Role of diffusion-weighted MRI in differentiating benign from malignant bone tumors

To evaluate the role of diffusion-weighted MRI in differentiating benign from malignant primary bone tumors. To know the sensitivity and specificity of diffusion weighted MRI and calculating apparent diffusion coefficient (ADC) cutoff in differentiating benign from malignant primary bone tumors.

This is a prospective observational study of 50 patients, who were clinically or radiologically suspected with primary bone tumor and referred to the Department of Radiodiagnosis, for radiography or for MRI. These patients underwent routine MRI sequences including diffusion-weighted MRI with b-values of 0, 500 and 1000, followed by pathological examination supplemented by immunohistochemistry (wherever necessary). Hematological malignancies, recently biopsied cases and recurrent cases were excluded from the study.

Out of 50 patients with suspected bone tumors, 15 were benign (and tumor like lesions) and 35 were malignant primary bone tumors. The most common age group involved for both benign and malignant primary bone tumors was 11-20 years (23 cases-46%). In our study, total number of affected males were 27 (54%) and total number of affected females were 23 (46%) with M:F ratio of 1.17:1. In this study 72% lesions had appendicular bone involvement and 28% had axial bone involvement. 94.3% of malignant lesions showed restriction on diffusion-weighted imaging (DWI) and in 80 % of benign lesions restriction was absent on DWI which was statistically significant. Mean ADC levels in malignant lesions was 1.092 ± 0.497 and in benign lesions was 1.62 ± 0.596 which was statistically significant. Chondrosarcoma had highest ADC and Ewing's sarcoma had lowest ADC values in malignant lesions. Chondroblastoma had highest ADC and Osteomyelitis had lowest ADC values in benign lesions. ADC value of 1.31 had highest sensitivity and specificity to differentiate between benign and malignant lesions.

DWI is helpful in differentiating malignant from benign bone tumors and tumor like lesions with diffusion restriction favoring malignancy. Inspite of some overlap, ADC values of benign and malignant bone tumors are different and measurement of ADC values improves the accuracy of the diagnosis of bone tumors and tumor like lesions. Calculation of ADC may also be used as baseline reference to assess response to treatment in future or for follow up.

DWI imaging (and ADC values) has been extensively used in neuroimaging. Extension of this application to musculoskeletal-oncologic imaging is not so well studied. Apart from differentiating benign from malignant lesions which is the main focus of this study, assessment of response to treatment by ADC values may be possible in near future.