MRI analysis of simple and aneurysmal bone cysts in the proximal humerus: what actually matters in clinical routine

To evaluate magnetic resonance imaging (MRI) characteristics of simple and aneurysmal bone cysts (SBC/ABC) of the proximal humerus and the intermittent difficulty in the imaging differentiation between the two in daily clinical routine.

MR images of 26 patients with suspected SBC/ABC in the proximal humerus were retrospectively assessed by two independent radiologists blinded to the final histological result. Based on a standard MRI protocol, different morphologic features and signal intensities of the lesion on non-enhanced and enhanced sequences were documented. The radiological diagnosis was correlated with histology.

Eighteen patients had the image-based diagnosis of an SBC, yet the histology confirmed only 12, the residual 6 were identified as an ABC, despite the imaging criteria corresponding unambiguously to the former. One of the main reasons was the unicameral morphology of lesions, found in 9/14 (64.3%) cases of all ABCs, i.e., in 19/26 cases in total. Therefore, the sensitivity of the radiological diagnosis was moderate (57.14%), yet specificity very high (100%). In total, 69.2% (18/26) presented with a pathological fracture at admission, which correlated strongly with both circumferential (MCC = 0.65, p = 0.01) and septal (MCC = 0.42, p = 0.06) enhancement patterns. Circumferential enhancement was also found to correlate strongly with the histological diagnosis, being recognized in all cases of ABC (MCC = 0.44, p = 0.06).

MRI characteristics of ABCs/SBCs in the proximal humerus are indifferent and ABCs may morphologically present as SBCs. Radiologists should be aware of the different, often confusing presentation of both entities in daily clinical routine.