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Structured ACR Bone-RADS Versus Unstructured Assessment of Bone Tumors on Radiographs: A Multicenter, Multireader
Chunlin Song1, Tianzi Jiang1, Tongyu Wang1
1Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, China.
Journal of the American College of Radiology : JACR
|August 10, 2026
Summary
The Bone-RADS (Bone Reporting and Data System) improved diagnostic accuracy and radiologist agreement for early-career physicians interpreting bone tumors. This structured system also led to more appropriate management recommendations for potentially malignant lesions.
Area of Science:
- Radiology
- Oncology
- Medical Imaging
Background:
- Assessing bone tumors on radiographs is crucial for diagnosis and management.
- Current unstructured assessment methods can lead to variability in interpretation and recommendations.
- Standardized reporting systems aim to improve diagnostic consistency and accuracy.
Purpose of the Study:
- To compare the diagnostic performance and interreader agreement of the American College of Radiology (ACR) Bone Reporting and Data System (Bone-RADS) versus unstructured assessment of bone tumors on radiographs.
- To evaluate the impact of Bone-RADS on management recommendations.
Main Methods:
- A multicenter study involving nine musculoskeletal radiologists with varying experience levels.
- Radiologists independently performed unstructured classification and Bone-RADS (1-4) grading on bone tumor radiographs from retrospective and prospective cohorts.
- Diagnostic performance was assessed using the area under the curve (AUC) via a multireader, multicase receiver operating characteristic model; interreader agreement and management recommendations were also analyzed.
Main Results:
- Overall diagnostic performance (AUC) did not differ significantly between unstructured assessment and Bone-RADS.
- Early-career readers showed significant AUC improvements with Bone-RADS, while mid- and late-career readers had nonsignificant changes or slight declines.
- Bone-RADS increased interreader agreement and shifted management recommendations towards increased referral or workup for potentially malignant lesions, particularly among early-career readers.
Conclusions:
- Bone-RADS offers stable risk stratification and enhances diagnostic performance and interreader agreement, especially for early-career radiologists.
- The system effectively guides management toward appropriate referral or workup for concerning bone lesions.
- Future refinements could improve accuracy by incorporating patient age and anatomic site, and by providing targeted training on features with lower agreement.