001)]. The areas under the curve were 0.98 for PDFF and 0.97 for PDFFratio, yielding an accuracy of 96% and 95% for differentiating between acute benign and malignant VCFs. PDFF remained as the only imaging-based variable to independently differentiate between acute benign and malignant VCFs on multivariate analysis (odds ratio, 0.454; p = 0.005).

Conclusions

Quantitative assessment of PDFF derived from modified Dixon water-fat MRI has high diagnostic accuracy for the differentiation of acute benign and malignant vertebral compression fractures.

Key Points

• Chemical-shift-encoding based water-fat MRI can reliably assess vertebral bone marrow PDFF

• PDFF is significantly higher in acute benign than in malignant VCFs

• PDFF provides high accuracy for differentiating acute benign from malignant VCFs

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Abbreviations

6E-mDixon:

Six-echo modified Dixon

95%CI:

95 % confidence interval

mDixon:

Modified Dixon

NPV:

Negative predictive value

PDFF:

Proton density fat fraction

PET/CT:

Positron emission tomography/computed tomography

PPV:

Positive predictive value

ROC:

Receiver operating characteristic

ROI:

Region of interest

SE:

Spin echo

SENSE:

Sensitivity encoding

SPAIR:

Spectral attenuated inversion recovery

TE:

Echo time

TR:

Repetition time

VCF:

Vertebral compression fracture

References

  1. Chapman J, Smith JS, Kopjar B et al (2013) The AOSpine North America Geriatric Odontoid Fracture Mortality Study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine (Phila Pa 1976) 38:1098–1104

    Article  Google Scholar 

  2. Hansen EJ, Simony A, Carreon L, Andersen MO (2016) Rate of unsuspected malignancy in patients with vertebral compression fracture undergoing percutaneous vertebroplasty. Spine (Phila Pa 1976) 41:549–552

    Article  Google Scholar 

  3. Jung HS, Jee WH, McCauley TR, Ha KY, Choi KH (2003) Discrimination of metastatic from acute osteoporotic compression spinal fractures with MR imaging. Radiographics 23:179–187

    Article  Google Scholar 

  4. Link TM, Guglielmi G, van Kuijk C, Adams JE (2005) Radiologic assessment of osteoporotic vertebral fractures: diagnostic and prognostic implications. Eur Radiol 15:1521–1532

    Article  Google Scholar 

  5. Geith T, Schmidt G, Biffar A et al (2012) 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 199:1083–1092

    Article  Google Scholar 

  6. Disler DG, McCauley TR, Ratner LM, Kesack CD, Cooper JA (1997) In-phase and out-of-phase MR imaging of bone marrow: prediction of neoplasia based on the detection of coexistent fat and water. AJR Am J Roentgenol 169:1439–1447

    Article  CAS  Google Scholar 

  7. Zajick DC Jr, Morrison WB, Schweitzer ME, Parellada JA, Carrino JA (2005) Benign and malignant processes: normal values and differentiation with chemical shift MR imaging in vertebral marrow. Radiology 237:590–596

    Article  Google Scholar 

  8. Erly WK, Oh ES, Outwater EK (2006) The utility of in-phase/opposed-phase imaging in differentiating malignancy from acute benign compression fractures of the spine. AJNR Am J Neuroradiol 27:1183–1188

    CAS  PubMed  Google Scholar 

  9. Eito K, Waka S, Naoko N, Makoto A, Atsuko H (2004) Vertebral neoplastic compression fractures: assessment by dual-phase chemical shift imaging. J Magn Reson Imaging 20:1020–1024

    Article  Google Scholar 

  10. Douis H, Davies AM, Jeys L, Sian P (2016) Chemical shift MRI can aid in the diagnosis of indeterminate skeletal lesions of the spine. Eur Radiol 26:932–940

    Article  CAS  Google Scholar 

  11. Fischer MA, Nanz D, Shimakawa A et al (2013) Quantification of muscle fat in patients with low back pain: comparison of multi-echo MR imaging with single-voxel MR spectroscopy. Radiology 266:555–563

    Article  Google Scholar 

  12. Ruschke S, Pokorney A, Baum T et al (2017) Measurement of vertebral bone marrow proton density fat fraction in children using quantitative water-fat MRI. MAGMA 30:449–460

    Article  CAS  Google Scholar 

  13. Gee CS, Nguyen JT, Marquez CJ et al (2015) Validation of bone marrow fat quantification in the presence of trabecular bone using MRI. J Magn Reson Imaging 42:539–544

    Article  Google Scholar 

  14. Karampinos DC, Melkus G, Baum T, Bauer JS, Rummeny EJ, Krug R (2014) Bone marrow fat quantification in the presence of trabecular bone: initial comparison between water-fat imaging and single-voxel MRS. Magn Reson Med 71:1158–1165

    Article  CAS  Google Scholar 

  15. Latifoltojar A, Hall-Craggs M, Bainbridge A et al (2017) Whole-body MRI quantitative biomarkers are associated significantly with treatment response in patients with newly diagnosed symptomatic multiple myeloma following bortezomib induction. Eur Radiol 27:5325–5336

    Article  Google Scholar 

  16. Baker LL, Goodman SB, Perkash I, Lane B, Enzmann DR (1990) Benign versus pathologic compression fractures of vertebral bodies: assessment with conventional spin-echo, chemical-shift, and STIR MR imaging. Radiology 174:495–502

    Article  CAS  Google Scholar 

  17. Minne HW, Leidig G, Wuster C et al (1988) A newly developed spine deformity index (SDI) to quantitate vertebral crush fractures in patients with osteoporosis. Bone Miner 3:335–349

    CAS  PubMed  Google Scholar 

  18. Mauch JT, Carr CM, Cloft H, Diehn FE (2018) Review of the imaging features of benign osteoporotic and malignant vertebral compression fractures. AJNR Am J Neuroradiol. https://doi.org/10.3174/ajnr.A5528

    Article  CAS  Google Scholar 

  19. Faul F, Erdfelder E, Buchner A, Lang AG (2009) Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41:1149–1160

    Article  Google Scholar 

  20. Yoo HJ, Hong SH, Kim DH et al (2017) Measurement of fat content in vertebral marrow using a modified dixon sequence to differentiate benign from malignant processes. J Magn Reson Imaging 45:1534–1544

    Article  Google Scholar 

  21. Schmeel FC, Luetkens JA, Wagenhauser PJ et al (2018) Proton density fat fraction (PDFF) MRI for differentiation of benign and malignant vertebral lesions. Eur Radiol. https://doi.org/10.1007/s00330-017-5241-x

    Article  Google Scholar 

  22. Kim DH, Yoo HJ, Hong SH, Choi JY, Chae HD, Chung BM (2017) Differentiation of acute osteoporotic and malignant vertebral fractures by quantification of fat fraction with a Dixon MRI sequence. AJR Am J Roentgenol 209:1331–1339

    Article  Google Scholar 

  23. Kugel H, Jung C, Schulte O, Heindel W (2001) Age- and sex-specific differences in the 1H-spectrum of vertebral bone marrow. J Magn Reson Imaging 13:263–268

    Article  CAS  Google Scholar 

  24. Ragab Y, Emad Y, Gheita T et al (2009) Differentiation of osteoporotic and neoplastic vertebral fractures by chemical shift {in-phase and out-of phase} MR imaging. Eur J Radiol 72:125–133

    Article  Google Scholar 

  25. Baum T, Yap SP, Dieckmeyer M et al (2015) Assessment of whole spine vertebral bone marrow fat using chemical shift-encoding based water-fat MRI. J Magn Reson Imaging 42:1018–1023

    Article  Google Scholar 

  26. Karampinos DC, Ruschke S, Dieckmeyer M et al (2015) Modeling of T2* decay in vertebral bone marrow fat quantification. NMR Biomed 28:1535–1542

    Article  CAS  Google Scholar 

  27. Reeder SB, Robson PM, Yu H et al (2009) Quantification of hepatic steatosis with MRI: the effects of accurate fat spectral modeling. J Magn Reson Imaging 29:1332–1339

    Article  Google Scholar 

  28. Karampinos DC, Yu H, Shimakawa A, Link TM, Majumdar S (2011) T(1)-corrected fat quantification using chemical shift-based water/fat separation: application to skeletal muscle. Magn Reson Med 66:1312–1326

    Article  CAS  Google Scholar 

  29. Hines CD, Yu H, Shimakawa A, McKenzie CA, Brittain JH, Reeder SB (2009) T1 independent, T2* corrected MRI with accurate spectral modeling for quantification of fat: validation in a fat-water-SPIO phantom. J Magn Reson Imaging 30:1215–1222

    Article  Google Scholar 

  30. Bray TJP, Bainbridge A, Punwani S, Ioannou Y, Hall-Craggs MA (2017) Simultaneous quantification of bone edema/adiposity and structure in inflamed bone using chemical shift-encoded mri in spondyloarthritis. Magn Reson Med 79:1031–1042

    Article  Google Scholar 

  31. Kukuk GM, Hittatiya K, Sprinkart AM et al (2015) Comparison between modified Dixon MRI techniques, MR spectroscopic relaxometry, and different histologic quantification methods in the assessment of hepatic steatosis. Eur Radiol 25:2869–2879

    Article  Google Scholar 

  32. Yokoo T, Serai SD, Pirasteh A et al (2017) Linearity, bias, and precision of hepatic proton density fat fraction measurements by using MR imaging: a meta-analysis. Radiology 286:486–498

    Article  Google Scholar 

  33. Zampa V, Cosottini M, Michelassi C, Ortori S, Bruschini L, Bartolozzi C (2002) Value of opposed-phase gradient-echo technique in distinguishing between benign and malignant vertebral lesions. Eur Radiol 12:1811–1818

    Article  Google Scholar 

  34. Stabler A, Baur A, Bartl R, Munker R, Lamerz R, Reiser MF (1996) Contrast enhancement and quantitative signal analysis in MR imaging of multiple myeloma: assessment of focal and diffuse growth patterns in marrow correlated with biopsies and survival rates. AJR Am J Roentgenol 167:1029–1036

    Article  CAS  Google Scholar 

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Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Department of Radiology and Radiation Oncology, University Hospital Bonn, Rheinische-Friedrich-Wilhelms-Universität Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany

    Frederic Carsten Schmeel, Julian Alexander Luetkens, Simon Jonas Enkirch, Andreas Feißt, Christoph Hans-Jürgen Endler, Leonard Christopher Schmeel, Peter Johannes Wagenhäuser, Frank Träber, Hans Heinz Schild & Guido Matthias Kukuk

Authors
  1. Frederic Carsten Schmeel
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  2. Julian Alexander Luetkens
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  3. Simon Jonas Enkirch
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  4. Andreas Feißt
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  5. Christoph Hans-Jürgen Endler
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  6. Leonard Christopher Schmeel
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  7. Peter Johannes Wagenhäuser
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  8. Frank Träber
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  10. Guido Matthias Kukuk
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Corresponding author

Correspondence to Frederic Carsten Schmeel.

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Guarantor

The scientific guarantor of this publication is Priv.-Doz. Dr. med. Guido Matthias Kukuk at Bonn University Hospital.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all patients in this study.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• prospective

• diagnostic or prognostic study

• performed at one institution

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Schmeel, F.C., Luetkens, J.A., Enkirch, S.J. et al. Proton density fat fraction (PDFF) MR imaging for differentiation of acute benign and neoplastic compression fractures of the spine. Eur Radiol 28, 5001–5009 (2018). https://doi.org/10.1007/s00330-018-5513-0

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  • DOI: https://doi.org/10.1007/s00330-018-5513-0

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