Comparative analysis of RADS classification systems for solitary bone lesions: malignancy risk stratification
Arash Azhideh1, Sara Haseli1,2,3, Chankue Park4
1Department of Radiology, Division of Musculoskeletal Imaging and Intervention, University of Washington, Seattle, WA, USA.
European Radiology
|March 6, 2026
Summary
Osseous Tumor (OT)-RADS offers the best balance for assessing solitary bone lesion malignancy risk, while CT Bone-RADS, MRI Bone-RADS, and Bone Tumor Imaging (BTI)-RADS show excellent reader consistency.
Area of Science:
- Radiology and Imaging Science
- Oncology and Bone Pathology
Background:
- Accurate risk stratification of solitary bone lesions is crucial for patient management.
- Several Reporting and Data System (RADS) algorithms exist to standardize interpretation, but their comparative performance is not well-established.
Purpose of the Study:
- To compare the diagnostic performance and inter-reader reliability of four RADS algorithms for solitary bone lesions.
- Algorithms evaluated: CT Bone-RADS, MRI Bone-RADS, Osseous Tumor (OT)-RADS, and Bone Tumor Imaging (BTI)-RADS.
Main Methods:
- Retrospective analysis of 207 patients with solitary bone lesions who underwent both CT and MRI.
- Three radiologists independently assessed lesions using the four RADS systems.
- Diagnostic performance metrics (AUC, sensitivity, specificity, etc.) and inter-reader reliability (Gwet's AC1) were calculated.
Main Results:
- OT-RADS demonstrated the highest consensus diagnostic performance (AUC=0.91), with 93% sensitivity and 71% specificity.
- CT Bone-RADS (AUC=0.52), MRI Bone-RADS (AUC=0.60), and BTI-RADS (AUC=0.89) showed varied performance.
- Inter-reader reliability was excellent for CT Bone-RADS (AC1=0.978), MRI Bone-RADS (AC1=0.931), and BTI-RADS (AC1=0.822), but moderate for OT-RADS (AC1=0.585).
Conclusions:
- OT-RADS provides the most balanced diagnostic performance for malignancy risk stratification of solitary bone lesions.
- CT Bone-RADS, MRI Bone-RADS, and BTI-RADS exhibit excellent inter-reader reliability, facilitating consistent application.
- Understanding the performance characteristics of each RADS system aids clinicians in optimizing solitary bone lesion assessment.
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