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A retrospective external validation study of the Birmingham Atypical Cartilage Tumour Imaging Protocol (BACTIP) for the management of solitary central cartilage tumours of the proximal humerus and around the knee

  • Musculoskeletal
  • Published:
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Abstract

Objectives

This study aimed to externally validate the Birmingham Atypical Cartilage Tumour Imaging Protocol (BACTIP) recommendations for differentiation/follow-up of central cartilage tumours (CCTs) of the proximal humerus, distal femur, and proximal tibia and to propose BACTIP adaptations if the results provide new insights.

Methods

MRIs of 123 patients (45 ± 11 years, 37 men) with an untreated CCT with MRI follow-up (n = 62) or histopathological confirmation (n = 61) were retrospectively/consecutively included and categorised following the BACTIP (2003–2020 / Ghent University Hospital/Belgium). Tumour length and endosteal scalloping differences between enchondroma, atypical cartilaginous tumour (ACT), and high-grade chondrosarcoma (CS II/III/dedifferentiated) were evaluated. ROC-curve analysis for differentiating benign from malignant CCTs and for evaluating the BACTIP was performed.

Results

For lesion length and endosteal scalloping, ROC-AUCs were poor and fair-excellent, respectively, for differentiating different CCT groups (0.59–0.69 versus 0.73–0.91). The diagnostic performance of endosteal scalloping and the BACTIP was higher than that of lesion length. A 1° endosteal scalloping cut-off differentiated enchondroma from ACT + high-grade chondrosarcoma with a sensitivity of 90%, reducing the potential diagnostic delay. However, the specificity was 29%, inducing overmedicalisation (excessive follow-up). ROC-AUC of the BACTIP was poor for differentiating enchondroma from ACT (ROC-AUC = 0.69; 95%CI = 0.51–0.87; p = 0.041) and fair-good for differentiation between other CCT groups (ROC-AUC = 0.72–0.81). BACTIP recommendations were incorrect/unsafe in five ACTs and one CSII, potentially inducing diagnostic delay. Eleven enchondromas received unnecessary referrals/follow-up.

Conclusion

Although promising as a useful tool for management/follow-up of CCTs of the proximal humerus, distal femur, and proximal tibia, five ACTs and one chondrosarcoma grade II were discharged, potentially inducing diagnostic delay, which could be reduced by adapting BACTIP cut-off values.

Clinical relevance statement

Mostly, Birmingham Atypical Cartilage Tumour Imaging Protocol (BACTIP) assesses central cartilage tumours of the proximal humerus and the knee correctly. Both when using the BACTIP and when adapting cut-offs, caution should be taken for the trade-off between underdiagnosis/potential diagnostic delay in chondrosarcomas and overmedicalisation in enchondromas.

Key Points

• This retrospective external validation confirms the Birmingham Atypical Cartilage Tumour Imaging Protocol as a useful tool for initial assessment and follow-up recommendation of central cartilage tumours in the proximal humerus and around the knee in the majority of cases.

• Using only the Birmingham Atypical Cartilage Tumour Imaging Protocol, both atypical cartilaginous tumours and high-grade chondrosarcomas (grade II, grade III, and dedifferentiated chondrosarcomas) can be misdiagnosed, excluding them from specialist referral and further follow-up, thus creating a potential risk of delayed diagnosis and worse prognosis.

• Adapted cut-offs to maximise detection of atypical cartilaginous tumours and high-grade chondrosarcomas, minimise underdiagnosis and reduce potential diagnostic delay in malignant tumours but increase unnecessary referral and follow-up of benign tumours.

Graphical Abstract

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Abbreviations

°:

Degree

2D/3D:

Two-/three-dimensional

ACT:

Atypical cartilaginous tumour

ADC:

Apparent diffusion coefficient

AUC:

Area-under-the-curve

BACTIP:

Birmingham Atypical Cartilage Tumour Imaging Protocol

CCT:

Central cartilage tumour

cm:

Centimetre

CS:

Chondrosarcoma

DCE:

Dynamic contrast-enhanced

DDCS:

Dedifferentiated chondrosarcoma

DWI:

Diffusion-weighted imaging

ETL:

Echo train length

FOV:

Field-of-view

HP:

Histopathological

ICC:

Intraclass correlation coefficient

IQR:

Interquartile range

IVIM:

Intravoxel incoherent motion

Kep:

Rate constant

Ktrans:

Volume transfer constant

mm:

Millimetre

ms:

Millisecond

n:

Number

NA:

Not available

NPV:

Negative predictive value

PD:

Proton density

PPV:

Positive predictive value

Q:

Quartile

ROC:

Receiver operating characteristic

SD:

Standard deviation

SUVmax:

Maximum standardised uptake value

T:

Tesla

T1:

T1-weighted

T2:

T2-weighted

TE:

Echo time

TI:

Inversion time

TR:

Repetition time

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Acknowledgements

The authors would like to thank Heleen Coreelman (MSc in Biochemistry and Biotechnology, MSc in Forensic Science) for the editing of Fig. 1 and for proofreading the final version of the manuscript. They would also like to thank the pathology department of the Ghent University Hospital (Belgium) for their technical support and Griet Alleman (BSc Radiographer, Study Coordinator, Ghent University Hospital, Ghent, Belgium) for data collection and study management.

Funding

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

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Authors and Affiliations

  1. Department of Radiology and Medical Imaging, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium

    Thomas Van Den Berghe, Felix Delbare, Esther Candries, Maryse Lejoly, Chloé Algoet, Frederiek Laloo, Wouter C. J. Huysse & Koenraad L. Verstraete

  2. Department of Diagnostic Sciences, Ghent University, Sint-Pietersnieuwstraat 25, 9000, Ghent, Belgium

    Thomas Van Den Berghe, Felix Delbare, Esther Candries, Maryse Lejoly, Chloé Algoet, Frederiek Laloo, Wouter C. J. Huysse & Koenraad L. Verstraete

  3. Department of Radiology, Peking University Shenzhen Hospital, Shenzhen, 518036, China

    Min Chen

  4. Department of Pathology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium

    David Creytens

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Correspondence to Thomas Van Den Berghe.

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The senior scientific guarantor of this publication is the head of the research unit, Koenraad L. Verstraete (MD, PhD, Full Professor of Radiology).

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Statistics and biometry

Two of the authors, Thomas Van Den Berghe (MD, PhD Researcher) and Esther Candries (MSc), have significant statistical expertise. Nevertheless, no complex statistical methods were necessary for this manuscript.

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Written informed consent was waived by the Ethical Committee (Institutional Review Board) for this retrospective study involving human participants. For this type of study, formal consent is not required.

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Institutional Review Board approval was obtained (BC-08631 E01). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Van Den Berghe, T., Delbare, F., Candries, E. et al. A retrospective external validation study of the Birmingham Atypical Cartilage Tumour Imaging Protocol (BACTIP) for the management of solitary central cartilage tumours of the proximal humerus and around the knee. Eur Radiol (2024). https://doi.org/10.1007/s00330-024-10604-y

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